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A ministerial task team committee was appointed to investigate the state of affairs at identified hospitals. The team assessed patient rights, professional conduct, management contributions, support services, procurement procedures, oversight role, and more.
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MINISTERIAL TASK TEAM COMMITTEE INTO INVESTIGATION OF SERVICE DELIVERY IN SELECT HOSPITALS
BACKGROUND The Minister of Health, Dr. Aaron Motsoaledi, appointed a five-member task team on the 14 July 2015 to investigate the state of affairs at identified hospitals. The Ministerial Task Team comprises: a) Prof R. Green-Thomson, Former Head of Department, KwaZulu-Natal Department of Health. b) Dr R. Mgijima, Former Head of Department, Gauteng Department of Health. c) Prof KC Househam, Former Head of Department, Free State and Western Cape Provincial Departments of Health d) Ms NomvulaMarawa, Former Director Policy Planning and Coordination, National Department of Health and Senior Technical and Advisory Support TAU/GTAC, National Treasury e) Mr A. Karim, Procurement Support, South African Revenue Service.
BACKGROUND Contd. A chairperson was not appointed by the National Minister and the MTT agreed to a rotating chairperson. Three members of the MTT acted as chairperson during the term of the MTT and they were: a) Professor Green-Thompson until September 2016 b) Professor Househam September 2016 until March 2017 c) Ms Marawa from April 2017
TERMS OF REFERENCE b) Whether or not: • The rights of any patients were violated. • Any health professional breached any professional health ethical or other code of conduct. • The conduct of the management of the hospital contributed in any manner to the state of affairs at the hospital. • Support services are functioning optimally
TERMS OF REFERENCE Contd. • Procurement procedures are in place and compliance adherence thereof • The oversight role of the Provincial Health Department and District Management to the hospital was exercised adequately • The role supervisors played in bringing to the attention of the Provincial Health Department, National Health Department and the Health Professions Council of South Africa the state of affairs in the hospital. • Make recommendations on the corrective measures required to address whatever shortcomings or transgressions have been found.
PROVINCIAL STAKEHOLDER ENGAGEMENT AND INVOLVEMENT Provincial stakeholder engagement and involvement in this project was deemed critical. The first intention was to engage with a range of stakeholders to determine the respective hospital services strengths and weaknesses, acknowledge what facilities are achieving in the delivery of health services under often trying and demanding circumstances. The second intention was to explore, without being judgmental, what is being achieved or not being achieved in a spirit of partnership with stakeholders. An open approach, confirming and validating the responses of stakeholders was deemed a critical ingredient of the success of the task team’s approach. Finally, together with stakeholders the task team would discuss and confirm the next steps for improvement.
PROVINCIAL STAKEHOLDER ENGAGEMENT AND INVOLVEMENT Contd. The key stakeholder’s interviews focused on: Exploring what has been done with regard to the findings of previous investigations and reports where applicable as well as the recommendations from Office of Health Standards Compliance (OHSC). Interactions will focus on documenting stakeholder experiences and lessons learnt related to:
PROVINCIAL STAKEHOLDER ENGAGEMENT AND INVOLVEMENT Contd. • Health service delivery • Hospital and health services planning • Health professional staffing • Operational and support issues including human resource training and staff development • Funding, supply chain and logistics • Infrastructure, equipment, ICT • Risks and concerns in the context of OHSC assessment findings and required improvement plans
PROVINCES VISITED BY THE MTT Provinces and hospitals visited by the MTT A decision was taken in consultation with the Minister that not all Provincial Departments of Health would be visited given the fact that the MTT was able to identify and integrated cross-cuttings findings and recommendations. The following Provincial Departments of Health were visited by the MTT and they are: a) Limpopo b) Eastern Cape c) Free State d) KwaZulu-Natal e) Mpumalanga f) Northern Cape
HOSPITALS VISITED BY THE MTT Limpopo • Pietersburg (Polokwane); • Mankweng; Eastern Cape • Bisho • Grey • Victoria • Cecilia Makiwane • Frere • Nelson Mandela Central
HOSPITALS VISITED BY THE MTT Contd. Free State • Pelonomi • Universitas • National Hospital • J.S Moroka KwaZulu Natal • Prince Mshiyeni • Mahatma Gandhi • King Edward • Addington
HOSPITALS VISITED BY THE MTT Contd. Northern Cape • Harry Surtie (Upington) • Prieska • De Aar • Colesburg • Kimberley Mpumalanga • Witbank • Middleburg • Emerlo • Piet Retief
FINDINGS a) Hospitals are operating under extreme service pressure within an environment of constrained financial, technical and human resources. b) The situation is exacerbated by the ongoing instability of management appointments and political office bearers and an apparent environment characterized by uncertainty and at times interference in the line functions of appointed officials at the hospitals. c) There are a significant number of key managerial posts that have been vacant for a considerable period of time in the provincial departments of health.
FINDINGS Contd. d) A tendency exists for management, both provincial and hospital to defer accountability for the deficiencies to others. e) The inability of the hospitals to recruit and retain skilled staff both in the clinical areas (doctors, nurses and allied health professionals) and the support areas (administrative and technical) has negatively impacted on the ability of the hospitals to provide quality health care. f) Critical shortages of staff exist, particularly medical and nursing staff due to the “freezing of posts” at the hospitals.
“FREEZING OF POSTS” I wish to comment on this particular finding because I was accused of having lied to the public when I responded to a query on this issue of freezing of posts when questions were asked by stakeholders I was not lying, I was just putting the official position of Government
“FREEZING OF POSTS” Contd. I belong to a Committee of Ministers called MinCombudwhich deals with the Budget of the country before it gets presented to Cabinet and subsequently read as a Budget Speech by the Minister of Finance in Parliament. I want to quote from the Budget Speech of the Minister of Finance of February 2016:
“FREEZING OF POSTS” Contd. “Taking into account the current fiscal framework, the Provincial MECs for Finance have agreed to a Joint Action Plan to address expenditure management and service delivery improvement challenges. Key measures include: containment of administrative personnel expenditure while protecting education and health service staff…”
FINDINGS Contd. g) The difficulty in recruiting staff, particularly those with scarce skills, to rural provinces has resulted in severe skills shortages both clinical and non-clinical at the hospitals. The cost and availability of housing as well as the availability of appropriate schools was described as a limiting factor in the retention of staff particularly in the hospitals in smaller towns. h) Moratoriums have been placed on all staff appointments in many provinces with the exception of clinical staff in some provinces. All appointments in several provinces require the direct approval of the MEC for Health. In several provinces, human resource delegations have not been approved by the MEC and therefore all appointments require the approval of the MEC.
FINDINGS Contd. i) The current limited delegations available to the management of hospitals for human resource management functions with the centralization of all appointments together with the imposition of a moratorium on staff appointments has worsened the situation as evidenced by examples of suitably qualified persons applying for critical posts at hospitals going elsewhere due to delays in the appointment processes. j) The overall financial position of the Provincial Governments and that of the Provincial Departments of Health has impacted both indirectly and directly on the ability of the hospitals to fulfil their mandate of providing quality clinical care to the patients they serve.
FINDINGS Contd. k) Significant budgetary pressures exist with resultant over expenditure and accruals, including accruals for personnel expenditure such as overtime and rank promotions, which would appear to be irregular in nature. l) The current budget allocations to hospitals are: • Either inadequate in terms of the need to fund the current staff establishments since the current budget allocations often require up to 75% of the total budget to fund the personnel budget as opposed to the ideal of around 60% for hospitals, resulting in inadequate funding of good and services required to operate the hospitals effectively. • Or adequate but required to fund a staff establishment that is inappropriately large and incorrectly distributed in terms of staff categories for the effective delivery of quality health care, which would then require a restructuring of the staff establishments to ensure that the revised establishment does not consume more than 60% of the available budget.
FINDINGS Contd. m) Procurement is limited by provincial decisions to centralize all procurement to a provincial level in various provinces and this has had a very significant and detrimental impact on the ability of hospitals to ensure the availability of medical consumable items and equipment. n) The current situation of limited delegations available to the management of hospitals for financial management impacts severely on the ability of the hospitals to function efficiently. The impact of these steps on the functioning of the hospitals cannot be minimized. It is certainly not clear that all the restrictions currently in place are either required by the budgetary constraints experienced by provinces or the need to exercise governance over the functioning of the hospitals. The result of this is seen, for instance, in the inability to procure timeously essential equipment and services at hospitals.
FINDINGS Contd. o) The absence of, or inability to access, appropriate transversal provincial or institutional contracts has placed an undue emphasis on procurement by quotation, rather than an ordered procurement process governed by need, having tested the market and ensuring that the best value for money is obtained in every case. This has resulted in limited resources being inappropriately utilized and in certain instances an important service such as maintenance not being acquired. Despite the existence of transversal national contracts in certain instances, hospitals are prevented from accessing these contracts due to Provincial Treasury instructions. p) Patients are managed in unacceptable conditions in certain hospitals due to unavailability of essential medical equipment, medical consumables, linen and in places crumbling infrastructure resulting from a failure of maintenance leading to interruptions of water supply, sewerage blockages, failure of lifts and unserviceable air conditioning amongst others.
FINDINGS Contd. q) Many hospitals suffer from various infrastructural and design challenges, which militate against the cost-efficient delivery of health care, which could be corrected but would require significant capital investment. Nevertheless, with improved maintenance and judicious replacement of equipment and technology the functionality of hospitals could be significantly improved. r) Observations of the MTT suggest that there is a need for emergency relief as the current approach to the procurement function has led to decreasing levels of patient care and increasing levels of wastefulness.
FINDINGS Contd. s) The weaknesses related to the management of the procurement function has a direct bearing on low levels of staff morale and teamwork, poor financial and operational efficiencies, levels of care and service, and negatively impacts on patient rights.
SUMMARY OF FINDINGS This clearly shows the four purely provincial functions (not concurrent) that I have mentioned to this Committee before • HR • Procurement/Supply Chain Management • Financial Management • Maintenance of Infrastructure and Equipment
SUMMARY OF FINDINGS Contd. The two major healthcare crises that occurred in the country last year and this year – Life Esidimeni in Gauteng and Oncology Services problem in KZN, are clearly procurement and HR problems as I have said in this Committee before
SUMMARY OF FINDINGS Contd. My conclusion is that a minister in health has a huge responsibility, but zero authority where it matters the most. Such authority is with the MECs of both Finance and Health, their Premiers and Executive Councils
RECOMMENDATIONS 1. That the managerial and operational challenges experienced by the hospitals are accepted as real, not necessarily related only to managerial inadequacies at the hospitals and in need of urgent and decisive managerial intervention. 2. That the separation of powers and functions between political office bearers and management are clarified and entrenched as set out in the relevant legislation in particular the Public Finance Management Act (Act 1 of 1999 as amended) and the Public Service Act (Act 103 of 1994 as amended) taken together with the relevant regulations
RECOMMENDATIONS Contd. 3. That it is accepted that the challenge to improve the performance of hospitals does not lie solely within the hospitals themselves but rather reflects a wider challenge within the Provincial Departments of Health and the respective Provincial Governments. 4. That the instability of management as evidence by the number of managers in acting positions at both the level of the Provincial Departments of Health and within the hospitals is urgently addressed as without managerial stability and certainty of tenure no successful turn-around strategy is likely to succeed.
RECOMMENDATIONS Contd. 5. That appropriate national human resource delegations are developed (templates available from some provinces) and approved by the Provincial MEC’s for Health to enable the timeous and efficient appointment of key clinical, technical and administrative staff at both hospitals. 6. That the undertaking of the WISN or similar standardization of staff establishments exercises at hospitals are expedited in order to implement evidence-based and collectively agreed staffing norms within facilities. 7. That an approved post list of funded posts within the allocated budget be developed and utilized to manage the appointment of staff.
RECOMMENDATIONS Contd. 8. That within the framework of this approved post list that the authority to fill posts be decentralized to the hospitals to enable the more effective recruitment and appointment of staff particularly in the scarce skills disciplines. 9. Leadership and governance requires urgent decisive action including effective implementation of accountability and consequence management. Monitoring and follow through is important. 10. Quality of care and patient’s rights needs attention at all levels given the increasing litigation cases, vacant critical costs, weak productivity and performance management of clinical and support staff.
RECOMMENDATIONS Contd. 11. That the Provincial Treasuries are engaged on the baseline allocations to the provincial Departments of Health and the priority in terms of health care services particularly given the very high dependency of rural communities on the public health sector is highlighted and addressed. 12. That the share of the provincial budget allocated to health departments is adequate in terms of being around 38% of the total provincial budget, which appears not to be the case in several of the provinces. 13. That the provincial health budgets are not made unrealistic by an initial subtraction of accruals without consideration of the service consequences.
RECOMMENDATIONS Contd. 14. That in the case of significant outstanding accruals that a financial management plan is developed with the respective provincial treasury (PT) to amortize these accruals over a manageable period and amount per annum. 15. That once the final health budget has been allocated that it is accepted by the health department as binding and cannot be exceeded. 16. That a process is undertaken in provinces whereby budgets are equitably and realistically allocated to health facilities (hospitals) taking into account the respective priorities of each facility in line with the provincial priorities. This process will require an analysis of the historical budget allocations and the breakdown of these budgets according to the standards items (personnel and goods and services) as reflected in the provincial budget documents.
RECOMMENDATIONS Contd. 17. That the budget allocations to hospitals are urgently reviewed with a view to temporary relief of the unmanageable budgetary allocation when this results in the consumption of 75% or more of the total budgets allocated to hospitals by personnel expenditure. As with the provincial health allocation, each facility budget will have to take into account accruals and where these exist as at a provincial level an agreed strategy adopted to manage these accruals to a zero figure. 18. That in exchange for this budgetary relief that an urgent and time-bound investigations (6 months) of the staff establishments is undertaken with a view to addressing the need to reduce the expenditure on personnel progressively over a 3-year period towards the accepted norm of not greater than 65%.
RECOMMENDATIONS Contd. 19. That where this has occurred that the decision to centralize the procurement to the Provincial Department be reviewed urgently and with the necessary control measures to ensure financial compliance that procurement for non-contract and contract medical consumables and medical equipment be undertaken at the hospitals 20. That urgent attention is given, possibly with the assistance of the National Treasury (Office Central Procurement Officer) and National Department of Health, to the implementation of provincial (ultimately national) contracts to facilitate the procurement of essential goods and services by the hospitals in the most cost-effective and efficient manner to address the needs of quality health service provision. 21. That provincial goods and services expenditure is reviewed and prioritized according to the need to ensure that essential items, maintenance and equipment is available at all health facilities in the province but especially the key hospitals.
RECOMMENDATIONS Contd. 22. That systems are put in place that allow management at all levels i.e. national (Treasury and National Department), provincial (Treasury and Health Department), regional and district where relevant and facility (hospital) to actively monitor and where necessary control the levels of expenditure against the standard items referred to above. The current system of “non-negotiables” instituted by the NHC is an after the event mechanism and only identifies “symptoms” rather than allowing management of the problem. Although the National Treasury and Department of Health as well as the provinces have access to both PERSAL and BAS, what is required is an extraction of this data in such a manner that it is applicable and accessible to the level of management concerned. In the case of hospitals to the level of the CEO and the management team within the hospital.
RECOMMENDATIONS Contd. 23. That urgent attention is given to the functionality of the primary and regional health service platforms (equipment and staff) from which patients are currently referred to the tertiary and central hospitals to reduce unnecessary referrals and walk-in patients to hospitals.
RECOMMENDATIONS Contd. 24. That once managerial stability has been achieved with necessary support that hospitals develop detailed, action-orientated and time-bound action plans to address the following: • Clinical services with a focus on the provision of appropriate quality care at the most appropriate level in cooperation with the regional and district health services supported by a participatory system of clinical governance. • Human resource management with a focus on the appointment of key staff and the review and restructuring of the staff establishments to within affordable limits cognizant of the need to address staff morale. • Financial management with a focus budgetary control to limit expenditure within the allocated budget and supply chain management to ensure cost-effective procurement of goods and services. • Equipment and physical infrastructure to facilitate and ensure the optimum delivery of quality health services within the allocated resources.
RECOMMENDATIONS Contd. 25. Although procurement system is broken, corrective action must be properly considered as the current system will not cope with immediate, complex and far reaching interventions. A phased approach will have to be adopted which should: • Phase 1: Get basic system working with simple interventions and improved governance to get products to the hospital – use much of the current system with some changes and a set of priorities. • Phase 2: Establish the required foundational capabilities and infrastructure to ensure the functioning of the procurement system as required by policy and service outcomes. This should be based on a centre-led model and differentiated procurement strategies for each of the critical items used by hospitals. • Phase 3: Systematically migrate all procurement operations onto the new system.
