Department of Health 2021/22 Annual Report

Meeting report

The Chairperson welcomed all those in attendance, both those in the Chambers and those on the virtual platform.

Members who were present in-person introduced themselves.

Mr C Fry (DA) had sent his apologies and indicated that Ms D Baartman (DA) would be standing in for him on the virtual platform. Ms N Baku-Baku Vos (ANC) also sent her apologies, as she was ill.

Dr Nomafrench Mbombo, Western Cape Minister of Health, and Dr Keith Cloete, Western Cape HOD for Health, were in attendance.

The following WC Health officials were in attendance and introduced themselves:

- Ms Anda Nkosi, Chief Director: Strategy
- Dr Saadiq Kariem, COO
- Mr Simon Kay, Corporate Support Services
- Ms Lesley Shand, Deputy Director: Data Management and Governance
- Dr Melvin Moodley, Director: Health Intelligence
- Mr Glen Carrick, Acting Chief Director: Finance
- Ms Santie Roy, Director, Supply Chain Sourcing
- Ms Ronell Gouws, Director: Supply Chain Governance
- Dr Laura Angeletti du Toit, Chief Director: Facility and Infrastructure Management
- Ms Bernadette Arries, People Management
- Dr Anita Parbhoo, Chief Director and CEO, Red Cross War Memorial Children's Hospital
- Dr Douglas Newman, Head of Ministry
- Mr Andre Luck, People Development
- Mr Peter Smith, People Management

Briefing by the Western Cape Department of Health on its 2021/22 Annual Report

Minister’s remarks
Dr Nomafrench Mbombo thanked the Department for being in attendance. She highlighted that the 2021/22 annual report being discussed was the year hit hardest by the pandemic. It was a year of vaccination and a year of trying to reintegrate services, as everyone returned to working in-person. It was a year in which the system had been shocked after COVID-19. There had been illness and mental health challenges post-COVID. The Department had had a ‘lessons learned’ moment after building the largest hospital in the province within a month. The hospital then had to be converted into a vaccination site. The Department had had to also set up vaccination and drive-through sites. This was the year of the journey to recovery, as many had been lost and some were still living with long COVID-19 – including the Department’s staff. This was one of the saddest years, as 2020 had been, but at least there had been lessons learned from 2020 that had been applied to the last year.

HOD’s Input

Dr Keith Cloete, WC HOD Health, echoed the Minister’s words. April 2021 to March 2022 represented the time during which the third wave had played out – from June to July 2021 – and then the Omicron fourth wave in December. In December, there had been a spike in cases but decreased hospital admissions and deaths.

Over five million vaccines had been administered in the Western Cape at that time. It was a year of great celebration and recognition of the staff, especially because it was just after 24 months of dealing with COVID-19, and entering into the post-COVID era in April 2022.

Dr Cloete recognised the significant number of staff members lost during these 24 months, and said that the staff who were with the Department now had been through 24 months of COVID-19.

After losing staff, starting the vaccination programme, and everything else that happened in the past year, the Department achieved its fourth clean audit in a row. Recognition was given to all the staff members’ hard work in the annual report, specifically, the staff lost during that time.

Discussion

Part A: General Information
Mr D Plato (DA) congratulated the Department on dealing with important challenges and receiving a clean audit. The Department’s unqualified audit during the trying times of COVID-19 was a highlight.

What had been highlighted in the Annual Report was what the staff had had to go through. Despite the death of many staff members, the story of 2021 was not one of despair, but rather one of resilience. For the Committee, as politicians, that was very important and needed to be recognised.

He recalled from the report that the “health system had been pushed to its brink”, which was important to highlight. Despite every hit the system took, the Department continued moving forward.

The staff had had to deal with the personal risk of contracting COVID-19 and the fear of who would be next. Nurses and doctors were still human beings who feared this.

The Department had lost 150 staff and had had to deal with intentional greed. Despite this, the health workers had never faltered and had risen to meet the challenge of caring for those who needed it most.

From a political perspective, Mr Plato thanked the Department and all the health practitioners for what they had done for the Western Cape.

The Chairperson asked members of the public to introduce themselves. She recognised that they stated that they were from the areas of Atlantis, Langa, and Tygervalley. She thanked them for being at today’s meeting.

Ms R Windvogel (ANC) congratulated the HOD, Minister and the Department for the positive audit opinion. She thanked them for at least having some good news.

Ms Windvogel was concerned that TB (tuberculosis) remained the leading global infectious disease killer. South Africa and the Western Cape continued to be amongst the most seriously impacted by TB. It was a cause for serious concern. The foreword by the Minister and the Accounting Officer’s report did not give this “killer virus” the attention it deserved. Was there any reason for this?

Secondly, the Minister had previously mentioned that there had been no cost involved in the Department’s name change. Ms Windvogel needed to understand whether there really was no cost involved.

The Chairperson interrupted to ask for clarity on Ms Windvogel’s question – if she was still on the foreword.

Ms Windvogel confirmed that she was.

Ms Windvogel continued and said that it was difficult for her to understand because there was a cost involved in changing letterheads and other branding. Was there really no cost involved?

The Chairperson wanted to ascertain whether Ms Windvogel’s question was about the report omitting the name change and cost.

Ms Windvogel confirmed. She then referred to page eight of the Annual Report and asked the Minister whether the Department could have handled the outbreak better. Had the Minister committed any grave mistakes, and what lessons had been learned from these mistakes?

Referring to the last paragraph of page eight, Ms Windvogel said that, for her, the pandemic had exposed and widened healthcare inequalities. The poor had been vulnerable, as there had been too few vaccination sites in areas such as Mitchells Plain. Why was that the case? To what extent had it contributed to low vaccine rates? What measures had been put in place to address this?

Ms A. Bans (ANC) referred to page 11, under programme expenditure, where the Department had recorded under-expenditure. R273 million was a small amount compared to R28 billion, but remained a huge amount. What were the reasons for this under-expenditure? When had the Department picked up on the possibility of underspending? What action plans were there to prevent underspending?

On the spending programme, it was known that hospitals such as KDH (Khayelitsha Hospital) had been allowed to overspend the budget to address service pressures. How was this reflected in the programme expenditure, as there was no overspending?

Her second question referred to page 12, on unauthorised, wasteful and fruitless expenditures. An amount had been incurred there. What were the details of this fruitless and wasteful expenditure? How many incidents had been involved? Had disciplinary action been taken on this incident?

There were introductions of members of the public.

Responses to Part A

Lessons learned from the Pandemic
Minister Mbombo said, on how the Department would have handled the pandemic differently, that it was about lessons learned. One was about having a pandemic that exposed many cracks in the health system – nationally, provincially, and locally. It had exposed how fragile the health system was. After the pandemic started, other illnesses had to be put on hold, including TB and diabetes, as they had had to deal with the pandemic. There should not be an illness or virus that just paused other illnesses. It was a work-in-progress concerning learning because it had been a new virus. It had been difficult for South Africa to just transplant some of the research evidence from elsewhere. A lesson learned was that it was not just about the virus. It was also about the population and environment. So, it had been difficult to just take things as they were.

Another lesson learned was that they did not need planning meetings three months in advance, as the situation changed within an hour or even 30 minutes. It was better to take a break and relax then regroup.

Lastly, the South African health system had not considered the social determinants of health. They had talked about it. But, how poverty, inequality, and unemployment challenges impacted health was not considered in the bigger picture, only in terms of health.

Minister Mbombo recalled questions on what the Department had been doing in Khayelitsha during COVID-19, as people were not unable to social distance. One could not social distance in a shack with 15 other people. If the shack was two metres in size (length or width), then you could not social distance by 1.5 metres. This challenge had been directed to the Department as if it were the Department’s fault.

There had been a question about some rural areas in the farming communities, where there was normally a weekly mobile clinic; vaccines had to be available, too. But most people knew that the mobile clinic only came on a Wednesday. So, if the Department brought in vaccines on a Monday, people would not be there. The Department had to accommodate these types of situations. If the community was used to Wednesdays, they had to include vaccines on Wednesdays to ensure people got vaccinated.

The last lesson was that there was no health system without health workers. When staff were dying during that period, particularly in December 2020 – when about 40 people died, despite there being 33 000 health workers – it hit home that the Department was in its worst moments. According to the system, it had been about the faces; it had no longer been about Case A or Case B. It was about Chief Director ‘so-and-so’, sister ‘so-and-so’, Security ‘so-and-so’, and EM ‘so-and-so’. That had been when they had realised that they were humans too. They bled the same colour. They were like everyone else. They were vulnerable.

Minister Mbombo thanked the researchers and scientists who had kept feeding information not just to the South African health system, but to the whole world.

Tuberculosis
Dr Cloete responded to Ms Windvogel’s question on TB. He referred to the fourth paragraph, stating that the Department had had to put almost everything else on hold during that period, to deal with the third and fourth waves, and vaccinate everyone to prevent future waves with multiple deaths, including healthcare workers.

Paragraph four states that this had had a cost on the rest of the healthcare system. TB, HIV, diabetes, child health, maternal health, or other conditions were not mentioned specifically. It was a general statement, that everything had taken a backseat. The extent to which it had taken a backseat had become clear to the Department after 10 April 2022. So, the next reporting period would have a very strong focus on everything that had been put on the backburner, by necessity, by COVID-19.

He said that Ms Windvogel’s point had been considered – that TB was one of those key aspects. The Department would clearly articulate what had happened in the next annual report.

Just before the end of March, the Premier had announced the Provincial Aids and TB Council, which had not been included in the foreword. It had been reported that there was a TB emergency, which had been acted on in April.

Name Change
The Department’s name change had not occurred in this reporting year. In next year’s report period, there would be a full engagement on the name change.

Lesson Learned
To add to Minister’s Mbombo’s words, the pandemic had been a global experience. It humbled not only healthcare systems, but society. The lesson was that, globally, society had not been prepared for the pandemic. So, healthcare systems around the world have not been prepared. The biggest lesson was to “be ready”. This generation had learned about being prepared, because the last generation that had experienced a pandemic, in 1918, was long gone. This was why the Department had made the point about resilience. The biggest lesson was to be ready for anything at any time.

Vaccine sites in Mitchells Plain
Dr Cloete said that the Mitchells Plain vaccine side had produced the most vaccinations of any site from its outset this was across the province. The uptake of residents from Mitchells Plain at the site in their own neighbourhood had been low.

People had driven from Sea Point to go to the Mitchells Plain site to get vaccinated, and therein lied the lesson. It was not that the Department had underprovided access to vaccines in Mitchells Plain. There had been other factors preventing people from getting their second vaccine.

This situation had repeated in Khayelitsha and in Central Karoo. These factors had been the power of social media and misinformation, which overpowered the Department’s ability to convince people that getting vaccinated was in their best interests.

Under-Expenditure
Mr Simon Kay, Corporate Support Services, WC Health, said that the Department would detail its under-expenditure in the SCOPA meeting. So, he would give a brief overview.

The Department had never fully understood its costs would be when it came to COVID-19. The Department’s testing had been lower than the required budget. About R60 million saved from testing, which the Department had requested to move to the following year. The Department had been using its savings from this year to push into the following year, as there could have been additional waves.

Medico-Legal had also been deferred, as fewer cases had been finalised last year. Some of those cases had not come through to this year. It was a timing difference. It was about having a budget and anticipating it would be spent in the previous year, which it had not been. The budget would be moved to this current year, where the expenditure had been incurred.

Mr Kay said that Dr Cloete had answered the question on Khayelitsha. The Department was permitted within Section 43 to move savings to where there were pressures within the system. That is what the Department did annually to avoid unauthorised expenditure. That was what it had done in this instance.

The other two major areas were bursaries and education, as there had been a very disruptive educational cycle. Students have not been able to complete or register. There had been a hiatus in issuing the bursaries. This was again a timing difference because of COVID-19.

The last challenge had been with infrastructure and facilities. The Department’s focus had been on rolling out vaccination sites everywhere. The same way some services had had to be reprioritised, some infrastructure maintenance projects needed to be reprioritised. That expenditure had been pushed into the following financial year.

Fruitless and Wasteful Expenditure
On fruitless and wasteful expenditure, it was three occurrences totalling R12 000. The details were provided on page 259 of the Annual Report.

With fruitless and wasteful expenditure, as with irregular expenditure, there was a process where each transaction needed to be looked at. Then circumstances were applied, and then the appropriate consequence management was meted out, whether that was recovery or corrective, depending on the case. This held true for irregular expenditure.

Follow-up Discussion: Part A

Ms Bans asked a follow-up question on unauthorised expenditure. She asked the Department to explain how the expenditure was recovered and provide an example of recovering fruitless expenditure. What was the process? How did the Department recover?

Mr Glen Carrick, Acting Chief Director: Finance, WC Health, responded that it was first determined whether there was a possibility of recovery from the supplier. He referred to two cases – PPE invoiced but not received, and the payment for printed trays that had been included in the quote. The first point of call would be to go there and say that an error had been made – given that the Department had a standing relationship with suppliers. And then a credit note from the suppliers would be requested or for future purchases made in the current financial year. If that was not forthcoming, the Department would look at the actual instance and see whether any negligence had been involved.

With the amount of transactions the Department did annually, there was a chance of human error and unauthorised expenditure. Only in cases of real negligence would there be a recovery of those funds from the official who had been found to be negligent.

Ms Windvogel referred to page nine of the Accounting Officer’s Report, looking at the third bullet. She said the statistics showed how important community health workers were to our system. Over the past few years, these workers had protested outside the Department’s building to demand better working conditions and remuneration. What had the Department done to meet their demands and address their grieving grievances?

Secondly, given the funds the Department had transferred to NGOs for community health workers, programmes and activities, were there any conditions attached to these funds? How much was allocated for salaries?

Also, on page nine, bullet four, given the identified need for a regional hospital in the Klipfontein area, which would cater for Khayelitsha and Mitchells Plain, would it not have been beneficial to convert one of the two district hospitals into a regional hospital? How long would such a process take if this was done, and what would it entail? Lastly, was there still a backlog? How many?

Minister Mbombo said that Dr Cloete would respond on the specifics, but she would contextualise the community health workers.

In 2012, phase one (of three) of the NHI pilot was initiated, where one district per province had been chosen, except for Eastern Cape and KZN, which had requested additional districts covered by their own budgets. Part of the ten pillars of the pilot to be part of those districts were ward-based outreach teams, which community health workers were part of. It was a system that had been borrowed from Brazil.

At the time, she had been a consultant for the National Department of Health. That was why she was passionate about this. What the National Health had not done was to ensure that wherever there was money involved, whether that was for NGOs or a grant. So, it had always been a pilot.

The then-Minister, Dr Aaron Motsoaledi, had made an announcement on the bargaining council, about resolution one of Council 18. This had been on renumeration, including hours worked, that needed to be reviewed.

Across all the provinces, what Gauteng had done and what KZN had partly done had been to consider everything together, including the number of health workers and healthcare workers. Unfortunately, that had been found not to have followed the processes. This included the Eastern Cape. Training had to be standardised. The Brazil model had been adopted without standardising training. With the Western Cape, in 2015, the Department had had a community health workers-based summit, where a strategy needed to be devised to standardise training, as each province had been doing “its own thing”. That was when the Department had agreed that community health workers were part of the health system, and they needed to strengthen the primary health care system.

The pillars talked about public procurement, public participation, and inter-sectoral collaboration. The NGOs and civil society participating in the health system needed to be part of that.

The government did not train health workers because they had been trained by the NGOs, through these processes of the health and welfare sector, SITA, and others. That needed to continue until national government developed a strategy, because Human Resources did not even cover this.

Here, in the Western Cape, the challenge was about continuing with civil society and NGOs, who had been training the community health workers. The only change was that they were kept for three years instead of renewing the service providers annually. And the Department then sources the community health workers from the service providers.

On the processes of where they were to be allocated: they were part of the system. So, the community health workers assisted the Department during the community screening for COVID-19, with the vaccine rollout, and with mother and child services. These healthcare workers were as much a part of the healthcare system as the service providers and NGOs.

Recently, three or four months ago, it had been one of the items on the agenda of the National Health Council, where community health workers were being integrated into the healthcare system nationally.

Dr Cloete said that, as Minister Mbombo had described, the current situation was that there was no standardisation across the country. So, the current National Health Council recommendation was that the concern Ms Windvogel had raised was now registered as a national issue.

There would be satisfaction in each province until there was one national dispensation. The current position was that, whatever it was that was in every province, the renumeration must be standardised so that all community health workers would receive the same remuneration across the country. That was the first thing. The second thing was that there was a national training standard that everyone needed to adhere to. The third thing was that all the conditions, which were not standardised, needed to be uniform. Based on the third aspect, and linked to the others, was that the Department and the national Health Minister should have approached the Minister for Labour and should have asked for a specific sectoral dispensation for community health workers, as the Minister for Labour would have then made a decision on the dispensation for all community health workers in the country. That had been explored. Technical work was starting between the national Department of Health and the Department of Labour on sectoral determination and standardisation for the country.

Dr Kariem and his team were meeting all the MPOs the next day. The Western Cape had a rigorous contract system in place, which had been improved over the last 10-15 years. It was very prescriptive in detailing what the funds were for. The renumeration for each community health worker was very clearly articulated. Administration, uniform, and transport fees were all covered clearly. Dr Cloete reiterated that the contracts were standardised across the province.

On Ms Windvogel’s second question, about Mitchells Plain and Khayelitsha Hospitals, Dr Cloete recognised the pressures on Mitchells Plain Hospital and on Khayelitsha Hospital. When did either become a regional hospital, and what did it entail? A large metro district hospital, which Khayelitsha and Mitchells Plain were, had specialist services. These were not ordinary district hospitals. The services at Caledon Hospital would not be the same as the services at Khayelitsha or Mitchells Plain. District hospitals were bigger; their emergency centres were very busy. District hospitals had specialist services.

The distinction between a district hospital with specialist services and a regional hospital is very small. It is more on the availability of minor specialities such as ENT. In terms of the bigger specialities, such as internal medicine, there were two specialists at Khayelitsha and two specialists at Mitchells Plain. In psychiatry, there were psychiatrists. In surgery, there were surgeons. In the emergency room, there was an emergency medicine specialist. But, the difference between district hospitals and Somerset is that there were no ENT specialists at district hospitals.

District hospitals, which had more capacity than regional hospitals, had more pressure. The Cape Flats, which Khayelitsha Hospital served, was a pressure area. The burden of disease, the social determinants that the Minister had mentioned, caused the pressure to be higher in those areas.

As part of the Klipfontein development, the Klipfontein Hospital would not be a district hospital with specialist services; it would be a regional hospital. Then Mitchells Plain and Khayelitsha would have specialist services, and Klipfontein would be the regional hospital. The Tygerberg redevelopment would be a central hospital at Tygerberg, and there would be a regional hospital in Belhar. The future planning for the next 8-10 years would see Helderberg getting a regional hospital. This would alleviate the pressures on the Cape Flats basin.

Dr Cloete responded to the backlogs noting that Dr Kariem and his team had recognised the backlog of TB cases, including TB cases to be diagnosed and TB cases to put on treatment. There were more than 60 cases of TB being admitted to hospitals. There was a similar backlog for diabetes, HIV, and other illnesses.

Access to testing cases was increased, which revealed that more cases and more cases were put on treatment. That was this year’s strategy. The team then worked out in each geographic area, and Dr Melvin Moodley (WC Health Intelligence) started the dashboard.

The marker for TB, which was very similar to COVID-19, was sending many people to be tested for TB and looking at smear positivity. If it was 100 cases, and 17 were positive, it was interpreted as an increase in TB cases. That was where the biggest backlog of finding TB cases had been. That was the kind of detail the Department had worked on towards the end of March. Specifics would be included in the next reporting period.

Dr Kariem said that, by the end of March, in this reporting period, there were about 80 000 backlogged surgeries, including major and minor surgeries. In the reporting period, the Department had begun to address it, including the robotic machines that had been purchased, which the Minister had reflected on. The number was about 80 000 surgeries, half of which included major surgeries that were more than 30 minutes long, and the other half of which were minor surgeries that were under 30 minutes.

Ms Windvogel asked about what the Department could do for the community health workers while the standardisation of their remuneration was being sorted out. They were being paid minimum wage, around R3 500. What other benefits were there for these workers?

Dr Cloete responded on the benefits for community health workers. He recalled what Minister Mbombo had said on the Department having no option but to keep to Chamber’s wage agreement. There had been a discussion on what minimum wage was. He thought it had increased to R4 000, but would revert with the exact amount. This was what had been decided nationally as the remuneration for community health workers. The Department ensured that every community health worker in the Western Cape was paid in terms of what was required. The Department had included additional allowances in its contract with the NPO. Remuneration for the healthcare sector and compensation of employees were huge risks. Whatever the Department committed to, it needed to be sustainable. The Department was doing whatever it could to supplement the allowances and ensure fair remuneration.

Ms Windvogel asked whether the additional benefits were a national norm or just in the Western Cape.

Dr Cloete responded that the Department recognised its employment benefits and was benchmarking it on employment practices and payroll standards. It was the cost of employing that group of people. The Department has worked with NGOs for many years to clarify the additional benefits. It was similar to an employment package, in addition to paying salaries.

Minister Mbombo said that what had been decided at Chambers, which was part of the Bargaining Council, was non-negotiable. This had to be given to the community healthcare workers. This was a work in progress. She emphasised that they were recognised as part of the healthcare system, despite not being appointed by government.

Ms Windvogel asked about the organisational environment, on page nine. Of the remaining 12%, how many were agency personnel, including the respective occupations? How much had the Department spent on agency personnel during the year under review? When the Department carried out oversight of the district hospitals, a common complaint from the heads of those district hospitals was that agency personnel was a problem for them.

Dr Cloete responded to the agency personnel. He said that 33 612 staff members were the total staff complement, which was the Department's employees. About 80% were employed permanently; the other 20% were not in a permanent position, but in a contract position. As explained in previous years, most of those contract positions were for interns because an intern was only appointed in a contract position. The sum was for registrars, who were only appointed in contract positions. There were short-contract staff employed for the COVID-19 response. These were three-month, six-month, and one-year contracts. They were not part of the 33 612 people employed by the Department.

Dr Cloete said that, outside of the 33 000 staff members, someone would be on maternity, sick, disciplinary, or long leave at any given time. For example, an institution had 50 staff members who were actually paid and employed within the institution, but on any given day, there may only be 40 on duty. The institutions did this out of necessity, because 40 people could not maintain the workload for 50 people, to bring in four or five people on agency to make up for the people that were actually employed and paid but were not on duty on that day. That was how agency complemented the institution workforce.

The challenge was how the Department worked with the available workforce, as opposed to the paid workforce. Dr Cloete said he always asked how many people were employed full-time in the institution, and how many full-time employees were on duty that day, when he went to facilities.

Minister Mbombo said it was difficult to indicate how many staff needed to be employed through the agency, as it depended on the circumstances and where staff were needed.

There was a national system that looked at the HR dispensation of the facility, which managed the satellite clinic or clinic. Situations were dealt with case-by-case, depending on salary challenges, or a lack of staff.

Part B: Performance Information
The Chairperson indicated that SCOPA would deal with Part C and E in the afternoon, but Members were welcome to ask questions relating to Part C.

Mr Plato referred to page 28, asking for an update on the discussion between the city and the province on clinics.

He asked whether home-based care would become an important feature of community healthcare.

Ms Bans referred to page 28, asking about the three district hospitals in the Western Cape that provided emergency care. She recalled that the Khayelitsha District Hospital (KDH) management had told the Committee that they needed about R150 million to address the bed and staff shortages to improve service delivery. Why had the Department not allocated this R150 million? Were there other provisions that could be redirected, or could the underspent funds be reallocated to KDH? What was the process for KDH to become a regional hospital?

Her second question referred to page 28, on specialised hospitals. The specialised hospitals category included six TB hospitals, four psychiatric hospitals, and one rehabilitation hospital. The AUMP had alluded to the challenge of the burden of disease, where the Western Cape had the highest lifetime prevalence of mental illness in South Africa, at 39%. It also affected the provision of acute psychiatric units, which created a shift in priorities. The 2019 rapid review of the Western Cape burden of disease had indicated intended injuries as the leading cause of early death in men, impacting the function and provision of ECs. How had the Department factored these challenges into its planning and budgeting? How were they being prioritised? What was the number of beds available in WC psychiatric hospitals? Could the Department be provided with details on the number of total patients and those admitted in beds being utilised?

Lastly, on page 70, it had been noted that there was overspending on mental hospitals. Could the Department be provided details of which hospital overspent, and for what reasons? Why was the Department not increasing the budget for this hospital, as mental illness had increased?

Mr M Xego (EFF) asked a question on page 27 that linked to page 36, on service delivery environment. The Department mentioned a decrease of 3.2% in employment in the report, from quarter four of 2020 to quarter four of 2021. It highlighted the impact of that, that it caused a regression in service delivery. What was the impact of that on service delivery itself? What were the financial implications on areas such as TB and other chronic illnesses?

Referring to page 36, Mr Xego asked about the Department’s plans implemented since 2016 on MEAP towards envisaging health outcomes. What had been the impact of this decrease towards envisaging this goal?

Ms Windvogel referred to page 28. The Department’s strategy plan had stated that planning of the much-needed new Klipfontein regional hospital, which was being planned as part of the greater long-term vision for the Mannenberg upgrade – which was ongoing. It would require seven hectares of land to accommodate this 550-bed facility, which was much larger than either of the existing hospitals in Mitchells Plain and Khayelitsha. Due to the limited availability of land in Mannenberg, the Western Cape Department had been engaging in constructive and robust discussions with the community steering committee and local education structures and how best to effect this overall upgrade.

Can the Department provide an update on the rebuilding of GF Jooste? What were the details of all action steps taken thus far? What were the engagement updates with the local education structure? What are the updates on the PSP appointment for phase one of the replacement of Klipfontein Regional Hospital? Of the budget that was allocated for the year under review and the current financial year, how much had been spent towards the project? What were the annual targets for rebuilding? What tasks had been completed, and what were the outstanding tasks over the MTSF period?

Secondly, on the emergency medical services on page 29: what did the National Health Act say about ambulances? What was the required ambulances to population ratio, and how far were we from achieving it? What was the breakdown of the ambulances per district in the province in the number of cases attended to? Given the high number of cases attended to, was there not a need to increase the number of ambulances and staff in what was the standard ratio of EMS personnel and ambulances to population? What was the ratio in the province?

The Chairperson asked about client satisfaction rate, on page 43. It dealt with an output indicator that spoke to the client satisfaction survey, the satisfaction rate, which was indicated at 88.7% - which also indicated an overachievement of this indicator as stated. Did this mean that more clients indicated satisfaction with the Department holistically? Could the Department provide some insight into how these surveys were conducted, and insight into the distinction between rural and metro areas?

Responses to Part B

Regional Hospitals
Minister Mbombo, on regional hospitals, said she was unsure whether the question was about the number of beds. The original hospitals were in Paarl, Worcester, George, and New Somerset. Without including Mowbray, these were the four regional hospitals. If the number of beds in these hospitals was compared with Khayelitsha, Khayelitsha had more beds. George was a regional hospital that catered for the whole of GRD and Central Karoo. Paarl catered for the West Coast and Paarl. Worcester catered mostly for Overberg, the lower parts of Laingsburg, and all the parts in that area. The point she was trying to make on the number of beds was that, in the metro, other district hospitals, Mitchells Plain, Karl Bremer, were more or less the same size. She wanted to clarify what the Members meant when they referred to a regional hospital.

Dr Cloete said that he had explained that part of the package was that it was a specialisation, which was a level two. Tertiary central hospitals were at level three, of which there were two. District hospitals were normally categorised as level one. Dr Cloete explained that Khayelitsha and Mitchells Plain Hospitals were in-between. They had packages there between one and two, at 1.5. There was no such thing, but she was just making an example. Some services were in the regional hospital already, which had been taken out and placed there as part of the specialisation, which was not found in other district hospitals.

At Wesfleur, Caledon, and all the other district hospitals, Prince Albert and the like, they did not have the package that Khayelitsha and Mitchells Plain had. She needed clarity on what the Members meant by regional hospital needing more beds than other regional hospitals outside the metro.

Update on the City of Cape Town
Dr Cloete said that, as of 31 March 2022, the Department had had an agreement with the City of Cape Town, based on a council decision from January 2022, that nine facilities – which were under the City of Cape Town management – would be managed by the Western Cape government from 01 July 2022.

The current status with the City of Cape Town, which was in this financial year, was for the Department to move towards an understanding that that was one phase in consolidating primary healthcare services, under the authority of the Western Cape government. The process needed to be concluded during this year. At the end of March, there had been an agreement that nine plus Santa Clara would be under the Department’s authority in this financial year. There was then a process that, once that phase had been concluded, a second phase would begin. That second phase was in process and would be part of this reporting period.

Community Health Workers
Dr Cloete, on community health workers, said that the question had been answered with Ms Windvogel’s question. He reiterated that community health was integral to the primary healthcare system. The Department’s commitment was to stabilise that platform, to recognise community health workers, and to continue working with them as an essential part of the healthcare system.

Engagement with the CEO of Khayelitsha Hospital
On Ms Bans’ question about engagement with the CEO of Khayelitsha Hospital, Dr Cloete responded that it was an engagement with someone from one institution with all the pressures experienced by that one institution.

Every CEO of every hospital in the province would ask for the same thing – that they needed R50 million to solve every problem. That amounted to R5 billion, which the Department did not have. There were many competing needs in the healthcare system. This was not unique to the province; it was an international problem, where staff had to make difficult choices on what to prioritise. Some of the best healthcare systems in the world were continually cutting service provision. The ethical thing to do was to have a conversation with the public about what it meant to ration healthcare service provision. How could every one agree?

The Department had never had hard conversations about what it did with its limited resources and fairly ensured that it covered all the challenges and received a clean audit. Making Khayelitsha a regional hospital would not change the essential conditions on the ground for the reality of Khayelitsha.

His comment at the time was to recognise the pressures that existed in Khayelitsha and competing pressures at other places. The Department had decided to use its budget instrument at the end of the year to see where certain pressures were higher than others, adjusting its expenditure patterns. Khayelitsha was allowed to overspend whereas another site was allowed to underspend.

The Department’s finance team was looking at a fair allocation of resources, to then adjust the budgets through an equity-based resource allocation process. The Department would repeat this for this financial year, and would be able to provide an answer next year. That was the context of the R150 million shortfall at Khayelitsha.

Specialised Hospitals and the Burden of Disease in the WC
Dr Cloete responded to the question on specialised hospitals, about the burden of disease in the Western Cape Province. He said that, regardless of what the Department did as a healthcare system, the burden of disease was the societal burden of disease. The healthcare system did not cause the burden of disease. It was caused by societal and social factors, referring to mental health illness being higher in this province than in other provinces.

Secondly, the burden in this province is mostly related to the interpersonal violence affecting young men – young men being stabbed and dying. And if they did not get stabbed and die, they were injured and ended up in ECs in Khayelitsha Hospital and all the other hospitals on a Friday and weekend. That was the burden society faced. The answer did not lie with the Department but in how society did things.

Reallocating the little money that the Department did not have to psychiatric hospitals was not going to solve the problem of why the burden of mental health illness was higher. What was going to solve the problem was if the Department engaged communities and people, helped them and supported them – including supporting young people in schools.

The answer was not for the healthcare system to have more ambulances and emergency beds; the answer was to prevent young people from stabbing one another and being at risk of stabbing. That was why a multi-sectoral intervention with all the sectors with law enforcement was needed, with everyone else working in an area-based team to bring sectors together so they can work effectively.

If young people did not have jobs, they did not have outlets. The 3.2% unemployment drop was disproportionately higher for 18-25 year olds. It was higher than 3.2% for that group. A group of young people had no jobs, no prospects, and nothing to live for. The impact was that substance abuse went up. More mental health clients were in the Emergency Centres at Khayelitsha Hospital, and Mitchells Plain Hospital, and they could not get into Lentegeur Hospital.

The impact was that more and more young people were at risk of being stabbed. More young people were at risk of gunshot wounds. More of them come to the Emergency Centres to exactly the same hospitals. So, the pattern repeated itself in the same places.

The scary part of that unemployment was that the vulnerable people in those households were now starting to suffer, and the Department had started to see things that it had not for 15 years, including malnourished children. There had recently been a shocking report in the Eastern Cape, of malnourished children. There were recently children in the Western Cape too. It was children because there was not enough food in the house. The children were thinner and more malnourished. They came to the health facility sicker.

What used to be the case was babies coming in for injections. But now there were more ill babies in hospital. The increase in unemployment was serious. It drove the social determinants even higher.

Klipfontein
Dr Cloete said that Klipfontein Regional Hospital had not spent all of its allocated funds in the reporting period, because there had been a delay in the appointment of the consultants up until 31 March 2022. Since 01 April 2022, there has been a different process.

Dr Laura du Toit, Chief Director: Facility and Infrastructure Management, said the site had been selected before COVID-19, in 2018. As mentioned in the report, it had been in collaboration with the rest of the provincial governments. The Department had been working in a committee that the Premier had chaired with all departments to find the site. Finding a site for a regional hospital was difficult, as it needed to be large enough.

The Education Department was building a school of skills at the Silverstream Secondary School, just on the site of GF Jooste. That was currently under construction. In 2024, as far as she recalled, the Education Department was planning to relocate the Silverstream School to the school of skills. That would be phase one of the hospital.

The consultants had been appointed this week. The planning design was hoped to start soon. The national department had approved the project. Infrastructure South Africa (ISA) had approved the project, and funding for the full construction and medical equipment had been secured. No funds had been spent yet. The Department would spend some money to secure the site as soon as the site was available.

Client Satisfaction Survey
Dr Melvin Moodley, Director: Health Intelligence, WC Health, said that the client satisfaction survey was a survey that the Department did every year in its health facilities. It was a paper-based survey, and different facilities had different ways of conducting it. The Department engaged with clients in its facilities by asking them a range of questions. These questions ranged from access to care, to experience of care and quality of care. In 2021/2022, the Department was over-target.

The second thing was to understand the context. The year in question was the perfect storm year, as COVID-19 was still present. And it had been very much present in 2021/2022. There the largest vaccination programme in history, and then the Department had tried to catch up with services. So, its services had been particularly under pressure. He was pleased that the number actually exceeded the target.

The third thing was that, as much as the number exceeded target, overall, the individual facilities needed to take that report and use it as an opportunity to engage with clients. This was the Department’s opportunity to talk to the client and have a meaningful conversation about what was working and what was not working. On what was not working in a particular facility, the facility manager was responsible for working on a quality improvement plan to improve what was happening. It was a good opportunity to get objective information about the clients’ experience of the Department’s services. It was then incumbent upon the Department to improve the things that did not seem to be working quite as well as patients would like.

Ambulances and the Staff-Ambulance Ratio
Dr Kariem recalled that Dr Cloete had mentioned that there was no national prescribed norm. There were international norms on the EMS number of vehicles per population. The WHO prescribed or suggested that at least one ambulance per 100 000 people. There should be at least around 253 ambulances on our roads. Details could be provided on the breakdown per district.

There were about 49 EMS stations around the province. A very large contingent of private ambulances were added to the 250 Department vehicles, which were utilised very effectively during COVID-19.

The private ambulances had been contracted to continue providing services to people and had supplemented the 250 vehicles. This had worked so well, that in the following period under review, the Department had extended that arrangement – which would become a permanent feature.

Minister Mbombo, on the EMS, said it was about the ambulances in numbers. Dr Kariem had not said what each ambulance did and the skills thereof. There was the rescue team, advanced lifesaving, and the air ambulance as the Department, which included the fixed-wing plane and the helicopters stationed permanently in George, for the Oudtshoorn route. It was a whole package of EMS.

She reiterated the lessons learned about the social determinants of health. The question now was about what makes people sick. Research showed that about 40% were socioeconomic challenges and also caused by the physical environment. The problem of violence in Khayelitsha was an example.

What was happening needed to be questioned. Despite putting gin more beds, if the socioeconomic issues were not addressed, the beds would end up looking like a mortuary.

The gap needed to be closed so that it did not end up in a situation of mopping the floor beds. It was about the social determinants of health. It was about what made children malnourished when they were producers of food. Most of them were from the farming communities. She did not understand how one could be a farm worker, produce food on their farm, export food and feed the Europeans, yet their country has malnourished children. Questions of health needed to be addressed by all sectors.

Follow-up Discussion: Part B
Ms Bans asked about mental illness. It was a burden that we could not run away from. How could the Department address it now?

Ms Windvogel said that health was everybody's business. It needed community leaders and the community to be involved. The services were needed now. The questions about making Khayelitsha a regional hospital had to do with reports of people sleeping on the floor in the hospital. Her understanding was that it was converted to a regional hospital, and there would be more beds. She sought clarity on this.

The Chairperson said that reality really struck the Committee when it visited the mental institutions. They had realised how the determining factors impacted people, and had resolved to have all department’s ministers and officials at the Committee to start somewhere. What was it that was going to be done, going forward? The Committee had a role in bringing those departments and saying this was their responsibility.

They did not want more mental hospitals. People were stigmatised after being institutionalised. They faced many barriers as individuals, impacting them as human beings in their lives forever. The Committee needed to make those kinds of interventions, solving problems that the Committee had identified during those oversight visits.

Minister Mbombo responded to the questions about mental health hospitals. She recalled that the Department had made an additional R30 million available for this year. Although R500 million was required to respond to the burden of mental health, this was what the Department could do. It was not mental illness; it was a whole community mental well-being problem. The least the Department could do was something specifically for adolescent mental health, child mental health, and older people’s mental health. Mental health care for staff was also being prioritised. Instead of sitting at a specialised medical hospital, psychiatrists provided support at a primary healthcare level to see those patients.

Lastly, as part of the Western Cape government response to mental well-being, a committee had been established, which Dr Cloete and other HODs sat on. They were chairing that mental well-being under dignity and wellness and were looking at various interventions, including outreach. Substance abuse was also being looked at, especially at the school level.

The special skills school would offer courses not normally offered at the Silverstream Secondary School.

Dr Cloete said that the Department had R30 million in this year's budget. The reporting period ended on the 31 March 2022. It was in this reporting period that it had been adding additional money, and that would be for next year's reporting period’s purposes. Specifically to tackle mental health, which caused the biggest backlog in the key hospitals (Khayelitsha, Mitchells Plain and Karl Bremer), because the psychiatric hospitals did not have enough capacity to take people out of those hospitals, people were on long waiting lists and sitting in the overcrowded and busy waiting rooms in Khayelitsha and Mitchells Plain.

Child and adolescent health was a big pressure point. There was additional capacity. The Department had been there last week and had seen the progress being made, so more adolescents could be taken into that to relieve the pressure on other hospitals. And then at Alexandria to add psychiatric illness for older people, such as dementia and psychosis – that would also be taken out of the system, because those were the two pressure points in the system.

Over and above that, additional resources were being put in place because of the mental health pressures, including additional capacity in Khayelitsha. It did not have to be made into the R50 million, to cope with more mental health clients in Khayelitsha. That was irrespective of whether it was regional or district. The same went for Eersterivier Hospital, Somerset Hospital, and Karl Bremer Hospital.

Dr Cloete said he appreciated the pressure the metro hospitals were under. The pressure would be escalating disproportionately in different areas, because the social determinants disproportionately affect the people living there. Because of that pressure, the Department tried to equalise pressure across the hospitals. Equity-based resourcing looked at where the need was the greatest. A regional hospital entity was a more expensive entity to run than a district hospital entity. So, district hospitals would have fewer resources if Khayelitsha was made into a regional hospital. That was why specialist services were brought to hospitals with the highest pressure.

Mr Xego referred to page 37, on leadership and management development interventions. He was concerned about the lack of women in management. He said that the Committee had done several oversight visits to several health institutions – institutions that were predominantly managed by women who carry a burden of work at home and at work managing institutions. What was the rationale behind such a low figure of women in management in a department that a woman led?

Ms Windvogel was mostly inaudible, as she was not speaking into her microphone.

Dr Cloete spoke about the Management Efficiency and Alignment Programme (MEAP). He explained that it dealt with the restructuring. The management efficiency in the alignment programme was focused on management, which was rationalised management in the Department. The intention had been to free more resources for services. What was on the organogram, at the end of part A, was that, on 01 April 2021, the Department had implemented a new macrostructure, which saved R7.4 million. The Department also had one fewer DDG, and three fewer directors. The whole output of MEAP was to reduce the number of managers, and R7.4 million was saved as a result of that. That was R7.4 million of funds to be made available for service delivery.

Dr Cloete clarified that individuals in the Department went to specific leadership events. The last one had been a course on women in leadership. That did not mean that the Department was training very few women to be managers in the Department; it was to support women in leadership, and 31 members had been exposed to that course.

The key issue raised was that senior management in the Department was almost predominantly women. Looking at CEOs of hospitals, district managers and senior management, the Department had about 65% women in senior management. The entire organisation was actually woman-centred. So, everything that the Department does is really about looking and becoming a women-friendly department. Development or training, exposure, everything was really about preparing women.

Dr Cloete spoke about 2021/2022 targets. He said that the figure on page 34 showed the 2021/22 year, the year under review, listed 200 clinics with ideal status, out of 256 that had participated. That was 78%. It was definitely something that the Department wanted to improve. As Dr Moodley had stated, this was a measure for the Department in the year of two waves of -19 and dealing with vaccinations. The target was definitely not 78%.

In the current financial year, the Department was making a concerted effort to increase this, per district. The ideal clinic mechanism was a national departmental preparation for the Office of Standards Compliance. It was an internal evaluation. The management team was meeting with the Office of Standards Compliance board again next week to discuss and engage with them. Ultimately, they worked towards the Office of Standards Compliance for all primary care facilities. At some point, the Office of Standards Compliance would have the delegated authority to close the facility. They currently came to evaluate clinics. If the clinics were satisfactory, they gave it a score, or said that certain things needed to be fixed. After six-months, an evaluation was done.

Dr Cloete said that he had received all those reports and had not yet had a report from the Office of Standards Compliance, where they had given them six months to fix things but it came back unfixed. The latest one had been sent about two weeks ago. Compliance was taken very seriously in the Department.

Ms Windvogel asked whether independent boards normally did these visits to the Department’s institutions.

On ideal clinic status visits, Dr Cloete said that the ideal clinic status was the Department’s facilities participating and the health system sending teams to check the facilities. This was an internal assessment. In the Western Cape, a team from one district was taken to review the scores for another district, which worked with the national team. The scores were entered into an integrated national system. It was like an internal audit of the sector. The gold, silver or platinum scores meant that the facility was in a good position for when the Office of Standards Compliance came; it was preparation. They were an independent statutory body with their own inspectors. They determined whether a health facility met the standards, and whether that facility needed to be closed or allowed to continue operations.

Ms Windvogel asked whether the Department’s team was visiting all the facilities in the different districts.

Dr Cloete clarified that he was talking about two different systems. The first system was the ideal clinic system. All the facilities participated and were visited. All facilities were rated on whether they met the ideal clinic standard. They received a silver, gold, or platinum status if they did.

The second system was independent of the first system. That was the Office for Standard Compliance, which operated on a three-year cycle to get to most health facilities in the country. Their reports had remained non-satisfactory after being evaluated at the six-month mark.

Questions about Part B: Performance Information (p39-56)

Ms Bans referred to page 41, on community health clinics, rendering a nurse-driven primary healthcare service at the clinic level, including visiting points and mobile clinics. What was the number of clinic that did not have full-time doctors? What was being done to ensure secure waiting areas for the patients queueing outside from the early hours of the morning?

On page 58, all the targets had been missed for the programme on emergency medical services. What were the reasons for this? How were attacks on personnel dealt with? What strategies had been employed? How were challenges in rural areas handled? How did the Department intend to deal with these challenges, going forward?

Ms Windvogel referred to page 43, on the indicator. She said it was difficult to understand how the target was achieved when complaints about patients sleeping on the floor were received.

Ms Windvogel then referred to page 57, in the institutional response to COVID-19. Can the Department provide a detailed breakdown of all service providers, including the names of directors, the value of contracts received, and BBBEE levels?

She also asked about overspending on the two programmes and whether details could be provided on the un-spent funds.

Mr Plato referred to page 56 and asked about the role socioeconomic conditions played in mental illness admissions and infant mortality.

The Chairperson looked at page 43, and said that the Department had responded to the 88.7% client satisfaction survey. It also mentioned the 97.3% patient safety indicator and case closure rate. These two indicators showed that people felt safe and satisfied with the facilities. How was this information compiled? What were the benchmark standards between rural and metro hospitals?

Responses about Part B: Performance Information

Client Satisfaction
The Minister said that the client satisfaction surveys were carried out by an independent company, which randomly approached patients in outpatients or the dispensary, who were then asked to fill out a form.

Socioeconomic Conditions
Minister Mbombo responded to Mr Plato, saying that the Western Cape government had identified some priorities. There was a dignity and wellness committee under the Minister of Social Development. The Department of Agriculture co-chaired that steering committee, but every department contributed. Socioeconomic challenges were indeed taken into account and discussed holistically.

Clinics
Dr Cloete said that the definition of a clinic was a nurse-driven service. There was no full-time doctor. Doctors visited the clinics one-three days a week.

Waiting areas
Dr du Toit said all new facilities had a pre-waiting area, outside the main waiting area. The old facilities did not have these, but a plan had been put in place to construct modular shelters. The Department had already received a list from the rural and metro facilities that required these. There could be 20-40 modular shelters, depending on the number of people in each area. Funds had been set aside in the budget for this.

Staff Safety in Rural Areas
Dr Kariem said there were processes in place to deal with attacks on personnel. The Department could not prevent it. Once it had happened, counselling and other support were offered. It happened frequently.

There had been engagement with the Department of Community Safety to support the Department when attacks occur. There were safe zones, which were vehicle routes where ambulances could drive through safely. The Department had liaised with community organisations to negotiate these safe zones. If a response was required, the driver would know which route to travel to try to avoid attacks in the red zones. The attacks still happened and were traumatising for staff. Support was provided to the staff and families affected.

There were a number of safety measures in the vehicles. Cameras had been considered to provide additional safety, and staff were encouraged not to keep cell phones and personal belongings on their person.

EMS Rural Response Times
Dr Cloete said that the challenge of rural areas was that the towns were very small and widely spread. If there was an ambulance or two in a town, at any given time, one may be transporting a patient to a city hospital, and the other ambulance would have to respond to local calls. It became very difficult for that single ambulance to attend to all the calls. The Department looked at ways to consolidate and support the different geographic areas to have a minimum presence.

There was an innovative rural model that trained local community members for first aid as an initial stabilisation before an ambulance could arrive. There were many projects in place in different areas to bring this together.

Client Satisfaction Surveys
Dr Cloete said that the staff were surveying people in the facilities. It would be both inpatients and outpatients being asked a range of questions. The question had been that it was difficult to believe the high patient satisfaction. This was a true reflection of what people said. The reported incidents were isolated incidents. It was a small number compared to the total number of patients.

Additional Capacitation
Dr Cloete referred to page 57, about the COVID-19 resources allocated in each area. Additional capacitation had specific details attached to the municipalities. Additional capacity included additional goods (including PPE), services, and staff capacity. There were no external contracts. It was additional money used for the COVID-19 response.

Over-Expenditure
Dr Cloete referred to page 57 again – to the third line on the third column, where there was a breakeven for programme two. He said that district hospitals overspent by R82 million. There was a saving against HIV/AIDS, of R16.5 million, and against community health centres of R38 million. There was only R1 million of over-expenditure against community clinics. Within the programme, for Khayelitsha, expenditure was against the mentioned R82 million.

Interpersonal Violence and Mental Health
Dr Cloete said that provinces had made interdepartmental priorities. It was moved from a health priority to a Western Cape government priority.

For both interpersonal violence and mental health, Dr Cloete sat on interdepartmental committees and he was the co-chair for both. Due to municipality involvement, the mental health committee was with the Department of Education, Social Development, Cultural Affairs and Sport, and the Department of Local Governance. In safety, it was him, Community Safety, and the Department of the Premier. Other departments and municipalities were also involved.

With COVID-19, there was a dashboard that had regularly updated data. The data from Health became the data of the Western Cape government’s response to COVID-19. On the back of that capacity was a provincial data centre that compiled all the data from health services. It was available in real-time on the dashboard. This data was shared with DSD, and other departments for evidence-informed, data-led strategies.

Patient Incident Closure Rate
Dr Moodley said the definition was patient safety incidents closed within 60 days. For rural, this was at 99%; for metro, 96%. In healthcare, errors or potential for errors were identified. It was not about safety or how safe one felt, but rather on, for example, the chance for a patient to be prescribed the incorrect medication. A quality improvement plan was then put in place to prevent risks from occurring. It was a proactive mechanism.

Data
Dr Moodley said that the health data was shared with SAPS, the City of Cape Town, and anyone who could use it.

On socioeconomic factors, the Department looked at data and identified concerns about nutrition early on, around January this year. This had been shared with other departments, as a prediction that children were going to be hungry. Information was shared with other departments to find proactive solutions.

Waiting Areas
Ms Bans asked for clarity on her previous question on the waiting areas. Would all clinics get a structure outside for queueing?

Dr Cloete responded that Dr du Toit had said that all new clinics, built in the last two years, would have a pre-waiting area built in, while old clinics would get modular structures for the pre-waiting areas.

Part B: Performance Information (p57-80)

Mr Plato referred to page 67 in socioeconomic challenges, particularly concerning children. There had been fewer deaths of under-fives than anticipated. But it had also been mentioned that very ill children were being presented late to healthcare facilities. How serious was this? What could be done about it?

Ms Bans said that on page 75, there was an increase in child mortality. What caused the increase in child mortality? How large was the increase? What was the impact of worsening socioeconomic conditions?

On page 76, on complaint resolution within 25 days, what had the complaints been about? How had they been resolved?

On page 77, on the third indicator of inpatient bed utilisation rate, to what extent had mental health contributed to this bed utilisation?

Ms Windvogel asked about page 63 on linking performance with budgets. What were the reasons for overspending on emergency transport?

On page 63, on reasons for deviation, what were the number and causes of child death? Why had the targets not been achieved? What were the updates on the cases that could not be discussed and reviewed? What has been the impact of staffing challenges?

On pages 95-98, on HIV, TB, malaria and community outreach, she was concerned that, while the Department claimed to meet most of its targets, a number of serious targets had been missed. Could the Department explain the reasons for missing targets and measures that had been put in place to address underperformance on this programme's progress? What were the challenges with the HIV and TB targets, especially tracing defaulters? Why was the Department always missing these targets? How was the Department planning to address these challenges?

Responses to Part B

Children Under-five
Minister Mbombo said that the healthcare system was still able to track the health status of a child when a mother was pregnant. The child was born and delivered in most cases at a healthcare facility, so that could be tracked. During immunisations, from birth to two years old, a child came to the clinic and growth monitoring took place, with the Road to Health card. After about age three, the child was not being monitored by the healthcare system. Some may go to Early Childhood Development Centres (ECDs), but this was the age at which children were not in school. So, there was a gap in monitoring children at this age.

COVID-19 Waves – Health Effects on Children
Dr Cloete said that, because this reporting period had a third and fourth wave, which were big waves, children had actually been protected from usual exposure to infections they would have had in other years, as children were at home and not interacting with other children.

Towards the beginning of January this year, when there had been a relaxation of regulations, children had returned to crèches and schools. Children’s immunity was then compromised, as they had not been exposed to other children. Children became acutely ill in the first three months of the year, in “diarrhoea season”. There had been more diarrhoea deaths this year than was expected, as the diarrhoea season had been higher, because children had had a more sudden exposure to diarrhoea and less protection.

Also, during COVID, parents were taking care of their sick children. They had been scared about taking them to hospitals. So, they had come late to hospitals.

The effect of these two phenomena coincided in January, which had carried over into this financial year. Red Cross had been under severe pressure late into June because of childhood illness.

There was a broader phenomenon that people had less food, less money for healthcare, people had lost their jobs. Children were more at risk, because they were not getting the childcare they should or the food they should be getting.

A society should be measured on how well it looks after its children. Health would say that children were more at risk of illnesses, potentially of malnutrition, and dying. This data should be used to advocate for platforms to support families with small children because that was where the risk was currently sitting.

In-patient Data
Dr Cloete responded to the question on in-patient data on page 77, which had information on the average length of stay, but not inpatient mortality. He said that the average length of stay, the severity incident report, and the bed utilisation had all been affected by mental health overlay, because people presented later to hospitals. It was all linked to that. But this was mainly adults, because this data crowded out children.

It was all because there were sick TB patients, all of a sudden. The healthcare system had not picked them up, they had not been tested, and now they were coming to hospitals. There was a whole range of factors, and mental health was one of them. This was because of socioeconomic conditions. It was driving TB, HIV/Aids and diabetes, but also mental health. For adults, the length of stay was slightly longer than it should be because of the length of presentation.

Dr Cloete spoke about the EMS performance. He indicated that Dr Kariem had responded to this question earlier, saying that the EMS was always under pressure. But at the peaks of the waves, the EMS pressure was exacerbated. What the Department had done in this reporting period was to draw on private EMS during those peaks.

Overall performance from a client perspective had actually been relatively good and well maintained. It was not that it under-pressured the EMS, and now there was big pressure from all the COVID cases that the EMS had come to a standstill. However, the Department moved with that wave of more requests. Because of that, it has been carried into this financial year. The performance of EMS at the highest periods of peak was normally on a Friday night to Sunday. This was the time the Department received the most complaints over the slow response times of ambulances. What helped with this was the additional private ambulances being part of the system with a formal contract in that period. The Department continued to leverage that for those peaks of demand.

Dr Cloete responded to the questions about child mortality. He said that the child death review differed from the others, as there was a panel of people appointed from various sectors and forensic pathology, so they looked at all deaths of children. Every death was investigated as an abnormal event. They formally evaluated and ruled to see if any system failures could be picked up and reviewed.

The challenges are detailed on page 84. This had been partially achieved because not all cases could be discussed and reviewed. It was because, at that time, the pressures had been quite high. It had been an abnormal time. All the cases would have been covered if it had been normal.

Dr Cloete responded to the question about the conditional grant and targets met. He said that the basic answer was that the difference between targets and performance was due to COVID-19.

Follow-up Discussion

Mr Plato commented that if the HOD had all the answers, then why did the Department do all this research?

Ms Bans referred to page 88. The bottom table lists reasons for deviation. What were the updates regarding the projects that were stated on page 80?

Her second question was on pages 92-93, on the table listing transfers to non-profit institutions. How were these NPIs elected? Could the Department provide details of the NPOs and the names of the board members serving on the NPOs?

Her third question was on page 93. She referred to the bottom table – the first two rows. What were the details of these claims? How many had they been in total? How many had been related to COVID-19?

Her last question was on page 101, on the health facility revitalisation grant. The funding allocation for infrastructure had mainly been provided through the health facility revitalisation grant. What were the reasons for underspending and missing targets in details or facilities affected? Had the Department surrendered these funds or had they been applied as roll-overs?

Ms Windvogel asked about the NHI grant. How did the appointment of these health professionals work? Were they paid per session? What was the breakdown of these health professionals by occupation, race and gender? How had this improved services in the province? What was the expenditure breakdown?

Lastly, on page 106, if any of the workers had been recruited from agencies, could the Department provide a breakdown of these agencies? How much had been paid to each staff member per agency? Were any posts made permanent, or had any staff ended up being employed permanently?

Dr Cloete first responded to staff appointments. He said that, on page 106, it was very clear that there were 357 staff members. The breakdown was clear. These were not agency but contract appointments. As he had explained earlier, this was the total number of people, where it was stated that 80% were full-time staff and others were contract staff. At the end of the reporting period, which had been the end of March 2022, all of those people had still been on contract. What happened to them would be reported for next year, but they had all been employees at the end of March.

On page 104, the NHI sessions were for select health profession sessions. This was for Garden Route, mainly for medical doctors and other staff categories, including clinical nurse practitioners, dentists and dental assistants. Those were the professions specifically targeted by the grant. Not all the sessions could be filled because there had not been enough people to be appointed on sessions, specifically around dentists and dental assistants.

Sessional doctors, sessional dentists, and incisional dental assistants worked in the primary care system where they were needed. They would go and do these sessions as part of all the clinics in that geographic area.

Dr du Toit confirmed that the Department had asked for rollover, and had received approval from the Department of Health and Treasury. The reasoning for under-expenditure were quite a few, which included COVID – as it had had a big impact on the industry.

The grant had been used for construction and medical equipment, which came from overseas. The logistic crisis that had come up after COVID-19, and lockdown of the harbour in Shanghai, where some of the equipment was coming from, meant that the Department could not receive its equipment or install it in time.

Dr du Toit referred to page 88. The Department had finalised some projects, but some had experienced delays. The Department carried out some projects, and some by the Department of Public Works. The COVID pandemic has contributed to some delays. The Department had achieved the ambulance and cyber forensic pathology.

Mr Kay, on the concern about claims to the state, explained that Medico-Legal was from where those claims were paid. There had been no claims in this province relating to COVID-19, because the COVID-19 claims had been covered at a national department level. The details for the Medico-Legal and the cases were in the annexure to the annual financial statements.

Dr Cloete added that the first payment listed, which was called injury on duty, leave continuity, retirement benefit, and severance package, was paid to the Department’s own staff members, at R77 million.

The next line, which was claims against the state's household, was what Mr Kay was talking about. That R64 million was what was paid out for Medico-Legal claims. And, as Mr Kay had just indicated, none of that was for COVID. The national department dealt with any claim against the state from a Medico-Legal person from COVID-19, or vaccination. These were for other conditions. In the annexure, there was detail on what exactly each claim had been paid.

Then there were bursaries for students who were studying, and that was the amount that went against that.

He was not sure what payment made as an act of grace was. R 48 000 had been paid as a compassionate act to somebody.

Mr Kay added that the R48 000 was for contributions to some funeral costs for people who had passed. It had been one of the nurses who had passed at Tygerberg. The family had been unable to afford the repatriation of the body, so the Department contributed to that.

Dr Cloete answered Mr Plato’s questions on why the Department needed research if it had all the answers.

There had been a major reduction in the admission of sudden unexpected deaths in children to forensic pathology. It was attributed to a reduction in number of deaths deemed to be due to natural causes. This was a sudden drop in one category because the classification of natural causes changed. The sudden drop was due to the data classification and what required research. So, the Department needed to go back to the individual cases to see whether the drop really was due to the change in classification.

Ms Windvogel referred to page 147. What were the details of this plan? What is the update on the new EE plan that has been in the process of being developed?

On page 149, could the Department provide the exact figures of the 29.47%?

Responses to Part D

Employment Equity Plan
Dr Cloete said that Ms Arries would provide details of the employment equity plan, as it was quite a detailed process and there was also a provincial process.

On overall total engagement, all the services provided amounted to 29.47% during this period under review. It indicated that a third of the health workforce, 30%, used the service. This was almost three times, or at least about two and a half times more than what would happen normally. It had doubled. The detail was provided in a momentum report. A metropolitan report provided specific details of what exactly people had come through, and what kind of support they had sought.

Ms Bernadette Arries, People Management, said this was from 2017 to 2022. This was the five-year plan of the past five years. Included in there were the targets, the norms that were set in terms of race and gender, as well as the issue of how the Department dealt with policies, what needed to be informed, the barriers that prevented the Department from employing people, and specifically, the area of disability.

It was not just the numbers, but also the assistance on how individuals were recruited, and how the Department supported the person through the entire process. So, it was a very encompassing process. There was a forum that was both organised labour that was part of that. The Department had been reporting to the Department of Labour regularly.

The Department had just finished drafting its new plan, which started on 01 September 2022. It was not just about numbers; the challenge was about how to transform and change the culture in the organisation, for people to be comfortable to come into it, in terms of access, keeping people there, recruiting them appropriately, but also how to deal with succession planning, and the area of how people were supported through processes.

It was important to look at addressing the barriers to get to all the targets. As Dr Cloete had said on wellness, the Department was really very happy about where it was. On uptake, people were comfortable doing so because of this process's confidentiality. This was spread across the organisation.

Follow-up Discussion for Part D

Ms Bans said that the last speaker had triggered another question based on page 60 on recruiting certain health professionals. The recruitment of qualified and competent health professionals posed a challenge due to the scarcity of specialities in rural areas and the restrictive appointment measures imposed on certain occupations. Could the Department provide details regarding this challenge, as well as strategies that had been put in place to address it? If there was a plan, could the plan be shared with the Committee?

Her last question was on page 159, on the second last paragraph. During the 2022 cycle that had commenced on 01 January 2022, a total of 842 medical interns had been placed at WC’s 11 health facilities. In the past few years, there has been a challenge regarding unplaced, medical interns and complaints of some interns experiencing burnout, due to being overworked. How had these challenges been addressed? Had the Department experienced any challenges in this regard?

Dr Cloete answered the question about attracting certain professional categories to rural areas. He said that professional category people normally had career aspirations, family aspirations, and were looking for schools for children, job opportunities for a partner, and the social conditions of the area where one raised a family in – which were all important considerations. This made it difficult to attract young, newly married couples, with small school-going children to a rural area where those aspirations could not be fulfilled.

The Department rather places and prioritises young professionals in community service for rural towns. If possible, all community service doctors were placed in small rural towns. Normally, community service doctors were obliged to do the work; they were generally not married yet. They were early in their careers. Through that placement of young doctors, they fell in love with the town, which would not be their first choice. This was seen in Beaufort West, which had many young doctors.

What happened with young professionals was that word-of-mouth was very powerful. If someone had had a good experience, and they knew someone else, they would encourage them to go there. The Department was now in a situation where every year it was being asked for community service placements and other provinces wanted to come to the Western Cape and to rural towns in the Western Cape, because of the experience that people had had. Because this was done with doctors, so it had been easily extended to pharmacists, dentists, OTs, physiotherapists, and nursing.

The issue of the 2022 cycle was that there were additional resources made available from the national department because of a huge under-availability of posts countrywide. What happened was that the national department had made additional resources available and that the Western Cape department had then taken in additional interns. The intern problem described, which was very evident between Christmas and New Year of 2020 and ran into 2021, was obviated by the fact that additional resources had come into the system. So, other provinces had absorbed their fair share of additional people into intern posts, but also community service posts. The allocation of interns in Cosmos happened last week, which was the first time in many years.

There was a national process. Dr Cloete said that he was also serving on that committee with other HODs in the national department, looking at whether they should be looking at the community service programme and the intern programme, and also formally evaluating its effectiveness and what should be happening. But the short answer was that the interns placed were in what were called complexes. Interns placed at Worcester Hospital would also do service at small hospitals from Worcester and communities. The system was quite sophisticated in absorbing the interns into the hospital's healthcare system and the surrounding community health centres, where they had to do overtime and day work.

Mr Xego referred to page 172. Why was there no one with a disability in top and senior management of the Department?

On page 178, on the profession of lower-skilled employees by salary pay and why they there was not any progression: it is notable that COVID-19 has only just ended, and the budget had mostly been allocated to rendering of services and then staff progression had been deliberately cancelled by government. Having noted all those reasons that were conditions and that the Department found itself in, at the broader level, these people felt so much financial and emotional/mental distress.

Dr Cloete responded to the question on disability. He said that, about two years ago, his colleagues in people management had done a survey, wherein there was a question about whether somebody with a disability declared that they had a disability. Not everybody who had a disability declared that they had a disability, especially in most senior categories. People were not willing to declare their disability. On the second question, he said that it had been a blanket rule that there would not be progressions.

Ms Arries said that it stood out. But looking at stability in the top management, many posts had been recently appointed. It was something that people were asked to declare, and this was confidential. But people may not like to disclose their disability. It was also indicated in the advertising of roles that there would be no discrimination on the basis of disability.

Ms Arries spoke about the progression of lower-skilled workers. On the non-progression that had taken place in this financial year, she said that it was the answer to the 178 that was still something that needed to be completed. That would be reflected on in this new financial year because there was the challenge of salary negotiations, and then the Department would implement. It had done all its assessments, and things had been completed. It was just a matter of when the negotiations were completed, and there was agreement. Then implementation happened, then the progression of people would be implemented.

Dr Cloete said that the basic negotiations, getting the resources and paying and all of that had been delayed. That was why it had been difficult to complete all of those processes towards the end of the financial year. It had been on hold for one year to allow for the wage negotiations and all of that to come in so that it could be corrected, going forward.

Questions from the public
The Chairperson said there would be further deliberation and recommendations from the Committee.

Mr Dion Carelse shared his concerns about ambulances. Response times in the Cape Flats were slow, leading to deaths, compared to the quick response times in richer areas even with traffic. He knew many people who died because of these slow response times, including his neighbour. There were problems in the hospitals, with people being turned away.

The Department was being sued for millions. He did not see this in the budget. How did GBV (gender-based violence) and police brutality factor into the Department’s budget? People were assaulted and had to go to a facility. With GBV, there were no ambulances or resources in rural areas, so people died. People needed to have private transportation in these areas.

In wealthier areas, within a few minutes of an accident, a fire truck, three ambulances, private paramedics and police were on the scene. There were no resources in the Cape Flats. At UCT and CPUT, ambulances were being used as vaccine sites.

The Chairperson ruled that incidents such as these needed to be reported to and dealt with by the Department directly, where it would be looked into after the meeting.

Mr Lesley Sylvester said there seemed to be an increase in TB due to socioeconomic situations – young people were on drugs. How could they be encouraged to get help from clinics and facilities?

Disabilities were not talked about enough – access to services and resources was limited. Mr Sylvester detailed his experience at a hospital that was not accessible.

COVID-19 was still around, but COVID-19 vaccination sites were not being used. Were there statistics on COVID-19 deaths? Were vaccine and testing facilities still being used?

Ms Kiewiets (sp), who worked in healthcare, referred to page 11 on under-expenditure for the community, saying that in her experience, there had been situations where there were no staff in facilities because there was no budget. If there was an under-expenditure of R273 million, was there no way that money could have been redirected to appoint staff?

On page 13, on new and approved activities, on telemeds: her concern was on the lack of communities’ awareness on how to access their medication through this service. What was the Department’s communication strategy to communities around activities like this, that gives the community a way to access their medication? The concern about the COVID-19 period and the defaulting on medication had been observed was that people did not know how to access their medication in the period under reporting.

On page 24, under the organisational organogram, there were two vacant posts – one in Cape Winelands, a very large district, and another one under emergency and clinical support services, for clinical service improvement. How long had these posts been vacant? How soon would the post be filled?

On page 24, Dr Carver (sp) is the Director of Facility Management under Dr du Toit. The concern was because of the challenges facing Khayelitsha at the time. When had this role been filled by Dr Carver? With the challenges in the public domain, how was this appointment made?

On child mortality rate for under-five children. If deaths were preventable, why was the Department not preventing it? The Department had a programme that worked. She had sat with Dr Cloete in 2019, on community integrated management of childhood illnesses (community IMCI). In previous reporting years, children’s deaths had not been as high as they were now. There were contributing factors but there was no programme or system in place now. Could the Department bring back the community IMCI?

The working conditions at Salt River state mortuary were not acceptable. What happened to Observatory that would have opened in the year of reporting? What caused the delay? How could the Department improve life for officials working at Salt River, because their working conditions were not conducive?

Another public member mentioned that Groote Schuur Hospital had improved, but that was not the case with Khayelitsha Hospital. What did the Department plan to do to change the situation?

Resources and facilities in black communities such as Khayelitsha, Philippi and KTC were lacking. What plan did the Department have to upgrade the services in these areas? There were complaints more than compliments. The community was not happy with the services.

On GBV, she mentioned her experience working with those affected by GBV, needing to take them to clinics or hospitals up to the court level. There were serious problems with how nurses dealt with these patients. Did the Department have a plan for sensitising GBV in clinics and hospitals?

Another public member said that, during COVID-19, there were Vaxi Taxis in many areas. These taxis were very costly when transporting people from informal settlements far from the government’s vaccination sites. A lot of these community members did not have a chance to return to the sites for second doses, and they are also complaining about their individual health conditions, suspecting that they may have fallen sick due to the first doses they took or due to not having gone back to get second doses. What can be done to help these people?

Secondly, in the Atlantis area, the public member found that there was only one mental health doctor, yet the area has a population of over 200 000. The hospital in the area was built 40 years ago, back when the population was not this large. There is now an unknown number of foreign nationals who benefit along with the population. She asked whether the government has allocated a budget that would specifically cater to these foreign nationals, given that there is already a national medication shortage.

Thirdly, there are long queues in a lot of the public hospitals. When one comes for their appointment, they find long queues that extend outside the fence, where there is no shelter. She asked if this could be addressed so patients would not be sunburnt.

Lastly, she asked if there was a way for the Department to repossess the hospitals that it had lent to the City of Cape Town, because community members are not pleased with the way that the city has kept these hospitals. For example, there is an area with a temporal that runs on Tuesdays and Wednesdays. It is falling apart, and it is not even cleaned thoroughly. It also does not have many things that people usually need at healthcare centres. She suggested that the Department take back these healthcare centres so that community members would also have wellness hubs in their areas to minimize the number of people that are overcrowding the Atlantis hospital.

There is also a bedridden child, who was involved in a car accident in 2019. He cannot do anything because his injury is on his neck. His parent is jobless, and the child only gets R1 800. When going for appointments with a physiotherapist, he would spend money hiring transport to go to the appointment, only to get there and not find the doctor. The money would then go to waste. How does it happen that one books an appointment but ends up not finding the doctor? The child then ends up not affording to go to a rescheduled appointment. Can government organise transport for patients located in remote areas so they can get to hospital? This boy is only 22 years of age, and his accident happened while he was still in grade 11. He has lost schooling time, and that has prevented him from becoming what he wants to become.

Another matter has caused her pain. There is a girl who had an appendix operation. She fell pregnant last year. This year, she was meant to give birth at Somerset in July. Instead of getting her to give birth through a C-Section operation, they operated her on top of where she had had an appendix operation. She ended up with three operations on one body part and fell sick. She then had a stroke, and her mouth was twisted to the side. How can it be ensured that doctors do not release patients before they are checked – that the patients have undergone the right operation and will not face any side effects?

It is also frustrating that the whole of Atlantis gets allocated only two ambulances. One phones and calls for an ambulance to no avail, ending up resorting to hiring a private vehicle. Why does the Department not commission certain minibuses to transport patients from such areas, and then submit invoices to the Department?

Because of time, the Chairperson interjected and asked to stop the lady from continuing with her questions. The Chairperson said that the lady should take her concerns to the Department, and urged her not to wait another year to raise her concerns.

The last member of the public asked about the client satisfaction survey. Was it the results that the Department wanted, or did it genuinely want to improve?

Responses to the public

Minister Mbombo said there were bound to be challenges in areas like Tygerberg – heavily oversubscribed areas. The question for the Department was about how to identify and solve root causes. That was why the hotline (086 014 2142) was in place – so that people did not wait until it was too late to voice their concerns and then something could be done about the problems to prevent it from occurring again. The hotline and email address allowed concerns to be redirected to where they needed to go, rather than sharing it on social media where the Minister would not be able to see concerns.

The Department needed to ensure that lessons were learned and how to accordingly deal with someone who had done something wrong.

Vaccines and other services would be integrated into the wellness hub to strengthen the primary healthcare system.

The Vaxi Taxis were not fully fledged ambulances; they were more like panel vans that they put gazebos outside. It was not about taking an ambulance that was supposed to be going and fetching people; it was more like a mobile clinic managed by the EMS.

The Minister said that she had been to Salt River to check on the progress of the new pathology services. It had to do with the service provider. If the Department’s skilled staff, who had known what was needed, a house with cracks would have been used.

Dr Cloete said that he appreciated the feedback from members of the public. It was important to create avenues to listen to people. It was unfortunate that this occurred once a year in an annual report session – that there were no appropriate places where concerns could be heard. The Department needed to create spaces and fora to listen to people, as it was difficult to relate an individual experience to 17 million experiences, at the Committee level.

He encouraged everyone present to document their experiences and register it on the Department’s system, so it could be attended to. He responded to each concern briefly, encouraging engagement with the Department through the system, and providing all the specific details to ensure that others did not have to experience these incidents.

Closing Remarks from the Minister and HOD
Minister Mbombo said that the next report was crucial. The challenge was in the lessons learned and in comparing what was being said now to what had been done and implemented. Budgets needed to have input from the public. Afterwards, when the annual reports were shared, this should receive feedback from the public. She thanked the members of the public for their questions.

Dr Cloete thanked the Committee Members. He thought that they had a very good relationship over the years. He recalled bursting into tears at the last meeting, soon after COVID-19. He was thankful for the Committee’s support to the Department. He thanked his team for their dedication and commitment.

He said they felt the pain of the public, and understood that, in the areas where they came from, people experienced the healthcare services in a certain way. They would never minimise that the healthcare system was based on dignity. Until every single person had an experience of dignity, their job was not finished.

Chairperson’s Remarks
The Chairperson thanked Dr Cloete. She said that everything was not always sunshine and rainbows. The Committee had heard about the challenges from the community that occurred regularly. She thanked Minister Mbombo for highlighting that there were channels within the Department with which these concerns could be raised, along with how the community could be included more in these processes, going forward – not just when it came to the point of looking back on a financial year, but actually becoming more involved in the processes, going forward.

She commended the Department for its work and for getting a fourth clean audit outcome, which was the first and only Department in the country that had done so. This did not take away from the lived experiences the public shared today. It was also commendable that 99% of the equitable share had been spent. Credit needed to be given where credit was due, especially as this was during a national energy crisis where 75% of facilities had reached the energy consumption benchmark. It was indeed commendable.

As the Minister had indicated, she encouraged the members of the public to bring those matters to the attention of the Department.

Committee Recommendations

Ms Windvogel asked about the Wall of Remembrance. She recounted that this was a matter discussed in the previous annual report, and that there had been some commitment from the Department’s side through the HOD. Could an answer be provided on the plan for the Wall of Remembrance for the fallen healthcare workers?

Second, could the Department provide more details on ambulances per district?

Lastly, could more details be provided regarding the funding model for regional hospitals? She was unsure whether the cost of converting a district hospital to a regional hospital was the issue. The Committee needed to get a picture of the cost and a more detailed explanation of why it was not feasible for the KDH to be converted into a regional hospital.

Ms Bans asked about the benefits of the NPOs. The NPOs that had been listed seemed to have benefitted, as per page 90. Could the Department provide a list of all those NPOs that benefited and their board members?

Her second question was on the list of old clinics that had received secure waiting areas. Which old clinics had already received these structures, and which ones were on the waiting list?

Mr Xego referred to page 168 on staff leaving the employ of the Department. The rate was very high. There were 2 227 contract workers, and there had been 1 618 resignations. Staff complements were close to 4 000 people, including contract workers. He asked the Department to provide a retention strategy, because that was a very low number for a department that was complaining that it was understaffed.

The Chairperson said that she had also written that down. There had also been quite a significant amount of resignations where people had not wanted to indicate why they were leaving the Department. A large number of young people, between the ages of 18 and 34, included in that.

Mr Plato was inaudible, as his microphone was off.

The Chairperson had one recommendation that had been coming up regularly in almost all their sessions. When the Department spoke about a community-based approach, the issue of community-based workers came up, but so did the remuneration and stability within the sector. Why was there a hesitation at the national level to deal with this problem? What had National Health been saying? Could the Department provide that information?

Ms Windvogel said that there was a problem with Khayelitsha Hospital. She wanted the Department to explain what they would do with the current situation, not what they would do in 2030 when the GF Jooste was going to be rebuilt. KDH had requested funding to assist in providing better services. What was the Department going to do about KDH’s situation? She became inaudible because her microphone was off.

The Chairperson thanked the Members for attending the meeting and said they would meet at the SCOPA meeting, at 14:00.

The meeting was adjourned.