SA Military Health Services briefing on improving capacity and capabilities at Military Hospitals; with Deputy Minister

Meeting report

Apologies from Minister Thandi Modise, Acting Secretary of Defence; Dr Gamede, and Chief of Staff; Lt Gen F.M Ramantswana were recorded.

SAMHS presentation
Maj Gen Dr N.P. Maphaha, Surgeon-General (SG), briefly outlined the presentation. The scope included a reflection on the responsibilities, challenges, and achievements despite the shortcomings. Measures were introduced to mitigate the outsourcing of services based on the requirements and related costs.

Brig Gen M.P. Langa, Director Military Health Planning, presented on behalf of the SAMHS. The SAMHS mandate is to provide prepared and supported healthcare capabilities and services for the defence and protection of South Africa. The mandate is measured in terms of the following two outputs:

Joint Force Employment Capabilities (JFEC)
A capability of five medical battalion groups, including accompanying field hospitals and one specialist medical battalion group in support of deployed and contingency forces; and

Base-orientated Support (BOS)
A comprehensive multidisciplinary military health care service for a projected patient population of 302 000 members per year including Military Veterans and the Presidential Medical Unit.

Personnel structure
To execute the mandate, the SAMHS requires a personnel structure consisting of 10 748 posts. National Treasury limited the number to 6 612 which means an operating capacity of 62%. The current capacity level does not allow for the provision of a 24-hour service without using the overtime dispensation. National Treasury deemed overtime payments too costly and arranged for the reallocation of the funds to the acquisition of ambulances.

Estimate of Expenditure
The costs to improve the capacity and capabilities of Military Hospitals are estimated at R2 707 billion. The cost of human resources is estimated at R1 521 billion annually and a once-off capital injection of R1 182 billion for other resources is required.

(See Presentation)

Discussion
The Chairperson sought clarity about whether ambulances were last purchased in 2010 and the difference between the 2010 and 2022 acquisitions.

Maj Gen Dr N.P. Maphaha explained that an allocation for ambulances was last made in 2010. The ambulances bought in 2022 were a result of the reallocation of funds from other services. The 2022 acquisition included ICU ambulances, mobile clinics, and state ambulances.

Mr S Marais (DA) asked if the expenditure estimate of R1.5 billion for human resources was additional money needed to achieve the required level of services. He sought clarity about the correlation between the budget of R3.9 billion for human resources and the expenditure estimate of R1.5 billion. The establishment of in-house capabilities was listed as one of the key requirements to optimise healthcare. He wanted to know if this role was not the responsibility of the Defence Works Formation. He asked what the current medical inflation index was. He queried why no reference was made to progress on the Repair and Maintenance Programme (RAMP) considering that almost R1 billion was required to complete construction at 1 Military Hospital and more than R1 billion needed for equipment and technology. He asked if the Deputy Surgeon-General had resumed services. He wanted to know if medical costs related to outsourcing, were a cost to the budget or the medical fund. He asked how the medical fund works, if it was for serving and retired members, and how it was impacting the bottom line of the SAMHS. He asked if the SAMHS was considering cooperation with provincial and training hospitals subsequent to National Treasury not providing funds in the current budget for the three Military Hospitals. The approved SAMHS personnel structure provides for 10 748 posts. He asked if this was the minimum required or if more could be done with the 6 612 funded posts. He wanted to know how the corruption and overcharging by private ambulances would be mitigated.

Mr D Ryder (DA, Gauteng) requested an analysis of the number of available beds over the last five years and the number of beds used or needed over the same period. He asked if the SAMHS was optimally staffed or if the entity was losing capacity.

Mr T Mafanya (EFF) said the information presented a horrible picture. After dealing with the issues for four years, there seemed to be no good results. The condition in public hospitals was equally in a mess and the majority of the hospitals are in shambles. He asked how the SAMHS was mitigating load shedding, especially in ICU. He sought clarity on whether the litigation costs were due to malpractice by the SAMHS. The SAMHS was in a disastrous situation that caused foreign presidents to downgrade the Military Hospitals. The hospitals were at risk of losing accreditation due to the lack of equipment to train medical students and employ professionals. It was only after the pressure that 1 Military Hospital is being capacitated. The lack of improvement dates back to 2014 which indicates a lack of will and leadership from the Ministry.

Mr K Motsamai (EFF, Gauteng) found the situation at 1 Military Hospital disastrous. Since 2010, more than R150 million was spent to build two rooms, which are yet to be completed. He visited the hospital over the past weekend and found that administration only happens between 08:00 and 16:00 and no one is answering calls after 14:30. He asked if it was the end of 1 Military Hospital. A dish is placed into position to stop the leaking on the second floor of the hospital. He bemoaned the fact that no one had been prosecuted for using public money and asked when will people be arrested.

The Chairperson asked that further questions be halted and the SAMHS be allowed to respond to the first round of questions.

Maj Gen Dr N.P. Maphaha said R1.5 billion is required to fund additional posts in order to bring the services to an appropriate level. To employ 10 748 members requires a budget of R6 billion but R3.9 billion was allocated for 6 612 active posts, due to budget cuts.

The Chairperson wanted confirmation about the number of funded posts.

Maj Gen Dr N.P. Maphaha replied that 6 612 posts were funded while 10 748 posts were required in terms of the approved structure.

The Chairperson asked what the minimum required number was if 10 748 was not possible.

Maj Gen Dr N.P. Maphaha replied that the minimum number required, including support personnel, is 1 631. This number falls within the more than 4 000 unfunded posts. He explained that the in-house capacity is for first and second line capabilities to service medical equipment. With funding, the SAMHS would be able to train its own artisans and extend the services to base hospitals. He stated that the medical inflation index is 12% which is double the CPI of more than 6%. He reported that nothing was happening at the refurbishment project which is being managed by the Defence Works Formation. The members found to be involved in corruption at 1 Military Hospital were fingered in the Abacus Forensic report but they have either retired or passed on. The matter had been referred to the SIU to pursue those members no longer in service. He stated that the Deputy Surgeon-General was still not back at work. The medical costs for military veterans must be reimbursed but the Department of Military Veterans has failed to repay the outsourced medical costs. The SAMHS is expected to pay the medical expenses of members that are referred to the private sector for treatment. Outsourcing was consuming the operational budget of the SAMHS. The budget for 1 Military Hospital was depleted within the first quarter of the financial year. The SAMHS is being charged private sector fees for services at public hospitals even though the services are not at the same level as private hospitals, therefore members are referred to the private sector.

Maj Gen Dr N.P. Maphaha remarked that ambulance service providers admitted to the corruption exposed by whistle-blowers and agreed to pay back the money. The service providers would claim for distances not travelled or for the use of ICU ambulances when it was not needed. Measures were implemented to avoid being overcharged, e.g. GPS tracking is used on ambulance routes. Regarding bed availability, he stated that when fully operational, nearly 500 beds are available at 1 Military Hospital but the number had been reduced to 250 due to budget cuts. The 270 beds available at 2 Military Hospital are not being utilised due to the lack of health professionals. At 3 Military Hospital, 145 beds are available. A full staff complement is needed to use all of the beds. He agreed that the picture being painted was horrible and added that the hospitals are in ICU. Litigation costs were in respect of amounts claimed, not paid, or owed. Most times, the amount claimed is reduced when the SAMHS offers to take care of the patient instead of making a lump sum payment. He stated that staffing within the facilities is used productively. The primary mandate of the SAMHS is to support the troops when they are in operation. Productivity cannot be compared to hospitals such as the Steve Biko Hospital because the SAMHS is not allowed to apply a shift system. He confirmed that no calls after 16:00 are answered because overtime for administrative staff had been stopped. National Treasury allocated the money to the acquisition of equipment but it compromised other services.

Mr T Mmutle (ANC) asked for more detail about the plans of the Military Health Informatic systems. He wanted to know if advanced technologies would be put in place to restore the pride of the Military Hospitals. The facilities at 1 Military Hospital should be more advanced than that of the private sector. He asked how the situation could be turned around to restore the pride. He felt it was incorrect to wave away the RAMP project because the SAMHS is the end-user of the services. Some of the problems at 2 Military Hospital were due to the SAMHS distancing itself from the project and because medical specialists were not involved in the initial stages of the project. He said it was not helpful to complain only at the end of the project. He was expecting the SAMHS to update the Committee on the status of the project.

Ms M Mothapo (ANC) expressed concern about the age of the debt. She asked if measures were in place to ensure that the debt of R800 million does not prescribe. She wanted to know if litigation costs related to medical malpractice included legal fees or if the SAMHS was briefing their own counsels. The risk of the once prestigious hospitals losing accreditation was a serious cause of concern. She questioned how the soldiers would be able to perform their tasks if their health is not taken care of.

Ms A Beukes (ANC) said the money paid for legal fees could have been used for upgrading the hospitals. She asked what the percentage of successful claims was. She enquired about the impact of increased outsourcing on the budget and asked if it would not be better to recruit rather than to outsource. She enquired about the measures in place to monitor compliance and timeframes for the installation of new equipment and upgrade at the health facilities.

Ms P Phetlhe (ANC) said overtime that is not linked to the shift system is a concern and that overtime regulations are in place. The projection is to have three instead of two shifts because working overtime could be tiring. She asked what the criteria were for the recruitment of new staff members. She suggested a rotation of the budgetary system to ensure that it does not deteriorate. She asked how much was saved from outsourcing and what the money was used for. She questioned whether it was still prudent to work with outsourced service providers if they were the cause of litigation.

Ms A Mthembu (ANC) asked how a situation of an urgent case is managed if calls are not answered after hours.

Maj Gen Dr N.P. Maphaha said due to technological advancement, the situation of 20 years ago cannot be compared with the position today. Most medical equipment need to be serviced in order not to pose harm to patients and must be serviced by the original manufacturer. The statutory requirement to certify medical equipment cannot be outsourced. He replied to Mr Mmutle about the RAMP project stating that people managing the project are engaged in contractual disputes therefore no progress had been made. The SAMHS is not involved in the disputes but the medical technologists on the project are working with the SAMHS specialists. On the issue of overtime, he explained that in fulfilling its mandate, a SAMHS unit is deployed along with a battalion but does not have reserves to cover 24 hours in a hospital. He replied to Ms Mothapo that veterans had been made aware in writing to pay back the money. If someone is informed of and acknowledges the debt, then it would not prescribe. R174 million is owed by veterans from the previous financial year. He stated that the SAMHS has lost its prestigious status. Heads of state no longer use the facilities and the treatment of patients by students in training has stopped. He agreed with Ms Beukes that the money could have been used for other purposes if there had not been claims. The society has become litigious, and some are using it as a money-making scheme. The legal team would be requested to provide a report on the claims’ success rate. He confirmed that advertisements are placed but the organisation was finding it difficult to retain new recruits because of outdated equipment and dysfunctional facilities. People leave due to the lack of tools for the trade. Six specialists were lost at once due to the risk of medical claims. He agreed regulations for paying overtime are in place but National Treasury questioned the payments and took the money away. He explained that calls after hours are rerouted to casualty but the doctors and nurses are usually too busy treating patients to answer the telephone.

Maj Gen M. Simelane, Chief Director Military Health Force Preparation, said the professionals that are recruited are experienced and cannot be compared to people who recently qualified. The remuneration depends on the expertise and experience of specialists.

Maj Gen Dr N.P. Maphaha remarked that remuneration is based on the current notches at the highest level of posts, taking into account inflation and the cost of the employee budget. This is valid as long as the person is employed.

Mr Ryder was not fully satisfied with the response to his question about the bed occupancy rate juxtaposed with the number of staff needed. He would be submitting his question in writing for a more detailed response.

The Chairperson asked if the bed capacity of 823 beds and the reduced occupancy rate of 500 beds were due to challenges with the RAMP project. He wanted to know if the numbers represented available beds or the current occupancy rate.

Maj Gen Dr N.P. Maphaha replied that the numbers are in respect of available beds.

The Chairperson asked what the average occupancy rate was.

Maj Gen Dr N.P. Maphaha replied that it was 51%. He explained that the SAMHS is supposed to be a strategic reserve and assurance to be on standby when needed. He undertook to provide a detailed written response.

The Chairperson said Mr Ryder is juxtaposing the bed occupancy rate to the personnel shortage. He asked what the occupancy rate is for all three military hospitals.

Maj Gen Dr N.P. Maphaha said he would provide a written response because he did not have the figures. He explained that not all patients are at 1 Military Hospital. Some patients are outsourced to the private sector due to the lack of personnel and equipment for patient care.

The Chairperson asked about the turnaround plan in terms of what is available and what is funded.

Maj Gen Dr N.P. Maphaha replied that the plan was presented earlier in this meeting.

The Chairperson asked if the medico-legal claims were covering negligence by outsourced facilities or facilities owned by the SAMHS.

Maj Gen Dr N.P. Maphaha replied that the claims arose in SAMHS facilities and by its own people.

The Chairperson asked if the medical claims figure is accumulative.

Maj Gen Dr N.P. Maphaha said the figure is accumulative and based on pending claims at 31 March 2023.

The Chairperson identified a number of issues that require follow-up:

Overtime; money has been reduced and reallocated for acquisition of ambulances and equipment with severe implications on the functionality at hospitals. Overtime is needed to stretch the capacity of existing personnel resulting in a heavy impact on service delivery. The extent to which service delivery is compromised is not explained. The number of hours a medical officer can work overtime across shifts may impact the effectiveness of services delivered and may endanger patients or lead to further medical claims. The situation of not having sufficient employees to provide services to patients highlights the risk to patients and the government in terms of medico-legal claims.

Bed occupancy; a detailed written response is expected.

Military Veterans debt; a process to facilitate the refund of the money to the Department must start without delay. In the past, money was returned to National Treasury due to unsettled claims.

Private fees charged; public hospitals charge private hospital fees when they treat referrals from military hospitals even though the services are not at the level of private hospitals. Measures to mitigate this expenditure should be introduced.

Ambulances; the Department should implement measures to mitigate the fleecing of funds by ambulance operators.

Losing specialists; due to old equipment and poorly resourced facilities, the Department is unable to retain qualified and experienced personnel. The amount allocated for equipment should be closely monitored to ensure that it is used optimally. Even if only one facility is urgently equipped, it might help to not lose more specialists and to restore the lost prestige.

Contractors at 1 Military Hospital; the recommendation of the forensic investigation was to sever ties with the contractors and for the Department to take over and engage other contractors. But due to the legal disputes, the contractors have not pulled out. A suggestion is made for the legal advisors of the Minister to review the agreement with the goal to release the Department from contractual obligations.

Mr Marais agreed that feedback on the contractual agreement was needed even if the contractors have a legal case against the Department. The information would indicate the complexity of the matter.

The Chairperson asked the Deputy Minister for his input. The legal advisor should guide the Department on withdrawing from the agreement and the way forward. The Committee needs to know why it was so difficult to disengage from the arrangement.

Deputy Minister’s closing remarks
Deputy Minister Makwetla was satisfied that the team presented sufficient information and explanations of the challenges facing the SAMHS. The Committee was now aware of the state of affairs regarding medical services concerning troops both in and out of service. The SAMHS was operating at 62% capacity but should theoretically be above the level of the Air Force. It was helpful that there were not only complaints about the shortages but the detail was provided of the need to cover basic service areas in terms of personnel and budgetary implications. The SAMHS used to be at the cutting edge of research and technology and held first place in the development and technological and general know-how. In the past, heads of state were referred to 1 Military Hospital for the best medical care available. The SAMHS seemed to be the worst affected by the budget cuts. To mitigate against the challenges of a reduced budget, man-days services were reduced. The numbers are not sufficient to support the regular force without bringing in the reserves. Reducing the cost of the employee budget has severe consequences for medical services in terms of the mandate. He agreed that it was important to get an update on the renovation project at 1 Military Hospital. He stated that failing to optimise opportunities with limited allocations is a pointed weakness. There is no luxury insofar as getting the utmost outcome from National Treasury allocations. He undertook to return to the Committee with an update on 1 Military Hospital.

The Chairperson said the presentation made the Committee fully aware of the challenges. The Committee was in discussion with National Treasury. The funding issue had been escalated to the highest authority and the feedback was positive. The Committee needed to understand how much was required to address the challenges. Unless the SAMHS is assisted, the services would continue to decline until it would no longer be worth to maintain the hospitals. He feared that the Department would only exist as an agency on behalf of private hospitals for referral of patients instead of performing the services itself. The refurbishments of the hospitals would have been a waste and personnel would be lost if full services could no longer be provided. He agreed with the Deputy Minister that resources should be optimised. Suspended staff must return to continue their services for which they get full pay while on suspension. Funds must be used optimally in the year in which it is allocated. The auditor-general reported on wasteful expenditure, e.g. at 2 Military Hospital machines were purchased but became obsolete because it was never used and the equipment bought at 1 Military Hospital became obsolete because it could not fit into the rooms.

The Chairperson thanked the Deputy Minister and the SAMHS team for the engagement. He sympathised with the situation and undertook to bring the issues to the attention of the authorities.

Actions and resolutions
The Chairperson requested that the adoption of the minutes be deferred to the next meeting.

The meeting on 15 June 2023 will be a closed meeting in Cape Town. It will precede the oversight visit to Simonstown on 14 June 2023.

The meeting was adjourned.