THE PORTFOLIO COMMITTEE ON HEALTH 20 MAY 2015

1. PRESENTATION: CONSOLIDATED REPORT ON INSPECTIONS OF DISTRICT HOSPITALS AND CLINICS REGARDING AVAILABILITY OF MEDICINES AND MEDICAL EQUIPMENT AND THE ROLE OF HEALTH DISTRICT OFFICES (FREE STATE, NORTH WEST AND WESTERN CAPE) THE PORTFOLIO COMMITTEE ON HEALTH 20 MAY 2015

2. OVERVIEW OF THE PRESENTATION • INTRODUCTION AND BACKGROUND • AIMS AND OBJECTIVES • SCOPE AND METHODOLOGY • KEY FINDINGS: ANNOUNCED INSPECTIONS • KEY FINDINGS: UNANNOUNCED INSPECTIONS • IMPLEMENTATION OF THE 2009 PSC’s RECOMMENDATIONS • RECOMMENDATIONS

3. INTRODUCTION AND BACKGROUND • The Public Service Commission (PSC) is mandated to promote the values and principles set out in Section 195 of the Constitution, and to propose measures to ensure effective and efficient performance within the Public Service. • Accordingly, the PSC Act, 1997 provides that “the Commission may inspect departments and other organizational components in the Public Service and has access to such official documents or may obtain such information from Heads of those departments or organizational components as may be necessary for the performance of the functions of the Commission under the Constitution or the Public Service Act”. • Amongst government's priorities and outcomes is: A long and healthy life for South Africans. The PSC has during 2012/13 conducted inspections regarding the availability of medicines and medical equipment and the role of health district offices.

4. INTRODUCTION AND BACKGROUND • The PSC acknowledges the amendment of the National Health Act 2013, which provides for the establishment of the Office of the Health Standards Compliance (OHSC). • As the health quality watchdog, the OHSC will lead the much needed improvement in service quality and changes in public health care management. • The PSC has held engagements with the OHSC to explore possible collaborations and cooperation in the improvement of health care services.

5. AIMS AND OBJECTIVES OF INSPECTIONS • 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 have 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.

6. SCOPE AND METHODOLOGY • The inspections were conducted during 2013/14 FY in four provinces, namely, Free State, Limpopo, North West and Western Cape Provinces. 11 District Offices, 2 Regional hospitals, 7 District hospitals, 21 clinic and 6 Community Day Centres were inspected (both urban and rural). • Both announced and unannounced inspections were conducted, led by PSC Commissioners. • All identified sites were 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 Batho Pele framework.

7. KEY FINDINGS: ANNOUNCED INSPECTIONS Product selection • MANAGEMENT OF MEDICINES • The diagram below maps the key functions of effective and efficient management of medicines as outlined in the National Drug Policy of South Africa, and thus form the basis of the findings of the inspections. • Management support: • Information system • Organisation/staffing • Budgeting • Training Rational use, monitoring and evaluation Procurement Distribution and storage

8. KEY FINDINGS: ANNOUNCED INSPECTIONS (cont…) • Product selection • In all provinces, Pharmaceutical and Therapeutic Committees (PTCs) were established at hospital, district and provincial levels for 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. • List 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.

9. KEY FINDINGS: ANNOUNCED INSPECTIONS (cont…) • 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. • This level of flexibility contributed towards the efficient acquisition of urgently needed medicines at the health sites, and therefore, ensured stock availability. • 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.

10. KEY FINDINGS: ANNOUNCED INSPECTIONS (cont…) • In particular, the challenge in the Free State was attributed to the late payment of suppliers during the financial year as most of them decided to withdraw their services to the 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 CDCs and clinics whenever the latter experienced shortage. • However, at the Knysna District Hospital (Western Cape) concerns were mainly around insufficient vehicles to transport the 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 unauthorized access. • In addition, all facilities used “first expired, first out” principle in identifying outdated medicines for disposal. Waste buckets were also used for safekeeping medical waste.

11. KEY FINDINGS: ANNOUNCED INSPECTIONS (cont…) • Rational use, monitoring and evaluation • Guidelines for district pharmacists on visiting health facilities were developed in the Free State, North West and Western Cape in terms. • Only the Western Cape was found to have evidence of adherence to its guidelines with district pharmacist conducing workshops and analysis of stock levels. In the other provinces, district officials and nursing staff indicated that visits were conducted, however no proof could be obtained. • Various systems were used to monitor and evaluate the availability of medicines. In the North West hospitals utilized the RX solution whilst 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.

12. KEY FINDINGS: ANNOUNCED INSPECTIONS (cont…) • MANAGEMENT OF MEDICAL EQUIPMENT • In Free State and North West provinces, procurement of medical equipment was centralised at the Provincial Head Offices. All health facilities raised concerns with this approach, especially since it resulted in delays of procuring new or replacing broken equipment. In Western Cape, it was found that this function had been decetralised to district offices. • In North West province, the procurement of poor quality equipment was attributed to the supply chain management processes of selecting cheapest quotations. • Asset management and control were found to be in place at all visited sites. • In North West, disposal of medical equipment was not properly adhered to, since broken equipment was found lying around at Unit 9 Clinic with some posing a hazard to citizens.

13. …KEYKKEY FINDINGS: UNANNOUNCED INSPECTIONS • 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 needs 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. 13

14. …KEYKEY FINDINGS: UNANNOUNCED INSPECTIONS (cont…) • Waiting Time: Most citizens at the visited facilities were highly concerned that waiting time was long ranging from 2 to 4 hrs. • Access to services: Citizens at Phuthaditjaba clinic (Free State) and Sledgefield Clinic (Western Cape) raised concerns about the travelling distance to their clinics indicating that they travel 10km to 20Km to access their clinic which is 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. 14

15. …KKEY FINDINGS: UNANNOUNCED INSPECTIONS (Cont…) INSPECTIONS • GENERAL CHALLENGES • Facilities within Thabo Mofutsanyana District in North West experienced power failure. • There was a general shortage of health professionals in all visited sites. In Free State and North West this was exacerbated by lack of accommodation and key amenities. • Emergency medical services were poor in all districts visited in North West due to insufficient ambulances.

16. IMPLEMENTATION OF THE PSC 2009 RECOMMENDATIONS • Overall, the findings show that 29 (76%) of the 38 recommendations contained in the 2009 PSC repots on inspections of primary health care have been implemented. • Limpopo: 100% • Western Cape: 100% • Free State: 94% • North West 58% • 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.

17. RECOMMENDATIONS • Upon completion of the provincial reports, copies were 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 6 weeks of the receipt of the reports. • None of them responded within the set time. • The PSC through its Provincial Commissioner have recently engaged the MECs and HoDs to obtain feedback on the PSC’s recommendations. • A schedule of the recommendations is provided with implementation on-going.

18. THANK YOU!