SAHRC Report on KZN Oncology Services: Minister of Health & KZN Department of Health response

Meeting report

The Chairperson welcomed the Minister and delegates from the KwaZulu-Natal Department of Health (DoH). She said the meeting followed the presentation of the South Africa Human Rights Commission (SAHRC) to the Committee, which was giving KZN provincial DoH a chance to present its own side of the story.

KwaZulu-Natal DoH presentation

Dr Sibongiseni Dhlomo, Member of the Executive Council (MEC): Health, KZN, said the Department had received much support from the office of the Minister and the Province. He the document presented was an update of a report that had been sent to the SAHRC on the progress of interventions following its recommendations. The three areas to work on had been the repair of equipment, the recruitment of oncologists, and the management of patients.

He said the two Varian Rapid Arc Linear Accelerator (VRALA) machines at Addington Hospital had been assessed and a report provided in August. The report had been discussed with the Department and two alternatives had been considered. The Provincial Treasury had considered the two options and decided the option to repair and upgrade one of the machines which required less work, and to buy a second one which had better technology compared with the current machine, instead of repairing both. In the absence of the machine at Addington Hospital, it was currently functioning at half capacity.

There were three oncology centres and a satellite site in the province which provided both chemotherapy and radiotherapy. The three hospitals were Addington Hospital, Grey’s Hospital, Inkosi Albert Luthuli Central Hospital (IALCH), and a new site had been established on the North Coast where chemotherapy provided by the state was administered by a private oncologist from Joint Medical Holdings (JMH). The development was not a reactive plan, but part of an ongoing plan. The contract would cater for about 100 to 200 patients per month.

The Provincial Department and the national DoH (NDoH) were required to collaborate and develop a strategy to meet current medical staffing challenges in KZN. The Department had advertised the posts of the IALCH Head of Clinical Unit and three oncology specialists, which had proved unsuccessful. The Department had engaged two registrars currently training to become specialists, who had indicated an interest in taking up the positions should they pass their examinations. He said medical specialists provided services and should also provide training to junior staff. Having specialists was important to maintain staff employment stability. Management needed to reach a decision on staff retention and how it treated staff.

Dr Aaron Motsoaledi, Minister of Health, said the NDoH had not being aware of the investigation by the SAHRC, and had become aware only when it was published on 15 June 2017. Before the SAHRC publication, there had been the protest by the South African Medical Association of KwaZulu-Natal. He had sent almost all the Department’s Directors General (DGS) to KZN for about a week to investigate what the problem was. The team had visited various hospitals, including Addington, and had spoken to representatives of the South African Medical Association (SAMA) to understand the problem and make the right diagnosis.

The challenges found during their investigations were in the areas of human resource planning, development and management, and the procurement and supply chain management (SCM). It was found that rate of attrition was higher than the rate at which positions were being filled, and the shortage of staff had put pressure on the available staff, causing some to leave the employment of the Department in KZN. There had also been a disinclination of senior management in the province to delegate recruitment functions. Peculiar to KZN, the internal instruction to gazette purchases of over R30 000 had made the delegation of R200 000 purchases ineffective.

There were four linear accelerators in KwaZulu-Natal, apart from the two that were currently not working. He believed that the crisis was not related to the non-functional linear accelerators, but due to other fundamental problems. He had met with an oncologist who had left KZN, a call that had become necessary because there had been no exit interview. The former member of staff had confirmed that it was a human resource management problem.

The provincial DoH technology department would no longer be allowed to purchase equipment on behalf of institutions. The resolution made was that the NDoH would purchase medical equipment on behalf of the Province, guided by the National Equipment list. From 28 August to 1 September, a team had been sent by the NDoH to stay at the KZN DoH, to coordinate all activities with the Premier office, the Treasury, the University and the Department. The procurement delegations of R200 000 would not be subject to gazetting from 1 October.  The NDoH would start the process of procuring the one machine and repairing another one at Addington Hospital.

A list of critical posts was presently being complied, along with the cost, and was expected to be ready by 6 September. The result of the forensic audit of the KZN DoH which was being carried out by Treasury would be released on 8 September.

Finally, he said the Premier had appointed Professor Ronald Green-Thomson to manage all health related projects in the Province.

Discussion

Mr A Shaik Emam (NFP) welcomed the process that had been put in place to remedy the situation. Despite the oversight functions and money spent, issues in the KZN DoH had gone to the extent of affecting people’s lives. There must have been a gap in communication, because the problem should have been identified and prevented. Closer communication to the people on ground was important. He commented that the Minister had said if there were four machines and two were bad, it would not have had a huge impact, and asked what happened when the machines were several kilometers away from the people that needed them. He asked about the consequences of non-performance and mismanagement. He wanted to know why the Department was losing oncologists, and suggested oncologists’ should be imported because the lives of people were at stake.

Ms S Kopane (DA) said it was unfortunate that people had lost their lives, and observed that the presentation by the MEC had been “sugar coated.” The SAHRC had said the KZN DoH had not given them a list of people who had died. She asked how long the private sector could continue to be of assistance. Why was there still a backlog? The SAHRC had said it took up to five months for a cancer patient to receive treatment. It appeared that there was a matter before the court on the award of a contract, and she asked why this was so. Did the Department face any litigation over the loss of lives?

Dr S Thembekwayo (EFF) thanked the Minster for his quick intervention and the scrapping of the gazette requirement . She asked the MEC to state how many patients were seen in the hospitals on a daily basis. The SAHRC had said the KZN DoH had contracts with private oncologists who came for two hours per week -- how many patients could be seen within two hours? She asked for a guarantee that oncologists would be interested in the vacanct positions. What was the back-up plan if the two oncologists in training declined the positions when they completed their training?

Ms L James (DA) thanked the Minister for speaking about the SAMA protests in KZN. What interventions were in place to remedy the concerns? How were patients in hospitals far way able to access treatment? Another concern was the late knowledge about the crisis in KZN by the NDoH. She asked if the NDoH had a problem working with some MECs of Health.

Mr A Mahlalela (ANC) asked for the view of the MEC on the findings of the SAHRC, that the Department had violated the human rights of people in the two hospitals as a result of the violation of acceptable norms. The SAHRC had said the MEC had not responded to its requests, and the lack of a response meant a lack of cooperation with SAHRC, which he wanted the MEC to explain. The MEC should also indicate if the resources of the province were adequate to provide the needed quality of health care, because he had mentioned in his response that the provincial Department had had to undertake cost cutting due to limited resources. Had the MEC established the reason why health care workers, especially oncologists, were leaving the Department? The Minister had said the reason for an oncologist leaving had not been documented though an exit interview, as it should have been done. The Department had a certain number of specialists, and the SAHRC had asked if there had been any improvement, and what the percentage of the improvement was. It had also asked for the expected percentage or number of oncologist the Province was expected to have. Was the MEC aware of the investigation going on in the province, what the problem was, how serious it was, and the extent to which the problem had been resolved to facilitate service delivery? He asked what steps the Department was taking to train staff who could not use the equipment. He observed that there was. Did the National Department have early warning systems to detect instability in the retention of senior management, and were the systems in place working?

Ms L James (DA) asked if the MEC had the right to decline attending to Members who had gone on an oversight visit to the KZN DoH. She asserted Prof Green-Thompson had a “dodgy record,” and expressed fears on his ability to deliver. She asked if there was a possibility that the Department could provide transport in areas where such services did not exist, because the Gauteng provincial DoH made such provision, and this would make it easier to reduce the waiting list.

The Chairperson said Members had an oversight responsibility over provincial departments, and when they were disallowed from carrying out this duty they should report it to the ANC or MEC. However, if being disallowed was because the Members had been sanctioned by the Committee, then the Members had to report back to the Committee.

KZN DoH’s response

Dr Dhlomo said he already foresaw an over expenditure of about R1.7 billion based on the invoices that had not been paid by 31 March, which the Department had started paying from 1 April. The pressure of finance had been enormous. The organogram could not be filled with staff, but because of the financial limitations, the Department had to determine what was critical. Cost-cutting always impacted negatively on service delivery. The whole Department had to determine what was crucial.

It was difficult to determine how many people would require oncology services. The increase in the number of patients seeking oncology services had been driven by the KZN provincial Department, when it had decided that the hospitals should scan all female patients that came to the hospital for breast and cervical cancer. The process had saved the lives of several women. The challenge afterwards was matching the resources with the needs that arose.

The Department was engaging on the issue of the violation of human rights, because the provision of the law for providing health care services had a clause stating that ‘as long as it is within the resources’. The pool of people awaiting treatment was becoming larger, and the waiting list was around five to seven months.

He had decided that senior staff leaving had to be interviewed, but the lack of records was because of management problems. He apologised for the non-response to the SAHRC’s particular request, but said he had not received the correspondence from the Committee, and he knew that it was the law to work with Chapter 9 Institutions.

He said all the doctors had been trained There was a problem of stability, and the absence of a chief financial officer (CFO) had brought about finance issues.

If Gauteng, a smaller province could provide transport for its patients, then KZN had no choice but to do the same. The Department had been providing transport from the rural areas, and it was siting a hospital closer to some rural areas to reduce the time required to travel for treatment.

He said the allegation against Professor Green-Thompson had been cleared, as it had been aired in the media.

The private oncologists were sympathetic, and were willing to work until the Department got sufficient oncologists to work in the hospitals. About 120 patients were attended to per day. At Grey’s Hospital, the private oncologists worked five days of the week, and there had been negotiations to extend service hours.

The functional Health Technology Services (HTS) was supposed to be the advisory unit, but it was always at loggerheads with the SCM.

He was alarmed that it had been alleged that a Commissioner had been denied access, but the parties concerned had denied being aware of the allegation and the KZN DoH did not have a record of the visit.

It had been mentioned to the SAHRC that the number of people that had died could be sourced from the Cancer Registry, and the Department did not have a record of the 300 deaths indicated earlier by the Committee.

He added that certain awards had been made to a certain company to supply, and it had been alleged that the award was irregular. However, there had been a counter charges by the supplier and the Department was waiting for the court ruling on this.

Ms Precious Matsoso, Director General: NDoH, said the Act was clear about the definition of roles and functions. The system at the technical level came up with norms and standards. There was a technical Committee made up of officials of the national and provincial Departments of Health. There were several of such committees, and they met regularly to deal with specific issues to provide schedules for the heads of departments (HODs). There was a team called the Provincial Support Team, led by a Chief Director, and they were required to visit two districts per province. They had set up a Multiparty Service District and Facility Forum comprised of representatives from the provincial Treasury and Health Department, and the district. It meets regularly to hold hearings and do reviews.  The forum of CFOs had an early warning system called the ‘Non Negotiable’. There were pharmaceutical tracking systems installed in almost all hospitals, and reports were drawn up to establish the reason for shortages of supply.

The district clinical support team had a dashboard that was used to track maternal and child health to identify the districts that needed intervention There were peer reviewers which consisted of teams swapped across provinces, but it had been discovered that clinics borrowed from other clinics to get a clean report, and this had been a challenge. The NDoH encouraged “whistle blowing” to expose such activities.

The scheduled technical National Health Council (NHC) meetings were held in the provinces, and if time allowed they visited and checked facilities.  The team that did the planning was always on the ground in the provinces. The district health expenditure review had been suspended and replaced with the provincial support team. The tracking systems in all the NHCs had the human resource tracking matrix. Infrastructure spending and projects were also tracked. The Health Patient Registration System (HPRS) information system was installed at 1 900 facilities as at June 2017, and hopefully at 2 800 by the end of 2017, with over 12 million patients registered on it.

There were quarterly meetings with health professionals which were independent of the provinces, with SAMA and nursing officers to track issues.

Dr Motsoaledi said in response to Mr Mahlalela question, that it was a problem of concurrency. A mental health summit had been held in 2013 which had elaborated on what should be done and how it should be done. Despite the summit, Gauteng had not complied with the system specified, though the NDoH had tried to intervene. He submitted that the policies had been breached deliberately.

The issue with KZN had been detected since 2014, when a machine was not working, but he had been informed that the company that supplied the machine was charging double, which the province would not pay. The province had declined because it would be against their financial record. An investigation in Switzerland showed that the company that supplied the equipment was not the manufacturer, but an agent that had swindled other provinces, such as North West and Gauteng. He said after investigation into this problem, there had been an instruction to arrest, but no one had been arrested on this issue. He had tried but he had limited power.

The issue in KZN DoH was provincial, and not concurrent. The Minister did not have the power over human resources either to hire, fire or reinstate staff. Apart from conditional grants, the Minister had no control over equitable shares. He explained how conflicts of interest, limitations in his mandate and the insensitivity of other departments affected the delivery of quality health services in the country. There had been advice to review some laws.

He denied implying that having two machines out of order would not change anything. What he had meant was that KZN had more machines than other provinces, so the absence of the two machines should not cause a crisis. 

There were no problems with oncologists but there was a shortage of specialists in the country. The degree of shortages of specialists in different fields varied, and it was a challenge common to Africa.

It was difficult for people to determine how many people died from cancer, as determining the cause of death was technical, and the 300 mentioned by the SAHRC could not be accurate -- and the number was not from the province.

The dispute between KZN and TechNet had resulted in the Department discarding the company and going to another company to service the machine. The report on the issue would be released on 8 September. The new company that had received the contract to service the machine had gone to court against the request of SAHRC, to stop the province from using another company for the maintenance.

There was a ministerial advisory committee on cancer. There was an explosion of cancer, and the challenge was outweighing the resources of the nation and becoming like HIV/AIDS in South Africa. The issue of smoking had to be addressed because a preventive measure was needed.

Ms Kopane said she believed that many people had died as a result of the situation, and those responsible had to be held accountable. She wanted the Minister to indicate when the people would be held liable. It had been reported that the MEC was liable for the lives lost. The response, sent and signed by Dr Dlomo, had stated that 12 people had died of cancer in 2015, while 229 had died in 2016.

The Chairperson said Ms Kopane was reading information that was not in the report, which was not fair.

Mr Mahlalela said he would like to clarify the information about the refusal of access. A provincial commissioner had said she had been denied access. The Committee was dealing with the SAHRC report, and should avoid any matter not raised in that report.

Dr Motsoaledi said the number of people who died from any illness could be obtained only from a specialised service provided through the Rapid Mortality Surveillance Report, Statistics South Africa (StatsSA) or UNAIDS. Even if the MEC gave any figure, it would not be right because he was not an authority in that field, except when he quoted one of the stated authorities. He did not have the authority to punish anyone on the problem. He said the SAHRC was a Chapter 9 Institution which now had to say what must be done.

In 2015, a ministerial task team had been appointed to make findings on the problems in the hospitals. The report had indicated that the problems were not with the hospitals, but with the provincial government. The challenges were in the areas of human resources, finance and procurement and he would like to present the report before the Committee.

The Chairperson said health was a sensitive issue, and required that leaders in the discipline should keep their differences apart to improve service delivery. There was a need to stick with the oncology problem, which had raised other issues of corruption. When discussing health issues, the history of the Department should be considered, as many specialists had left. Despite the issue of concurrency, there was a need for service delivery. The Premier in the provinces called the shots, and left the challenges to the Committee and the Department. The Committee would look at how best to conduct its oversight for service improvement, despite the political differences of its members. It had to return to the province and make the necessary corrections to improve service delivery with the resources available to it.

Mr Mahlalela said he would request that the MEC formally table the letter from the SAHRC and the response, so that the Committee could have copies.

The meeting was adjourned.