REPORT ON A SERVICE DELIVERY INSPECTION OF DISTRICT HOSPITALS AND CLINICS REGARDING AVAILABILITY OF MEDICINES AND MEDICAL EQUIPMENT AND THE ROLE OF DISTRICT HEALTH OFFICES

DEPARTMENT OF HEALTH: PROVINCE

APRIL 2014

TABLE OF CONTENTS

FOREWORD ...... iv LIST OF ACRONYMS ...... v 1. INTRODUCTION ...... 1 2. OBJECTIVES OF THE INSPECTIONS ...... 2 3. SCOPE AND METHODOLOGY ...... 3 3.1 Scope ...... 3 3.2 Methodology ...... 3 4. LIMITATIONS OF THE STUDY ...... 4 5. KEY FINDINGS ON ANNOUNCED INSPECTIONS ...... 4 5.1 Contextual background ...... 4 5.2 Management of medications…….………………………………………………………………………………………….5

5.2.1 Product selection………………………………………………………………………………………………………………….6

5.2.2 Procurement…………………………………………………………………………………………………………………………6

5.2.3 Distribution and storage……………………………………………………………………………………………………….7

5.2.4 Rational use, monitoring and evaluation…………………………………………………………………………….10

5.2.5 Management support…………………………………………………………………………………………………………11

5.5 Challenges…………………………………………………………………………………………………………………………17

6. KEY FINDINGS ON UNANNOUNCED INSPECTION ...... 17 6.1 Observing facilities………………………………………………………………………………………………………………17

6.2 Observing access to information…………………………………………………………………………………………20

6.3 Talking to citizens………………………………………………………………………………………………………………..21

7. IMPLEMENTATION OF PSC RECOMMENDATIONS ...... 23 8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL OUT OF THE NATIONAL HEALTH INSURANCE (NHI) ...... 23 9. RECOMMENDATIONS ...... 24 9.1 Announced Inspections ...... 24 9.2 Unannounced Inspections ...... 25 10. CONCLUSION ...... 25 11. ACKNOWLEDGEMENT ...... 25

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western ii

12. LIST OF TABLES, FIGURES, PICTURES AND ANNEXURES

TABLES

Table 1: Objectives of inspections………………………………………………..…………………………………..……2 Table 2: Sites and dates of inspections……………………………………...………..…………………………..………3

FIGURES

Figure 1: The JAC Pharmacy System’s end-to-end management process………………………...………….….…..5 Figure 2: Medicine management cycle…………………………………………………………….…………...………….6 Figure 3: Mobile unit to be used during the NHI Pilot Project………………………………….……….………..…….24

PICTURES

Picture 1: CC TV monitoring system in the office of supervisor pharmacist at Kwanokuthula CDC………...... ……9 Picture 2: Neatly packed Pharmacy of Kwanokuthula CDC with working air-conditioning system……...….....……9 Picture 3: Working refrigerators for safe-keeping of medicines at Cloetesville CDC………………………...... …....10 Picture 4: The Registry at secured with burglar bars…………………………………..………………….11 Picture 5: Well-ordered and professional filing system at Cloetesville CDC………………………………………....13 Picture 6: Oxygen equipment and wheelchairs at Cloetesville CDC…………………………………………………..14 Picture 7: Equipment at Kwanokuthula CDC in excellent condition…………………………………….…………….14 Picture 8: The waiting area at Clinic……………………………………….……….……………………...18 Picture 9: Construction of the Rawsonville Clinic underway………………………………………….………………..19 Pictures 10 & 11: Consultation area (Above) and waiting area (Below) at Kayamandi Clinic…………...………….20 Picture 12: The grounds of Kayamandi Clinic required gardening attention………………..………………………..21

ANNEXURES

ANNEXURE A: list of facilities visited and officials that were engaged…...... 26 ANNEXTURE B: announced inspections in the visited facilities………………………………………………………28 ANNEXURE C: unannounced inspections in the visited health facilities…………………………………..………….35 ANNEXURE D: the status on implementation of recommendations of the PSC’s inspections conducted in 20091………………………………………………………………………………………………………………………….37

1 Republic of . Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of Health. 2010. Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province iii

FOREWORD

South Africa’s burden of disease, consisting amongst others of a high rate of HIV/AIDS is consistent with health challenges affecting many developing countries which are characterized by high levels of poverty. Thus, health care is one of the key government priorities as well as an essential service which should be accessible to all the citizens of the country.

Key to ensuring a long and healthy life for all is having sustainable health care infrastructure that is responsive to the needs of the citizens. To this end, primary health care facilities have been established to ensure that citizens receive health services at the local level. Furthermore, the National Health Insurance (NHI) has been established to ensure equal access to quality health care for all citizens. Amongst others, it is important that health care facilities should at all times have sufficient medicines as well as adequate medical equipment for timeous and quality treatment, if government is to succeed in mitigating the burden of disease and ensuring a long and healthy life for all citizens. Furthermore, health facilities should function in a manner that is in line with the Batho Pele principles of service delivery.

It is against this background that the Public Service Commission (PSC) deemed it necessary to conduct inspections to determine the availability of medicines and medical equipment. Furthermore, the inspections sought to determine the implementation of the PSC’s previous recommendations in this area and readiness of the health care facilities for the imminent roll out of the NHI. The findings of the inspection show that despite concerns of limited space and delays in the process of disposing of and replacing obsolete medical equipment, especially at clinic level, the WCDoH has ensured constant availability of medicines and medical equipment at the inspected facilities, and thus providing sustainable quality service delivery. The 100% implementation of the PSC’s previous recommendations is also a commendable achievement. As a result, it is the PSC’s view that the visited health facilities were capable of providing the required health care service and as such, ready for the roll-out of the NHI.

It is a pleasure to present the Report on Service Delivery Inspection of Hospitals and Clinics regarding Availability of Medicines and Medical Equipment and the Role of Health District Offices in the Western Cape. We believe that the inspections remain a valuable monitoring mechanism which findings could contribute towards service delivery improvement.

The PSC wishes to thank officials of the Western Cape Department of Health (WCDoH) for their cooperation and willingness to share information. We trust that the findings will help the WCDoH in its efforts to improve service delivery for sustainable and quality health care.

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LIST OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome AO Accounting Officer CCTV Closed Circuit Television CDC Community Development Centre CEO Chief Executive Officer CHC Community Health Centre DDV Direct Delivery Voucher DHS District Health System EA Executive Authority EDL Essential Drugs List FEFO First Expired, First Out HIV Human Immunodeficiency Virus ICT Information Communication and Technology MEC Member of the Executive Council MMS Middle Management Service NEDLC National Essential Drugs List Committee NEMLC National Essential Medicine List Committee NDoH National Department of Health NDPSA National Drugs Policy of South Africa NHA National Health Act NHI National Health Insurance PFMA Public Finance Management Act PHC Primary Health Care PPPFMA Preferential Procurement Policy Framework Act PSC Public Service Commission PTC Pharmaceutical and therapeutic Committee RDM Remote Demander Module SA South Africa SOPs Standard Operating Procedures STG Standard Treatment Guidelines WCDoH Western Cape Department of Health WHO World Health Organisation

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1. INTRODUCTION

South Africa (SA)’s burden of disease mainly consists of HIV/AIDs (i.e. Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome), communicable diseases, non-communicable diseases, and trauma emanating from violence and injuries with consequent high levels of morbidity and mortality2. The impact of this burden of disease is a shortened life expectancy. To address this burden of disease, government at its Cabinet Lekgotla held from 20 to 22 January 2010 adopted as one of its twelve Outcomes: A long and healthy life for all South Africans.

Health care is one of the key government priorities as well as an essential service which should be accessible to all citizens of the country. The foregoing is predicated on a sustainable quality health care infrastructure. However, unless sufficient medicines as well as adequate medical equipment are available at health facilities, government will not succeed in its key objective of ensuring a long and healthy life for South Africans.

The introduction of the National Drug Policy of South Africa (NDPSA), in line with the World Health Organization (WHO) guidelines, by the National Department of Health (NDoH) in 1996 aimed at ensuring equal access to medicines for all South Africans. It is the aim of the NDPSA through the Essential Drugs Programme, which includes an Essential Drugs List (EDL) and Standard Treatment Guidelines (STG) to ensure that medicines are available at all health facilities. It is against this background that the citizens expect health facilities to always have medicines in sufficient quantities as well as the necessary medical equipment.

Furthermore, our constitutional imperatives dictate that government should devolve certain responsibilities for health services to the provincial and local government 3 . As a consequence, the District Health System (DHS) was established in terms of section 29(1) of the National Health Act, 2003 to ensure that communities at local level have access to the quality health care that they are entitled to4. Accordingly, the Provincial Departments of Health created District Health Offices to facilitate the delivery of health services by hospitals and clinics at district level. District Offices are expected to play a critically supportive role of ensuring that health facilities are adequately resourced at all times for the optimal provision of quality health care to citizens.

It is against this backdrop that the Public Service Commission (PSC) deemed it necessary to conduct service delivery inspections on availability of medicines and medical equipment at selected health facilities, as well as to determine the role of District Health Offices in this regard. Inspections are meant to entrench a citizen and service-centred culture, and reinforce accountability across the Public Service. In addition, they provide the PSC with a first-hand opportunity to experience what is happening at service delivery sites, and thus strengthen the oversight work of the PSC. The inspections at the selected health facilities also present an opportunity of determining their readiness for the imminent roll-out of National Health Insurance (NHI).

2 Republic of South Africa. National Department of Health. Strategic Plan for Nurse Education, Training and Practice 2012/13 – 2016/17. 3 Republic of South Africa. National Department of Health. White Paper for the transformation of the Health System in South Africa. 1997. 4 Republic of South Africa. National Health Act. 2003.

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Conducting inspections is in line with the Public Service Commission Act, 1997, Section 9, which 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 Act5.”

2. OBJECTIVES OF THE INSPECTIONS

According to the PSC’s protocol on announced and unannounced inspections, the broad aim of inspections is to assess the quality of services rendered by departments, the state of facilities and the conditions at service delivery sites, in order to ensure adherence to stipulated regulations and other government frameworks 6. Table 1 below provides the specific objectives of an inspection as defined in the PSC Protocol as well as those pertaining to this inspection on the availability of medicines and medical equipment.

Table 1: Objectives of inspections Objectives of an inspection Objectives of inspections on the availability of medicines and medical equipment  To afford a personal opportunity to  To determine the availability/adequacy of medicines experience the level of service delivery and equipment at clinics and district hospitals. first-hand and to see what kind of service delivery challenges are facing staff.  To engender a sense of urgency and  To establish the role of district health offices in seriousness among officials regarding ensuring the availability of adequate medicines and service delivery. equipment at clinics and district hospitals.  To introduce objective mechanisms to  To establish whether provincial departments of identify both weaknesses and strengths Health have developed guidelines and procedures towards improving service delivery. to manage the selection, procurement, distribution and use of medicines.  To report serious concerns about the  To establish whether provincial departments of quality of service delivery and Health have developed guidelines to manage the compliance with Batho Pele procurement, distribution and maintenance of requirements. medical equipment.  To carry out investigations of serious  To determine the plans of the provincial failures as pointed out by inspections. departments of Health to resolve any identified problems experienced in relation to the procurement, distribution and use of medicines as well as maintenance of medical equipment.  To improve service user care relations in  To establish the specific institution’s compliance order to promote a user-oriented public with the implementation of the Batho Pele service. Framework in relation to medicines and equipment.

 To determine the challenges experienced by the district offices of health in ensuring that medicines and equipment are available at the health institutions.

5 Republic of South Africa. Public Service Commission. Public Service Commission Act. 1997. 6. Republic of South Africa. Public Service Commission. Protocol on Announced and Unannounced Inspections. 2007.

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3. SCOPE AND METHODOLOGY

3.1 Scope

The inspections sought to gather first-hand information regarding availability of medicines and medical equipment at selected district hospitals and clinics. A representative sample of both urban and rural health facilities, including the sites previously inspected in 2009, was targeted for inspection to determine the availability of medicines and medical equipment. In particular, the Eden District was selected on the basis that it has been identified for the pilot of the NHI.

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. For a detailed list of the officials, refer to ANNEXURE A. The table below shows the inspected sites.

Table 2: Sites and dates of inspections Provincial/District Office Component/Institution Date of Inspection Provincial Office Directorate: Communications 11 October 2013 Eden District District Office 17 October 2013 Sedgefield Clinic, Sedgefield 16 October 2013 Knysna District Hospital, Knysna 16 October 2013 Kwanokuthula CDC, Plettenberg Bay 16 October 2013 George Regional Hospital, George 17 October 2013 Alma CDC, Mossel Bay 17 October 2013 Great Brak River Clinic, Mossel Bay 17 October 2013 Thembalethu CDC, George 17 October 2013 George CDC, George 17 October 2013 Cape/Winelands District District Office 08 November 2013 Nduli Clinic, Ceres 07 November 2013 Clinic, Tulbagh 07 November 2013 Clinic, Touwsriver 07 November 2013 Montague CDC, Montague 07 November 2013 Bergsig Clinic, Robertson 07 November 2013 Worcester Regional Hospital, Worcester 07 November 2013 Phola Park Clinic, Wellington 08 November 2013 Rawsonville Clinic, Rawsonville 08 November 2013 Kayamandi Clinic, 08 November 2013 Cloetesville CDC, Stellenbosch 08 November 2013

3.2 Methodology

The methodology for conducting the inspections followed both the announced and unannounced inspections as prescribed in the PSC’s protocol for conducting inspections7. The inspections sought to understand the challenges experienced by the citizens in accessing quality health care especially regarding the availability of medicines and medical equipment at the sites visited.

To initiate the inspection process, letters were forwarded to the Executive Authorities (EAs) and the Accounting Officers (AOs) of the National and Provincial Departments of Health,

7 Republic of South Africa. Public Service Commission. Protocol on Announced and Unannounced Inspections. 2007.

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informing them about the PSC’s intention to conduct inspections at the selected hospitals and clinics.

4. LIMITATIONS OF THE STUDY

The inspections were conducted at selected district offices and health facilities and as such the findings relate to views and observations made at the said sites. The following limitations were identified:

 The PSC inspection team comprised members who are not experts in the medical field and relied on the officials of the department to identify the medicines and medical equipment at the visited sites. It should, however, be mentioned that the officials appreciated the importance of honesty in this regard as the availability of these resources will enable them to function optimally.

 The inspections did not evaluate the implementation of NHI. However, critical issues to NHI such as the availability of medicines and medical equipment were inspected to determine its readiness for roll-out.

5. KEY FINDINGS ON ANNOUNCED INSPECTIONS

The findings of the announced inspections are presented into key thematic areas, which are the management of medicines and the management of medical equipment. More details are attached as ANNEXURE B.

5.1 Contextual background

The inspection team held meetings with officials of both the Eden and Cape/Winelands District Offices on 17 October 2013 and 08 November 2013, respectively. It emerged during discussions that the two districts were predominantly rural in nature and that the Cape Medical Depot situated in was the primary point of supply of medicines. In the case of Eden District there is a medical sub-depot in Oudtshoorn that services the health facilities in the area. Staff informed the inspection team that although most of the health facilities falling within the districts were located far from the depot, they were nevertheless satisfied with the efficient process of medicine supply by the Depot. The inspection team was also informed that the WCDoH has introduced an Information Communication and Technology (ICT) system called the JAC Pharmacy System, which was being piloted at tertiary hospitals. It also became evident that the WCDoH intended to roll-out the system to all health facilities in the province. According to the officials, the JAC system is designed to provide clinical and administrative support to prescribers, pharmacists and nurses throughout the medicines distribution process. For instance, it was indicated that the system provides for drug ordering, stock control, ward stock top-up, dispensing, labelling, costing and supply chain management. Based on the foregoing the PSC is of the view that the system has the potential to ensure consistent availability of medicines at health facilities. The diagram below illustrates the system’s end-to-end management process.

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Manufacturer Wholesaler Hospital Ward Care Patient orders pharmacy stock provider

Figure 1: The JAC Pharmacy System’s end-to-end management process

According to the Handbook for Clinic and Community Health Centre (CHC) Managers, supervisors should visit these facilities monthly8. District officials informed the inspection team that the necessary support is provided by districts to ensure efficient operations. For instance, it was indicated that District Pharmacists conduct regular workshops and meetings with pharmaceutical staff in their districts as well as consolidating orders of medicines by health facilities. Following discussions with District officials, the inspection team conducted announced inspections at the selected health care facilities within these districts to determine the availability of medicines, medical equipment and the maintenance thereof as well as the support received from the District Offices.

5.2 Management of medicines

An analysis of the National Drug Policy of South Africa (NDPSA) indicates that the management of medicines essentially involves five key functions namely; selection, procurement, management support, distribution, and use. The diagram below maps the critical steps of effective and efficient medicine management (it should be noted that for the purpose of this report, reference to medicines includes pharmaceuticals, medical consumables and medical stationery). In this regard, the findings of the inspections are structured according to this management process.

8 Republic of South Africa. Department of Health. Handbook for Clinic/Community Health Centres Managers. October 1999.

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Figure 2: Medicine management cycle

Product selection

Management support: Rational use,  Information system Procurement monitoring and Organisation/staffing evaluation   Budgeting

Distribution and storage

5.2.1 Product selection

The national essential drug list, together with standard treatment guidelines, serves as the basis for formal education and in-service training for health professionals and for education about medication use for the public9. Scrutiny of the NDPSA indicates that the National Essential Medicines List Committee (NEMLC) or National Essential Drugs List Committee (NEDLC, appointed by the Minister of Health, is responsible for the selection and revision of a national list of essential medicines for three levels of care, i.e. PHC, secondary, and tertiary hospitals.The NEMLC/NEDLC is composed of experts in all spheres of medical and pharmaceutical practice.

During interaction with officials of both Eden and Cape/Winelands District Offices, it emerged that Pharmaceutical and Therapeutic Committees (PTCs) were established at Provincial, District and hospital levels. The main objective of the PTC is to “ensure the rational, efficient and cost-effective supply and use of drugs”10. Officials also indicated that the PTC’s function includes the identification of new drugs for possible inclusion on the EDL based on consideration of scientific evidence of efficacy, substantial safety and risk/benefit ratio as well as best cost advantage of the identified drug. It is the view of the PSC that product selection is well institutionalized and contributes effectively towards the availability of medicines at health care facilities.

9. United States of America. The Role of Essential Medicine Lists in Reproductive Health. Volume 36.Jane Hutchings et al. December 2010. 10 Republic of South Africa. Department of Health. National Drug Policy of South Africa. 1996.

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5.2.2 Procurement

The NDPSA advocates for all institutions to channel their purchases through the medical depots. The inspection team established that the primary supply of medicines to visited health facilities was done through the Cape Medical Depot. It was also established that District Pharmacists may also use the Direct Delivery Voucher (DDV) method to order medical supplies. In terms of the DDV method, the order is placed through the Medical Depot by the District hospital, but the medicines are delivered directly to the facilities by the supplier and/or pharmaceutical company. It was also observed that other creative ways were in place to ensure sustainable availability of medicines by these facilities.

Regional and District Hospitals: It was found that these health facilities use an online stock management system to generate orders which ensured that the ordering of stock was prompt. Usually, orders were placed a month in advance. However, any urgent orders for specific items had a maximum three day turn-around time from placement of order to delivery to the facility. Emergency supplies were also provided from tertiary hospitals or by approaching private hospitals. The collaboration with other hospitals was commendable and in line with an integrated approach to ensuring constant availability of medicines at facilities for sustainable quality health care.

Community Day Centres and Clinics: In the Eden District, a sub-depot has been established and situated in Oudtshoorn, which supplies Community Day Centres (CDCs) and clinics given the rural location of these health facilities. Interviewed managers indicated that the ordering of medicines was efficient and delays or stock-outs on certain drugs were minimal. As a result, there was a regular cycle of ordering and receiving, and pharmacists and operational managers expressed confidence in the system. These health facilities also established relations with the nearest district hospitals for support whenever they experienced shortage of medicine supplies arising from circumstances beyond their control.

It is the view of the PSC that the foregoing level of flexibility allows for efficient acquisition of urgently needed medicines at the health facilities, and thereby ensuring sufficient stock availability, and as such, needs to be commended.

5.2.3 Distribution and storage

Distribution: The main objective of the NDPSA is to ensure prompt, efficient, timely and equitable distribution of essential drugs and medical supplies to all institutions. It is against this background that provincial departments have been allowed to make own distribution arrangements. Managers in both Eden and Cape/Winelands Districts informed the inspection team that they found the distribution system of both the Cape Medical Depot highly effective in that any delays and other complications relating to stock-outs were negligible. According to the staff, the transportation of medical supplies was the responsibility of the Medical Depot and was undertaken efficiently. This was also corroborated at the inspected facilities. It also emerged that district hospitals regularly had buffer stock from which they supplied the CDCs and clinics whenever the latter experienced shortage. In this regard, district hospitals use own vehicles to deliver the requested items to the CDCs and clinics. In addition, the Oudtshoorn sub-depot was able to

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replenish any shortage timeously in the case of Eden District. As a result, the rural nature of the two districts, with significant distances between the Cape Medical Depot and the facilities, has not emerged as a serious factor.

It was also noted that additional measures were also put in place to ensure that patients on chronic medication receive their pre-packed medication at the nearest facility. For instance, the districts, together with clinics, have arranged for patients to collect their pre-packed chronic medication at identified sites in the region, such as municipal centres and community halls. Nurses were also on hand to explain the usage of these medicines and further educate the community on other health issues. The process was corroborated by the staff at the visited health facilities and they stated that the arrangement has shortened the waiting time for the dispensing of medication, which did not exceed 45 minutes in most cases. However, management at the Knysna District Hospital raised concerns of not having sufficient vehicles to transport the chronic medication to the various sites. Furthermore, management at both districts were concerned that the hospitals were utilizing existing pharmaceutical staff for pre-packing chronic medicines which affected the efficiency of the facilities since there was no dedicated human resource capacity in this regard. The idea of employing local residents with vehicles on a part-time basis to deliver this service is an option that can be considered.

Storage: Proper maintenance of medicines in the right quantity and quality is critical for effective treatment. In addition, the security thereof is essential to prevent unnecessary shortages. The inspection team established that Standard Operational Procedures (SOPs) for purposes of control of access to the pharmacies and safeguarding measures (i.e. locking facilities to the pharmacies) were in place. Overall, pharmacies of the inspected facilities were found to be sufficiently protected by means of locked doors, security gates, burglar bars on doors and windows, and alarm systems with armed response. Additional security measures included Closed Circuit Television (CCTV) systems and keys to the facilities being held only by the operational managers and two other designated employees in case of emergency. Key-holders to the premises would also be the only persons with access codes to the alarm systems at the facilities.

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Picture 1: CCTV monitoring system in the office of supervisor pharmacist at Kwanokuthula CDC

The condition of the pharmacies appeared clean and medicines were neatly packed on the shelves. It was also observed that air-conditioning systems were installed and in working condition to provide cool temperatures in order to maintain the quality of medicines.

Picture 2: Neatly packed Pharmacy of Kwanokuthula CDC with working air-conditioning system

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According to the NDPSA, all unwanted and expired drugs, medical supplies and associated waste should be disposed of promptly, efficiently and safely. As a result, proper stock control measures should be put in place to ensure safety of medicines and medical supplies as well as to minimise discrepancies. The inspection team established that stock- taking was conducted monthly and recorded on stock cards at all the inspected health facilities. This was done to ensure that minimum and maximum stock levels were always adhered to and also to manage the expiry as well as ensure quality of medicines. It was observed that the health facilities were using the “first expired, first out” (FEFO) principle in identifying outdated medicines on their shelves in keeping with the provisions of the NDPSA. Medicines such as vaccines and insulin that required cool temperatures were kept in refrigerators to maintain their life cycles.

Picture 3: Working refrigerators for safe-keeping of medicines at Cloetesville CDC

The inspection team also found the registries of most inspected facilities where patients’ records were kept, secured with burglar-doors to prevent unauthorised access.

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Picture 4: The Registry at Kayamandi secured with burglar bars

5.2.4 Rational use, monitoring and evaluation

Rational use: According to the NDPSA the key educational role of pharmacists is to instruct patients in the correct use of medicines and to provide preventive health services. Guidelines for the district pharmacist in the province also require clinic supervisors to visit their facilities monthly and that written record of the supervisor’s visit should be left with the clinics. The purpose of the visits is to oversee the operations and provide pharmaceutical support, especially in ensuring that the Standard Treatment Guidelines (STGs) are strictly followed by the nursing staff. The inspection team learned that District Pharmacists conduct regular workshops and meetings with pharmaceutical staff in their districts. It was further noted that during these workshops a comprehensive analysis of drug use and stock levels was undertaken. The practical assessment of the medicine situation at the inspected health facilities by district pharmacists was a critical intervention, which empowered the facilities to maintain quality service delivery in line with the NDPSA.

Monitoring and evaluation: District Offices should manage the availability and safe use of medicines at health facilities. The inspection team observed that the Cape/Winelands District instituted its own assessment instrument that indicates the efficiency levels of their pharmacies in all its health facilities. Surveys were regularly conducted with citizens on their experiences on medicine availability and usage as well as operations of the facilities. The inspection team was also informed that the tool enables District officials to identify areas where their support was most needed.

Furthermore, it is the function of the Pharmaceutical and Therapeutic Committees (PTCs) to develop medicines safety systems to obtain information regarding medication errors, prevalence and importance of adverse drug events, interactions and medicines quality as

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well as inform essential medicines decisions as well as local interventions that may be required to improve safety11. It was observed that the PTCs regularly provided advice on the development of policy documents and circulars to guide implementation of decisions relating to changes to treatment guidelines. According to staff at Eden District, the committee would share information on the use of medicines, the trends with regard to dispensing of certain medicines and usage in certain regions, and the quality of care as a result of medicine supply. It was further noted that each District has a monitoring mechanism to assess stock levels and to isolate problems of low or lack of supply of certain drugs. Trends of expired medicines at facilities were monitored against applicable standards and measures instituted for the managing pharmacist to effectively prevent these.

5.2.5 Management support

On-going support in terms management systems and processes is crucial for the effective functioning of facilities.

Information Management and Technology System: The NDPSA has advocated for computerized inventory control systems to be established in all hospital pharmacies and clinics, and for these to be linked to computerized inventory control systems in the depots. The key objective is to ensure the prompt, efficient, timely and equitable distribution of essential drugs and medical supplies to all health care institutions12. The inspection team was informed that all visited health facilities use the WINRDM (an electronic system for ordering of stock). It was indicated that the system was linked to the Cape Medical Depot through the Remote Demander Module (RDM). According to the staff, the ordering process was prompt and that only pharmacists at district hospitals and CDCs had access to the system for placing orders.

In addition, the inspection team established that records of monthly purchasing orders were kept chronologically in files and the information was used to plan for the following financial year, including preparing the relevant budget. The process enabled the facilities to adequately provide for seasonal illnesses such as allergies and flu, which also addressed the challenge of storage space in pharmacies at the inspected health facilities. The PSC found this to be a good practice and in line with the NDPSA.

The filing systems at Cloetesville and Kayamandi CDCs seemed well-ordered and professional, which made it easy for staff to locate files of patients.

11 Republic of South Africa. The National Department of Health. Standard Treatment Guidelines and Essential Medicine List for South Africa.2012 12 Republic of South Africa. Department of Health. National Drug Policy of South Africa. 1996.

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Picture 5: Well-ordered and professional filing system at Cloetesville CDC

Training: Knowledge empowers employees to handle what is expected of them. Training, therefore, ensures that staff is kept abreast of new developments in order to improve on the quality of services provided to clients. The inspections found that district pharmacists regularly conducted workshops and meetings with pharmaceutical staff within their districts.

Staffing: In terms of the NDPSA, pharmacists play the critical role of managing medicine supply in both hospital pharmacies and clinics. It was found that visited district hospitals and CDCs had supervisor pharmacists, production pharmacists and post-basic pharmacist assistants, whilst clinics had post-basic pharmacist assistants. Although the management of the inspected facilities was satisfied with their human resource capacity, it was indicated that the pre-packing of chronic medicines requires dedicated staff to allow pharmacists to discharge their responsibilities effectively. Staff shortages often result in employees being overworked and thus leading to low staff morale, which may impact negatively on the quality of service.

5.3 Management of medical equipment

Availability of sufficient medical equipment at health facilities is integral to providing quality health care.

Procurement: The main objective of the Preferential Procurement Policy Framework Act, 2000 (PPPFMA)13 is to ensure proper control and consistency of procurement processes. District Offices informed the inspection team that the procurement of medical equipment in the province has been decentralized to ensure that needed items were timeously procured for the facilities. Systems were also put in place to ensure the procurement of high quality

13 Republic of South Africa. National Treasury. Preferential Procurement Policy Framework Act, 2000 (PPPFMA).

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equipment. In this regard, a Medical Equipment Acquisition Plan was compiled annually where emerging needs were considered for procurement. Prospective suppliers were listed on the provincial database to promote open competition and that committees have been established at facility level to deal with procurement of medical equipment. These committees consist of clinical physicians and artisans who are well-acquainted with the issues of quality of medical equipment. According to the District officials, clinical physicians regularly interacted with the procurement section on the quality of the equipment and the compilation of specifications. Medical or operational managers also serve on the adjudication committees to provide input on priority areas relating to availability of equipment during evaluation of bids.

Furthermore, the Monitoring and Response Unit meeting, comprising management of sub- districts, convenes regular meetings to discuss operational challenges, which include equipment utilization and availability. District officials were confident that the process ensured that all the health facilities falling within their control had sufficient medical equipment. During inspection of the visited facilities, it was found that all the facilities had adequate equipment. The PSC found the procurement system of the WCDoH to be well- institutionalized to ensure the timeous procurement of quality medical equipment at the visited facilities. It is also the view of the PSC that the WCDoH’s procurement process was in line with the PPPFMA.

Picture 6: Oxygen equipment and wheelchairs at Cloetesville CDC

Asset control: Medical equipment involves the use of state funds and must be safeguarded to ensure accountability. It for this reason that section 38(1) of the Public Finance Management Act, 1999, as amended (PFMA)14, requires the Accounting Officer (AO) to ensure the effective management, including safeguarding, and maintenance of public assets. Accordingly, Treasury Regulation 10.1.1(a) requires the AO to take full responsibility and ensure that proper systems exist for assets and that preventative

14 Republic of South Africa. National Treasury. Public Finance Management Act, 1999, as amended (PFMA).

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 14

mechanisms were in place to eliminate theft, losses, wastage and misuse of assets15. The inspection team found that heads of administration at district hospitals and operational managers at CDCs and clinics were responsible for the overall control of assets at their respective facilities. The necessary delegations were in place to enable these officials to discharge their responsibilities effectively in keeping with the PFMA and Treasury regulations.

Maintenance of equipment: During interaction with the Eden District officials, it emerged that district hospitals have artisans who maintain the equipment in all the facilities falling within the district. In addition, the District has established close relations with the George Regional Hospital whose artisans were prepared to provide maintenance services in the facilities within the district, whenever the need arose. Although the Cape/Winelands District did not have similar human resource capacity at its district hospitals to do maintenance services, it was, however, found that most of its equipment had warranties and service plans as part of the purchase agreement with the suppliers. It also emerged that there were instances where the engineering section at Tygerberg Tertiary Hospital provided maintenance services for facilities falling within the Cape/Winelands District.

Generally, all the visited facilities were satisfied with their respective Districts’ support in this regard. However, officials at Sedgefield Clinic were concerned about the delays by the Eden District Office in facilitating responses to requests for maintenance of equipment. Notwithstanding the foregoing, all the visited facilities informed the inspection team that their medical equipment was in very good condition.

Picture 7: Equipment at Kwanokuthula CDC in excellent condition

15 Republic of South Africa. National Treasury. Public Finance Management Act, 1999, as amended (PFMA). Treasury Regulations, 1999.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 15

Disposal of medical equipment: The applicable asset management framework of the PFMA provides for regular inspection of assets and identification of obsolete items to be disposed of. The inspection team observed that the visited districts followed disposal processes of marginal variations. In the Cape/Winelands District, broken equipment is sent to the regional workshop for examination and recommendation by the workshop manager on whether it can be repaired, disposed of or replaced. The process in the Eden District requires the asset control manager to visit the facility upon receipt of notification of broken equipment, to inspect and make a recommendation on the condition thereof. The equipment is thereafter sent to the repairs workshop to validate the asset control manager’s recommendation. In both instances, the said managers would present their recommendations to the disposal committee which may approve or reject the recommendations. It was observed that the disposal committees convened meetings quarterly, and that the necessary delegations were in place to enable the managers and the disposal committees to execute their responsibilities. The PSC found both processes to be consistent with the applicable provisions of the PFMA.

Furthermore, the districts indicated that when facilities such as hospitals purchased new equipment, the older and still functioning units would be made available for use at lower facilities within their areas. The districts assured the inspection team that the replacement process was strictly applied and that the inputs of clinical physicians and artisans were always sought on the quality of the equipment in order to maintain standards. The PSC found the arrangements of both districts to be good practice that translated into the economical use of financial resources as required by the PFMA.

It should, however, be mentioned that most of the visited clinics were concerned about the time which lapsed between broken equipment being reported and when it was finally replaced. The clinic staff mentioned that it sometimes took approximately six months to replace broken equipment and they attributed the delay to the intervals between the meetings of the disposal committees. It was noted that the affected facilities were then forced to borrow equipment from another institution to prevent disruption of service delivery. Such practice would, however, result in the latter institution having to function with less equipment and thus impacting negatively on its service delivery. Although the clinics indicated that they would sometimes refer patients to other institutions, this however contributed to longer queues and increased waiting times at the receiving institutions, which may give rise to dissatisfaction amongst patients. It is the view of the PSC that these challenges point to weaknesses in the process from the time of reporting to presentation of cases to the disposal committees.

5.4 Governance of health facilities

In order to ensure, amongst others, responsiveness and value for money in the delivery of services, it is important that those entrusted with the delivery of public services are held to account. Section 41(6)(a) of the NHA requires of the relevant MEC to appoint a representative board for each public health establishment classified as a hospital and to prescribe its functions and procedures for meetings. In terms of section 42(1) of the NHA, provincial legislation must at least provide for the establishment of clinic committees.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 16

Hospital boards: In line with the provisions of the NHA, one of the eight core management standards of the DHS is that the community acts as a shareholder in hospital management and its representatives should be on the hospital board16. District officials indicated that hospital boards have been established, and that they were functional. This body is mandated by the Executive Authority. According to officials, the structures provide a platform to communities to make inputs on the effective and efficient operations of the hospitals. For instance, community inputs in the Cape/Winelands District led to the introduction of outreach programmes to farming communities in order to empower them on health issues. It is the view of the PSC that the WCDoH considered the views of the community at this critical level to improve the quality of service delivery, and has clearly complied with the applicable provisions of the NHA.

Clinic Committees: Clinic committees are meant to give expression to the principle of community participation at a local level. The inspection team found that these were not functional. Officials indicated that the level of interest in serving on these committees was a challenge. This points to weaknesses in the public participation mechanism of the Department, and compromises the community of an effective platform to contribute towards quality health service at the clinic. This is also not in keeping with the constitutional principle of public participation.

5.5 Challenges

The following challenges were identified as impacting negatively on effective and efficient service delivery at the inspected facilities:

 There was insufficient space to stock pharmaceutical supplies in most of the clinics.  Not all facilities had high-tech security such as CCTV systems.  There was lack of dedicated human resource capacity for pre-packing chronic medication distribution.  The turnaround time for the disposal and replacement of equipment was unreasonably long at times, which mostly affected clinics.

6. KEY FINDINGS ON UNANNOUNCED INSPECTION

The findings from unannounced inspections are presented below. Batho Pele as a key strategy for the transformation of Public Service delivery sets out specific principles that should be adhered to at all times17. It was the purpose of the unannounced inspections to determine the extent to which the visited health care facilities adhered to these. Detailed findings of these inspections are attached as ANNEXURE C.

16 Republic of South Africa. A District Hospital Service Package for South Africa. A set of norms and standards. May 2002.

17 Republic of South Africa. Department of Public Service and Administration. The Batho Pele White Paper on the Transformation of Public Service Delivery, 1997.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 17

6.1 Observing facilities

Lack of space: All the staff interviewed indicated that more space would be welcomed. The inspection team observed that in the majority of the day care centres accommodation and space seemed to be a problem especially in the smaller towns. This was due to the fact that the structures of clinics in small towns were usually small, and as such there was insufficient space to store equipment (Refer to picture 6 above depicting wheelchairs at Cloetesville CDC). Rawsonville Clinic was worst affected as its facilities was rundown. Its reception area appeared cluttered and unprofessional, and the waiting area was not a conducive environment. However, the inspection team observed that the construction of a new facility is underway.

Picture 8: The waiting area at Rawsonville Clinic

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Picture 9: Construction of the Rawsonville Clinic underway

Condition of premises: The majority of the inspected facilities were in good condition. However, the Great Brak Clinic and Alma CDC required general maintenance, including painting of the external walls, to address their unattractive appearance. It was observed that newly built clinics such as Kayamandi were in immaculate condition with an impressive inside layout that exuded a sense of professionalism.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 19

Pictures 10 & 11: Consultation area (Above) and waiting area (Below) at Kayamandi Clinic

However, the inspection team observed that the grounds of Kayamandi Clinic required proper gardening attention.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 20

Picture 12: The grounds of Kayamandi Clinic required gardening attention.

Security: All the visited facilities had sufficient security measures in place such as locked gates, burglar bars and alarm systems. In some instances, security guards were appointed who patrolled the perimeters of the clinics during the day.

Water and electricity: The inspection team observed that water and electricity were available at all the clinics. Some of the clinics had generators in case of power failure.

Physical resources: It was observed that all necessary physical resources were available. For example, all facilities had sufficient computers and refrigerators. Although telephones were available, it was a concern that some facilities did not have two-way radios to be used in case of emergencies.

6.2 Observing access to information

According to the Batho Pele principle of access to information, citizens are entitled to receive adequate information on available public services as well as the standards on delivering those services in order to empower them should they need to query the quality thereof.

Services and guidelines: Key information such as personal hygiene and health care was provided at all inspected facilities by means of posters in the waiting areas. Information indicating specific service points was clearly visible and mostly provided in languages predominantly spoken in the respective areas. Batho Pele posters were publicly displayed as well as on walls in offices of officials.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 21

Redress: In order to elicit feedback from citizens on the services they received, all national and provincial departments were expected to have complaint/suggestion boxes. The inspection team observed that the suggestion/complaints boxes were strategically placed close to the entrance of the majority of the facilities.

Observing staff: Most officials at the inspected facilities were wearing identifiable name tags. In those instances where some staff members did not have name tags, the inspection team was informed that the staff members concerned were recently appointed and their name tags were in the process of being issued. Nevertheless, the conduct of staff in general was found to be professional.

6.3 Talking to citizens

Citizens as consumers of the services provided by the institutions are in the best position to give feedback on the state of service delivery. Their views and comments are important in any effort meant to improve service delivery. Interviews were conducted with randomly selected citizens on the quality of services rendered.

Availability of medicines and medical equipment: Patients informed the inspection team that they were satisfied that medicines and medical equipment were sufficiently available at visited facilities. They were also largely satisfied with the quality of care received at those facilities.

Access: One of the critical focus areas of transforming the Public Service was ensuring that citizens were able to access public services in their localities. Although most citizens were happy with proximity of the facilities in their neighbourhoods, patients at Sedgefield Clinic were concerned about the distances they travelled to access the clinic services. The citizens were unable to provide the inspection team with the approximate distances travelled. It was observed, however, that the norms and standards for health clinics determines that clinics should be within a 5 kilometres (km) radius from residential areas.

Waiting time: A distinction should be made between waiting time for consultation and waiting time to receive medication. Most of the patients at the visited facilities were highly concerned about the length of waiting time for consultation. Many reported that the waiting time in some instances exceeded four hours which was even more problematic for patients traveling long distances especially those found at Sedgefield Clinic. However, the citizens at all the visited facilities were satisfied with the waiting time for receiving medication. They informed the inspection team that the time varied from 10 to 45 minutes, which was attributed to the WCDoH utilizing various nearby health and community facilities for this purpose.

Consultation: The Batho Pele principles of consultation and information require public institutions to adequately consult with citizens and provide them with sufficient information in order to empower them in providing inputs on the quality of services they receive. Patients at all the inspected facilities were satisfied with the manner in which they were treated by the staff. They also indicated that the staff seemed amenable to the views of the citizens. However, patients at the inspected clinics were concerned about the lack of formal

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 22

structures at clinic level to enable them to consistently contribute to the improvement of service delivery. Although the interviewed patients indicated that they were able to channel their concerns through the ward councillor in certain instances, they found the mechanism inadequate. The foregoing is in line with the inspection team’s finding at paragraph 5.4 that clinic committees were not functional.

7. IMPLEMENTATION OF PSC RECOMMENDATIONS

As part of the scope of the inspections, the inspection team followed up on the PSC’s previous recommendations emanating from the inspections of primary health care facilities conducted in 200918. It was observed that all three (100%) recommendations in respect of the Phola Park Clinic were implemented by the WCDoH. The Department should be commended for demonstrating this level of commitment in supporting the PSC’s work in its oversight role as enshrined in the Constitution. Most specifically, it is in keeping with section 196(3) which stipulates that “no person or organ of state may interfere with the functioning of the Commission”. Detailed findings on the status of implementation of the recommendations at the sampled facilities are attached as ANNEXURE D.

8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL OUT OF THE NATIONAL HEALTH INSURANCE (NHI)

The NHI is a financing system which aims to ensure that all SA citizens, including non- citizens who have attained permanent residence, are provided with essential healthcare, regardless of their economic status. According to the National Department of Health (NDoH), during the first five years of the NHI pilot the focus will be on strengthening the following key priority areas:

 Management of health facilities and health districts;  Quality improvement;  Infrastructure development;  Medical devices including equipment;  Human resource planning, development and management; and  Information management and systems support.

The ancillary aim of the inspections at the selected health facilities was to further provide the PSC with an indication of the sites’ readiness for the roll out of the NHI.

18 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of Health. 2010.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 23

Figure 3: Mobile unit to be used during the NHI Pilot Project

It was found that there were very few challenges at the inspected facilities. Key challenges observed related to delays in the process of disposing of and replacing obsolete equipment which mainly hampered service delivery at clinic level. Furthermore, lack of space, which was due to the clinics’ inherent small structures, limited these facilities from stocking sufficient medicines as well as properly storing their medical equipment. Notwithstanding these challenges, the inspection team was largely impressed with the systems in place to effectively manage the availability and distribution of medicines and medical equipment in the inspected Health Districts. In view of the foregoing, it is the view of the PSC that the inspected facilities were ready for the roll-out of the NHI.

9. RECOMMENDATIONS

The recommendations contained in 9.1 and 9.2 below emanate from the inspections. These recommendations should apply to all health facilities in the province that may be experiencing similar challenges and not only those that were visited by the inspection team.

9.1 Announced Inspections

 The Western Cape Department of Health should implement a standardized electronic system for ordering medicines in all the health facilities in order to ensure

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 24

sustainable efficient service delivery. The suggested roll-out of the JAC System, currently used in tertiary and regional hospitals in the province, should be expedited. In this regard, a plan of action should be put in place by January 2015.

 The WCDoH should consider installing improved security measures such as CCTV and alarm systems at all facilities. A plan of action must be in place by January 2015.

9.2 Unannounced Inspections

 The WCDoH should refurbish the clinics to address the challenge of space (In this regard, a plan of action must be in place by April 2015).

 The Department should urgently ensure the general maintenance of Great Brak River Clinic and Alma CDC, including painting of the external walls, to address their unattractive appearance.

 The delays relating to the process of disposal and replacement of medical equipment should be addressed urgently.

10. CONCLUSION

The inspected sites were largely found to have medicines and medical equipment. However, of worrying concern was the delay in the process of disposing of and replacing obsolete medical equipment which must be addressed without delay. Notwithstanding the foregoing, it is the view of the PSC that the WCDoH has demonstrated impressive performance in the delivery of health care at the inspected facilities. It is hoped that the recommendations in this report will further enable the Department to ensure sustainable quality health care at the inspected health care facilities.

11. ACKNOWLEDGEMENT

The PSC would like to express its appreciation for the cooperation received from the officials of the Department in all the visited sites. It is the view of the PSC that the officials were appreciative of the importance of the inspections in supporting the work of government in its key objective for a long and healthy life for all South Africans.

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 25

ANNEXURE A: A LIST OF FACILITIES VISITED AND OFFICIALS THAT WERE ENGAGED Name of Institution Date Names and designation of interviewed personnel Inspection Team Members Sedgefield Clinic 16 October 2013 Sister Elizabeth Kombrink, Nursing Sister Paul Rockman Ms Melanie Marthinus [Primary Healthcare Manager] Ronald Erasmus Knysna District Hospital 16 October 2013 Dr Brink, Chief Executive Officer (CEO) Ms Rein, Senior Admin Clerk Mr D Matthee, Finance Kwanokuthula CDC 16 October 2013 Sister Petronella Peters, Operational Manager Ms Magda Pienaar, Pharmacist George Regional Hospital 17 October 2013 Mr Michael Vonk, CEO Mr M Viljoen, MMS Ms GE Sellers, Head of Nursing Mr N Lotter, DD: Admin Ms S Janki, DD: Finance Ms S Brink, Head of Pharmacy Mr G Swanepoel, Clinical Technician Alma CDC 17 October 2013 Sister Iris Josephs, Operational Manager Noluthando Goniwe Sister Maria Manuel, Primary Health Care Manager/Area William Wilkinson Manager (Mossel Bay and Great Brak) Phumla Willie Ms Gerda Terblanche Great Brak River Clinic 17 October 2013 Sister Hester Marais, Operational Manager Thembalethu CDC 17 October 2013 Sister Karin Kittas, Acting Operational Manager George CDC, George 17 October 2013 Sister Elizabeth Kombrink, Operational Manager Ms Melanie Marthinus [Primary Healthcare Manager] Nduli Clinic 07 November 2013 Dr Prince, Area Manager Noluthando Goniwe Mr W Waweni, District Manager William Wilkinson Sister NM Mnqayi, Nurse Marlene Slier Tulbagh Clinic 07 November 2013 Sister Petronella Peters, Operational Manager Ms Magda Pienaar, Pharmacists Touwsriver Clinic 07 November 2013 Mr Michael Vonk, CEO Mr M Viljoen, MMS Ms GE Sellers, Head of Nursing

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 26

Name of Institution Date Names and designation of interviewed personnel Inspection Team Members Mr N Lotter, Deputy Director: Admin Ms S Janki, Deputy Director: Finance Ms S Brink, Head of Pharmacy Mr G Swanepoel, Clinical Technician Montague CDC 07 November 2013 Ms Anita Metlerkamp, Primary HealthCcare Paul Rockman C De Kock, Pharmacist Ronald Erasmus Sister Pengelley, Assistant Manager: Nursing Bergsig Clinic 07 November 2013 K Fourie, Operational Manager VB Jake, Pharmacist Worcester Regional Hospital 07 November 2013 L Philips, Director Charles Williams, Pharmacist S Neethling E Essen, Finance Ms Badenhorst, Nursing Manager V Adams, Support Services M McPherson, Pharmacist E Westenberg, Support Maintenance L May, Finance Phola Park Clinic 08 November 2013 Sister Minaar Rawsonville Clinic 08 November 2013 Sister F Kafaar, Acting Operational Manager Noluthando Goniwe Ms S Jaftha, Pharmacist William Wilkinson Ms Majiet, Principle Health Care Manager Marlene Slier Kayamandi Clinic 08 November 2013 Sister ZD Ndlebe, Operational Manager Dr D Johnson, Primary Health Care Manager Dr R Davis, Regional Manager Cloetesville CDC 08 November 2013 Sister Esau, Operational Manager Dr Denise Johnson, Primary Health Care Manager Dr Richard Davis, Regional Manager Mr Ashton Joseph, Pharmacist

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 27

ANNEXTURE B: ANNOUNCED INSPECTIONS IN THE VISITED FACILITIES

X Norms and standards adhered to 0 Norms and standards not adhered to

Availability of medicines at inspected facilities

Cloetesville CDC

level

Medicines

Medicines supply according to STG STG to according supply Medicines Hospital EDL: and STG to according supply Medicines level Care Primary DL: and in always supplies and Medicines stock. and drugs emergency with Trolleys equipment resuscitation Therapeutic Pharmaceutical place in Committee

X X X X X

Sedgefield Clinic

X X X X X

Phola Park Clinic

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 28

X X X X X

Kayamandi Clinic

X X X X X

Kwanokuthula CDC

X X X X X

Alma CDC

X X X X X

Great Brak River Clinic

X X X X X

Rawsonville Clinic

X X X X X

Montague CDC

X X X X X

Nduli Clinic

X X X X X

Bergsig Clinic

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 29

X X X X X

Thembalethu CDC

X X X X X

George CDC

X X X X X

Tulbagh Clinic

X X X X X

Touwsriver Clinic

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 30

Availability of medical equipment at inspected clinics

X Norms and standards adhered to 0 Norms and standards not adhered to

sizes

children

samples

cylinder and mask and cylinder

Glucometer

Stethoscope

Diagnostic set Diagnostic

Measuring tapes Measuring

Emergency trolley Emergency

Sterilization system Sterilization

taking blood & other other & blood taking

Heamoglobinometer

Pregnancy test strips test Pregnancy

Speculums of different different of Speculums

where easily accessible easily where

Sharps disposal system disposal Sharps

Two working refrigerators Twoworking

Blood pressure machines pressure Blood

Scales for adults & young young & adults for Scales

Telephone/ two way radio way two Telephone/

Condom dispenser placed placed dispenser Condom

Oxygen Oxygen

Equipment & containers for for containers & Equipment Cloetesville CDC x x x x x x x x x x x x x x x x x Sedgefield Clinic x x x x x x x x x x x x x x x x x

Phola Park Clinic Medical Equipment Medical x x x x x x x x x x x x x x x x x Kayamandi Clinic x x x x x x x x x x x x x x x x x Kwanokuthula CDC x x x x x x x x x x x x x x x x x Alma CDC x x x x x x x x x 0 x x x x x x x

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 31

Great Brak River x x x x x x x x x 0 x x x x x x x Rawsonville Clinic x x x x x x x x x x x x x x x x x Montague CDC x x x x x x x x x 0 x x x x x x x Nduli Clinic x x x x x x x x x x x x x x x x x Bergsig Clinic x x x x x x x x x x x x x x x x x Thembalethu CDC x x x x x x x x x 0 x 0 x x x x x George CDC

x x x x x x x x x 0 x 0 x x x x x Tulbagh Clinic

x x x x x x x x x x x x x x x x x Touwsriver Clinic

x x x x x x x x x x x x x x x x x

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 32

Comments

 Khayamandi Clinic – Only large and Medium size speculums, Call log for emergency transport, only one way radio.  Thembalethu Day Centre - Emergency service takes 10-20 minutes, only one electronic oxygen cylinder, no two way radio, refrigerator used for immunization and for medication, no burglar bars in rooms, Pharmacist attend weekly meetings. No spare autoscopes available, generators available.  George Central Day Clinic – Ambulance takes 10-15 minutes, only a telephone no two way radio, no burglar bars and no cupboards, Generator shared with municipality.  Great Brak River Clinic – no transport stationed at clinic for emergencies, transport takes 20 minutes depending on diagnosis, telephone and no radio. Primary care childline for adults (For all types of diagnosis for medication).  Nduli Clinic – No extra batteries available, Ambulance and GG Vehicles stationed at hospital, one two way telephone, only sharp containers, sterilization based at hospital.  Alma Clinic – No ambulance stationed at the clinic, 10-15 minute waiting time for ambulance from Mossel Bay Hospital.

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Availability of medical equipment at the inspected hospitals

s in OPD OPD in s

ment for for ment

ray room with supine supine with room ray

-

unit with screening & & screening with unit

puncture set puncture

-

Basic equipment for for Basicequipment patient of examination wards and electronic child and Adult measuring scales, weighing and pediameters rods Proctoscopes Larynscopes meters flow Peak Glucometers Heamoglobinometers kits puncture Lumbar unit monitoring Cardiac X General &bucky mattress table chart Snellen Veno set giving Fluid storage waste clinical A oxygen mobile Fixedand/or supply counseling for area private A HIV/AIDS) (e.g. conduct to Basicequipment deliveries normal ECG equip Emergency emergency and trauma drugs emergency with Trolleys equipment resuscitation & Knysna District Hospital

x x x x x x x x x x x x x x x x x x x x

Medical equipment Medical George Regional Hospital

x x x x x x x x x x x x x x x x x x x x

Worcester Regional Hospital

x x x x x x x x x x x x x x x x x x x x

Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 34

ANNEXURE C: UNANNOUNCED INSPECTIONS IN THE VISITED HEALTH FACILITIES

X Batho Pele requirement adhered to 0 Batho Pele requirement not adhered to

Batho Pele

requirements

sign

Ramps

Parking

Reception

Inside

friendliness

Cleanliness

Air conditon Air

Outside sign Outside staffed Desk

Namebadges

Service charter Service

Business hours Business

Suggestion box Suggestion

Professionalism

Cost of services of Cost

Information desk Information

Desk with material with Desk

Prior requirements Prior

Staff to guide people guide to Staff

Complaint procedure Complaint

visibility of service charter service of visibility

Building in good condition good in Building

Service charter in local language local in charter Service Name badges of back office staff office back of Namebadges Sedgefield X X X X X 0 X X X X X X X X X X X X X X X X X X Clinic Knysna X X X X X X X X X X X X X X X X X X X X X X X X District Hospital Kwanokuthula X X X X X X X X X X X X X X X X X X X X X X X X CDC George X X X X X X 0 X X X X X X X X X X X X X X X X X Regional Hospital Alma CDC X X X X X X X X X X X X X X X X X X X X X X X X

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Great Brak X X X X X X X X X X X X X X X X X X X X X X X X River Thembalethu X X X X X X X X X X X X X X X X X X X X X X X X CDC George CDC X X X X X X X X X X X X X X X X X X X X X X X X Nduli Clinic X X X X X X X X X X X X X X X X X X X X X X X X Tulbagh Clinic X X X X X X X X X X X X X X X X X X X X X X X X Touws River X X X X X X X X X X X X X X X X X X X X X X X X Clinic Montague X X X X X X X X X X X X X X X X X X X X X X X X CDC Bergsig Clinic X X X X X 0 X X X X X X X X X X X X X X X X X X Worcester X X X X X X X X X X X X X X X X X X X X X X X X Regional Hospital Phola Park X X X X X X X X X X X X X X X X X X X X X X X X Clinic Rawsonville X X X X X X X X X X X X X X X X X X X X X X X X Clinic Kayamandi X X X X X X X X X X X X X X X X X X X X X X X X Clinic Cloetesville X x X X X X X X X X X X X X X X X X X X X X X X CDC

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ANNEXURE D: THE STATUS ON IMPLEMENTATION OF RECOMMENDATIONS OF THE PSC’s INSPECTIONS CONDUCTED IN 200919 Name of the clinic Recommendations Implemented Phola Park Clinic  The facilities of the Phola Park clinic, such as toilets should Yes. be refurbished and properly maintained.

 The Phola Park clinic should be provided with a new key to Yes. their complaint box.

 Clinic managers should device a strategy of dealing with Yes. the long waiting periods at the clinics. The Department has a Chronic Dispensing Unit which prepares patient medicine packages which are delivered to the users’ nearest clinic. This measure has eradicated the practice of patients having to queue at pharmacies and has created a rather quick pick-up collection point for medicines.

19 Republic of South Africa. Consolidated Report on Inspections of Primary Health Care Delivery Sites: Department of Health. 2010. Report on Service Delivery Inspection of Hospitals and Clinics: DoH: Western Cape Province 37