Western Cape Appropriation Bill: Health

Meeting report

Minister’s overview

Minister Nomafrench Mbombo informed the Committee that the Western Cape Department of Health had brought forward the appropriation of its budget for the 2022/23 financial year. The tabled budget amount was R29.094 billion.

Minister Mbombo reminded Members that whilst the country was not in a COVID wave yet, it was still under the direct influence COVID. The budget had therefore factored in the associated healthcare costs in the event of a fifth wave of COVID. The Department had begun to recover some of the non-COVID related health services. These services had been put on hold since the outbreak of COVID-19, as the Department had to prioritise its health budget on combating COVID-19 during the first four waves. Though the Department was trying to recover some of the health services, it would not be possible for the Department to bring all health services back to their pre-COVID levels.

Many health services, such as mental health service, surgeries, etc., were lagging behind as a result of COVID-19. In addition, the Department also had to attend to the aging infrastructure in the health sector in the province, as some hospitals were more than 100 years old.

Referring to the wage bill, she said the issue had been under negotiation with the unions when it was last tabled at the Committee. The Finance Minister subsequently took the matter to court arguing that the state could not afford to pay public servants that much. Whilst the Minister had won in court, the province still needed to have the funds readily available for those employees, as would be shown in the budget.

The Minister said it was not only the patients who had suffered mental issues as a result of COVID-19. Staff members had also suffered in terms of their mental well-being. For instance, they may have witnessed their colleagues having passed on, as well as those who had been affected by COVID, which may also have affected staff morale.

The Department had had to review its methods and approach in dealing with contractual staff members now that the country was exiting the COVID wave.

Minister Mbombo explained the economic context of the country on the budget, saying that it remained crucial to realise that the budget was determined by other social, economic and cultural determinants.

Head of Department's (HoD's) opening remarks

Dr Keith Cloete, Head of the Western Cape Department of Health (DOH), confirmed that the Department was tabling an appropriation budget of R29 billion before the Committee.

He urged the Members to understand the context under which this budget had been prepared. 2022/23 was a financial year that followed severe disruptions caused by COVID-19. He reminded them of the havoc that the previous four waves had caused to the Western Cape's health services. As COVID-19 was not yet over, the budget also showed that the provincial health department had set aside funds readily available to deal with a possible fifth or sixth wave. From an overall perspective, the provincial health department had to cope with a myriad of issues, such as vaccination, etc.

As a result of COVID-19 and the Department’s shifting of focus toward combating COVID-19, the health system in the province had a lot to catch up on. For instance, there were significant delays and backlogs in tuberculosis (TB) treatment and surgeries, as well as mental health issues. He commented that mental health issues had been exacerbated by COVID.

It was commendable that the Western Cape generally had coped with all the difficulties during this trying time. However, it would take at least five to ten years before the Department could truly recover from the catastrophe left by COVID. It was not an easy journey, as the Department was facing more needs from citizens than its own resources could provide, and these challenges would require wise decisions.

Dr Cloete highlighted the importance of the social compact and informed the Committee that the Minister would be hosting a summit on 29 April. The purpose of the summit was to bring together all the stakeholders to navigate through those difficulties.

Discussion

Ms R Windvogel (ANC) welcomed the inputs from the Minister and the HoD. She fully understood that it was a difficult time for the Department, and indicated that Members were willing to assist the Department in ensuring that it would be able to offer better service delivery.

Mr D Plato (DA) agreed and remarked that he had witnessed what a difficult time it had been in the past two years for government of all spheres to deal with COVID-19. He commended the Department for its excellent work under these trying circumstances. He sought clarity on the state of clinics, and whether the Department was making the necessary inroads into the maintenance programmes for day hospitals, as Members received a lot of complaints from the public around those issues.

Minister Mbombo replied that the clarity which Mr Plato sought would be covered in Programme 2 of the budget report.

The Chairperson indicated that Members may ask questions from pages 215 to 220 of the Department’s budget report. Each Member would be limited to three questions.

Ms Windvogel referred to page 215 of the report and asked how it applied to health facilities in poor, working communities such as the Khayelitsha District Hospital. She wanted the DOH to give an indication as to how the budget prepared by the Department responded to the plea made by the hospital's management for an additional R150 million allocation -- whether the budget had made provision for that R150 million. If not, she wanted an explanation and how much additional allocation was being provided to the Khayelitsha hospital this year if not R150 million.

Referring to page 216, she enquired about the Department’s strategy to address the increase in service backlogs of other non-COVID related healthcare services. She wanted to get an overview of the backlog in surgeries and other types of health services.

She referred to page 217 of the report and asked the Department to provide more explanations on its spending of the National Health Insurance (NHI) grant, the conditions attached to the grant, as well as an opinion on how the grant had assisted in improving services at hospitals. What were the Department’s measures to ensure the full expenditure of this grant?

Ms N Bakubaku-Vos (ANC) referred to page 218 of the report and asked how much of the Department’s own revenue had been collected in the current financial year, how much had been re-invested within the Department, and how much had been returned to the provincial treasury. She asked the Department to provide the Committee with a breakdown of its revenue collection since 2014.

She noted that the Department calculated the demands of health service access based on the population growth in the area, which in turn informed the Department of its budget. She thus asked the Department to provide her with a breakdown of the population growth in the Khayelitsha area from 2012 to 2022.

She wanted to know what the reasons were for the decrease in the cost of employees (CoE) item in the budget. What was the estimated number of staff who would be affected by this decrease, and what would its impact be on service delivery?

Minister Mbombo said that she would leave answering those specific questions to the DOH's officials, but wished to highlight some of the policy imperatives which guided the Department’s approach to the budget.

She explained on what basis the Department allocated the funding that it got from National Treasury. The basis was on the population growth of an area. Although the last census was done in 2011, the Department could still rely on Stats SA for population data, as well as the population that were medically insured and those who were uninsured. She pointed out that the majority of the Western Cape population living in farming communities used public healthcare facilities even if they had medical aid since there were no private hospitals in areas such as Matzikama or Beaufort West. The Department also took into consideration risk factors like disease exposure -- such as HIV AIDS and TB -- to determine its allocation of funding. She guaranteed that equity would be factored in as part of the methodology going forward.

In response to Ms Windvogel’s remark on the NHI, she said that the provincial government could not answer on behalf of the Democratic Alliance on its position on the NHI bill. From the provincial Department’s point of view, the NHI was an insurance which formed part of the universal health coverage, which was part of a bigger thing. The Western Cape DOH had stressed that point to the National Department of Health, as well as to the National Parliament, in its submissions on the NHI Bill.

Dr Cloete responded to the question on page 215 and indicated that the Khayelitsha District Hospital would not be getting the R150 million additional allocation for which it had pleaded. He explained that in order to balance the demands of all the government hospitals in the province, the Department’s allocation factored in equity, the population in the area, the number of people going to that hospital, etc. Doing this was to ensure that there was an equitable allocation for not only the Khayelitsha District Hospital but also other equivalent hospitals such as Karl Bremer, Mitchells Plain and Victoria hospitals. This had been the benchmark practice in the Department for many years. He believed the current allocation was equitable. Regarding Khayelitsha Hospital, he urged Members to look at the disease profiles of those patients who went to that hospital. In fact, there was a history of social determinants that led to more patients being admitted to that hospital because of the higher percentages of trauma and violence cases in the area. Thus, in response to the social drivers which led to the situation at Khayelitsha Hospital, the Western Cape government’s recovery strategy focused on addressing violence and safety issues in the area. It looked at taking the pressure off the health system by looking at the entire system to mitigate the risk for that hospital.

Dr Cloete responded to the question on the demands for services on page 216 of the report. He urged Members to understand that this would be the key question with which every country that had been affected by COVID-19 would be grappling for the next five to ten years. It was a global phenomenon. The important point to be borne in mind was that the government needed to work with what resources were available in order to wisely balance and meet the backlogs that had been incurred during the COVID-19 period. The Department was aware of the long waiting list of elective surgeries at government hospitals. Elective surgeries meant that patients could wait to be operated on at a later stage and their conditions were not life-threatening. Those surgeries included surgeries such as knee surgery, etc.

On Mandela Day, the Department would be meeting with all stakeholders to find a solution to address the backlog which would be in the public health sector in the next two to three years. Emergency surgery cases caused by trauma and violence, as well as cancer, were deterring the Department’s efforts to clear up the backlog. Also, the priority in testing COVID-19 during the first four waves had resulted in a neglect of TB patients, so government hospitals would now be expecting an increase in the amount of TB patients in emergency sections.

Dr Cloete also emphasised the detrimental impact on mental health of factors such as drug abuse that were resulting in more young people landing up in the emergency wards. These factors could all add a burden on to the existing health system and further deter the progress of clearing the backlog in elective surgeries.

He said that the NHI grant was just like any other form of conditional grants given by the national Department with conditions having to be met. The NHI fund had been spent on contracting sessional general practitioners (GPs) in rural areas. The national Department of Health (NDoH) had consolidated grants and included mental health provisions in the NHI grant this year. There was also an additional grant for the first time for the Department to test out the model of public private partnerships, working together in geographical areas. The provincial Department was working with the NDoH to spend that grant. The NDoH had approached the Western Cape because it was the only province that had health facilities that were suitable for testing the model. He clarified that the NHI grant was a means of funding, and had nothing to do with the implementation of the NHI bill which was currently being discussed in the national Parliament.

The money being referred to on page 218 of the report was not being spent on the purchase of vaccines, as the NDoH was the purchaser. However, the provincial DOH was responsible for safely delivering vaccines to different sites, ensuring sufficient cold chain capacity for the storage of vaccines, as well as paying nurses who were on those sites to administer vaccines. The latter was the main item which the Department spends its money on.

Dr Cloete said the Department did have data for population growth in each of the relevant geographical areas. However, the population growth in Khayelitsha was not significantly higher than that in other areas. He was willing to provide more details to the Committee.

He said that currently, it was a common practice in South Africa to budget for CoE for only one year. In terms of the labour agreement, he guaranteed that the Department had sufficient funds to pay staff for the 2022/23 financial year. As the budget included only one year of COE, the financial years for 2023/24 and 2024/25 were not included in the preliminary allocation.

Mr Simon Kaye, Chief Financial Officer (CFO), Western Cape DOH, said the provincial revenue was included in the report as part of the R396 million budget for next year, and anything that exceeded that amount would be surrendered to the Provincial Treasury. However, that amount would be given back to the Department in its adjustment budget.

He said 250 employees would be cut in order to balance the CoE item in the Department’s books. He asked Members to note the declining number of employees in the Department, which had dropped from 36 170 to 33 915 in the 2023/24 financial year. He pointed out that this trend was happening across all government spheres in order to meet the CoE increases based on the wage agreement reached with the unions.

Ms Windvogel referred to the Khayelitsha Hospital issue. She expressed displeasure at the Department’s response and remarked that Dr Cloete would be using the same allocation system again this year, which would only lead to the same outcome -- patients sleeping on the floor. The issue was something close to her heart, as patients sleeping on the floor was simply unacceptable. She wanted Dr Cloete to give an indication of the exact additional amount of budget that would be allocated to Khayelitsha Hospital which would be used to respond to the many unfunded mandates at that hospital.

Minister Mbombo agreed with Ms Windvogel’s view and sympathised with her sentiment. However, she urged Members to look at the overall picture of government hospitals in the province, as the lack of funding happened not only at the Khayelitsha Hospital. The causal factors which led to those hospitals being unable to cope with the pressure were related to social determinants such as poverty, unemployment, COVID-19, etc. Members needed to look at the root causes that led to the situations that Members had witnessed. It was more likely that people living in those areas were queuing up outside of the South African Social Security Agency (SASSA) every month for social grants.

She also cautioned against Members’ untrue perception that the Department was spending its resources in affluent areas. It was simply untrue, as there were no government hospitals in affluent areas such as Bishopscourt. Quite the contrary, almost all of the Department’s funding had been spent in poor communities. For example, when COVID-19 pressure had just started, the Department came up with a Khayelitsha health plan which included buying beds from a non-governmental organisation (NGO) to ensure that there would be sufficient beds for all the patients. Even though district hospitals usually were not equipped with psychiatry wards, the Department had decided to put all those wards in place for such district hospitals in poor areas.

She said Members should remember that many of the issues with which the health system was currently dealing should not be seen in isolation, disregarding of the bigger picture of the social context. She assured Members that the Western Cape DOH was dedicated to assisting poor areas. For example, it was deliberating on the efficient use of health resources so that more of the patient flow could be diverted to other sites in order to ease the patient traffic at Khayelitsha hospital. She also reminded Members that what they had witnessed in Khayelitsha was not uncommon at other hospitals and indeed, all hospital managers were pleading for more funding. However, the Department simply could not meet their demands, given its limited resources.

Dr Cloete agreed with the Minister’s point and indicated that the Department’s spending on the Khayelitsha Hospital was comparable to that at other hospitals. The Department also used its discretion to allow the hospital to overspend by R40 to 50 million per year more than other hospitals. That part of the funding was met by the DOH's own collective saving. He emphasised that the solution to address the issue should be focused on how to prevent those patients who were causing the congestion, from coming to the hospital. The answer to that was the need of investment in other areas, rather than in the hospital itself.

The Chairperson said that Members may proceed to ask questions on pages 221 to 230 of the report. In this round, due to time constraints, she asked them to limit their questions to a maximum of two questions.

Ms Bakubaku-Vos referred to page 222 of the report and asked the Department what caused the decrease in the funding allocation from the provincial revenue fund. She questioned why the Provincial Government was not allocating funds from its revenue fund to address the other health priority matters, such as the Khayelitsha District Hospital.

She thanked the national government for the increase in the equitable share given to the province. She requested a breakdown of the priorities that the Department had decided to fund from the increased share.

Referring to page 224, she asked Dr Cloete to explain the reasons for the budget passed under programme 1.

On page 225, under table 8.2, where it stated maintenance and repair, she had noted a funding decrease for that item and wanted to know which projects would be affected.

Ms Windvogel indicated that she had a problem with the Chairperson’s rule to set time and question limits. It was not every day that Members got to have both the Minister and her team in the meeting. She complained that it was usually quite difficult for them to get the Minister to answer their questions.

The Chairperson explained that because the Committee had been given a time limit within which to conclude the meeting, there had to be a time limit. In addition, members of the public would also be given an opportunity to engage with the Minister and the Department which they would otherwise not have. She pointed out that the public did not have the same privileges as those of Members, who could write and demand answers from the Minister.

Ms Windvogel highlighted the Khayelitsha issue, and said that patients were sleeping on the floor. She had been informed by the management that there were insufficient beds at the hospital, so it was not quite as what the Minister had explained -- that patients were waiting to be allocated to a bed or waiting to be transferred to another hospital.

Ms Windvogel asked the Department what had caused the fragmentation of the primary healthcare platform in the metro. She wanted to know if the issue had received adequate attention and been addressed. The state of those clinics around the Cape metro negatively impacted on citizens’ constitutional right to health.

On page 225, she noted that there had been an increase in the budget which the report stated would be spent on the building of new infrastructure, as detailed. Hence, she did not understand why the building of the GF Jooste Hospital still had not been started. She asked for a detailed update, which must include the total cost of building the hospital. The update must also indicate when the project would commence and by when it would be completed, what work had been done and the tasks that would be undertaken this year.

Mr Plato commented on the aging infrastructure of health facilities in the province and highlighted the significant risk of fire incidents. He thus wanted to know how the Department was dealing with this matter.

Ms Bakubaku-Vos said that if the question session for members of the public was completed before the afforded time limit, she would like to chip in and ask more questions.

The Chairperson commented on the aging infrastructure and asked what the Department saw as a priority, such as the most needed services in a specific health facility. She believed that the Department had the people’s best interests at heart. With regard to the various external factors which were contributing to the overflow of patients at those struggling health facilities, she wanted to know what the Department’s approach was, as well as its strategies in working with other sectors to solve the issues together.

Mr M Xego (EFF) joined the meeting and wanted to ask questions, but was stopped by the Chairperson. The Chairperson guaranteed that she would give him his turn to ask questions after the Minister and her team complete their responses.

Minister Mbombo indicated that the Western Cape province, just like any other provinces in the country, was facing the quadruple burden of diseases. Those diseases included maternal and child health, mental health issues, interpersonal violence, TB, HIV and AIDS, as well as chronic diseases such as diabetes. In 2019, the Department had undertaken an assessment of the disease profile in each metro area. The finding was that in the southern and the western parts of the metro, there were more cardiovascular diseases. In Khayelitsha, there were more young people that had HIV and TB. In the Overstrand area, cancer was more prominent. The provincial Department had also noted an increase in HIV and TB in the Overberg area. In Beaufort West, TB and respiratory infection cases were increasing. It was based on those risk factors that the National Treasury allocated funds.

Regarding the Department’s indicators in its annual book, she was confident that all information such as the details of the grants, as well as what was expected of the Department to perform quarterly in order to satisfy the grants' criteria, was clearly provided.

Minister Mbombo said the DOH had a process to determine its priorities in spending the grants. Firstly, it had to determine the disease profile in an area. For instance, in Khayelitsha, there was a high level of HIV/AIDS, as well as TB among the young population. Thus, the 350-bed hospital did not meet the demands of the population. Since Khayelitsha District Hospital was a district hospital, it would not be possible for the hospital to add another bed. The high level of violence was a driver for the increasing number of patients in the hospital. Lastly, there were mental health issues which saw young people coming to hospitals for substance abuse, which had been noted as another driver that added to the hospital's burden.

Minister Mbombo summarised that those issues were outside of the terrain of the health system and should be seen as a socio-economic problem. The solution was simple -- the more jobs the country created, the more girls staying at school to complete their matric, and the fewer people abusing drugs and alcohol, the more likely that the hospital burden would be significantly lessened. She urged the government to invest in social determinants that would reduce the burden on the health system.

Responding to Ms Windvogel, she said she was not disputing the fact that patients were sleeping on the floor. She believed that it was inevitable, regardless of how much more budget the Department allocated to Khayelitsha District Hospital. Her own oversight visits had noted a consistent pattern with that of Ms Windvogel. For instance, at the new Somerset Hospital, the 15-bed psychiatric ward had ended up having 40 patients in that ward during Christmas time. The ward was full of young people who had ended up there because of alcohol and drug abuse.

She recalled her one encounter with a professor who was the head of Groote Schuur Hospital at the time. The professor had told her that Groote Schuur had to save patients using battlefield medicines, as they frequently had to rush to save patients who had suffered multiple gunshots. In one extremely severe case, one survivor had suffered 42 gunshots. Thus, given the high number of trauma cases in those hospitals and the fact that those patients needed emergency treatments, those patients who were sleeping on the floor at Khayelitsha District Hospital during Members’ visits were probably waiting for non-emergency treatment. They were there because they could not be turned away since the health sector was different from other sectors -- one could not simply ask a patient to go home and wait at home. In some cases in hospitals, patients were being asked to wait for eight hours because some of them had symptoms that were not as life-threatening as others, such as those who had suffered gunshots. Some of these situations were out of the Department’s control.

What was worse was that Gauteng and the Western Cape had to face a budget cut because the national Department believed that poorer provinces should be getting a bigger share of the budget in terms of equity. The budget was so tight at the moment that the provincial Department had to let go of those staff members who had been employed on a contractual basis to assist during the COVID-19 period. She indicated that the country was facing a conundrum, where the health system needed more doctors and there were doctors who had just graduated, completed their community service and were ready to serve, but the government had no funding to employ them. Therefore, the situation that Ms Windvogel had raised was not unique and was happening in other government hospitals in other areas as well.

Dr Cloete urged everyone to work with the provincial Department to find a solution to the difficulties such as those indicated at the Khayelitsha District Hospital. The focus of their approach should be to work on a solution that could reduce the number of people showing up at those hospitals.

Regarding the remark about the fragmentation of primary healthcare services in the metro, it had always been the Western Cape government’s position that primary healthcare services in the metro should be under one authority, and be placed under the provincial government. The process to work with its City of Cape Town (CoCT) counterpart was underway, as the Minister was working with Mayoral Committee Members to review the phased process of the consolidation of services. The process had been initiated, and there were specific plans with specific timelines.

The delay in the construction of the GF Jooste Hospital was related to the delay in the allocation of a tender. The provincial DOH was working with the Department of Transport and the Department of Public Works, and the tender had been published. It would be allocated in May. Once the tender had been allocated, the project could start.

Dr Cloete told Mr Plato that the Department had an appropriate scoring system for facility assessment. It also had a complete list of all the clinics needing refurbishing, upgrading or replacement. Generally, in allocating its budget, the Department looked at those clinics and places dealing with the most pressure. A priority list did exist, and he referred Members to Budget 8.1 in the report.

He said the Department operated within a de-centralised system, as it divided all health facilities into eight geographical areas. There were five districts in the rural areas. The Garden Route and Central Karoo went together as one area. Overberg, the West Coast and the Cape Winelands were seen as one area. There were four districts in the metro. The expectation was that each geographical area management team must understand the healthcare needs in the various geographical areas and the various facilities in their own geographical area. The Department took its leads from them to prioritise those needs in each of the geographical areas. The allocation of budget was therefore informed by those facts. Each geographical area had its own prioritisation process including the movement of people, facility assessment, etc. The recent arrival of a large number of undocumented people in an area between Robertson and Ashton in the last two months had caused chaos in the health sector of the Cape Winelands area. The area would have been very well prepared but did not anticipate the sudden arrival of a lot of people in the area.

Mr Kaye said the allocation of the provincial revenue fund was primarily based on its COVID response and provincial priorities last year. The funds would not be given to the provincial level but would be given through the national equitable share. This explained why the national equitable share had been increased by 8.1%, whilst provincial revenue fund had been reduced by 86%.

He referred to page 224 and a Member’s question on the reduction in the administration budget by 10%. He said that the COVID allocation was decreasing on a year-on-year basis. The slight increase in the 2021/22 financial year, from R1.14 billion to R1.25 billion, had been due to the provincial Department using its reserves from previous years to fund COVID activities in the current year. The amount which the Department spends on testing had decreased significantly. For instance, a PCR test costs R500, and an antigen test costs about R120, so basically four antigen tests cost the same price as one PCR test. In addition, the Department had also taken the personal protective equipment (PPE) budget out of the cost centre, because it had a warehouse with stock. It had allocated the PPE directly to facilities, so now that budget was being spent on programmes two, three, four and five.

Mr Kaye responded to the maintenance and repair issue and remarked that the demand always exceeded the funds which were available. He referred Members to Annexure Table B5 from pages 273 to 287 of the report, which detailed every project that the Department had planned for the next three years, their estimated costs and cumulative expenditure. Members would be able to see how and where the Department prioritised its projects. He also referred to table 981 on page 249 of the report, which showed the different allocations between goods and services, which was primarily for repairs and maintenance, and the buildings and fixed structures, which were primarily capital work. Members would have noticed that there was a decrease in the goods and services maintenance budget because the Department had shifted its focus to doing more work on the capital side of things. The shift was marginal, and generally showed a very healthy increase on the capital side.

Mr Xego referred to page 225 of the report, and asked about the Department’s infrastructural development plan for Tygerberg Academic Hospital, and for the Committee to be provided with a progress report on the matter.

Dr Cloete responded that there were a few things that were happening at Tygerberg Hospital. The provincial Treasury had just allocated maintenance money to upgrade various parts of the hospital. There were three concurrent processes that were taking place. The first was the upgrade of the Tygerberg hospital, the planning of a future central hospital, as well as the planning for the Belhar Regional Hospital.

Mr Kaye said the Department was finishing its internal clinical brief for the Belhar site with the understanding that the central hospital would be taking over certain additional services, and another 68 beds would be added to the central hospital. This whole process would require a feasibility study on the affordability of building a central hospital. That feasibility study had been circulated among Department officials last week. The outcome of that study would impact the clinical briefing of the Belhar site, as well as the methodology that the Department would employ to implement the brief.

The Department had so far secured a budget facility for infrastructure (BFI) funding for the Klipfontein and Belhar sites. The land for the Belhar site had also been secured, whereas the site for Klipfontein was still under negotiation with the City. The conundrum was that the Department would have to provide regional services out of the central hospital whilst maintaining it as a teaching hospital that was linked to the university. The site on which building work would be done was at the Tygerberg Hospital and would require demolition of certain buildings in order to create the footprint in order to move and decant the services out of the current central hospital and move those services over to the new central hospital. That was the Department’s progress in terms of the building at the Belhar and Klipfontein hospital sites.

The Chairperson indicated that Members may now proceed to ask the Department questions based on pages 231 to 245 of the report.

Ms Windvogel referred to page 235 of the report and welcomed the increase shown in table 9.3. She wanted to know how much of the budget would be spent on private ambulances and the justification for that. She asked the Department to describe how the increase would assist in improving the waiting time and conditions in rural areas. She also wanted to know how many additional ambulances had been procured this year.

Table 9.31 indicated the CoE, and she asked how many staff members were not being employed on a permanent basis, and why they were not being employed permanently.

She referred to page 245 and enquired about reasons for the decrease in funding for forensic services in table 9.7, and its impact on service delivery.

Mr Xego asked about the emergency medical services issue on page 234 and asked how ambulances responded to peoples’ demands, with the understanding that some destinations were high-risk areas. He wanted the Department to give an indication of the availability of ambulance services because people who utilised private ambulances were incurring serious debt. What was the Department’s plan to ensure that there would be sufficient ambulances?

On page 239, the transfers and subsidies referred to a R3.8 million transfer to non-profit organisations. How many NPOs was the Department targeting, and how much would each institution receive?

He enquired about Programme Six (health science and training) on page 241. He wanted the Department to indicate its plans on absorbing trained nurses. It was only yesterday that he had received complaints that trained nurses had not received some receipts and payments that were due since the Department had recently circulated an instruction requiring nurses to undertake certain training courses.

Ms Bakubaku-Vos enquired about Table 9.6 on page 242, which showed a decline in bursary funding. How many students would be affected by this decrease? She also requested a breakdown of the affected nursing students and doctors, as well as the total budget allocated for medical interns. She also wanted to know whether those interns had all been placed.

She asked about the decreased budget for district hospital services, as shown in table 9.8 on page 248, and asked the Department to provide details of which projects would be affected by this decrease.

Mr Allen referred to sub-programme 4.2 on psychiatric hospitals on page 237. He commented that the increase of R35.9 million was huge, and wanted to know whether the staffing resources required would be met in relation to that amount.

He agreed with the sentiment shared by his colleagues on the forensic pathology services and was delighted to see that the operational plans were going to be concluded within this financial year.

Dr Cloete responded to the question on the ambulance response time in high-risk areas. Mr Xego’s question pointed to a few compounding issues in dealing with the deployment of ambulances and the response time. He said the demand for ambulances was uneven and acknowledged that usually, the demand peaked when there was high violence and injuries, which was commonly found from 6pm on a Friday right through to Sunday midnight. He admitted that there would be backlogs during the peak hours, and situations got much worse during the month-end weekend. The consequence of that was that it would disproportionately affect those who were in need of ambulances, such as someone who was having a heart attack.

Secondly, the four waves of COVID-19 had exacerbated the demand for ambulances. The Department had been able to bring in additional capacity to assist. It had learnt the lesson of establishing contractual relations with private ambulances from the COVID-19 period.

Thirdly, he referred to the high rate of paramedics who were suffering from Post-Traumatic Stress Disorder (PTSD), and were thus unsuited to be working on ambulances, which also contributed to the delay in response time. He remarked that Members would be shocked to find that some ambulance staff were so traumatised that they had to be put on desk duties only. The Department was therefore facing a dilemma, and often had to find a balance because there were permanent staff who could not work because of PTSD, but there were also contract staff who could not work there permanently.

Dr Saadiq Kariem, Chief Operating Officer, DOH, said the Department had about 250 vehicles on the road on average, and the majority of them were operating in the metropole region. It was currently spending about R19 million on outsourcing private ambulances. In the 2022/23 financial year, the provincial Department had allocated an additional R5.4 million for this item already. The provincial Department would monitor how it rolled out and made a decision on whether more budget needed to be allocated to this item.

Dr Cloete assured the Committee that the Department distributes its ambulances based on geographical focus, time focus and the type of vehicle focus. He added that the Department made sure that pregnant women would not wait for ambulances, as there was a flying squad ambulance team specifically responsible for the transporting of pregnant women.

He responded to the increase of R35 billion spent on psychiatric hospitals that was referred to on page 237 of the report. He pointed out that the main psychiatric hospitals to which the document referred were the Lentegeur, Stikland and Valkenberg hospitals. The investment in those hospitals could effectively take the pressure off the surrounding hospitals. For instance, Lentegeur psychiatric hospital could help to take the pressure off the Khayelitsha Hospital, Valkenberg could take the psychiatric patient pressure off the Somerset Hospital, and Stikland Hospital could take the pressure off Karl Bremer Hospital.

Dr Cloete responded to the question on the R3.8 billion allocation on page 239 and directed Members to the schedule on page 227 which listed all the NPOs in detail. Those NPOs ranged from community health workers to licensed mental health homes.

Regarding the absorption of trained nurses, he clarified that the Department assisted in the training of nursing and medical officer staff because there was a statutory obligation that medical staff must complete their internships, and nursing staff must be provided with community service training. Once this training was completed, they became qualified professionals and then had to get into the labour market to apply for jobs, just like any other professionals. It was not the state’s responsibility to absorb them into the system.

Dr Cloete commented on the bursary decrease shown on page 242 and indicated that bursary recipients would not be getting bursary in the following year if they failed. In addition, bursary recipients had an obligation to work for the state after their graduation.

The placement of medical interns was not managed by the provincial DOH, as it was a national process. The provincial Department provided only a platform in which interns could be placed.

Dr Cloete assured the Committee that the Observatory Forensic Pathology Institution would become operational this year, and the Department was very much looking forward to it. The new institution would be very modern and was completely different from the current one in Salt River. It would significantly expand services on the metro's west side.

Mr Kaye explained that Members could not compare one bursary to another, as the bursary amount was dependent on funding sources. He said the total number of bursaries for the current year was 1 420, which was very much the same on a year-on-year basis.

He said the Department had invested significantly into the Salt River facility. Members may have noticed that there was a slight difference in the books due to the number of people the facility actually appointed, compared to the number of people it planned to appoint. The Department had also set aside an additional R18 million from other Departmental savings to fund the facility. The reason that the Department chose not to include it in the budget was because it would rather wait until the people were found and appointed before the Department disbursed the funds.

In response to the question around the 17% decrease in the budget for district hospital services, as shown in Table 9.8, he referred Members to the schedules on pages 273 to 287, where each specific project was listed. He said that capital was a once-off expenditure, and if the DOH incurred additional expenditure in this year, it did not mean it would incur it in the following year.

The Chairperson indicated that Members may proceed to ask the Department questions based on pages 246 to 251 of the report.

Mr Xego enquired about Programme Eight (health facility management), and asked whether a lack of generators would make a health facility eligible for an upgrade, given that load shedding was back. He emphasised the importance of health facilities having appropriate backup generators in order to provide quality service delivery.

Dr Cloete responded that the Department had an extensive programme to assess each health facility, as well as their zones, for load shedding. In many instances, there was an agreement with Eskom and the City of Cape Town that load shedding should spare hospitals in both the public and private sectors. He assured the Committee that all health facilities in the province had contingency plans, such as a generator backup in place to deal with load shedding in order for each hospital to carry out the essential workload and to continue its operation. The Department’s infrastructure colleagues were also responsible for ensuring that all generators were in good working condition, and performed regular checks to ensure that those generators indeed worked and had sufficient diesel capacity for the time required. Those aspects were all specifically covered in disaster maintenance for hospitals. The difficulty was the maintenance of generators at small facilities. However, the Department did have contingency plans in place to ensure that small facilities were not affected by load shedding and were able to deliver the same level of services.

The Chairperson indicated that Members may proceed to ask the Department questions based on pages 252 to 287 of the report.

Ms Windvogel referred to page 265, of the report and asked for the reason behind the budget cut for various municipalities.

Dr Cloete said that it was a requirement of those schedules that the DOH had to break down those provincial payments by districts and local municipalities.

Mr Kaye said the Department identified demand by geographical areas and allocated funds according to the demands and the population in that area.

Dr Cloete clarified that it was a technical issue. Since the entire budget was about R29 billion, this was where the money was being spent -- not the actual transfers to municipalities.

Minister Mbombo added that each district had its own district health plan, which informed the Department of the needs in each area.

That concluded the question and reply session with Members. The Chairperson said that the Members may make recommendations and resolutions once the Department and members of the public had been excused.

Mr Xego interjected and referred to page 267 of the report, which was close to his constituents’ hearts. He asked for the rationale behind the budget cut for 2022/23, compared to that of 2021/22. His constituents were in the Garden Route.

Dr Cloete responded that all the money was being spent in geographical areas. District health services were a subset of the total budget. In this case, because of the COVID-19 fund, the Department had adjusted what had been allocated. Since the Department had given more money for the Garden Route during COVID-19, it was only fair that it should get a decrease now to balance up.

Interaction with the public

Mr Leslie Sylvester, a member of the Klipfontein health sub-district, was disappointed at the Committee’s lack of attention given to members of the public. He said that he had been at Western Cape Parliament since 7am and had not even been offered a drop of water. He got the hard copy of the Department’s report only at 11:10 am, which had severely affected his ability to reflect on the content and make meaningful comments.

The Chairperson asked the procedural officer, Ms Nomonde Jamce, to explain why such an incident had happened.

She explained that as the documents had been received only yesterday via a link, she herself did not have a hard copy either.

The Chairperson apologised to Mr Sylvester and said that the Committee would make sure that they were better prepared next time.

Ms Tamara Kievits, member of the public, highlighted the outstanding matter which came up in 2020 among the Klipfontein clinic committee, the Department and the Committee itself which still had not been addressed because of COVID. She hoped that this issue would be prioritised at the Committee’s next briefing. She complained about the lack of engagement with the local community on that matter.

She enquired about the delay of forensic services in Observatory. She recalled that the Department’s annual performance plan of last year had stated that the services would be handed over between September or October in 2021.

She wanted to know who the carrier of the Global Fund was, and whether there had been an open and transparent process on how the fund would be utilised and initiated.

She asked whether Healthcare 2030, stated on page 240, had fallen away and whether the Department still held the same priorities as those that it contained. She also wanted to know the role of community engagement, as indicated in Healthcare 2030.

Ms Isaacs, member of the public, complained about the Klipfontein issue because she lived right at the back of where the hospital site would be put up. She said that the last engagement that she could recall was in 2018, which had been a meeting with engineers, planners and government departments in attendance. The issue had been a grave concern for the community because a school was going to be built on that site in the next few months. The community also wanted to understand and receive an undertaking by the Department that it would eventually benefit from the project. The last thing that the community wanted to see was another repeat episode of the GF Jooste Hospital because of non-action from the Department.

She asked the Department if there was any chance that community health workers (CHWs) could be employed by the government and be paid directly by the government, instead of by NPOs.

She raised concern over the triage process, commenting that there were instances where a patient had been given a green ticket and had then suddenly had a heart attack whilst in the waiting process. However, doctors had not rushed to treat the patient because the triage process regarded the patient as a non-emergency patient.

She noted that DOH officials had mentioned the merging of city and provincial clinics. She asked if there would be additional staff employed at the Heideveld Community Health Centre to assist with additional duties such as an increase in the intake of patients, the establishment of a TB outlet, and a baby clinic.

Ms Joyce Malebo, member of the public, indicated that she was representing the Gugulethu community, which was worried because they had been begging the government to build another clinic in the area for a very long time. The day hospital in the area had been built in the early 1960s. Since then, the community had grown and the day hospital could not keep up with the pace of the growing demands in that area. She therefore wanted the Department to tell her how far the process was for it looking for a piece of land to build another hospital or upgrade the current one.

Minister’s response

Minister Mbombo said the Department’s first priority and statutory obligation was embedded in the National Health Act, as well as the Western Cape statutory bodies, facilities and clinical committees. The Department got regular feedback on the progress from those statutory bodies and she could assure Members that progress had been very far advanced. However, she had noted a decrease in the percentage of community members being in those forums, as the requirement was a 50% minimum threshold.

On the question about the community engagements on Klipfontein, she said that part of the project was being managed by the Premier and the Mayor of the City of Cape Town. All the other interventions were related to the Manenberg precinct. A wide range of issues, such as safety, community sporting facilities, and a library for youth to create safe passages for all youth in Manenberg, had all been proposed and brought to the fore. She indicated that the engagement had taken place between the Premier and the Mayor, and at the time they had both had to meet with the school as the proposed hospital site fell on the school land, so the Department was not involved and could not involve itself in that process. The Department would usually be involved only at stage four, and engagement between the Department and the community would take place when the timing was right.

Department’s response

Dr Cloete asked members to refer to the Klipfontein budget on page 232 of the report. In that section, it clearly outlined Programme Two, in which 2.3 clearly identified the funding for community health Centres. He asked Members to be mindful that this figure was the entire budget for the Department. This table provides a breakdown of each individual allocation which included Community Health centres in Klipfontein, Gugulethu, Heideveld, Hanover Park, etc.

He clarified that the engagement which took place in 2018 on the Klipfontein issue was between the steering committee and the Department of the Premier. The Western Cape DOH was being guided by the Department of Education, the Department of Transport and Public Works on the matter. The building construction work was being done by the Department of Transport and Public Works on the Department’s behalf. There had also been engagements between the Department of Education and school governing bodies. He anticipated a wide range of issues that would need to be channelled through to the steering committee.

Dr Cloete explained that the delay with the Observatory Forensic Pathology Institute was due to the uniqueness of this building, as it was the first of its kind. The progress was that 96% of the work had been completed, while the remaining four percent was to make sure that all the technical parts were right. The delay was purely out of caution, with the intention of ensuring that everything was right.

Dr Cloete commented on the Global Fund and asked Members to refer to Table 9.2 on page 232. The Global Fund in the Western Cape had come to an end in 2020, and this was reported to the Committee in the 2020 annual report. That was the last time the Department had managed the Global Fund grant. The management of the fund had now been replaced by the NDoH, which allocates money to the principal recipients. The provincial Department plays an oversight role, and the Western Cape Council for HIV and TB was being chaired by the Premier.

Dr Cloete responded to the question on Healthcare 2030. He said page 240 of the report indicated the Department’s five-year strategic plan, which clearly indicated its commitments to 2030. Even the recovery plan which the Department was busy with at the moment was still within the parameters of Healthcare 2030. The DOH remained committed to building a social compact with all partners, using Healthcare 2030 as a statement incorporating the element of universal health coverage.

In response to Ms Isaacs’ question on in-sourcing community health workers, he said that there had been a discussion at the National Health Council on the subject. In South Africa, only Gauteng had unilaterally implemented the employment of community health workers as public servants in the province. His view on it was that there was no legal framework for it and that it was unaffordable, which had led to many unhappy complaints. The other seven provinces were paying community health workers through the Personnel Administration System (PERSAL). The Western Cape Department of Health maintained its clear relationship with CHWs -- that they were employed and paid by the NPOs, with the basic conditions of employment clearly set out.

He urged Ms Isaacs to report incidents such as those that she had witnessed or heard because theoretically, the situation which she described should not exist, as the system was designed to examine patients and give an early diagnosis.

Dr Cloete commented on the merger between the clinics run by the city and the province. He said there had been constant engagements between the Department and the City on the nine facilities in which the province and the City shared the same building. The agreement was that when a city staff member withdrew from a clinic, a staff replacement would be made by the province to fill that gap.

He reiterated the Department’s commitment to prioritising the two new sites for community health centres in Gugulethu and Hanover Park. The only processes remaining were for staff to secure the land and ensure sufficient budget.

Follow-up questions by members of the public

Ms Kievits enquired about the ten health facilities that were transferring from the City to the province, and sought clarity on whether this process was an amalgamation of services or a complete takeover.

She had noted in the Department’s response that the Standing Committee had had engagement with elected members of health committees,  but she disputed that. She said the truth was that not even those elected members were aware of the closing down of health facilities.

She did not think the dual running of facilities was a good idea. She used the example in St Vincent, which operated as a dual facility. When an incident had happened in the past, the provincial staff had blamed the city staff, and there had been unclear accountability.

She indicated that the NHI budget was not in full operation yet, as she had witnessed that mental health in communities was on the verge of a breaking point. She was confident that community health workers were capable of dealing with patients efficiently and effectively with the available resources.

She asked whether it was more affordable for the Department to use agency personnel or to appoint a person permanently.

Ms Isaacs agreed with Ms Kievits's view on mental health, calling it a grave concern. The unfortunate fact was that very few rehabilitation centres in her area took in drug addicts. She urged the Department to look at how it could assist those with mental issues as these had exacerbated and grown disproportionately, affecting not only children or teenagers but also their parents.

Ms Malebo complained about the lack of training provided for those people sitting on health committees in rural areas, as some of them were still not aware of the NHI. She wanted to know when training could be provided.

Minister’s response

Minister Mbombo said that the Department had held a big gathering before COVID on the NHI for those elected members on health committees. It could be possible that those who were unaware of the NHI Bill were newcomers. The DOH had not been able to conduct similar training lately because of COVID and social gathering limits.

She clarified that there were no facilities that were closing. She referred to the document and stressed that nowhere in the document had there been any reference made to closing facilities. What the Department had said was that where it was sharing with the City under one roof, there should be discussions to allow one sphere to take over. This issue had been taken to the City Council in 2021, and the Council had agreed that those nine health facilities should be run by the province because the City needed to prioritise other municipal-related services.

Department’s response

Dr Cloete reiterated that the closing of a facility was untrue. It had been the City’s decision to let the province take over and run those nine health facilities. The Department remained dedicated to ensuring that all services would be carried out.

The issue of mental health had been emphasised as a provincial priority after COVID-19. He assured Members that the Department was co-chairing the steering committee to address mental health issues as a challenge to the whole of society in the province. The Department was committed to pulling in resources in each geographical area in order to address it in a comprehensive way.

He said agency staff were cheaper to employ, although the Department did want to move personnel to a full-time basis if the budget permitted.

Dr Cloete said there should be a standard training programme conducted in a de-centralised way for both rural and metro committees. The training was provided by a combination of an outsourced and a local person in each of the geographical areas. He urged members of the public to report the situation to the Department if that was not the case.

Mr Kaye commented on the awarding of the tenders at Klipfontein. At the moment, the work was being done by professional service providers, such as the architects and engineers who were responsible for designing the building. In the absence of that information, the Department had nothing to present on paper. He guaranteed that the public would not be seeing primary schools being knocked down to be replaced by a health facility.

That concluded the Department’s interaction with members of the public.

The Chairperson excused members of the public and the Departmental officials.

Committee resolutions

Ms Bakubaku-Vos asked the Department to provide a detailed explanation on the integration of the clinics in the city. She requested full details of those clinics that may be closing, as well as the number of staff members who might lose their jobs.

Ms Windvogel requested the Department to provide the Committee with the district health plans for the Western Cape.

The Committee report on Vote 6: Health, in the Western Cape Appropriation Bill dated 15 March 2022, received majority support and was adopted.

Ms Windvogel indicated that the ANC would use its minority vote in accordance with Rule 90.

On behalf of the EFF, Mr Xego expressed his non-support for the Vote.

The meeting was adjourned.