REPORT ON A SERVICE DELIVERY INSPECTION OF DISTRICT ... …

[Pages:42]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: WESTERN CAPE 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

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

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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 AO CCTV CDC CEO CHC DDV DHS EA EDL FEFO HIV ICT MEC MMS NEDLC NEMLC NDoH NDPSA NHA NHI PFMA PHC PPPFMA PSC PTC RDM SA SOPs STG WCDoH WHO

Acquired Immune Deficiency Syndrome Accounting Officer Closed Circuit Television Community Development Centre Chief Executive Officer Community Health Centre Direct Delivery Voucher District Health System Executive Authority Essential Drugs List First Expired, First Out Human Immunodeficiency Virus Information Communication and Technology Member of the Executive Council Middle Management Service National Essential Drugs List Committee National Essential Medicine List Committee National Department of Health National Drugs Policy of South Africa National Health Act National Health Insurance Public Finance Management Act Primary Health Care Preferential Procurement Policy Framework Act Public Service Commission Pharmaceutical and therapeutic Committee Remote Demander Module South Africa Standard Operating Procedures Standard Treatment Guidelines Western Cape Department of Health 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

To afford a personal opportunity to

experience the level of service delivery

first-hand and to see what kind of service

delivery challenges are facing staff.

To engender a sense of urgency and

seriousness among officials regarding

service delivery.

To introduce objective mechanisms to

identify both weaknesses and strengths

towards improving service delivery.

To report serious concerns about the

quality of service delivery and

compliance with Batho Pele

requirements.

To carry out investigations of serious

failures as pointed out by inspections.

To improve service user care relations in

order to promote a user-oriented public

service.

Objectives of inspections on the availability of medicines and medical equipment To determine the availability/adequacy of medicines and equipment at clinics and district hospitals.

To establish the role of district health offices in ensuring the availability of adequate medicines and equipment at clinics and district hospitals. To establish whether provincial departments of Health have developed guidelines and procedures to manage the selection, procurement, distribution and use of medicines. To establish whether provincial departments of Health have developed guidelines to manage the procurement, distribution and maintenance of medical equipment. To determine the plans of the provincial 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 establish the specific institution's compliance with the implementation of the Batho Pele 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

Provincial Office

Directorate: Communications

Eden District

District Office

Sedgefield Clinic, Sedgefield

Knysna District Hospital, Knysna

Kwanokuthula CDC, Plettenberg Bay

George Regional Hospital, George

Alma CDC, Mossel Bay

Great Brak River Clinic, Mossel Bay

Thembalethu CDC, George

George CDC, George

Cape/Winelands District

District Office

Nduli Clinic, Ceres

Tulbagh Clinic, Tulbagh

Touws River Clinic, Touwsriver

Montague CDC, Montague

Bergsig Clinic, Robertson

Worcester Regional Hospital, Worcester

Phola Park Clinic, Wellington

Rawsonville Clinic, Rawsonville

Kayamandi Clinic, Stellenbosch

Cloetesville CDC, Stellenbosch

Date of Inspection

11 October 2013 17 October 2013 16 October 2013 16 October 2013 16 October 2013 17 October 2013 17 October 2013 17 October 2013 17 October 2013 17 October 2013 08 November 2013 07 November 2013 07 November 2013 07 November 2013 07 November 2013 07 November 2013 07 November 2013 08 November 2013 08 November 2013 08 November 2013 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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