Office of Health Standards Compliance & Office of Health Ombuds 2020/21 Annual Report

Meeting report

Opening Remarks
The Chairperson provided brief opening remarks. He noted that the Committee would be receiving two presentations, the first from the Office of Health Standards Compliance (OHSC), and the second from the Office of the Health Ombud, on their annual reports for the 2020/21 financial year. He noted that the Office of the Health Ombud was, in a manner of speaking, part of the OHSC and derived its funds from the budget of the OHSC, however two different reports would be given.

Presentation by the Office of Health Standards Compliance on their Annual Report for 2020/21 financial year
Dr Ernest Kenoshi, Chairperson, OHSC Board, introduced the members of the OHSC in attendance and the presenters.

Dr Siphiwe Mndaweni, Chief Executive Officer (CEO) and Mr Julius Maphata, Chief Financial Officer (CFO) and Executive Manager of Corporate Services presented to the Committee

The presentation covered the entity’s performance across its five programmes, which include administration, Compliance Inspectorate, complaints management and Office of the Ombud, health standards design, analysis and support and certification and enforcement. There were 21 output indicators tracked and reported in the 2020/21 Annual Report. 14 Or 67 percent of outputs indicators were either achieved or partially achieved. Seven or 33 percent of output indicators were not achieved.

Compliance Inspections
The Compliance Inspectorate achieved a low output indicator of 10.14 percent for the 2020/21 period. It was highlighted that 23 COVID-19 rapid inspections took place covering all provinces, except Limpopo.

It was noted that the compliance inspections in the private sector had not started. Consultations on the development of inspection tools for the private sector were conducted. The private sector compliance inspections would start in the 2022/23 financial year.

Challenges
With the growth of the organisation, inadequate funding for the fulfilment of its mandate remained a major challenge for the OHSC. Financial constraints impact on the ability of the OHSC inspectors to conduct the targeted number of inspections of health establishments. The number of inspections completed is proportional to available funding. Financial constraints have also led to HR constraints in the Complaints investigation unit (50 percent vacancy rate), which impacts on the resolution of backlog cases. The adverse impact of COVID-19 was felt particularly in relation to additional inspections of health establishments that had been found non-compliant with norms and standards during earlier inspection. The COVID-induced national lockdown had a significant impact on the Complaints Investigation Unit’s activities, particularly the conduct of on-site investigations.

Way Forward
The OHSC was working on a model for charging fees on inspections, as well as provision of guidance and support. The National fiscus would continue to be the main source of revenue. For purposes of increasing inspection coverage, the OHSC was working on a decentralisation model. 2021/22 is being used to address the key challenges faced by the OHSC.

Comments on Financial Performance
The entity achieved a clean audit. There was a one percent increase in allocation from the National Treasury, due to OHSC allocation being reduced, as a result of the COVID-19 impact. There was a decrease in interest on short term investment with the OHSC bankers, as a result of reduced interest rates by the South African Reserve Bank (SARB).

There were no salary increases implemented due to the moratorium on salary increases. There was a decrease in board costs due to reduced travelling from the lockdown.
A decrease in inspection costs was experienced due to reduced travelling as a result of COVID-19. There was an Increase in the asset base of the OHSC.

Main Contributors to Surplus
The main contributors to the surplus included the limited travelling due to COVID-19, no re-inspections, no private sector inspections and a moratorium on salary increases for the financial year. All stakeholder engagements were held virtually due to COVID-19. There was also additional revenue received from investment interest.

(See Presentation)

Discussion
Ms M Hlengwa (IFP) noted that the presentation was informative and comprehensive. In the presentation, the Committee was informed that only 41.7 percent of vacancies were filled. This figure was 48.3 percentage points away from the entity’s target of 90 percent. The Committee understood that the National State of Disaster impacted negatively on the entity’s ability to fill positions. Considering the importance of the senior positions, what urgent steps had been taken since to address the situation? Slide 28 stated that a total of 23 COVID-19 repeat inspections were conducted covering all provinces, except Limpopo. Why was Limpopo not covered?

Ms A Gela (ANC) stated that the audit outcomes were welcomed. She noted the statements of the Auditor General, especially about programme three, specifically complaints management. She noted that the complaints were already being dealt with. It was well-understood that the OHSC was operating under very difficult circumstances, given the COVID-19 situation. The OHSC had a plan in place to meet the outstanding targets. How much had been set aside for the implementation of the revised organogram. What was the rationale for appointing the service provider to assist with the implementation of the new organogram? Could this not have been done internally by the Human Resource (HR) Department, so that costs were saved? Lastly, she asked that the OHSC explain the budgetary constraints in fulfilling the entity’s mandate.

Ms E Wilson (DA) thanked the entity for the presentation. She stated that she was from Limpopo, so anything about Limpopo was a major concern for her because that was where she spent a lot of time doing  oversight. One of the mandates of the OHSC was to ensure that there were reliable and safe health services. Unfortunately, in Limpopo, very few hospitals and clinics could be considered safe and many did not supply reliable health services. A case in point was the Rosenekal Clinic, which she had visited a few weeks before. The Clinic was plagued by cable theft; the clinic went days, if not weeks, without electricity. The Clinic was open but there was no generator. Medicines that were stored in fridges, which had to be maintained at precise temperatures, were affected by this and yet, were still dispensed. There had been no water on the day of her visit to the Clinic. Apart from that, there was an old caravan parked at the back of the Facility that was filled with disgusting bloody and filthy linen. That was a concern. She recently gave testimony at the Human Rights Commission, which sat for a week on issues of water services in Limpopo, particularly at Rosenekal Clinic. It was very disturbing when representatives from the Department of Health appeared before that Commission and stated under oath, that all the hospitals, medical services and clines in the area had access to running water, which was not the case. She offered her services and assistance to the OHSC. These were areas that needed to be looked into with extreme urgency.

The Philadelphia Hospital was called the ‘hospital of death’ because one was more likely to die there than walk out well. She suggested that these situations need to be followed up and dealt with as a matter of urgency. Staffing was a major concern and she understood that there had been budget constraints; however the OHSC played one of the most critical roles in the Department of Health. She suggested that the budget needed to be re-assessed to determine what was required. It was alarming that the OHSC could not do what was required due to COVID-19, particularly when so many complaints were received about people in COVID-19 hospitals being forced into beds in garages and tents in areas that were unsafe and exposed to the weather. That should have been a priority of the OHSC. It was sad to hear that the OHSC could not get all their inspections done during that time, as that was a critical period.

Ms H Ismail (DA) asked what was needed to increase the compliance target from ten percent to 50 percent. There had been lots of discussion of COVID-19 restrictions, what resources were needed for the OHSC to improve on delivering their mandate, especially in light of COVID-19. What strategies were being put in place to ensure compliance was monitored, given that COVID-19 was a reality for the next couple of years. There was mention of charging fees for inspections. Who would pay these fees going forward? In the presentation it was stated that all the facilities would need to be compliant if contracted under National Health Insurance (NHI). What strategies were being put in place to ensure that these targets were reached so that facilities could be compliant under NHI and ensure service delivery on the ground?

Ms N Chirwa (EFF) asked what the tangible enforcement methods were for facilities that did not comply with the OHSC and the Health Ombud, beyond simply sending recommendations and threatening to revoke compliance certificates. In the past year, hospitals were overburdened and many hospitals in rural or township areas had collapsed. She stated that there were no hospitals in informal settlements, which needed to become part of the conversation of universal healthcare coverage. Had there been any certificates that were revoked in the past year? Which healthcare facilities had been prioritised by the OHSC to reach compliance standards? She requested an update on this.

The OHSC had stated that COVID-19 had constrained the entity from carrying out their duties in the past year and a half. This was understood but was sad, as this was when the most ‘vigour’ was needed form the OHSC and other entities. She noted that the South Africa Health Products Regulatory Authority (SAHPRA) had come to the party, despite some disagreements. There were other entities that had ‘lifted up their socks’ in the face of a global pandemic. The fact that one of the most crucial duties and responsibilities of the OHSC could not be fulfilled during a global pandemic was a cause for worry, over and above the budget constraints. How did the OHSC plan to implement the recommendations of the Auditor General (AG) and in what timeframes? How would the recommendations be implemented? She highlighted the issue of reliability and access to healthcare facilities, particularly in areas where people were unable to access clinics after 4pm or on weekends. She asked how the OHSC understood the ‘reliability’ of those facilities and access to quality healthcare. Who was the reliability understood to be on behalf of, the patient or the clinic?

In the Eastern Cape in Misgund, Kou-kamma, there was a tiny clinic that was renting by a garage, sometimes it was open and sometimes it was not. Such clinics had licenses with the OHSC and seemed to be compliant with the OHSC. There was a clinic in Storms River, which was similarly unreliable. It was open according to the convenience of the staff. This was not meeting the needs of the people or community. The Clinic closed at 4pm and on weekends, how did one meet reliability in such circumstances, especially where hospitals were more than 20 kilometres away? She requested a response from the OHSC, particularly on ‘reliability.’ The OHSC’s reach in field hospitals was not tangible over the past year and a half. There had been many complaints and grievances, people passing away, families saying they were neglected or that a facility did not have enough capacity. What kind of reach had the OHSC had over the past year and a half, during COVID-19, in investigating and analysing such field hospitals?. What had the OHSC’s footprint been, particularly with field hospitals in places such as Khayelitsha and Johannesburg. If such inspections had taken place, what were the OHSC’s findings? She asked that this be shared in writing after the meeting, in addition to the OHSC’s oral response.

Mr M Sokatsha (ANC) stated that in the presentation, it was stated that service providers would have to contract services for the NHI. The responsibility of the OHSC was to see that service providers were compliant. If a service provider was not compliant, was there any remedial action or effort to explain where the service provider needed to rectify things? Under programme three, the complaints directorate, the presenter indicated that a lot of complaints were received because of a ‘severe shortage of staff.’ The presenter spoke about reserve funding, part of the contribution to the reserve funding was due to not being able to appoint or fill some vacant posts. It was indicated in the presentation that the OHSC had engaged with Treasury, which gave them the go-ahead to roll the funds over. It was indicated that those posts would only be filled for one year – what happened after the one year?

Mr E Siwela (ANC) stated that the budgetary constraints would likely be there for a long time. His concern was similar to that of Mr Sokatsha; what happened after 12 months? What would the entity do to ensure that it was able to meet its mandate? The Act allowed them to visit or inspect a facility at least once every four years. What happened during those four years, when issues of non-compliance started to creep in? Did the entity rely on complaints from the public? If not, did random inspections take place to ensure that the health facility remained compliant?

The Chairperson welcomed the rapid inspections of the OHSC’s 20 newly established field hospitals. It was commendable that the OHSC was able to go and check if these had been prepared according to the required norms and standards, in order to be able to deliver services to the people. He noted the ‘under-achievement’ on a number of the targets. Some of those ‘under-achievements’ had been explained in the presentation, the explanations seemed acceptable. What could have been done differently or what would the OHSC do differently in future to be able to achieve all their targets? The HR challenges were concerning, as a large part of what the OHSC did was send people out to conduct inspections, report back to management on it, management needed to be able to engage according to the norms and standards, the mandate given to them or via a request from the public or department. It all had to do with human resources. Thus, this was a concern, given the lack of funding. It was noted that there was a 50 percent staff attrition rate, most of the positions were not funded but there was also difficulty in attracting people with the necessary skills. It was noted that there were resignations from the former CEO and Executive Manager. Was this a challenge that was particular to the OHSC; what was the reason for not being able to find suitably qualified people for the different positions? For proposed decentralisation, had a plan been developed or a cross-benefit analysis been done? Did the OHSC think that it should be exploring different venues, such as the district municipalities instead of the costly venues usually used, especially for the road shows? Road shows were quite expensive. What was the OHSC considering to do in future in order to change their financial position, improve on their HR plan and organogram and improve their targets? What their plans were to cost-save.

Dr Mndaweni responded to the question asked by Ms Hlengwa about the filling of vacancies, which was at 42 percent at the end of the financial year. This output indicator tracked the time period within which the OHSC filled a position, which should be within four months. This was to track the OHSC’s efficiency in filling vacancies. The OHSC reported that at the end of the financial year, ten out of 24 of the positions were filled. At the beginning of the new financial year, March 2021, the OHSC was standing at 119 positions filled out of a total of 127 posts funded – this reflected 94 percent. The OHSC used other methods, such as head hunting to fill the positions. It was difficult to fill some of the positions, due to the skills required. The OHSC did have a technical partner that assisted with technical support, where the entity was lacking. The OHSC had started discussions, of having some of the highly technical positions seconded by organisations such as the World Health Organisation (WHO) for a limited period of time. At the beginning of the 2021 financial year, there were only eight vacancies. It was true that the OHSC was unable to fill them within the prescribed four months.

She addressed the situation in Limpopo. The OHSC had indicated that the entity did not conduct repeat inspections. When the OHSC developed the tool for repeat inspections, the OHSC focused on all the field hospitals across the Country. At the time, Limpopo did not have a field hospital; therefore the OHSC went to the other provinces. As much as the OHSC did have a service provider that would assist the OHSC, it was only for those areas and aspects of the organogram where the OHSC did not have the technical skills to fulfil such services. She gave assurance to the members, that it was still the OHSC’s full responsibility to implement the organogram, the OHSC would not out-source this responsibility. The challenge the OHSC was experiencing was that some of the critical positions in the revised organogram were not funded. The OHSC would use some of the surplus funds toward this. When it came to posts, the OHSC would need to be able to sustain those positions. Due to the fact that the OHSC could not guarantee that there would be the same surplus funds in subsequent years, the OHSC had contracted positions for a period of only 12 months. She noted the concerns raised by Ms Wilson about the clinics in Limpopo; the OHSC would make a follow-up after the meeting to determine if the entity had conducted inspections of those facilities.

COVID-19 had been mentioned in the presentation; however that did not mean that the OHSC did not undertake operations per its mandate. During the hard lockdown in quarter one and quarter two, it was very difficult to travel due to the travel restrictions. During that time, the OHSC utilised its time to develop the inspection tools. The OHSC went to the field hospitals and engaged with the facilities. The OHSC closely monitored all the media reports about facilities where there were challenges. The OHSC interacted and visited some of those facilities.

She responded to the questions asked by Ms Ismail, particularly efforts to expand inspections, meet targets and increase the compliance of facilities to meet requirements of the NHI. The role of the Regulator was to get as many health establishments, public and private, compliant with the norms and standards. There was a thin line between the work that the OHSC did as a quality regulator and the day-to day activities that happened at a service delivery level. The OHSC intended to ascertain if the inspection findings about facilities were acted upon and breaches addressed. That lay within the district, province and national levels. It would be difficult to inspect and go back to the same facilities and assist them to comply with the norms and standards. That would conflate the role of the OHSC as a ‘quality assurer,’ as opposed to ‘quality improvement.’ It was important that the OHSC communicated these findings, communicated some of the commonalities and continuously engage with the facilities. To that end, when the OHSC issued its final inspection reports, the quality improvement plans were attached, this would outline all the breaches of the norms and standards. The OHSC then provided this to the health facility so that the facility could start working on this. The OHSC would then receive the improvement plans from the facilities and see if there was compliance. In as far as the actual work being done, this was one of the areas the OHSC needed to strengthen with its various stakeholders.

The OHSC had learnt lessons during the COVID-19 pandemic. It was for that reason the OHSC had increased its inspection target to 700 for this financial year. As much as the OHSC would like to cover every facility, there was a complement of only 61 inspectors. There were in excess of 5 000 public and private health establishments. It would be a challenge to reach out to all of them, even if the OHSC was required to inspect once every four years. The OHSC went to a health facility once every four years, should that facility be compliant, the OHSC would issue a certificate of compliance. In the event that there was non-compliance, either reported in the media or through a public complaint, it would trigger a re-inspection. The OHSC had the powers to revoke compliance certificates. In the interim, the OHSC relied on ‘quality of improvement, that it should be sustained.’ Indeed, the OHSC would like to reach a stage where the health establishments that were compliant, and had been issued with certificates of compliance, remained so. This would be done through the issuing of the quality improvement plans and interactions with the provincial Department of Health, both at a national and local level.

The provinces were audited, as much as there were issues that were raised, the OHSC had already developed improvement plans, particularly around compliance management and how the entity ‘disposed’ of some of the complaints. A project plan had been developed to deal with some of the backlog cases. She responded to the issue about access to clinics within prescribed periods. The OHSC wanted to know if there had been breaches of the norms and standards, where clinics had been issued with compliance certificates. The OHSC would re-look at those facilities. Access to clinics during certain hours fell under the local district. Such issues required engagement between the Regulator and the local health authority. When the OHSC spoke of reliability, indeed Ms Chirwa was correct, there needed to be reliable services.

She noted the request that the OHSC share field hospital inspection reports in-writing, this would be communicated to the Committee after the meeting. The OHSC inspected 23 field hospitals, and had issued those reports, which assisted the facilities to assess their state of readiness. The OHSC was able to respond to all the early warning signs received, either through the media or via members of the general public, who had reported some of the issues to the OHSC.

In the event that a health establishment was non-compliant, the OHSC would issue a compliance notice. A compliance notice should be recognised as a tool to assist the health establishment to comply with the norms and standards. A compliance notice detailed all the breaches of the norms and standards, it would assign a definite timeframe within which that health establishment was supposed to have remedied those breaches and report back to the OHSC.

She noted that the Chairperson had raised pertinent issues about what the OHSC would do differently to achieve its targets. Together with the Board, this was something that was discussed and translated into an OHSC business case. This business case was costed; however the OHSC started by identifying activities that could be implemented without additional funding. This included the establishment of units, like monitoring and evaluation, which the Office previously did not have. There was the resignation of the Acting CEO, who was the Executive Manager of the Compliance Inspectorate. That position had since been filled. Over the years there had not been an executive manager in Complaints Management, Dr Jacobs had since been appointed. There was now a director in Monitoring and evaluation, this was a new position. Some of the positions, that were required according to the implementation of the decentralisation model, required more staff to be positioned in different provinces.

She noted what was proposed in using the offices of the district municipalities which would save costs. This option had been explored and would continue to be. One of the main challenges the OHSC had experienced, and a criticism of the OHSC from various stakeholders, was that the OHSC was seen to be not fully independent. The OHSC was seen to be more aligned with the public sector or National Department of Health. As an independent regulator, it was important that the OHSC maintained that independence. It did not mean that being in a district office would ‘compromise’ the OHSC’s independence. The OHSC would need to look into options in the private sector as well to balance this. The suggestion put forward was acknowledged and accepted.

Mr Maphata stated that he would respond to the questions about finance and HR. There was a question asked by Ms Gela about the AG’s issues, which was similarly raised by Ms Chirwa. Once the AG had raised issues, the OHSC developed a plan on how to address the issues and progress thereon was reported to the Board on a quarterly basis. The Board oversaw and monitored the progress to ensure that the issues were addressed. At the end of October 2021, the OHSC was sitting at 80 percent. 80 Percent of the issues identified by the AG had been addressed. The OHSC was left with only two items to address, by the time the AG audited the following year the issues would be resolved.

The estimated cost of the revised organogram was about R210 million. For the current financial year, the remuneration budget was around R112 million. This meant that it was almost double what the OHSC had currently, around R323 million. That was the estimated cost. There were instances where service providers were required to move across systems, this might require job profiling and evaluation thereof. Most of the critical aspects would still fall under the OHSC.

He responded to the question about the charging of fees for inspections. The legislation stated that the OHSC could charge fees for services rendered. The OHSC had identified two areas where such fees could be charged, the first was for inspections, the second was for the provision of guidance and support. The OHSC got legal opinion whether the fees could be differentiated based on the sector (i.e. public or private). That opinion advised that, once the fees were gazetted, the fees would be applied uniformly and consistently across all sectors. The OHSC was looking at ensuring that the fees were not burdensome, especially on the public health facilities because they were all funded centrally by National Treasury. That was the balance that would be taken into account. Discussions had started with the National Department of Health on this.

In the past the OHSC would recruit staff on a 12-month contract basis, during the course of year, if the OHSC had any savings it would extend those contracts for another six to 12 months. The OHSC was cautious about taking long-term decisions about permanent staff, based on a surplus that was not sustainable. This was a situation that would be assessed on a yearly basis. The long-term solution would be to have proper funding for all posts.

One of the potential areas of cost-savings was to reprioritise internally. For example, with the emergence of virtual meetings, resources had been redirected to inspections, as the inspectors needed to go on site physically. Although the charging of fees would not be a major source of income, it would contribute to improving some of the targets that the OHSC had set for itself on an annual basis. This was being discussed with the National Department of Health. Once it was approved it would contribute toward increasing some of the targets that the OHSC had.

Adv Makhwedi Makgopa-Madisa, Director of Certification and Enforcement, OHSC, responded to the questions asked by Ms Chirwa about certification and enforcement. No certificates had been revoked in the previous financial year. The OHSC had presented the number of certificates issued in the 2020/21 financial year, between October 2020 and March 2021, during the presentation. Following the issuing of these certificates, no incidents or breaches were reported about the certified facilities. She outlined the process of revoking certificates of compliance. When a health establishment was certified and the OHSC identified serious breaches, or an incident was reported, the OHSC had to conduct a fact-finding inspection to verify the correctness of the incident reported. That process would be followed by an inspection report with a compliance notice. After the compliance notice was issued, and the breaches were not remedied or the non-compliance stood, the OHSC would follow this by revoking the certificate of compliance. This revocation, in terms of the Act, needed to take place in conjunction with recommending closure of that specific part of the health establishment that posed risks to users. If it was the whole health establishment, the OHSC would recommend that the whole facility was closed.

Enforcement was one of the processes that the OHSC would start to implement going forward, as reported in the previous financial year. Enforcement followed after a health establishment had been inspected and issued with a notice and had failed to comply with the conditions served in the compliance notice. The OHSC was currently conducting national inspections to determine if the previously inspected health establishments were still non-compliant and if it could enforce compliance. When one considered how the legislation was structured around enforcement, the OHSC’s process was progressive. Enforcement started once a compliance notice was issued. The non-compliance notice would detail the period in which the norms and standards would need to be met. The notice would also indicate the penalties that would be imposed, in cases where a health establishment was persistently non-compliant. That was the first step that took place in order to ensure that health establishments complied with the norms and standards. The regulations that governed the functioning of the OHSC, the relevant authorities or the provincial heads of hospital groups, were required to appoint or designate someone to be in charge of each and every health establishment. This person was one whom the OHSC would communicate with, around matters of inspections and compliance with norms and standards. If anything went wrong in the health establishment, the OHSC had to communicate with the person in charge. When the OHSC issued a compliance notice it was the responsibility of the person in charge to make sure that all those non-compliance items raised in the notice were addressed. When a warning was issued it was given to the person in charge and timeframes were indicated, in which those issues should be dealt with. The OHSC could request a written response, this could be addressed to the person in charge and be responded to in-writing for non-compliance, explaining what was leading to the persistent non-compliance. It could sometimes be due to issues outside the control of the health establishment, but the health establishment still had a responsibility to escalate it to the relevant authority. The OHSC could recommend to the relevant authorities, being the provincial heads, that appropriate action be taken against the persistent non-compliance in a health establishment. This included disciplinary processes against any official or person in charge for their contribution toward continued non-compliance in a health establishment. The OHSC could recommend to the Minister, temporary or permanent closure of a health establishment, if it was of the view that, following their inspection and findings, the health establishment was causing harm to the users and employees of the facility. Fines could be imposed and/or matters referred to the National Prosecuting Authority (NPA), this included matters where there were criminal elements or an offence was committed in terms of the Act. There had not been a health establishment on which such actions had been imposed, but going forward the OHSC would be doing so. The OHSC had issued compliance notices and did see responses from health establishments. The OHSC were monitoring the implementation of the recommendations, as well as the steps that were listed in the notices.

Dr Donna Jacobs, Executive Manager of Complaints Management, OHSC, responded to the question about the shortage of staff under programme three. The OHSC shared the concerns raised by Mr Sokatsha about the short-term staff hired and retention of skills and knowledge. In order to address this, as the CFO mentioned, the OHSC used the funding surplus that was approved by Treasury to hire short-term contracted staff. The OHSC was in the process of insuring that there was skills transfer and capacity building of staff, both permanent and contracted.

Dr Ziyanda Mgugudo-Sello, Director of the Compliance Inspectorate, OHSC, responded to the issue raised by Ms Wilson about the clinics in Limpopo, particularly the Rosenekal Clinic and Philadelphia Clinic. The OHSC could confirm the observations of Ms Wilson. When the OHSC carried out inspections, both health establishments were found to be non-compliant. When a health establishment was found to be non-compliant there was a grading attached to the non-compliance. The Rosenekal Clinic was found to be an ‘unsatisfactory’ health establishment, this meant that there were a large number of measures that were found to be non-compliant. Preliminary reports were given to the clinic and the Clinic had been given an opportunity to address those measures that were found to be non-compliant. The issues were broken down, to issues of clinical management, infrastructure or supply of electricity etc. When it came to unsatisfactory health establishments there were measures that were outside the control of the establishment. It was easy to fix issues within the control of the facility, but what kept facilities in a state of persistent non-compliance was usually due to measures outside their control, such as availability of water and other infrastructure issues. This required collaboration between different departments. Should the breaches not be addressed in the prescribed time period, then the enforcement route was taken. The clinic, for example, was still undergoing that process. The OHSC was monitoring these health establishments and checking if the breaches were being addressed.

Presentation by the Office of the Health Ombud on their Annual Report for the 2020/21 financial year
Prof Malegapuru William Makgoba, Ombud, Mr Monnatau Moses Tlholoe, Director: Complaints Centre and Assessment at OHSC, and Ms Helen Phetoane, Senior Investigator: Healthcare Compliance at the OHSC, presented to the Committee.

The presentation highlighted three key investigations on the National Health System, being the Life Esidimeni cases, the Tower Hospital Report and Tembisa Hospital Report. The lack of capacity and lack of funding was highlight as a significant issue, particularly in comparison to the United Kingdom’s (UK) Office of the Health Ombud.

Complaints Received
The number of complaints received had increased year on year since the 2016/17 financial year. This was due to the increase in awareness about the Office of the Health Ombud and its work. Capacity issues were highlighted in dealing with complaints and the assessment of cases. The consistent constraint protracted turn-around time for case resolution was attributed to the limited investigative capacity, compounded by the COVID-19 lockdown restrictions. The Complaints Investigation Unit was the most affected component in the Office.

Complaints Investigations
In 2020/21, a total of seven complaints were referred for investigation, two were investigated within six months. Five of the seven cases were received in the fourth quarter of 2020/21 financial year and are scheduled for completion in the new financial year. A total of ten backlog cases were investigated in 2020/21. Subsequently, four preliminary investigation reports were issued to the complainants and the health establishments for comments. Six of the ten are currently undergoing internal quality assurance.

(See Presentation)

Discussion
Mr Sokatsha thanked the entity for the comprehensive presentation. He noted what the organization managed to achieve with the limited staff and the challenges outlined. He noted it was mentioned that the Office of the Health Ombud went to the UK and benchmarked their standards. He asked why a benchmark in Africa was not used as well so that there are two experiences, with one closer to home.

Ms Wilson noted how sad it was that the situation had not changed since the Office of the Health Ombud first presented to the Committee years before. How could the Ombudsman operate successfully in a context of the current health situation in South Africa, the COVID-19 pandemic and ‘failing health system’ as noted by the Financial and Fiscal Commission is still sitting in this boat? She was glad to hear that there was a bill on route. She suggested that an urgent meeting needed to be held with the Portfolio Committee, the Office of the Health Ombud, relevant stakeholders and the Minister to put some of these issues on the table and find a way forward. There could not be cases that remained ‘un-resolved,’ where people’s lives had been put in jeopardy and lives were lost. It was an unacceptable situation – tragic! She stated that Professor Makgoba had her support and deserved a medal, likewise his team for the work they did.

Ms Hlengwa welcomed the briefing and indicated that it was an eye-opener for Members. She asked how complaints were communicated to the Office of the Health Ombud. In June 2021, she had forwarded the complaint of a family to the former Chairperson of the Committee and she had heard nothing further about the case. This complaint took place at a hospital in Kempton Park, where a woman was admitted early in the morning to the hospital by her children. The family was traumatised. At around 2pm the Hospital called the children to take their mother. When the children arrived at the Hospital at 4pm, they saw their mother in reception, with ‘burns on her and she was gasping’. The children lost their mother. Everyone was traumatized and they are looking for answers. On 19 June 2021 the family reported the details and Ms Hlengwa had forwarded this information to the Committee Secretary thereafter, as the family wanted to lodge a complaint.

Ms Ismail asked that the Office of the Health Ombud explain the modalities used to move staff from the OHSC to the Office and how it was affecting both sections of the entity. Apart from the Ombudsman, who else from the Office took part in stakeholder interactions both locally and internationally on its behalf. There was a gradual increase in complaints over the years, what were the main reasons for the increase? Did the Office have its own management and hold its own management meetings without the involvement of the OHSC? How would this be handled going forward?

The Chairperson stated that the Office had put forward important points and the Committee had seen the important role that the Office of the Health Ombud played in ensuring that there was somebody watching that people received quality health services and that the Country was not faced with another tragedy like the Life Esidimeni tragedy. He noted Ms Wilson’s request for an urgent meeting with the Office and the Minister. He asked for clarity about the progress of the Bill. He suggested that while the Bill was being redrafted, which was a lengthy process, such a meeting might be appropriate in the interim. He asked that the Office of the Health Ombud initiate that engagement. He noted that the Health Ombudsman had stated that there was a staff of two people, but had then referred to various units. He assumed staff were recruited on a temporary basis, if and when needed. He noted the complaint that Ms Hlengwa’s had forwarded to the Committee, he asked that this be commented on and if the letter had been received by the Office. He asked that Ms Hlengwa provide more detail about the matter.

Prof Makgoba responded to the questions asked by Ms Ismail. The Office of the Health Ombud held its own meetings, separately to the OHSC. Complaints were increasing, likely because the Office was becoming more well-known. Members of the Office, or members associated with the Office, went around the Country discussing the modus operandi of the Office. Many of the complaints were not about norms and standards, many wanted to be remunerated for something that had happened in the hospital. Many people confused the Office of the Ombud with the Health Professions Council of South Africa (HPCSA). According to the Act, the Health Ombudsman was entitled to go to the OHSC and request assistance from their staff. If investigators were required or an inspection report needed, he needed to approach the CEO of the OHSC for those staff members. There was no unit for inspection under the Office of the Health Ombud. This situation was ‘all well and good’ if those staff members were available, but if they were busy, the Office of the Health Ombud had to wait. Over time the Office and the OHSC had come to a ‘gentleman’s agreement,’ whereby staff members or certain units from the OHSC could be seconded to the Office of the Health Ombud, those members were not legally employees of the Office of the Health Ombud. All the investigators and inspectors were employees of the OHSC; he would request these employees when required. He had such modalities to deploy in order to do his work.

There were no offices of health Ombud in Africa. The British Parliament had taken an interest in the Office of the Health Ombud and had wanted to interact and engage with them. The embassy invited the South African Office of the Health Ombud to the UK, and funded six of the entity’s staff members to go there and spend time with them. It was a range of reasons that had contributed to that. He would have gone to Kenya, Malawi or Zimbabwe, but there were no offices of health Ombud there. The Office was in touch with the Offices of Health Ombud in Scandinavian countries through the Institute. When one was employed, one did not want to do things that looked like there may be a conflict of interest. He discovered this problem when he first started in 2016, that the way the Office and legal framework were structured, was not the correct way that the offices of the health Ombud operated. In order to raise that, he came into the Office with two purposes, to establish an Office of the best quality that followed best international practice and to be able to build capacity. He came into the Office as a retiree, he did not need to build his Curriculum Vitae (CV), he just needed ‘to do good public service and train young people.’ He found that he could not do both. He could not train young people because he did not have staff. These were issues that had plagued him. Whenever he had the opportunity he took as many people as he could with him to go and experience the world out there and how offices of health Ombud practiced.

In response to the query raised by Ms Hlengwa, the only way he would know if the complaint was received, was if she provided the Office with a reference number. His common sense told him that this had not been received by his Office. There was a way in which complaints were lodged; there was a Complaints Centre that received complaints and did an assessment of that. It registered and referenced the complaint. Once this had taken place the case could be taken forward. To his knowledge that case had not been received.

He agreed that a meeting could be arranged. The current Minister was part of the panel that appointed him and the current Deputy Minister was his special advisor, when he had been Vice Chancellor, he would be able to communicate more directly with them.

The Chairperson noted that there was no other health Ombud in Africa and that the letter would be written, as requested, so that the meeting could be initiated. He highlighted that his question about the redrafting of the Bill had not been answered – where was that process?

Prof Makgoba said he was employed by the Department of Health and the Minister. The matter was with the legal department of the Department of Health. He had been in communication with them about the legal structure of Ombud’s offices. The advocate had taken the Draft Bill to the State Law Advisors. He suggested that when he wrote the letter requesting a meeting to the Committee, he would indicate where that process was. The Bill had to come to Parliament so that the consultation process could take place. That process would take a long time.

The Chairperson asked that Ms Hlengwa communicate with Mr Monnatau Moses Tlholoe about sending the letter to the Office. He and the secretary of the Committee should be copied in on that communication.

The meeting was adjourned.