North West Health: The hits and misses of the section 100 intervention
It has been almost four years since the North West department of health was put under administration in 2018, but some healthcare users in North West say improvement in health services has been negligible.
The North West health department was placed under administration on April 25 2018 after several governance failures and allegations of fraud and corruption that resulted in widespread service delivery protests. The health department was among 10 departments in the province placed under administration in terms of section 100 of the constitution. Section 100 allows the national government to intervene in the running of provincial departments when a province cannot fulfil its functions. In terms of section 100 (1)(b), the national department of health assumed the role and obligations of the provincial health department to ensure the province was able to meet the national standards for providing healthcare services.
To this end, Dr Jeanette Hunter, deputy director of primary health care in the national department of health, was appointed as administrator for the North West health department.
The section 100 intervention is expected to be lifted in the coming months. In March this year, Cogta minister Dr Nkosazana Dlamini-Zuma announced during a government imbizo in the North West that an exit report has been sent to the National Council of Provinces (NCOP) to sign off and the section 100 intervention will be lifted for the 10 provincial departments. Dlamini-Zuma heads up the interministerial task team appointed to oversee the section 100 intervention.
“The plan was never to stay here forever,” she reportedly told residents.
So what was the plan?
Recalling the state of affairs upon her appointment as administrator, Hunter tells Spotlight, “The entire administration was on the brink of collapse, and workers were demonstrating, threatening to set alight departmental offices in various districts.”
Her first task, she says, was to bring stability to a health department she found in disarray.
“Workers were demanding performance management and development system (PMDS) incentives and the filling of vacant posts. They were angry because there were talks of millions being wasted through Gupta-linked companies such as Mediosa. The entire labour bargaining structure in the province had collapsed as staff members were demanding that vacant posts be filled,” says Hunter.
Since then, she says, there has been some improvement and some challenges remain. Below we assess progress in five areas.
1. Some vacancies filled
“The vacancy rate has been brought down from 19% to 11%. Five-thousand posts have been filled since the national government’s intervention. The intervention began with a workplan based on a diagnostic assessment. The workplan contains 111 activities and out of 111 tasks set out by the national health department, we have managed to complete 102 of them, which translates to a 92% success rate,” says Hunter.
Hunter says when she was appointed as administrator she found a staff organigram that was last updated in 2007 — which at the time meant more than a decade before. Due to budget constraints, she says she was told by Treasury that she could improve the staff numbers with only the funds that were available.
While presenting his 2022/2023 budget speech last month, health MEC Madoda Sambatha said 1,121 permanent posts were filled in the previous (2021/22) financial year and said this progress would go a long way in improving the capacity of the department to effectively deliver on its mandate.
However, a report released last year by the community-led clinic monitoring group Ritshidze, highlighted that severe understaffing in the province has made the management of patient loads in clinics a challenge. The report shows that out of 14 regularly monitored clinic sites, all the facility managers said they struggle with staff shortages.
To help address this, Sambatha said the department set up a database of unemployed health professionals in 2020. This week, however, when Spotlight enquired about this database there were only 57 names.
2. Emergency Medical Services
One issue that was flagged as a concern after the interministerial task team’s oversight visit last year was emergency medical services. Parliament’s (National Council of Provinces’) ad hoc committee on the section 100 intervention in North West, upon adopting the oversight report in May last year, recommended the task team “should ensure that the minister of transport together with the provincial department of community safety and transport management resolve the issues around the inability to promptly respond to provincial health transport needs, including the procurement and maintenance of the EMS fleet for the provincial department of health as soon as possible”.
Hunter says there has been some improvement. In 2018, she says, there were only 50 functional ambulances, which had been brought up to 147 by 2021. In April 2018, Spotlight reported extensively on the controversial outsourcing of ambulance services in the province to a private company called Buthelezi EMS.
According to national standards, 350 EMS vehicles are required to service the province. Sambatha in his budget speech this year said he believes it will take up to seven years to reach this level. At present the province is operating with 138 ambulances, he said.
In the meantime, however, Sambatha said the province is looking at a leasing model which will enable the department to increase its fleet using the same budget. This means the department will rope in private ambulances to help with patient loads and will mean the department will reach the national norm within two-to-three financial years, he said.
According to Hunter, poor record-keeping remains a problem because they are still using a manual system which leads to a delay in payments, keeping track of financial transactions, and staff records. She says when the auditor-general comes to report, it sometimes takes longer than it should because their systems are not automated. She says a new system should be budgeted for and put in place.
In its report last year, the NCOP’s ad hoc committee also noted that improving ICT infrastructure and automation of the health department’s document management and information generation processes are some of the challenges that still stick.
4. Medicine availability
Availability of medicine has also been a persistent challenge in the province. In its latest annual report for the 2021/22 financial year, the department’s healthcare support services programme “that [are] responsible for procurement, storage, and distribution of medicines and surgical supplies, and other support services, achieved 74% against a target of 80% for medicine availability”.
In his budget speech this year, Sambatha referred to ending medicines stockouts as his “second mega health delivery intervention”. “The department has continued with efforts to improve medicines and medical supplies availability to serve our communities,” he said.
Sometimes I have to wait nearly six hours or spend the entire day at the clinic.Lerato Modise
By March 2022, he said the department “met its standard national average medicine availability target of 80.5%”. “The different categories of medicines such as ARVs, [and] vaccines for child immunisations remained above 90% since the third quarter, while the availability of TB medication was consistently above 80%.” Sambatha said the department also paid all its suppliers that were on hold since 2021/22 and this improved medicine availability.
According to some healthcare users like Lerato Modise, not all medicines are always available.
“I have to wake up at 5am on the day I visit the clinic [Ratlou Clinic]. If I don’t get a lift along the way I have to walk nearly two kilometres. Sometimes I have to wait nearly six hours or spend the entire day at the clinic. In some instances, I come back with my baby not receiving her [immunisation] vaccine. I will then be told to come the following month,” says Modise.
Last year, Koketso Gaesal gave birth to her second daughter and she told Spotlight her child has skipped her infancy vaccines because nurses told her the vaccines were not available. Since the closure of Thusong District Hospital, Gaesale says she has to spend R60 to travel to the General De La Rey Hospital in Lichtenburg because the Itsoseng CHC’s pharmacy is not licensed to dispense some medication. She says this makes her life difficult because she is unemployed and depends on a disability grant for her survival.
The EFF member of the provincial legislature who serves on the health committee Kelebogile Kerileng, says even though the department is under administration, there are still chronic medication shortages, infrastructure challenges and security challenges at facilities across the province.
“During our oversight visits we find that there are challenges relating to chronic medicine shortages but the medication is available at the depot. This comes as a result of poor communication and confusion relating to deliveries. Some nurses say that clinics order from district hospitals and then the medication is sent to them. Only in case of emergencies can the clinic use its own transport to go and fetch medication at the depot which operates on a 24-hour basis,” she says.
If budget has been returned, it simply means that services have not been rendered.Dr Oshupeng Maseng
According to the department, however, there is a plan in place to improve delivery timelines for medication. It involves direct deliveries of medication to hospitals while the medical depot will deliver directly to clinics.
5. Money matters
Sambatha in his budget speech said though the department had not grown its accruals over the past four years, it remains a concern. Accruals are funds that were supposed to be paid to suppliers in a specific financial year but were carried over to the next financial year due to a lack of funding. At present annual accruals still hover around the R1.2bn mark. Though the North West Treasury has allocated an amount of R350m to help finance the accruals, the challenges of insufficient budget allocations remain, Sambatha said.
The department has also underspent its budget by 1%.
Department spokesperson Tebogo Lekgethwane told Spotlight that of the about R14bn health budget for the province in the 2020/21 financial year, the department underspent by R144m. He says the underspending was mainly on the health facilities revitalisation grant, which means money that the department had for new facilities, upgrades, refurbishments, or maintenance was not spent in full. “A request for a rollover on committed funds was granted during the adjustment budget by the provincial Treasury,” he says.
According to Dr Oshupeng Maseng, a political science and international relations lecturer at the North West University, government underspending means that “government has failed its people”. “Under Section 100 there are still monies in the North West that were returned to National Treasury. When money is being returned, there is no clear indication of improvement. It simply means that government has failed in terms of service delivery. If budget has been returned, it simply means that services have not been rendered,” says Maseng.
The department says it is taking steps to address fraud and corruption. In its annual report, the department says it had put in place a fraud prevention strategy, fraud prevention plan, and an anti-corruption and fraud policy in the previous financial year.
The former head of department Thabo Lekalakala and several senior managers have been suspended pending the outcomes of disciplinary hearings. Hunter says she would like to see the department continue to take disciplinary action against junior and senior employees so that those employed by the department know they are accountable for their actions.
Still room for improvement
Ntombizodwa Moepeng, provincial secretary of Nehawu, says there have been some changes since the department was placed under administration but she believes there is room for improvement.
“We have noted some improvement in terms of filling vacancies and fighting corruption within the department,” says Moepeng. “Some workers are still complaining that they are overworked because some funded posts [for nurses] in public hospitals are still not filled since the department was placed under administration.”
Moepeng says the union would like to see community healthcare workers (CHWs) being employed on a full-time basis by the department. She went on to say that some workers do not fully understand the performance management and development system (PMDS). This is an important part of the public service regulatory framework that guides the work and conduct of public servants in delivering services to the public. She says in some instances you find supervisors completing reports that should be completed by workers. Moepeng says employees should be capacitated to fill out these forms themselves.
Dr Gilbert Asiranye, a medical practitioner who works in the province says he has seen some of the work done over the past three years but would still like to see more being done.
“I would like to see government providing enough finance to run all necessary and important programmes. More staff should be hired at clinics and hospitals so that workers should not feel overworked,” says Asiranye.
“Some challenges persisting in the department are a lack of skilled leadership with proper qualifications. Poor/dilapidated infrastructure with short staffing and unavailable resources are leading to poor service delivery.” He says the department must improve recruitment since staff are overworked and eventually experience mental illness like depression. Ongoing training must also be a focus, he says.
This article was first published by Spotlight.
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