Hospitals & clinics availability of medicines & medical equipment: Public Service Commission service delivery inspection; Health district offices’ role in Free State, North West & Western

Meeting report

Presentation by Public Service Commission (PSC)

Dr Henk Boshoff, Free State provincial commissioner, began by giving a brief introduction to the mandate and functions of the PSC before detailing the findings and recommendations from the mandated inspections of the various health facilities of the selected provinces. The PSC was a government entity responsible for promoting the effectiveness and efficiency of the public service, as outlined in Section 195 of the Constitution. The PSC Act of 1997 outlines the functions of the PSC as the entity which had the power to inspect departments and other organisational structures within the public service and had access to official documents or relevant information from heads of departments or organisational structures that assist with the inspection process. It was important to note that the inspections were done, but compliance with inspections was another issue which would be discussed further later in the presentation.

The overall health sector priority of the state was to improve the life span of all South Africans. In the period of 2012/2013, the PSC had conducted inspections on the availability of medicines and medical equipment, along with the role of health district offices. This was done in accordance with the state’s priority of ensuring that health sector conditions were favourable to the goal of expanding the life span of all South Africans. The PSC also acknowledged the amendments to the National Health Act of 2013 which provides for the establishment of the Office of Health Standards Compliance (OHSC). As the health quality watchdog, the OHSC would lead the much needed improvement in service quality and changes in public health care management. The PSC had held engagements with the OHSC to explore possible collaboration and cooperation in the improvement of health care services.

The broad aim of inspections was to assess the state of service delivery, thus assessing the quality of health care services rendered to the public, the state of facilities and the conditions at service delivery sites. The specific objectives of these inspections were:

• To determine the availability/adequacy of medicines and equipment at clinics and district hospitals;
• To establish the role of district health offices in ensuring the availability of adequate medicines and equipment at clinics and district hospitals;
• To establish whether provincial departments of Health had developed guidelines and procedures to manage the selection, procurement, distribution and use of medicines and maintenance of medical equipment;
• To follow-up on PSC’s previous recommendations emanating from inspections of primary health care facilities conducted in 2009;
• To establish service sites’ compliance with the implementation of the Batho Pele Framework.

The inspections had been conducted during 2013/14 in four provinces -- Free State, Limpopo, North West and the Western Cape. Eleven district offices, two regional hospitals, seven district hospitals, 21 clinics and six community day centres were inspected, both urban and rural. Both announced and unannounced inspections had been conducted, led by PSC Commissioners. All identified sites had been preceded by a brief discussion with the officials of the provincial and relevant district offices in order to obtain an overview of the situation in respect of the sites visited. The key themes for collecting data for announced inspections were the management of medicines and medical equipment. The unannounced inspections were guided by the Batho Pele framework.

The key findings of announced inspections focussed on the management of medicines and medical equipment. The key functions of effective and efficient management of medicines, as outlined in the National Drug Policy of South Africa, formed the basis of the findings of the inspections. These functions covered product selection, procurement, distribution and storage, and rational use, monitoring and evaluation. They also included the management support, which was the budgeting, organisation/staffing, training and information system.

Within product selection, the PSC observed that in all provinces, pharmaceutical and therapeutic committees (PTCs) were established at hospital, district and provincial levels for the identification of new drugs. District offices ensured that in the identification of new drugs, prevalence of diseases in the communities served by the hospitals and clinics were taken into consideration. Lists of new drugs were considered by district PTCs, consolidated and submitted to provincial PTCs for final approval by the National Essential Drug List Committee. Generally, product selection was found to be well institutionalised and contributed effectively towards the availability of medicines at health care facilities.

On procurement, in all provinces visited, supply of medicines to health care facilities was done through medical depots. District offices consolidated and forwarded the pharmaceutical, medical consumables and medical stationery orders directly to the depots. However, district hospitals were allowed to use either “buy out” or “direct deliver voucher” methods in cases of urgent needs. The term “buy out” meant the hospital ordered directly from the suppliers or pharmaceutical companies on a quotation basis, and could be used only on an emergency basis with pre-approval. The term “direct deliver voucher” (DDV) meant that medicine was ordered through the medical depots, but the medicines were delivered directly to the hospitals by the supplier or pharmaceutical company and only in cases of emergencies. This level of flexibility contributed towards the efficient acquisition of urgently needed medicines at the health sites, and therefore, ensured stock availability.

With regard to distribution and storage, medical depots were responsible for the distribution of medicines to all heath care facilities, except in the cases of “buy out” or DDV. North West and Free State had challenges regarding the timely delivery of ordered stock, which resulted in facilities having to use their own transport to fetch orders. In particular, the challenge in the Free State, at Thabo Mofutsanyane Clinic, was attributed to the late payment of suppliers during the financial year, as most of them had decided to withdraw their services to the Free State Department of Health (FSDoH). In the Western Cape, the distribution system of the Cape medical depot was found to be highly effective, with the transportation of medical supplies undertaken efficiently. In addition, the district hospitals also regularly kept buffer stock from which they supplied the community development centres (CDCs) and clinics whenever the latter experienced shortages. However, at the Knysna District Hospital (Western Cape), concerns were mainly around insufficient vehicles to transport chronic medication to the various sites. There was general compliance with the applicable standard operating procedures in the majority of health facilities, with pharmacies always locked and notices displayed, prohibiting unauthorised access. In addition, all facilities used the “first expired, first out” principle in identifying outdated medicines for disposal. Waste buckets were also used for safekeeping medical waste.

With regards to rational use, monitoring and evaluation, guidelines for district pharmacists on visiting health facilities had been developed in the Free State, North West and Western Cape. Only the Western Cape was found to have evidence of adherence to its guidelines, with the district pharmacist conducting workshops and analysis of stock levels. In the other provinces, district officials and nursing staff indicated that visits were conducted, but no proof could be obtained. Various systems were used to monitor and evaluate the availability of medicines in each province. In the North West, hospitals utilized the Rx Solution, while clinics used stock cards. Western Cape used WINDRDM for ordering and managing stock availability. In the Free State, the Tracer Drugs system in place ensured that all facilities achieved the target of 95% set in district health plans with regard to medicine availability.

The management of equipment findings was described, by province. In the Free State and North West provinces, the procurement of medical equipment was centralised at the provincial head offices. All health facilities had raised concerns with this approach, especially since it resulted in delays in procuring new or replacing broken equipment. In the Western Cape, it was found that this function had been decentralised to district offices. In North West province, the procurement of poor quality equipment was attributed to the supply chain management process of selecting the cheapest quotations. Asset management and control were found to be in place at all visited sites.

Dr Boshoff said that the issue of power cuts and poor sanitation in the Phuthadichaba Area and greater Free State province had been taken up with the MEC for Health in the province, and there would be collaboration with him to address this issue. In North West, disposal of medical equipment had not been properly adhered to, since broken equipment was found lying around at Unit 9 Clinic, with some posing a hazard to the public.

The findings for unannounced visits were:

- Condition of the buildings: In all provinces, inspected facilities required maintenance, with Bophelong clinic (Free State), Unit 9 and Tlapeng clinics (North West) requiring urgent refurbishing.

- Access to information: In all provinces visited, facilities had key information on health issues, business hours, and service charters visibly displayed. Suggestion and complaint boxes were also available and visibly displayed.

- Signage: Inspected sites had inside and outside signage. However, outside signage needed to be augmented with direction signs at key strategic points (i.e. road intersections) to improve accessibility.

- Observing Staff: In most sites visited, staff members had their name tags on and were friendly. However, pharmacists found at most inspected hospitals did not have name tags on.

- Waiting Time: Most citizens at the visited facilities were highly concerned that waiting time was long, ranging from two to four hours.

- Access to services: Citizens at Phuthaditjaba clinic (Free State) and Sedgefield Clinic (Western Cape) raised concerns about the travelling distance to their clinics, indicating that they travelled 10km to 20km to access their clinic, which was in excess from the set 5km radius of the applicable norms and standards.

- Water and Sanitation: Generally, there was no challenge of water and sanitation in most inspected facilities. However, BrentPark clinic (North West) experienced poor water supply, whilst Bophelong clinic’s quality of water led to a number of diarrhoea cases. Furthermore, Unit 9 clinic’s toilet facilities require urgent refurbishing due to damaged sanitation pipes.

General challenges encountered included power failure in facilities within Thabo Mofutsanyana district in North West, and a general shortage of health professionals in all visited sites. In the Free State and North West, this was exacerbated by a lack of accommodation and key amenities. Emergency medical services were poor in all districts visited in North West, due to insufficient ambulances.

The implementation of the 2009 recommendations had been met with some success. The findings showed that 29 (76%) of the 38 recommendations contained in the 2009 PSC reports on inspections of primary health care had been implemented. Limpopo and Western Cape had 100% implementation compliance, while Free State had 94% compliance and North West had 58% compliance. The overwhelming rate of implementation of the recommendations was indicative of the recognition of the value-add of the PSC’s work by the provincial departments. The 2012/2013 recommendations would be made available for the Committee at a later stage. Upon completion of the provincial reports, copies had been sent to the Executive Authorities and Accounting Officers. In particular, Accounting Officers were required to respond to the PSC on the implementation of the PSC’s recommendations within six weeks of the receipt of the reports. None of them responded within the set time. The PSC through its Provincial Commissioner had recently engaged the MECs and HoDs to obtain feedback on the PSC’s recommendations. A schedule of the recommendations had been provided, with implementation on-going.

Discussion

Dr W James (DA) commended the presentation but said that the stock outs due to non-payment by hospitals highlighted the problematic nature of financial management of health facilities. He asked what could be done to resolve budgetary problems, such as money allocation. Was spending taking place when it should be? Were budgeting guidelines being followed? What was the problem of budgeting?

Mr A Shaik Emam (NFP) said that professionalism and the attitude of staff had been satisfactory in the inspections, but there was a general trend of patients complaining about the attitude of the staff. With regard to the prevalence of disease, budgets seemed to be allocated in provinces according to the number of people per province, but did they also take into account the needs of the provinces and if not, could they be restructured to enable provinces to deal effectively with the prevalence of certain diseases? With regard to direct approvals, who was supposed to be paying for the medicine and medical equipment? What was the solution to the issue of late payments, especially in the Free State, because recommendations were not being followed? Had there been an improvement? How could the issue of distance travelled to clinics in rural areas be addressed? Was it possible for there to be a unified system of medical depots across provinces? There had been a failure to budget for maintenance of facilities, and that would then need to be included in the strategic plans of the departments.

Mr I Mosala (ANC) said that there was a problem of language in the presentation. On one slide, there had been a point listed as a challenge under distribution and storage, while there was a problem in the North West and Free State regarding time of delivery of stock -- was there a problem with suppliers, or with the depot system? On another slide, the problem of transport in the Western Cape was listed as a concern, but was that not the same as a “challenge,” rather than a “concern?” Were there any specific tools which were used to determine whether guidelines had been followed, especially in pharmacies? The shortage of professionals in North West and Free State was said to be due to a lack of accommodation, but in the Western Cape there was no reason cited -- why was that? The bad situation of ambulances in North West was cited, but what about the situation in the other two provinces? He congratulated the PSC on the presentation, as it assisted the Committee in its oversight role.

Ms L James (DA) asked if there had been any feedback on the waiting time in clinics and hospitals. At Mmabatho Clinic, had the smell problem been addressed? The cleanliness of the clinics and the waiting time had always been a problem for patients across the board. She also asked what criteria were used to select the districts and their health facilities.

Mr A Mahlalela (ANC) asked about the adherence to the recommendations of the PSC. Why was the North West cited to have done the worst in the implementation of the 2009 recommendations in the presentation, but the Free State was cited as the worst province out of the three in annexure F? The compatibility of the documents was questionable, so he asked for clarity. Looking at governance structures in the hospitals and clinics, North West and Western Cape had functional governance structures -- but how did the PSC define functionality? This question was raised because the national department was still in the process of developing norms and standards. On the issue of maintenance of infrastructure, did the provinces which were reported to be 100% in compliance have no issues at all, or did this imply that they needed no maintenance at all? There also needed to be clarity on what was meant by acceptable waiting time -- was this waiting time determined by the norms and standards, or by the patients? This included emergency services in the rural areas. He commented that the focus of the PSC should also be to inspect the areas the Minister of Health had highlighted to be significant problems in the system that could lead to collapse, such as financial management, human resources, and infrastructure.

Ms M Mokause (EFF) asked what the nature of the interaction was between political leaders, PSC Commissioners and Accounting Officers. Had there been any response from the Accounting Officers and political leaders to the recommendations of the PSC? Another issue was the suggestion boxes in hospitals -- would these work, and how could they be made effective?

The Chairperson said that there were inconsistencies with the facts stated in the presentation, especially with regard to North West and the Western Cape. The presentation needed more detail, especially in respect of the districts. Were there any risks of maladministration of the DDV system? Were there any monitoring systems?

Mr S Jafta (AIC) asked whether the working conditions of health professionals had contributed to the waiting time and attitude problems.

PSC’s response

Dr Boshoff replied to the questions by outlining the fact that the expansion of public health provision to the entire population guaranteed equal medical care. This right to public health care also included basic and specialised health care, but the state did not have adequate funding. Inspection of Pelonomi Hospital had revealed that the budget was not appropriate for the needs of the hospital because it served a tertiary health care facility, and a training and procedure facility. The cost of acquiring medical equipment was expensive and exorbitant, and the budget was spent mostly on operational costs, which were salaries. However, there was still a shortage of staff.

The Minister had pointed out that there were challenges to the health system, and the PSC provided recommendations to assist in addressing these challenges. No province was immune to the various challenges. The 100% implementation score given to provinces was for their compliance with 2009 recommendations, and not for the extent to which they were efficient. The 2013/2014 information required a lot verification before it could be made available to the Committee.

The medical professionals in clinics wanted to do more work and were positive about what was required of them, but there were exceptions to every rule because there were also some less interested health professionals. Those who had a professionalism and attitude problem needed to be addressed, but otherwise the inspections illustrated satisfactory conduct by most professionals. The waiting time for medicines was not the problem, but the waiting time for consultations was. There needed to be a review of human resources shortage in the health sector, as illustrated in the presentation.

The recommendations which the PSC had made were based on the documentation presented to them by the department and hospitals. The inspections had also been conducted through interviews with patients and staff. The problem with committees in hospitals and clinics was that they were dysfunctional in general, but some provinces had more dysfunctionality than others, and this was very true for rural districts. The issue of ambulances was worse in North West, because the interviews conducted with patients and community members indicated that ambulance arrival times were bad. Suggestions boxes did not work, because patients had the perception that the suggestions were not read by hospital management, or that they could be victimised through the suggestion boxes.

Ms Irene Mathenjwa, Chief Director: PSC, said that the issue of service providers applied across all levels of government, not only in the health sector. Public hearings had been held by the PSC with service providers, to investigate the challenge of the 30-day payment period, and non-payment of service providers. The problem which had become evident was the dishonesty within government -- people who were required to pay bribes before being paid for their services. The service providers were unaware of the invoice requirement by Treasury, the process of payment and the general requirement before becoming a viable service provider. Management of the budget, especially at the beginning and the end of the financial year, was problematic. Due to the need by government agencies and departments to have clean audits, or to the general problem of exhausted funds, the payment of service providers was delayed. The health district strategic plans were created under the guidelines of the National Health Act, and there had been problems with some of them, but overall they had been good. There was a new public hearing session for service providers which would take place in collaboration with the Department of Public Service and Administration, to address the payment challenges. There had been a collaborative agency formed by the Department of Planning, Monitoring and Evaluation and the Treasury to hold provincial and national accounting officers responsible for departmental expenditure.

The issue of staff attitude was problematic. There was problem with management styles in the hospitals and clinics. One had to look at human resource management and the grievances surrounding performance management, and how that impacted service delivery and staff attitudes. The announced inspections had been very open to management and staff, but most of the problems had been discovered during the unannounced inspections.

The issue of the DDV was that the hospital paid for the medication itself through its supply chain management department. The health district would determine beforehand exactly what the prevalent diseases were, and the medications for those were the only medicines allowed to be purchased on DDV with the district’s approval.

Distances travelled to access government services was a problem across government, but there needed to be more mobile sites and more cooperation with the communities in these areas, to enable collaborative service delivery. Service providers were not equipped with the necessary tools to deliver medicines to areas in North West.

Maintenance was more a Department of Public Works issue, rather than a health issue. There was a serious need to fast track implementation of maintenance.

Emergency Medical Services (EMS) was a problem in all provinces, especially in rural and disadvantaged communities. EMS vehicles could not get to some areas and the waiting time for ambulances was far beyond the 40-minute recommended waiting time, so the Department and community had to liaise to establish methods to make this easier. Also there was a need to ensure the safety of the EMS personnel in these areas.

Service delivery across the country was not consistent, because capacity was different in different parts of the country, but the situation spoke to the overall calibre of the public service and the challenges being faced by the public service overall. There had been compulsory induction done by the PSC for the whole of the public service as a way of introducing and entrenching a public service ethos, and what was expected of them as public service professionals. This had been done as a complement to the departmental inductions.

The districts inspected in 2009were a mixture of rural and urban, and those were districts again used in the 2012/2013 inspections. The attitudes of public health professionals from the 1980s were very different from those at present, and this needed to be addressed. The other issue with inspections was that the PSC did not have the capacity to have the inspections on a scale that would make them effective.

Ms Selinah Nkosi, National Commissioner: PSC, and Head of the Health Cluster, said that a recommendation for the use of one system of medical and medical equipment purchasing and distribution was not possible, because the systems were created to be context specific. The North West PSC office would address the issue of the smell at Mmabatho. The areas of concern that the Minister had pointed out would definitely be taken into account when inspections were planned and subsequently undertaken. The issue of the language of the presentation had also been noted and would be carefully considered in subsequent presentations.

The inspections also played a role in identifying gaps in the system, like the problem with suggestion box compliance by hospital management. There needed to be stronger measures put in place for compliance with the suggestion box requirement, because what was happening within these institutions had to be established. Who was to be held accountable by the community for upholding the grievances and dealing with them? The problem of capacity was also a problem in the PSC, so the inspections and findings tended to be not too specific.

Dr P Maesela (ANC) asked about expired medication and the practice of repackaging medicines. He said the methodology of inspection seemed to be very limited. Another issue was what recommendations the PSC could make about how to address the discrepancies in rural and urban health care. There needed to be further inquiry about introducing an integrated ICT system in order to deal with fraud. Another issue he raised was about health professionals not wanting to work in rural areas, and suggested there needed to be a way in which those who lived in rural areas could be pulled into the health profession, instead of having to import professionals from the urban areas. Another issue was how the PSC could help to address departmentalism and the absence of coordination?

Dr James said that there needed to be honest engagement about adopting systems that worked, and the Committee should not consider party politics when this took place. If the system of the Western Cape worked, why not adapt it for other provinces? He said that the presentation mandate had been limited, which was probably why so much detail was missing. The lack of budget experienced at Pelonomi was probably due to a lack of planning and appropriate management of the budget. If ever a hospital needed more money, they had to request it through the correct channels. Pelonomi was another example of a hospital that had medical equipment, but which was not used, and the general condition of the hospital was appalling. The problem of staff shortage at Pelonomi was what resulted in long waiting times. The problem with most hospitals lay in the quality of the leadership, especially the CEOs.

Mr Shaik Emam asked whether there was a process for following up with those who failed to manage hospitals properly. He said that the problem of long waiting times was not unique, and he used the example of a clinic in B Section of Khayelitsha, which had a waiting time of almost nine hours per patient.

Mr Mahlalela said the current presentation was about the 2009 recommendations and the 2013 report, but Members needed to see the recommendations of 2009 to make sense of the 2013 challenges. He also asked what recommendations the PSC had for dealing with non-compliance which could be binding.

The Chairperson asked whether the capacity issue of the PSC was about the number of commissioners, or about the resources at their disposal. She said the inspections needed to be related to the concerns of the ministry. Another issue was whether it would be appropriate to go beyond the scope of the PSC and request an audience with the Minister of Health and the Treasury to address the problems which had been identified.

Dr Boshoff thanked the Committee for its guidance. The comments would be taken into account to improve the process of inspection and reporting. Expired medicines had been found in Limpopo, and that issue was being addressed with all health facilities. The Pelonomi hospital report from the inspection done in February was being finalised. This report would highlight all of the challenges of human resources, financial management and general leadership issues. He also said that the issues of non-compliance had to be dealt with by the Committee, under the guidance of the findings of the PSC.

Ms Nkosi said that the capacity of the PSC had to do with financial resources primarily, as well as a human resource shortage. Each province had its own commissioner, but there had been budget cuts to the Commission’s budget. Each national commissioner had a cluster for which they were responsible, and she was responsible for the health cluster. There were also reports from the January and February inspections which would be released. However, there were reports on every province available on the PSC website.

Ms Mathenjwa agreed with the Chairperson about the need for the PSC to extend its scope and engage in more interventions, because it was able to do so. The three main components of the PSC were management and leadership; planning, monitoring and evaluation; and professional ethics. All these components had been included in the presentation but it was important that PSC went beyond the scope it had presented and dealt with issues which were beyond internal remedy and required intervention. The PSC would forward the 2009 report to the Committee, but there needed to be contextualisation because in 2013, not all provinces had been inspected.

The Chairperson said that the 2009 report was important for contextualisation. Health was a very emotive subject. Politics and ideology had to be involved in health. The PSC must not alleviate the situation of just professional nurses and doctors -- their observations must be inclusive of all workers in the health sector. The inspection of staff performance and attitudes must include everyone who worked in hospitals and clinics.

Commenting on the level of public awareness about the PSC and the role they played, she said the general population needed to be able to access the Commission, especially those in rural areas, because they were important for inspection too.

The Chairperson thanked the PSC presenters and excused them from the meeting.

Adoption of minutes

The minutes of 18 March 2015 were proposed and seconded by Dr James and Dr Maesela, and adopted with amendments.

The minutes of 24 March 2015 were proposed and seconded by Dr James and Mr Shaik Emam, and adopted with amendments.

The minutes of 25 March 2015 were proposed and seconded by Mr Mosala and Dr James, and adopted with amendments.

The minutes of 13 May 2015 were proposed and seconded by Mr Mosala and Dr James, and adopted with amendments.

Announcements

The Chairperson said there would be a Committee week from 21 to 26 June 2015. The Committee would be going on oversight visits, and Members should note that the Office of the Speaker had become very strict about cancellations without notification well in advance.

Dr James asked when the Medical and Related Substances Amendment Bill would be tabled in Parliament.

The Chairperson replied that it would be presented in Parliament at the next available sitting.

Mr Mosala asked whether it would be possible to deal with the issues presented in the report about the Bill before it was tabled in Parliament.

The Chairperson replied that doing that would not be procedural and within the rules.

The meeting was adjourned.