Provincial Department of Health briefing on name change & briefing by Department on integration of City of Cape Town facilities into the Department of Health

Meeting report

The Chairperson welcomed the Standing Committee, the Minister, the Department of Health (DOH) and the members of the public who were present in the meeting, and allowed everyone to introduce themselves.

Overview of DOH’s proposed name change

Ms Marika Champion, Director: Communications, Western Cape Department of Health, took the Committee through the presentation by the Department of Health on their name change to the “Department of Health and Wellness.”

(See attached document for all details).

She went through three key waves of reform from 1994 to 2020:

• Wave 1 – Provincial Health Plan. This included focusing on increasing primary health care (PHC) capacity, and certified nurse practitioners (CNPs) became the mainstay of the PHC capacity.
• Wave 2 – Healthcare 2010 & Comprehensive Service Plan (2010). This was accompanied by the promulgation of the National Health Act (2003), which guaranteed basic access to essential services.
• Wave 3 –  Planning towards Healthcare 2030 introduced the whole of society approach (WOSA) to address the upstream determinants of health.

After the three waves, COVID-19 happened and various challenges and opportunities arose.

There were already key steps towards a more holistic approach to wellness before COVID-19. These were:

First Thousand Days:

A provincial inter-sectoral project using a life-course approach to support the first 1 000 days (conception to two years), supporting the mother and the broader psycho-social environment.

Community Orientated Primary Healthcare (COPC):

This was where a range of PHC services were rendered in communities, building community capacity to take better ownership of their health, a key component of wellness.

WOSA learning sites:

The use of multiple inter-sectoral and multi-level networks, and partnerships to improve health outcomes in a geographic area by tackling social ills and issues.

Taking into consideration the lessons that COVID had taught them, she briefly explained what the future steps would be. The Department’s outlook over the next two years would be to balance the COVID-19 demands with core health services. The recovery outlook over the next five years (2022-2027) would ensure that reform occurred across all the service delivery, governance and public health policy domains. In 2027, the Department envisioned resetting the outlook over the next ten years to ultimately lead towards universal health care (UHC) reform.

The focus of resetting was based on using the lessons from COVID-19, and changing the vision to “health was everybody’s business.” The Department had noticed that there was a clear need to continue to build a health system that was agile in its response to emerging needs by being able to ‘innovate and learn’ (dynamic efficiency); ‘mobilise a broad range of stakeholders to act in the best interest of the health and wellbeing of the people (govern for health); ‘make the right choices’ about what to do (allocative efficiency), and then ‘doing it well’ (technical efficiency).

The Department had various goals on its agenda:

• It aspired to a health system that was people-centric, trusted and equitable;
• To provide the right care, at the right time, in the right place, at the right price -- care that puts people first; and
• To be a system based on a caring and competent, empowered workforce; clean governance; and innovative and accessible service delivery -- a health system for the people

The Department’s service delivery reform was focused on:

• Re-organising care around people’s needs and expectations;
• Making health services more socially relevant and more responsive to a changing world;
• Requiring a ‘whole of society’ approach, meant that health was everybody’s business and did not stop at the boundaries of the health system if it was to address the social determinants of health and wellbeing.

The governance reform would be focused on:

• Making the paradigm shift from a disproportionate reliance on command and control to more inclusive, participatory, consensus-building leadership;
• Building a trusted health system which was demonstrated by organisational and managerial practices and values, and norms that were reliable and legitimate.

The public policy reform would include changes, such as:

• Supporting and enabling healthy and ethical choices;
• Aligning with the aspirations for a healthier society;
• Calling for a whole government, whole society approach, with a social compact to build health resilience; and
• Supporting the wellbeing of people by positively influencing environmental and personal factors.

UHC reform was centred on advancing health equity by removing the barriers to accessing quality and effective health care without exposure to financial hardship, and making the health system more equitable with a set of proactive measures to reach the unreached.

Ms Champion said the name change was part of a whole journey that the Department wished to embark on. Changing the name of the Department was part of a whole process. The intent was welcomed by the Department, and was aligned with its strategic objectives. To put the whole name change process into effect, it had to go through a legislative request to the Presidency to publish an amendment to Schedule 2 of the Public Service Act. The Department of the Premier would undertake this on behalf of the Department. Once the approval was granted, the Department would implement it fully.

Discussion

The Chairperson raised a question to the Department on wellness. She asked what the Department planned to achieve a holistic approach, collaborating with others to relieve pressure, that would ultimately impact society at large

Mr M Xego (EFF) noted that the history of the presentation dates back only to 1994. He suggested that the health system should go back to pre-1994, as the Department had existed before 1994. He asked the Department to provide the Committee with a brief overview of the progress and challenges it had faced in the past.

He said involving stakeholders like municipalities and sister departments was a good thing. He wanted to know what their level of involvement and their level of cooperation would be. Since COVID-19, the health system has been under severe pressure and put under pressure by other departments as well. He asked how collaborating with other departments would lead the country in a positive direction.

What was the Department planning on doing to ensure that the community was involved and participating in the healthcare system?

Ms A Bans (ANC) referred to collaborating with other stakeholders, and asked what the relevant stakeholders’ role and involvement in the Department would be.

She supported the reset of the agenda by the Department, and said that it welcomed innovative ideas and motivation.

Ms R Windvogel (ANC) said that the other Members had covered her questions, but added that it would be beneficial to receive presentations in advance before the Committee meetings, as she did not have enough time to look over the presentation before today’s meeting. She asked if the Department had addressed staff wellness.

DOH’s response

Dr Nomafranch Mbombo, Western Cape Minister of Health, said that on the social determinants of health and collaboration, ‘health was everybody’s business.’ The Department wanted to look at UHC and the National Health Insurance (NHI). The current UCH models did not consider the social determinants of health.

She said the name change had been an ongoing journey, and had been a part of the Department’s plan for a long time. At the conceptual level, there were stakeholders throughout the whole process. At the implementation level, regarding the various aspects, it had also been a part of the consultation. By 2030, the Department aimed to have completed the consultations.

She said that since 1994, since South Africa became a democracy, it had started to have health reforms. After 1994, the focus shifted to primary healthcare from being hospice-centred. She said that even if you have an NHI, it needs to include the ‘wellness’ aspect. She highlighted that health and wellness affected all levels of society and all sectors. Therefore, it was of utmost importance to improve the health and wellbeing of the people of South Africa.

Dr Saadiq Kariem, Chief Operating Officer, DOH (WC), added that the challenges before 1994 were all significant. As the Minister had mentioned, South Africa had an extremely fragmented health service across departments, and all of the ‘fragments’ had to be integrated into one Department, nationally and provincially. One of the focus areas before 1994 was that it had been an extremely hospice-centred service. One of the key areas of focus was to transform from a hospice-centred health service to include a stronger focus on the preventive aspect that would link it to the ‘wellness’ part. Part of the ‘health was everybody’s business’ governance reform focused on having all the services under one system, in terms of health reform.

He said that alcohol was an upstream factor. The DOH had been working collaboratively with their colleagues and through the Department of the Premier to establish a violence prevention unit in the Department of Health and Wellness. This unit would use a preventive model – the Cardiff Model – to identify violence hotspots and try to address strategies in the hotspots to address violence in various communities. There was also an Alcohol Harms Reduction draft policy. The Department was already working with all the departments in government to reduce the harm alcohol produces, and it was already starting to show some benefits.

On staff wellness, he said that one of the key aspects of the Western Cape approach to COVID was to ensure that they had a strong focus on staff wellness, from emotional to physical support. They wanted to ensure that their staff was looked after and cared for. They had focused more on staff wellness since COVID.

Ms Champion referred to collaboration, and said there had been a move internally in the government and senior management to take active steps to bring about change. There was also a visible upstream in communities to make health everybody’s business. There were formal and informal bodies where various interactions were happening to bring people into the planning and implementation phases. 

Minister Mbombo, on the issue of clinic committees, said that from the political side, she had been driving the ‘nothing without us’ campaign, going between districts and sub-districts. She had also engaged in various interactions with stakeholders, such as clinic committees, hospital boards and Members of Parliament (MPs), the key stakeholders. Due to COVID, they had to put a hold on the training of clinic committees and hospital boards, which was why they hosted the Health Indaba to introduce the service re-design.

Further discussion

Due to time constraints, the Chairperson allowed members of the Health Forum to present their questions.

A member of the public commented on the name change, and asked what the communication strategy was on the Department’s decision for the name change.

On 29 April, the Department held an indaba at Century City. She mentioned that now, a few months down the line, there was hardly any staff at the healthcare facilities to deliver services. She asked how the Department was planning to focus on wellness, and how it would deliver the services if there were no staff.

Minister Mbombo said that the Department aimed to focus not only on the curative aspects of health, but to look into the promotive and preventative factors. All aspects and levels of peoples’ lifestyles need to be considered when approaching healthcare and wellness.

Another member of the public said that they had a challenge in accessing venues to host the wellness hubs. They had approached the City of Cape Town for possible venues, but these attempts had been unsuccessful and the available city centres already had programmes running.

She asked whether the Department was looking into the health and wellness of the caregivers of the youth with mental health issues. Was there any support available for the caregivers?

Ms Windvogel asked what powers and functions if any, would be added to the Department due to the name change, and if there would also be any changes to the organogram.

Ms N Bakubaku-Vos (ANC) asked what costs were associated with the Department’s name change. She asked for a breakdown of the costs and expenditure to date, as well as how far the Department was with the name change process.

Minister Mbombo said there would be no added powers and functions -- it was all about the paradigm shift and doing things differently, the service re-design, and the lessons the Department had learned from COVID.

Dr Kariem addressed the issue of staff pressure, and acknowledged that they had been experiencing a lot of pressure. However, they had been able to retain their staff and fill the vacancies quickly. The paradigm shift towards a stronger preventive focus would hopefully aid in reducing some of the pressures in the clinics and hospitals. They were looking into expanding their services and introducing additional services. The Department had been, and was still, busy expanding its services with the budget allocated.

Integration of CoCT clinics into Department of Health and Wellness

Dr Kariem took the Committee through the presentation on integrating the City of Cape Town (CoCT) clinics into the Department of Health and Wellness.

(See attached document for details).

As background, he said the COCT provided personal primary health care services (PPHC) in 105 clinics in the Cape metropole, of which shared services were offered in nine clinics. The Cabinet resolution that was taken on 15 May stated that “WCG: Health maintains that PPHC in the Cape Metro Health District should be rendered by a single authority and that WCG: Health was the only authority that could constitutionally assume that responsibility (in line with the Cabinet decision taken on 26 September 2012 and the IGC Resolution taken on the 23 June 2014).”

He went through the key reasons for the handover of the joint facilities:

• The current joint service delivery model was not ideal, since duplicate services were under the same roof.
• City staff rendered the same service as their provincial colleagues in the same building. In the current financial climate, they sought to find opportunities to streamline the services that would enable them to respond to population health needs more efficiently and comprehensively.
• The decision to hand over the services to WCGH was part of the bigger picture to improve service efficiency.
• They were moving towards a single accountable health authority in the metro, which was only one milestone in the future takeover by WCGH.
• Clients could access provincial health facilities that offered a large and comprehensive PHC service.
• Clients would now receive integrated health services at a single service point by staff managed by a single management team.  

The funding for running the PPHC services in the metro would be split between WCG Health and the CoCT, and the detailed funding would be determined jointly between WCG Health and the CoCT.

He said that Fisantekraal was the tenth facility that would be taken over by the provincial government, along with the other nine facilities in Durbanville, Scottsdene, Parow, Dirkie Uys, Heideveld, Bellville, Ravensmead, Nyanga and Nolugile. All the joint facilities were city-owned, except for Heideveld Clinic, which belonged to the WCGH.

He said the integration of the CoCT into the Department of Health and Welfare (DH&W) had gone relatively smoothly. The Department’s property management teams were resolving the ownership issues. The equipment had been procured, although some of it had not yet arrived, so the City had agreed to leave their equipment in place until the new equipment arrived. The clinical staff had all been appointed and had commenced work, while the non-clinical staff was in the process of being appointed, and interim arrangements had been made.

Some challenges had occurred in changing service providers for security and cleaning at Nolungile. They have since met with community structures to resolve the issue. Although they had consulted the health committees and the Karl Bremer Hospital (KBH) board, some community structures in Ravensmead and Bellville South were unhappy at the lack of consultation. They had since met with all stakeholders.

Other challenges were that the transfer payment reduction to the City had not yet formally been agreed upon, and there had been no firm decision about the remaining City facilities, although there were indications that the City wished to transfer these to the province over the next 36 months.

He mentioned that while some smaller facilities had been closed down, other small facilities in close proximity to larger facilities such as the Elsies River, Maitland, Northpine, Rocklands, Eastridge, Alphen, and Lavender Hill facilities, would therefore remain open.

The current service level agreement (SLA) had been updated to align with the discussions around the nine joint facilities and the nine facilities in close proximity so that the SLA took these processes into account. The parties had all agreed to sign a one-year SLA to correct any shortcomings, reach a final agreement, and sign a new one-year service level agreement.

Discussion

Ms Bakubaku-Vos asked how much had been transferred to the City each year between 2019 and 2022, and where the City accounted for the transferred funds. She called on the Department to invite the City to appear before the Committee to account for the funds and the quality of service at the mentioned facilities.

Regarding the challenges involving integrating the CoCT facilities into the DHW, she asked what the Department planned on doing to improve efficiency.

She asked what the costs associated with procuring the necessary equipment were, and what equipment had been procured. Which facilities had received their equipment and which did not, and what were the reasons for the delays?

She asked for details of the staff members who had not been employed, and what temporary arrangements the Department had put in place.

Ms Bans asked about the smaller facilities that had been relocated into closer proximity to one another. Regarding the SLAs renewed annually, how long had the Department had SLAs, or were they new to the Department?

Mr Xego asked about the difference between clinical and non-clinical staff. Would the staff be impacted by any of the changes that were occurring?

He asked the Department to provide the Committee with more information on the challenges with service providers -- what the challenges were, and how it planned to deal with them.

Referring to the smaller facilities, he said that there had been some wariness on the ground that some institutions might be closed. He asked the Department to provide more clarity around this matter, as it had assured the Committee that no facilities would be closed down, but rather that they would be improved.

Ms Windvogel asked if the move towards a single accountable health authority in the metro included integration of the 105 facilities that remained under the CoCT. She asked the Department whether staff members would lose their jobs or facilities would close down once the integration occurred.

She asked if the Department could provide the Committee with details of all ten facilities’ annual budgets, the vacancy rate, the breakdown per occupation, and the population served at each facility.

She asked when the city-owned facilities at Honeyside and Newfields had been closed down, how many people were served by the facilities, and how these people would be affected by this.

The Chairperson wanted to know how closing down the facilities in Honeyside and Newfields would impact the community regarding service delivery. For clarification, of the 105 facilities mentioned, she asked if the Department intended to take over all of the facilities.

DOH’s response

Minister Mbombo said that provincialising the rural areas and rural health services would take up to three years. Some of the clinics in the rural areas were attached to municipal halls or offices, and renovating some was difficult, so new clinics had to be built. They learned from that experience that one could not just take over the existing properties. She said they were working together at the Director-General (DG) level, with municipal city managers, and with the Western Cape Department of Public Works as a custodian of the properties, to take over the mentioned nine facilities.

In terms of the framework, the National Health Act clearly stated what municipal and provincial health services were. Before 1994, some municipalities were rendering health services that were supposed to be delivered at the provincial level. In the transition period, they had introduced an SLA where this problem was supposed to have been resolved. There were many metros in KwaZulu-Natal (KZN) and Gauteng that were running health services that were supposed to be run by the provinces. The constitution stated that personal health services were the responsibility of the national provinces, and the National Health Act of 2003 states that provinces were responsible for that. Municipal health services were responsible for environmental and disease services.

They could account for the ten smaller facilities that were already under them. The services that these facilities provided, would remain the same. Honeyside and Newfields were city clinics, and they could not account for them. From the provincial government’s side, they had no intention of closing any clinics they had absorbed. She added that nothing would change regarding the services these clinics provided, except that the province would provide them and the staffing would remain the same.

Dr Kariem said that the total transfer that they would be making to the CoCT was R680 million, and that was for PHC services, HIV, and some medication.

The total exposure on the equipment for the ten facilities was R64.5million, of which around R10 million was for goods and services, including equipment. The pieces of equipment were relatively small, but they could make the list available to the Committee. Where equipment had not yet arrived, the CoCT had agreed that they could use their equipment while they waited for it to arrive.

The CoCT had retained their staff and had already deployed them where needed. The Department had to go out and advertise the vacancies for the clinical and non-clinical staff, and had already appointed the necessary staff on their conditions. This process had taken place before the official transition on 1 July to ensure that the transition ran smoothly. Despite all of this, they expected a lot more challenges, but the transition had gone a lot better than they had expected it to go.

He said that the nine smaller facilities closer to bigger facilities would later become part of the bigger integration as a part of the 105 facilities.

On the question of security, he said that the City had deployed its own security company and when the transition took place, the Department had appointed its own security company. The same applied to the cleaning services -- there had been a switchover of the tender for a different cleaning company, and that was what had happened in the case of Nolungile.

The difference in services that the City and the Department offered, was a long list. The City provided promotive preventive primary care treatment for minor ailments, such as children’s primary healthcare services; maternal reproductive services; sexually transmitted disease treatments; an HIV programme; TB treatment and other specialised services, such as x-rays and drug medication supply. The healthcare services that the Department provides include all of these services, including curative and specialised healthcare services, such as treatment for chronic patients, 24-hour emergency services, laboratory services, etc.

He said they would make the information of the staff breakdown in the ten facilities available to the Committee, as they had employed the staff already.

Minister Mbombo said that Durbanville had several mobile clinics spread out to the surrounding farms, and that these buses belonged to the CoCT. The Department was still looking into taking over the mobile clinics.

Ms Bans asked where the alternate clinic was for the community of Philippi.

Minister Mbombo said that Philippi was not part of the ten facilities, and therefore there had been no changes there.

Discussion

The Chairperson allowed the Health Forum representatives to ask questions.

A member of the public said that the Health Forum had raised their concerns around the possible amalgamation of services earlier this year. She said that the list of the possible clinics for amalgamation that had been presented to them was not the same as the one presented today. She asked the Health Forum Committee to go back in their recommendation to the initial discussion about the amalgamation. If the nine facilities were amalgamated, it still raised concerns for the communities that were not taken over by the province. She said that when the province took over facilities in 2014, they had taken over all the facilities in the rural areas, and they thought that that would be the case in the metros. Some committees had been left out of the discussions, and most of the nominated health committees in most of the facilities did not understand their role. She suggested that the Department and the Portfolio Committee needed to come to an agreement on how they were going to engage when serious issues arose and had an impact on service delivery in the communities.

She said that people and communities mattered, and suggested that they needed to adopt a collaborative service around amalgamation. When people needed a service, they were not going to look at who rendered it and who did not. She highlighted that child health was still a serious issue, and they were still experiencing problems in this regard, as some children were still being turned away even after the amalgamation.

DOH’s response

Minister Mbombo said that there was no way that the facilities were different -- the nine facilities that had been mentioned all operated under the same system. The facilities all supplied different packages of services, depending on whether it was city-owned or provincially-owned. The packages could not change, and the facilities were required to deliver the service delivery packages that they had been ordered to deliver.

Dr Kariem commented on the plans for the 105 facilities moving forward, and said they would be working with their city colleagues over the next 36 months. They would be guided by the Minister, who would liaise at the political level. From the Department’s side, they would work with their city colleagues at the technical and operational levels. The Minister had been working hard at resolving the political issues, to the point where they had been able to take over the 20 facilities.

Discussion

Another member of the public suggested that the Department should check up on the nine facilities to give the Committee and the public a proper report on them. He was from the Nyanga area, where they had facility managers, and after a period of time, he was replaced by a temporary facility manager. He asked if the Department had plans to employ a permanent facility manager.

A member of the public asked a question about the wellness hubs in the communities, and the lack of services available. She asked if there was any support provided to the caregivers of people with mental illnesses.

DOH’s response

Minister Mbombo said that visits to the facilities had been made, and that she had been engaging with the clinic committees on this matter. She stressed that all the challenges that the facilities had faced before the transition had not all disappeared. It was still an ongoing process to address the existing challenges.

On the issue of mental health caregivers, she had committed an additional R30 million in the budget speech to adolescent health. After COVID, many older people and adolescents were diagnosed with mental health issues. They wanted to strengthen mental health at the community level, adding that mental health was part of the primary care packages at the healthcare facilities. There were additional special nurses, social workers and clinical psychologists for mental health and psychiatry patients, who could support people diagnosed with mental health issues.

Referring to the issue of the Nyanga facility, Dr Kariem said that a facility manager at Nyanga had lost her husband, and had therefore had to be replaced by another facility manager for a short period to help at the facility.

He said they would make the list of the nine facilities in close proximity to one another available to the Committee.

Ms Windvogel said that her question on the Honeyside and Newfields facilities was never answered. They were pouring millions of rands into the CoCT, and it was unacceptable that they were not present in the meeting.

She asked the Department for clarity on the nine facilities being mentioned as falling under the City -- whether they were now closing down and would now fall under the Department.

Dr Kariem said that the nine facilities that were in close proximity to one another fell under a different nine facilities from those that the Department took over. When the facilities in Honeyside and Newfields closed down,  the services continued from the Department’s side at Hanover Park, Silvertown and Dr Abdurahman Community Health Clinic, which were all in relatively close proximity to Newfields. Other facilities were near one another that they had decided not to close down due to City Council resolutions. These clinics fell under a different group of nine facilities. These facilities were Northpine, Elsies River, Rocklands, Eastridge, Alphen Clinic, Lavender Hill Clinic, Maitland, and Honeyside and Newfields were a part of these facilities. The facilities that the Department had taken over were the facilities on page five of the presentation -- Durbanville, Scottsdene, Parow, Dirkie Uys, Heideveld, Bellville, Ravensmead, Nyanga, and Nolugile.

Ms Windvogel asked, if the City refused to come and talk to the Committee, they could do nothing about it.

Minister Mbombo said she did not know to what extent the powers of the legislature would be able to do something regarding local government. On government-to-government issues, she met with her counterpart from the City every month. They had an intergovernmental committee (IGC), where any items on the agenda that had not been resolved were addressed and resolved.

The members of the public were excused from the meeting, as the Committee needed to attend to one more item.

Ms Bakubaku-Vos raised her displeasure that the Minister was allowed to leave the meeting without answering her question. The Chairperson must ensure Members’ questions are answered.

The Chairperson disagreed – she reminded Members they only had a specific amount of time for the meeting and opportunity also needed to be granted to the community members present.

A back and forth ensued between the Chairperson and Ms Bakubaku-Vos.

Ms Windvogel said time constraints must be made clear before the meeting started. She also had more questions she would have liked to pose. She asked that the Committee look at this in future when allocating time for agenda items.

Committee resolutions

Ms Windvogel wanted the City to explain the way forward (on the close proximity clinics) and account for expenditure provided.

The Chairperson said the City should also explain the staff benefits. 

Ms Bans said the Department must provide the Committee with a list of the clinics servicing the Philippi area.

Ms Windvogel requested stats from the Department on addressing the wellness of staff, especially nurses.

Establishment of a tuberculosis (TB) caucus

Ms Lisa Delcarme, Researcher, Western Cape Provincial Parliament (WCPP), took the Committee through the presentation by the WCPP on establishing a tuberculosis (TB) caucus.

(See attached document for details).

She started with a brief overview of the Global TB Caucus, established in October 2014 to accelerate progress toward combating the spread of the TB pandemic. The Global TB Caucus consisted of 57 national TB caucuses worldwide, with over 2 500 parliamentarians from more than 150 countries.

She said that the national and provincial caucuses performed a critical role in the fight against combating TB by:

• Leading programmes and interventions in each domestic context
• Holding governments accountable, and ensuring that commitments related to TB were delivered.

Discussion

Ms Bans asked the WCPP to provide the number of parliamentarians serving on the TB caucus. On the registration process, she asked what and who they as Members would be registering, or how would the registration process be done.

WCPP’s response

Ms Delcarme said they were still uncertain of the exact number of parliamentarians who would be serving on the caucus.

Mr Ben Daza, Senior Procedural Officer: Committee Support, WCPP,  said they must request this information from the Speaker’s Office.

The Chairperson said that there was a need in South Africa for such a body. However, they could not establish a caucus, but rather an ad hoc committee. She asked Mr Daza what the Committee could do to establish an ad hoc committee.

Mr Daza said that they could submit a request to the Speaker’s Office, as only the House and the Speaker could establish an ad hoc committee in terms of the rules and give permission for such a committee to be established.

The Chairperson suggested that they add all the information to the resolutions, and send it to the Committee, as all the Members were not present in the meeting. She said they would furnish the resolutions today, and have the meeting as soon as possible.

The meeting was adjourned.