report on a service delivery inspection of district

REPORT ON A SERVICE DELIVERY

INSPECTION OF DISTRICT HOSPITALS AND

CLINICS REGARDING AVAILABILITY OF

MEDICINES AND MEDICAL EQUIPMENT AND

THE ROLE OF HEALTH DISTRICT OFFICES

DEPARTMENT OF HEALTH:

NORTH WEST PROVINCE

MAY 2014

Page i Report on Service Delivery Inspection of District Hospitals and Clinics regarding availability of medicines and medical equipment and the

role of Health District Offices in the Department of Health: North West Province

TABLE OF CONTENT

FOREWORD ........................................................................................................................................ iii

LIST OF ACRONYMS ........................................................................................................................ iv

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 medicines .............................................................................................. 5

5.3 Management of medical equipment ............................................................................ 15

5.4 Governance of health facilities ..................................................................................... 18

5.5 Challenges ....................................................................................................................... 19

6 KEY FINDINGS ON UNANNOUNCED INSPECTIONS ............................................... 20

6.1 Observing facilities ......................................................................................................... 20

6.2 Access to information .................................................................................................... 26

6.3 Talking to citizens ........................................................................................................... 29

7. IMPLEMENTATION OF PSC RECOMMENDATIONS ................................................. 30

8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL OUT OF THE

NATIONAL HEALTH INSURANCE (NHI) ..................................................................... 30

9. RECOMMENDATIONS ................................................................................................... 31

9.1 ANNOUNCED INSPECTIONS ..................................................................................... 31

9.2 UNANNOUNCED INSPECTIONS ............................................................................... 32

10. CONCLUSION ................................................................................................................. 32

11. ACKNOWLEDGEMENT ................................................................................................. 32

Page ii Report on Service Delivery Inspection of District Hospitals and Clinics regarding availability of medicines and medical equipment and the


LIST OF TABLES

Table 1: Objectives of inspections ................................................................................................ 2

Table 2: Sites and dates of inspections ........................................................................................ 3

LIST OF FIGURES

Figure 1: Medicine management cycle .......................................................................................... 6

LIST OF PICTURES

Picture 1: Medicine stored in bulks at the pharmacy of Klerksdorp District Hospital .......... 9

Picture 2: Taung Station Clinic’s pharmacy shelves appeared sufficiently stocked up and

appropriately labelled ................................................................................................... 9

Picture 3: Refrigerators with medicines at Klerksdorp District Hospital ............................... 10

Picture 4: A roster displayed for cleaning of the refrigerators at Klerksdorp hospital ........ 11

Picture 5: Pharmacy of Klerksdorp District Hospital protected with burglar bars ............... 11

Picture 6: A note at Taung Station Clinic instructing personnel to regularly record and

balance stock cards ................................................................................................... 13

Picture 7: Broken equipment found at Unit 9 Clinic ................................................................ 17

Picture 8: One of unsecured broken glass doors at Unit 9 Clinic ......................................... 18

Picture 9: Cracks observed in the walls of Unit 9 Clinic ......................................................... 21

Picture 10: Damaged sanitation pipes at Unit 9 Clinic .............................................................. 22

Picture 11: A dripping water tap at Unit 9 Clinic ........................................................................ 23

Picture 12: Damaged ceiling and exposed electric wires at Unit 9 Clinic .............................. 23

Picture 13: Medical supplies and other equipment stored in the bathroom at Tlapeng ........

Clinic ............................................................................................................................. 24

Picture 14: Back-up generator stored with other items at Dryharts Clinic ............................. 25

Picture 15: Signage at Klerksdorp District Hospital................................................................... 26

Picture 16: Information about baby feeding was displayed in Setswana at Klerksdorp

District Hospital ........................................................................................................... 27

Picture 17: Costs of services clearly displayed at Brits District Hospital ............................... 27

Picture 18: Complaints Mechanism displayed at Klerksdorp District Hospital ..................... 28

Picture 19: Key information about management of Klerksdorp District Hospital .................. 29

Page iii Report on Service Delivery Inspection of District Hospitals and Clinics regarding availability of medicines and medical equipment and the


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. In this regard, 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. Despite supply chain management challenges relating to poor quality of

some of the procured medical equipment and delays by District Offices to attend to

maintenance thereof, medicines and medical equipment were largely available at the sites

visited. It was also found that out of 12 PSC’s recommendations, 7 (58%) were

implemented. Based on the findings and observations, it is the view of the PSC that the

visited health facilities were ready for the roll out of the NHI.

It is a pleasure to present theReport on Service Delivery Inspection of District Hospitals and

Clinics regarding Availability of Medicines and Medical Equipment and the Role of Health

District Offices in the North West. We believe that the inspections remain a valuable

monitoring mechanism whose findings could contribute towards service delivery

improvement.

The PSC wishes to thank officials of the North West Department of Health (NWDoH) for their

cooperation and willingness to share information. We trust that the findings will help the

NWDoH in its efforts to improve service delivery for a sustainable and quality health care.

Page iv Report on Service Delivery Inspection of District Hospitals and Clinics regarding availability of medicines and medical equipment and the


LIST OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

AO Accounting Officer

ARV Antiretroviral

BP Blood Pressure

CEO Chief Executive Officer

CHC Community Health Centre

DDG Deputy Director-General

DDP District Demand Plans

DEP District Equipment Plans

DHPs District Health Plans

DHS District Health System

EA Executive Authority

EDL Essential Drugs List

EMS Emergency Medical Services

FEFO First In, First Out

GPPSA Good Pharmacy Practice in South Africa

HIV Human Immune Virus

HoD Head of Department

HPCSA Health Professional Council of South Africa

HRP Hospital Revitalization Programme

MEC Member of the Executive Council

MoA Memorandum of Agreement

NDoH National Department of Health

NDP National Development Plan

NDPSA National Drugs Policy of South Africa

NEDLC National Essential Drugs List Committee

NEMLC National Essential Medicine List Committee

NHA National Health Act

NHIS National Health Insurance System

NWDoH North West Department of Health

NW North West

NWDPW North West Department of Public Works

PHC Primary Health Care

PPPFA Preferential Procurement Policy Framework Act

PSC Public Service Commission

PTC Pharmaceutical and Therapeutic Committee

SA South Africa

SCM Supply Chain Management

SLA Service Level Agreement

SMME Small Medium Micro-sized Enterprise

SOPs Standard Operating Procedures

STG Standard Treatment Guidelines

TB Tuberculosis

UV Ultra Violet

WHO Wealth Health Organisation

Report on Service Delivery Inspection of District Hospitals and Clinics regarding availability of medicines and medical equipment and the


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 mortality1. 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 dictated that government should devolve certain

responsibilities for health services to the provincial and local government 2 . 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 to3 .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 critical 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 Health District Offices in this

regard. Inspections are meant to entrench a citizen and service-centred culture, and

reinforce accountability across the Public Service. Furthermore, 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

1 Republic of South Africa. National Department of Health. Strategic Plan for Nurse Education, Training and Practice

2012/13 – 2016/17. 2 Republic of South Africa. National Department of Health. White Paper for the transformation of the Health

System in South Africa . 1997. 3 Republic of South Africa. National Health Act. 2003.



also present an opportunity of determining their readiness for the imminent roll-out of

National Health Insurance (NHI).

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 Act4.”

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 5 .Table 1 below provides the

objectives of an inspection as defined in the PSC Protocol as well as those pertaining to the

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

experience the level of service delivery

first-hand and to see what kind of service

delivery challenges are facing staff.

To determine the availability/adequacy of medicines

and equipment at clinics and district hospitals.

To engender a sense of urgency and

seriousness among officials regarding

service delivery.

To establish the role of district health offices in

ensuring the availability of adequate medicines and

equipment at clinics and district hospitals.

To introduce objective mechanisms to

identify both weaknesses and strengths

towards improving service delivery.

To establish whether provincial departments of

Health have developed guidelines and procedures to

manage the selection, procurement, distribution and

use of medicines.

To report serious concerns about the

quality of service delivery and compliance

with Batho Pele requirements.

To establish whether provincial departments of

Health have developed guidelines to manage the

procurement, distribution and maintenance of

medical equipment.

To carry out investigations of serious

failures as pointed out by inspections; and

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 improve service user care relations in

order to promote a user-oriented public

service.

To establish the specific institution’s compliance with

the implementation of the Batho Pele Framework in

relation to medicines and equipment.

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



To determine the challenges experienced by the

district offices of health in ensuring that medicines

and equipment are available at the health institutions.

3. SCOPE AND METHODOLOGY

3.1 Scope

The inspections sought to gather first-hand information regarding availability of medicines

and medical equipment at selected hospitals and clinics. A representative sample of both

urban and rural health facilities, which included the sites previously inspected in 2009, was

targeted for inspection to determine the availability of medicines and medical equipment. In

particular, the Dr Kenneth Kaunda was selected on the basis that it has been identified for

the pilot of the NHI.

A brief discussion was held with the officials of the Provincial Head Office, Bonajala and Dr

Kenneth Kaunda 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. Although meetings were not held with district officials of the

Ngaka Modiri and Dr Segomotsi Mompati, the inspection team was assured by the provincial

Head Office that processes for the management of medicines and medical equipment were

largely similar in all districts.

Table 2: Sites and dates of inspections

Inspection Sites Sphere of Government Date of Inspection

Mmabatho Provincial Government 21 October 2013

Ngaka Modiri Molema District

Tlapeng Clinic District 21 October 2013

Unit 9 Clinic District 21 October 2913

Bojanala District

Bojanala District Office District 22 October 2013

Brits District Hospital District 22 October 2013

Dr Kenneth Kaunda District

Dr Kenneth Kaunda District Office District 28 October 2013

Klerksdorp District Hospital District 28 October 2013

Dr Segomotsi Mompati District

Taung Station Clinic District 29 October 2013

Dryhartz Clinic District 29 October 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 inspections6.

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 and the role of the health district offices in this regard.

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



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,

informing them about the PSC’s intention to conduct inspections in 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 ONANNOUNCED 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. It was found that

processes relating to procurement of medicines and medical equipment differ. Detailed

findings of these inspections are attached as ANNEXURE B.

5.1 Contextual background

The inspection team held a meeting with the Deputy Director-General (DDG) for Health

Service in the North West Department of Health (NWDoH) on 21 October 2013. The purpose

of the meeting was to obtain an overview of the province’s District Health System (DHS) as

well as information regarding policies relating to the Primary Health Care (PHC) services,

with specific focus on the distribution of medicines and management of medical equipment.

It emerged during discussions that all pharmaceutical supplies in the province were procured

through national tenders. These were then distributed by the appointed suppliers to the

provincial Medical Depot in Mafikeng and the sub-depot situated in the Tlhabane Sub-District

of the Bojanala District. The inspection team was informed that Bojanala was densely

populated due to labour migration arising from mining development in the area. A

Memorandum of Agreement (MoA) has been entered into between the provincial Medical

Depot and Tlhabane Sub-District, which guides the relationship and operations of these

depots. In terms of the MoA, all health facilities in and around the Tlhabane Sub-District

were serviced by the Tlhabane sub-depot to facilitate the efficient distribution of medicines to

the facilities given their remote locations from the Mafikeng provincial depot.



Furthermore, it emerged that District Offices must develop District Health Plans (DHPs) as

required by section 33(1) of the National Health Act, 2003 (NHA). The inspection team was

provided with the DHP for Bojanala District, which included a situational analysis on the

burden of disease as well as mitigating strategies, in line with the NHA. The DHP for Dr

Kenneth Kaunda District was not produced during the inspections. According to the

Provincial Office, orders for medicines from clinics and district hospitals were consolidated

by District Offices and submitted to the respective depots. The medical depots distribute the

ordered medical supplies weekly to the district hospitals and the latter in turn distribute the

clinics’ orders bi-weekly. It was also noted that during the 2012/13 financial year the NWDoH

had achieved the national target of95%regarding availability of essential medicines,

including the distribution of anti-retroviral drugs (ARVs), at all health facilities in the province.

It was also indicated that the province was on track to maintaining the success rate during

the 2013/14financial year based on its performance of 87.5%by the second quarter.

However, the Provincial Office’s main concern was the lack of regular maintenance of

buildings of health facilities in all the districts. With regard to medical equipment, it emerged

that District Offices submitted annual demand plans for medical equipment items costing

more than R500 000to the Provincial Office, whilst items below the aforesaid threshold were

procured at district and hospital level in line with District Equipment Plans.

Meetings with officials of the Bojanala and Dr Kenneth Kaunda District Offices took place on

22 and 28 October 2013, respectively. It was established at Bojanala District Office that

there were no posts of nursing assistants on its organisational structure. Officials also

indicated that there was a need for additional posts of pharmacy assistants. Furthermore, it

was noted that the district’s human resource plan needed to be revised to align it with the

current population demographics, since the health facilities were unable to meet the

increased demand for health services.

The Handbook for Clinic and Community Health Centre (CHC) Managers7 determines that

supervisors should visit these facilities monthly to ensure effective and efficient service

delivery. District officials indicated that they provide support to health care facilities falling

within their control. It was indicated that District Pharmacists in the respective Districts,

together with hospital pharmacists, play a crucial role in consolidating orders for the districts.

The inspection team found the role of the District Pharmacists to be evidence of the support

the District Offices provide to health facilities in ensuring sustainable quality healthcare to the

public and was in line with the Handbook. Despite human resource capacity challenges,

District officials were confident that the health facilities were ready for the roll-out of the NHI.

The selected health care facilities within these districts were visited 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

The inspection team visited the selected health care facilities within the District Offices to

determine the availability of medicines as well as the support received from the districts.

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

1999.



Scrutiny of the NDPSA indicates that the management of medicines essentially involves five

key functions namely, selection, procurement, management support, distribution, and use.

The availability of medicines at health café facilities is reliant on this process. Therefore,

such is critical in ensuring that medicines reach the patients as and when needed. The

diagram below maps the critical steps of effective and efficient medicine management.(It

should be noted that for the purpose of this report, by medicines, reference is also made to

all pharmaceuticals, medical consumables and medical stationery).In this regard, the

findings on the management of medicines are structured according to this integrated

process.

Figure 1: Medicine management cycle

5.2.1 Product selection

National essential drug lists, together with standard treatment guidelines, serve as the basis

for formal education and in-service training for health professionals and for education about

medication use for the public8. According to the NDPSA, 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. As indicated in paragraph 5.1, the selection of medicines is a national competence

and the process is facilitated by the NDoH. Officials informed the inspection team that the

Pharmaceutical and Therapeutic Committees (PTCs) were in place, and were chaired by

pharmacists. It was indicated that the PTCs met regularly to conduct situational analyses on

prevalent diseases with a view to making recommendations on any new medicines for

8. United States of America. The Role of Essential Medicine Lists in Reproductive Health. Volume 36.Jane Hutchings et al.

December 2010.

Product

selection

Rational use,

monitoring and

evaluation

Distribution

and storage

Procurement

Management support:

Information system

Organisation/staffing

Budgeting

Training



inclusion in the EDL. In addition, the PTCs assess the availability of medicines within their

districts. It was also observed that the PTCs’ specific recommendations relating to the

handling of adverse drug cases were being monitored for implementation by the health

facilities. The PSC found that product selection is well institutionalized and contributes

effectively toward the availability of medicines at health care facilities.

5.2.2 Procurement

The inspection team found that the medical depots were the primary providers of medicines

to the inspected facilities. The signed MoA provided for a routine schedule for ordering of

medicines from the medical depots. It was established at the visited health facilities that

district hospitals order their stock weekly from the depots, whilst clinics order bi-weekly from

their respective District Hospitals.The staff at Tlapeng Clinic informed the inspection team

that the clinic mostly handled cases of diarrhea, chronic hypertension and HIV. Thus, the

clinic ensured that medicines for treatment of these conditions were always available. They

also commended the support they received from the District Offices in ensuring sustainable

service delivery. In instances where patients required special drugs that were not in the

relevant EDL, the visiting doctors would prescribe such medicines, and the patients would be

referred to the district hospital for dispensing of the relevant medicine. It also emerged that

clinics were able to “borrow” out-of-stock medicines from other clinics, and return the

borrowed medicine as soon as their stock was delivered.

The inspection team was also informed that in addition to ordering from the medical depots

through the district offices, District hospitals may use a “buy-out” method. The “buy-out”

method means the hospitals order directly from the suppliers or pharmaceutical companies

on a quotation basis. However, the “buy-out” method was only allowed in the case when the

required medicine was out of stock at the medical depot and the items were urgently

needed. Although District officials found the process to be cumbersome and costly, district

hospitals confirmed that they took advantage of the method when necessary to obtain

medicines. The PSC found this level of flexibility to allow for efficient acquisition of urgently

needed medicines at the health facilities, and thereby ensuring stock availability.

5.2.3 Distribution and storage

The NDPSA aims to ensure the prompt, efficient, timely and equitable distribution of

essential drugs and medical supplies to all institutions. In this regard, provincial departments

are required to develop own standard operating procedures (SOPs) for the distribution

arrangements and storage of medical supplies. The SOPs were found to be in place to

ensure control of access into the facilities’ pharmacies, safety and appropriate labelling of

medicines and medical consumables.

Distribution: In line with the NDPSA, the MoA provided for scheduled deliveries of ordered

stock to district hospitals by the medical depots. In this regard, the medical depots delivered

stock to district hospitals every Tuesdays of the following week from the date of receipt of

orders. District hospitals also undertook to deliver requisitions from clinics on a bi-weekly

basis from the date of receipt of orders. In addition, the MoA requires the depots to ensure



that emergency orders were ready for collection or distribution by the facilities within four

hours from receipt of such orders, provided the orders were placed before 10h00. The

Department has also contracted a service provider for the transportation of medicines to all

the clinics in the province. Although District officials appeared satisfied with the service by

the service provider, this was not the case at the visited clinics. The nursing staff at the

visited clinics raised concerns that they were forced to use their own vehicles to collect

emergency orders due to the service provider not always being available. While the selfless

efforts of the nursing staff were commendable, the practice cannot be encouraged as it may

result in low morale amongst staff. Furthermore, delays in transporting medicines to facilities

impacted negatively on service delivery, which may have serious consequences. It is the

view of the PSC that the specific provision of the MoA was not adhered to in this regard, and

it was also not in keeping with the NDPSA.

Storage: In terms of the NDPSA measures should be in place for the proper storage and

safeguarding of drugs and medical supplies to ensure the maintenance of quality and

security from the time of receipt into stock up to the time of issue to the patient. In addition,

the Good Pharmacy Practice in South Africa, Fourth Edition, 2010 (GPPSA) sets out the

minimum standards for procurement, storage and distribution of medicines9. The GPPSA

was developed in line with the scope of practice of the pharmacy profession as prescribed in

terms of Section 35A of the Pharmacy Act, 1974 (Act 53 of 1974). Furthermore, pharmacists

must take all reasonable steps to ensure that working conditions are so arranged as to

protect the safety of the public and people working in the pharmacies. The inspection team

was informed that the district hospitals order medicines from depots in bulk quantities, which

are stored at the pharmacies in hospitals. It was observed that the Klerksdorp District

Hospital had sufficient storage space, and boxes of medicines neatly packed. The storage

allowed for easier movement between shelves, including easier evacuation of staff in case of

emergency, which complied with the GPPSA and Occupational Health and Safety

regulations. In addition, the storage was in keeping with the NDPSA. However, the inspected

building at the Brits District Hospital appeared old with very little storage space. The

inspection team was informed that the hospital was in the process of moving to a newly built

facility.

9 Republic of South Africa. South African Pharmacy Council. Good Pharmacy Practice in South Africa, Fourth

Edition, 2010.



Picture 1: Medicine stored in bulks at the pharmacy of Klerksdorp District Hospital

The pharmacies of the visited facilities appeared sufficiently stocked up and the interior

appeared clean with medicines appropriately packed and labelled on the shelves for easier

access by staff in line with the NDPSA and GPPSA.

Picture 2: Taung Station Clinic’s pharmacy shelves appeared sufficiently stocked up and appropriately

labelled



It was observed that air-conditioning systems were installed and were in good working

condition to maintain the quality of medicines, as well as ensuring that working conditions

were conducive for officials working in the pharmacies. Medicines requiring constant cool

temperature such as vaccines and insulin were stored in refrigerators with thermometers to

regulate the required temperature. Most of the visited sites had sufficient refrigerators and

their temperatures were monitored on a daily basis. However, the inspection team observed

at Tlapeng Clinic that one of its refrigerators was not used despite being new. Officials

indicated that the refrigerator had an electrical fault as it was tripping up power whenever

they connected it.

Picture 3: Refrigerators with medicines at Klerksdorp District Hospital

At Klerksdorp District Hospital an updated roster was displayed for the cleaning of the

refrigerators in order to maintain the quality of medicines. This is a good practice, which was

in line with the NDPSA and GPPSA.



Picture 4: A roster displayed for cleaning of the refrigerators at Klerksdorp hospital

The SOPs also provided for safeguarding measures such as locking facilities to control

access to the pharmacies. In all the visited sites, the pharmacies were adequately secured

with burglar bars and entrance was restricted to authorized personnel as required by the

SOPs. It is also the view of the PSC that the facilities complied with the applicable provisions

of the GPPSA.

Picture 5: Pharmacy of Klerksdorp District Hospital protected with burglar bars



5.2.4 Rational use, monitoring and evaluation

Rational use: The NDPSA recognizes the key educational role of pharmacists in instructing

patients in the correct use of medicines and to provide preventive health services. It was

found that the NWDoH developed guidelines for district pharmacists who should oversee the

operations of health facilities as well as provide pharmaceutical support to ensure that the

nursing staff adheres to the STGs. Accordingly, clinics must be visited monthly by the

supervisor and written record of the supervisor’s visit should be left with the clinic. Scrutiny of

the attendance registers of the inspected clinics showed that only district officials in the

areas of maintenance, data and asset verification regularly visited the sites. Officials at

Bojanala District Office indicated that the district had a shortage of pharmaceutical staff. As a

result, monthly visits to clinics were not always conducted. However, they informed the

inspection team that District Pharmacists regularly conducted training for Pharmacy

Assistants and Nursing Sisters. The inspection team observed that all the visited health

facilities were provided with copies of the STGs to guide them during dispensing of

medicines. It is the view of the PSC that visits to health facilities by district pharmaceutical

officials provide an opportunity for observing whether health facilities adhered to correct

dispensing practices since errors may have serious health consequences.

Monitoring and evaluation: As required by the NDPSA, District Offices should manage the

availability and safe use of medicines at health facilities. Although officials informed the

inspection team that they provided support to the visited health facilities, they conceded that

regular visits to clinics by District pharmacists were not always conducted due staff shortage

as indicated in 5.2.4.During interaction with staff at the visited facilities it emerged that most

medicines listed in the EDL were available. They informed the inspection team that for

purposes of recording and monitoring pharmaceutical stock levels, hospitals utilise the RX

solution system (i.e. automated medicine management system), whilst the clinics use stock

cards. Scrutiny of the District Health Plan (DHP) for Bojanala District showed that the district

did not have shortage of ARVs and tuberculosis (TB) drugs. The inspection team was not

provided with the DHP for Dr Kenneth Kaunda District. However, officials at Tlapeng and

Dryharts clinics informed the inspection that the clinics had shortage of Ferrous Sulphate

(i.e. treatment for iron deficiency in pregnant mothers), anti-psychotic drugs as well as

surgical supplies. According to the staff, the shortage was as a result of the stock taking

process since health facilities could only place orders once this process was finalised. It was

noted, however, that Taung Station and Unit 9 clinics did not have a similar challenge. The

staff indicated that the District Hospitals issued circulars long before the commencement of

stock taking and thus, they were able to make provision in this regard. The foregoing points

to proper planning by staff at Taung Station and Unit 9 clinics, which officials at Tlapeng and

Dryharts clinics should emulate. It is also the view of the PSC that the challenge at Tlapeng

and Dryharts clinics is due to the inconsistent support by District Offices.



Picture 6: A note at Taung Station Clinic instructing personnel to regularly record and balance stock

cards

The inspection team was informed that there were no expired stocks in pharmacies at all the

inspected health facilities. It was indicated that the stock was regularly checked using the

“first expired, first out” (FEFO) principle. As a result, medicines nearing expiry date were

identified approximately three months before expiry date. These were then either taken to

other sites that may use them before the expiry date or were returned to the District

hospitals’ main dispensaries for incineration. According to staff, the process ensured that

there were no adverse drug events. The inspection team was provided with a copy of the

Department’s policy regarding the adverse drug management. The rationale of the policy is

that the Department should look for ways in which its health care system can be improved,

and managerial and staff behavioural choices adapted, so that the likelihood of a recurrence

of the same adverse/medical error was significantly reduced10. It was found that provincial,

district and hospital PTCs have been established, which review pharmaceutical dosage and

safety of use issues. Scrutiny of the Brits District Hospital minutes dated 1 October 2013

showed that issues discussed in the PTC meetings included medication that should be

discontinued. It was also indicated that the PTCs recommendations relating to the handling

of adverse drug events were being implemented. The foregoing indicated that PTCs were

fully operational and contributed to the safety of medicines and impactful health care.

10Republic of South Africa. North West Provincial Department of Health. Department of Health Adverse Management Policy. 2013



5.2.5 Management support

On-going support in terms management systems and processes is crucial for the effective

functioning of facilities.

Information technology system: According to the NDPSA computerized inventory control

systems should be established in all hospital pharmacies and clinics, and be linked to

computerized inventory control systems in the medical supply depots. The objective is to

ensure the prompt, efficient, timely and equitable distribution of essential drugs and medical

supplies to all health care institutions11.The inspection team observed that the RX solution

system (i.e automated medicine management system) was only installed at hospitals, whilst

the clinics were still using the manual system of stock cards to record information as well as

monitor stock levels. The inspection team was provided with a report on stock availability in

the Bojanala District12. According to the report information on the inventory management

systems at all hospitals in the district did not match items on the shelf. Furthermore, the

report mentioned that not all the necessary information was recorded on the stock cards.

This suggests weaknesses in the information management systems of the District. It also

raises questions of overstatement of stock availability in its health facilities, and thus

providing misleading information regarding the achievement of the 95% national target by

the NWDoH.

Training: Training plays a central role in ensuring that employees were knowledgeable

about what was expected of them and also to keep them abreast of new developments in

order to provide quality services. The inspection team was informed that all nurses

dispensing medicines were required to complete a dispensing course and were also

registered with the Health Professional Council of South Africa (HPCSA). It was observed at

the time of the inspection team that a similar training was provided to the nursing staff on 27

June 2013. In addition, all officials had received training on the Batho Pele principles in order

to ensure that they prioritised the needs of the citizens.

Staffing: It was noted that there was in general a shortage of medical professionals with

rural areas being worst affected. Staff atUnit 9 Clinic informed the inspection team that the

clinic provided a 24 hour service and approximately 300 patients visited the clinic per day.

The staff raised concern that citizens from areas such as Tlapeng, Mokgosane and Lokaleng

villages were visiting the clinic despite having similar facilities in their areas. The foregoing

was mainly attributed to the fact that the Unit 9 Clinic opened 24 hours per day and thus,

offered uninterrupted services. As a result, staff members were sometimes forced to leave

patients unattended during tea and lunch breaks as they did not anyone to relieve them.

Scrutiny of the post establishment of the clinic showed that the clinic had 16 professional

nurses, of which four performed night duty. Overall, the clinic’s day shift consisted of five

professional nurses, which resulted in one nurse attending to approximately 60 patients and

thus, far exceeding the national norm of 1:40 patient to nurse ratio.

11 Republic of South Africa. Department of Health. National Drug Policy of South Africa. 1996. 12 Republic of South Africa. Department of Health: North West. Stock Availability Report in Bojanala District.

2013



At Tlapeng Clinic it was indicated that there was only one nursing sister, and when she was

on annual or sick leave the clinic would request the assistance of a nursing sister from

Ramatlabama village, which was approximately 30 kilometres away. The inspection team

also noted that Klerksdorp hospital had a shortage of nursing staff. Officials were concerned

that the shortage of staff impacted negatively on service delivery. It is the view of the PSC

that 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.Generally, medical equipment or instruments help the medical personnel to

diagnose and/or monitor specific medical conditions as well as to sustain the lives of

patients. As a result, availability of these in good quality is crucial especially in emergency

situations such as when should be put on a life support machine to keep the patient’s heart

beating and to supports his or her weak lungs while awaiting recuperation.

Procurement: According to the provincial Head Office, medical equipment items of a total

value exceeding R500000 were procured at provincial level, whilst items not exceeding the

aforesaid threshold were procured at district and hospital level in line with District Equipment

Plans. According to officials, the processes were undertaken in terms of the Preferential

Procurement Policy Framework Act, 2000 (PPPFA)13. During interaction with senior officials

of the visited the District Offices it emerged that procurement of bulky medical equipment

exceeding the R500 000 threshold was the responsibility of the Provincial Head Office. In

this regard, all health facilities submitted their annual needs to the relevant District Offices at

the beginning of the new financial year for consolidation into District Demand Plans

(DDPs).The District Offices were accordingly expected to make budget provisions based on

the DDPs and forward the plans to the Head of Department (HoD) for approval. Once the

plans were approved and the budget allocated, the purchasing of equipment was dealt with

in terms of the applicable Supply Chain Management (SCM) procedures. However, both

districts raised concerns about the poor quality of the equipment such as blood pressure

(BP) machines being procured for the facilities, which required frequent repairs or

replacement. According to officials, this resulted in poor service delivery as the equipment

often provided incorrect readings. They attributed the poor quality of equipment to the

Supply Chain Management (SCM) process of selecting the cheapest quotations. Officials

suggested that the NWDoH should consider a provincial contract that would provide for

direct procurement from carefully selected and reputable suppliers, to mitigate the risk of

procuring poor quality equipment. The PSC found the Department’s procurement processes

to be in line with the PPPFA. However, it is the view of the PSC that concerns of poor quality

equipment point to weaknesses in the SCM process at District or hospital levels, whose

procurement specifications should be strengthened with input from medical professionals

who have expert knowledge on medical equipment.

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



During interaction with staff at Unit 9 Clinic, they raised concerns of insufficient medical

equipment such as Blood Pressure (BP) machines. In addition, they were concerned about

the quality of the electronic BP machines. According to staff the machines could not handle

the high number of patients visiting the clinic since they frequently stopped working or

provided incorrect readings. It was mentioned that sometimes the nursing staff have to stop

working to allow the equipment to cool down, which resulted in longer waiting times. The

inspection team found that only one blood pressure machine was working at Taung Station

Clinic. At Brits Hospital officials mentioned that the radiology equipment was old and

regularly required repairs.

Asset control: Medical equipment involves the use of state funds and must be safeguarded

to ensure accountability. As a result, section 38(1) of the Public Finance Management Act,

1999, as amended (PFMA) 14 requires the Accounting Officer 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 mechanisms were in place to eliminate

theft, losses, wastage and misuse of assets15. At all facilities visited, the inspection team was

informed that supply chain officials from District Offices record all procured equipment on the

asset register; which is updated on a monthly basis. It is the view of the PSC that the asset

control process has been sufficiently devolved to the District Offices, and was in line with the

PFMA.

Maintenance of equipment: In line withsection 38(1) of the PFMA, the applicable asset

management framework requires regular inspection and maintenance of assets, as well as

identification of obsolete for disposal purposes.The inspection team was not provided with

guidelines for the maintenance of equipment. It was established at all the inspected facilities

that medical technologists or technicians stationed at district hospitals were responsible for

the maintenance of medical equipment in accordance with the equipment specification.

These technicians regularly conducted visits to clinics to identify items requiring repairs or

disposal. In addition, it was noted that most large items included maintenance plans

providing for when these were due for service by the suppliers in line with the signed service

level agreements (SLAs).

Officials at Klerksdorp hospital informed the inspection team that the turnaround time for

repairing equipment was too long. At Unit 9 and Dryharts clinics, officials complained that

lack of maintenance of equipment resulted in the clinics being without key equipment for

considerable periods. The inspection team observed that the installed ultra violet (UV) lights

at Unit 9 Clinic for the purpose of quarantining microorganisms that cause tuberculosis (TB)

were not working. This posed a serious health challenge to other patients as they could

contract the germs emitted through coughing by the TB infected patients.

Disposal of medical equipment: Officials at the visited facilities indicated that the disposal

of assets, including medical equipment, was handled by the District Office. The inspection

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

Regulations, 1999.



team observed that old and broken equipment was left lying around in the Unit 9 Clinic’s

grounds. Officials at the clinic raised concern that despite the necessary documentation

being long forwarded to the District Office, they had not received feedback. Of concern to the

inspection team was that these items could be stolen or further damaged before being their

condition was assessed, and thus result in unnecessary financial loss to the State. The PSC

found this to be a violation of the PFMA.

Picture 7: Broken equipment found at Unit 9 Clinic

Furthermore, among these items were unsecured broken glass doors, which posed a

serious danger to children accompanying parents to the clinic. The neglected items were

also in contravention of the relevant health and safety regulations.



Picture 8: One of unsecured broken glass doors at Unit 9 Clinic

5.4 Governance of health facilities

Public funds are used to provide public services. As a result, citizens as taxpayers have the

right to a responsive public service as well as value for money in how these scarce financial

resources are spent in the delivery of services. It is for this reason that those charged with

the responsibility to provide such services are held to account. Consequently, section

41(6)(a) of the NHA requires of the relevant Member of the Executive Council (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.

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 board 16 . The provincial Head Office

indicated that the hospital boards were in place. It was also indicated that the Department

has, in conjunction with the North West University, developed a curriculum to capacitate the

board members on their roles and responsibilities. During interaction with the District Offices,

the inspection team was informed that hospital boards regularly convened meetings in line

with the applicable governance rules. However, at Brits Hospital officials raised concerns

that the board often involved itself in administration matters, and thus overstepped its

mandate as an oversight institution. It was also observed that board meetings were not

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



regularly convened. The foregoing points to lack of clarity on the role of the board, and was

not in line with the relevant provisions of the NHA.

Clinics Committees: The inspection team was informed in all inspected facilities that clinic

committees have been established and were operational. However, the inspection team was

not provided with the minutes of such meetings. The purpose was to have an indication of

the key issues discussed during the meetings as well as the specific recommendations

made. The unavailability of the minutes raised concern whether these meetings were being

regularly held as required by the NHA. It is also the view of the PSC that these committees

could be dormant, and thus depriving the community of a constitutionally enshrined avenue

to contribute to improved service delivery at these clinics.

5.5 Challenges

The following challenges were identified as impacting negatively on effective and efficient

service delivery at the inspected facilities:

Hospital accommodation: It emerged during inspection at the Brits Hospital that there was

no doctors’ quarters. For instance, the Clinical Manager daily travelled a distance of

approximately 100 kilometres per return trip between Brits and his place of residence in

Pretoria. The situation was further exacerbated by lack of residential properties in Brits due

to the area being largely industrial. According staff, this has led to a high turnover of doctors

or challenge in recruiting doctors at the hospital.

Infrastructure: Serious challenges relating to infrastructure were noted at Unit 9 Clinic. The

inspection team observed that owing to lack of space, the room for patients suffering from

TB and waiting to receive treatment was very small, and located next to the data capturer’s

office. Furthermore, the installed ultra violet (UV) lights intended to quarantine TB

microorganisms, especially from seriously coughing patients, were not working, and thus

increasing the risk of the staff and other patients being infected. In addition, the had a

shortage of linen.

The inspection team also observed that Taung Station, Tlapeng, and Unit 9 clinics did not

have back-up generators in case of power failure. There were no telephones in some of the

clinics in rural areas. At Tlapeng Clinic the nursing staff informed the inspection team that

they used their cellular phones in case of emergencies. Although they were provided with

airtime, signal connection to the network was a challenge especially during rainy seasons.

Emergency Medical Services: The inspection was informed that emergency medical

services (EMS) were in all districts generally poor due to insufficient ambulances. It was

noted that response times to calls often varied from an hour to four hours. At times

ambulances failed to arrive following repeated calls which placed the lives of the affected

patients at risk. It emerged that in some cases officials would be forced to transport patients

in their private cars or patients would hire private cars at excessive costs. While the selfless

efforts of officials were commendable, this was a huge risk to take since the vehicles were

not fitted with life-saving apparatus, and had the potential to invite legal challenges.



Budgeting: During discussions with the provincial Head Office it emerged that the

Department was operating under serious budgetary constraints, which impacted negatively

on service delivery. For instance, it was indicated at the Bojanala District Office that although

a new Brits Hospital had been constructed through the Government’s Hospital Revitalization

Programme (HRP), the District’s budget had not been adjusted according to the 36 bed

facility. According to staff, this had the potential to limit availability of beds and other critical

resources at the hospital, and would lead to crowding and thus, defeating the key objectives

of the HRP and the National development Plan (NDP).

6. KEY FINDINGS ON UNANNOUNCED INSPECTIONS

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.

6.1 Observing facilities

Condition of premises: The inspection team observed that the buildings of Unit 9 and

Tlapeng clinics were dilapidated and had cracks as well as paint peeling off the internal

walls. The ceiling of the Unit 9 Clinic was also damaged and its toilet facilities required

urgent refurbishing. For instance, an unbearable smell was noticed that filled the waiting

area and this posed a health risk. On close inspection of the facilities, it was worrying to

observe that sanitation pipes were damaged, and these were wrapped with pieces of plastic

in order to contain spilling. A water tap was damaged and officials used a bucket to trap the

dripping water.

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

Transformation of Public Service Delivery, 1997.



Picture 9: Cracks observed in the walls of Unit 9 Clinic



Picture 10: Damaged sanitation pipes at Unit 9 Clinic



Picture 11: A dripping water tap at Unit 9 Clinic

Equally concerning was the exposed electrical wires at the Unit 9 Clinic, which placed the

facility at the risk of fire breaking out or citizens coming into contact with them, and thus

resulting in serious consequences. Overall, the clinic requires complete maintenance.

Picture 12: Damaged ceiling and exposed electric wires at Unit 9 Clinic



Lack of space: Generally, there was a problem of space in all the inspected facilities with

Unit 9 Clinic being worst affected. Officials informed the inspection team that Unit 9 Clinic

had two consultation rooms, which were insufficient considering the high average number of

patients received daily at the facility as indicated in paragraph 5.2.5 above. This resulted in

the staff on occasion using the emergency room reserved mainly for pregnant patients. In

addition, medical equipment items were found at the entrance for medical emergency

deliveries. These may obstruct medical personnel in responding to calls to patients requiring

immediate attention, and result in serious health consequences.

At Tlapeng Clinic, the inspection team observed that boxes of medical supplies and other

equipment were stored in the bathroom due to insufficient space. Officials mentioned that

the challenge had been reported, which was consistent with the concerns of the provincial

Head Office stated in paragraph 5.1 above.

Picture 13: Medical supplies and other equipment stored in the bathroom at Tlapeng Clinic

The challenge of space was also observed at Dryharts Clinic. A back-up generator was

found stored with boxes for disposable items. This raised concern to the inspection team as

the generator can trigger fire and result in serious damage.



Picture 14: Back-up generator stored with other items at Dryharts Clinic

Signage: Despite the aforementioned challenges, the inspection team observed that in all

the inspected health facilities clear signage was provided to guide citizens to the service

points.



Picture 15: Signage at Klerksdorp District Hospital

6.2 Access to information

The Batho Pele principle of access to information requires information to be readily available

to citizens in order to empower them and address their needs.

Service charters: Service standards, patients’ rights charters and other key information

relating to health care services such as payable fees, where applicable, were clearly

displayed in all sites visited. It was even more heartening to observe at Klerksdorp District

Hospital and Taung Station Clinic that the information was available in Setswana. Setswana

is one of the predominantly spoken indigenous languages in the areas serviced by the

visited sites. Using indigenous languages was empowering to the previously disadvantaged

communities and also restored their dignity as enshrined in the Constitution. This was also in

line with the Batho Pele principle of Access.



Picture 16: Information about baby feeding was displayed in Setswana at Klerksdorp District Hospital

Picture 17: Costs of services clearly displayed at Brits District Hospital



Redress: To encourage feedback on the quality of services from citizens on the services

they received, all public institutions are expected to have complaint/suggestion boxes. It is

also required of these institutions to provide the procedure outlining how suggestions or

complaints should be lodged, as well as the manner in which feedback can be expected. In

all the facilities visited the inspection team found that there were complaint/suggestion

boxes. In addition, the suggestions or complaints mechanism was displayed to encourage

citizens to freely make their contributions.

Picture 18: Complaints Mechanism displayed at Klerksdorp District Hospital

Furthermore, it was observed that information regarding management was displayed at most

facilitates to empower citizens in escalating their concerns in instances where they were not

satisfied with the quality of feedback provided.



Picture 19: Key information about management of Klerksdorp District Hospital

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: An insignificant number of citizens

complained about shortage of medicines. For instance, interviewed citizens at Unit 9 Clinic

indicated that there was a shortage of pills for family planning and treatment for epilepsy.

None of the interviewed citizens at all the inspected health facilities raised concerns relating

to availability and quality of medical equipment.

Waiting time: Most citizens were satisfied with the timeliness with which they received their

medication after consultation. At Unit 9 Clinic citizens were mainly unhappy about the waiting

time before being attended to. The foregoing is in line with the findings of shortage of staff

highlighted in paragraph 5.2.5 above. In addition, citizens at Taung Station Clinic complained

about the waiting area since it was small. The inspection team highlighted the challenge of

space at all facilities in paragraph 6.1.



Consultation: During interaction with citizens in all visited clinics, the inspection team was

informed that there were clinic committees which provided them an opportunity to raise their

concerns with the clinic management to ensure improved quality of services. This finding is

in line with Batho Pele principle of consultation. It is also consistent with the observation

made by the inspection team with regard to redress above.

7. IMPLEMENTATION OF PSC RECOMMENDATIONS

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 found that 7

(58%) of the 12 recommendations were implemented by the NWDoH. The inspection team

was, however, informed that the erection of ramps and demarcated parking areas fell

outside the responsibility of the Department. It emerged that the provincial Department of

Public Works had been alerted in this regard. Detailed information relating to the

implementation the recommendations is provided as ANNEXURE D.

8. READINESS OF THE INSPECTED FACILITIES FOR THE ROLL OUT OF THE

NATIONAL HEALTH INSURANCE (NHI)

In essence, the NHI is a financing system that aims to ensure that all SA citizens, including

non-citizens who have attained permanent residence, are provided with the necessary

healthcare, regardless of their economic status. The NDoH has committed the first five years

of piloting the system to focus mainly on strengthening the following key priority areas:

Management of health facilities and health districts;

Quality improvement;

Infrastructure development;

Medical devices including equipment;

Human resources planning, development and management; and

Information management and systems support.

It is, therefore, the view of the PSC that streamlining of the operations of the health facilities

and health districts has been identified as critical for the success of the NHI. As the ancillary

aim of the inspections at the selected health facilities, the PSC sought to assess the sites’

readiness for the roll-out of the NHI. The inspection team observed that there were no major

challenges regarding availability of medicines. Concerns relating to medical equipment were

mainly about the poor quality of the procured BP machines as well as delays by District

Officials in attending to requests for maintenance of identified items. However, it was

observed that there was generally a challenge of space at the inspected health facilities. Of

serious concern was the condition of the buildings of Tlapeng and Unit 9 clinics which were

very poor. Equally worrying was the shortage of staff at Unit 9 Clinic, which manifested in the

disruption of service delivery with complaining that they often left unattended during tea and

lunch breaks. It is the view of the PSC that the NWDoH needs to address these challenges

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

Health. 2010.



without delay in order to ensure the readiness of the facilities for the successful

implementation 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 NWDoH should, in collaboration with the North West Department of Public

Works (NWDPW), address the shortage of accommodation for medical professionals

at the Brits District Hospital. (A plan of action must be in place by April 2015).

The NWDoH should ensure that all District Offices visit all health facilities, especially

clinics, monthly as required by the Handbook for Clinic/CHC Managers to oversee

their operations and ensure availability of the required medicines and other

resources. In this regard, the visits should be linked to the applicable performance

management system by April 2015.

The NWDoH should immediately ensure that asset management unit of the Ngaka

Modiri Molema DistrictOffice attend to the broken equipment found at Unit 9 Clinic in

terms of the relevant SCM prescripts. In addition, the responsible asset officials

should be held accountable for the delays in addressing the matter. (In this regard,

feedback should be provided to the PSC by 31 December 2014).

The NWDoH should strengthen its SCM process for procurement of medical

equipment and ensure that a system for suppliers of equipment in place to identify

those suppliers found to provide poor quality equipment for blacklisting. (A plan of

action must be in place by 31 March 2015).

Back-up generators should be provided to the Taung Station, Tlapeng and Unit 9

clinics in order to prevent disruption of services in case of power failure.(A plan of

action must be in place by 31 March 2015).

The NWDoH should immediately ensure availability of linen at Unit 9 Clinic.

Computers and network points should be provided at all the health facilities. (A plan

of action must be in place by 31 March 2015).

The NWDoH should review the human resource plan of the Bojanala District to

address the shortage of staff by 31 March 2015.



9.2 UNANNOUNCED INSPECTIONS

The NWDoH should engage the NWDPW in order to address the challenge of space

in all the inspected health facilities. This should include the refurbishing of the

buildings of Unit 9 and Tlapeng clinics. (In this regard, a plan of action should be put

in place by April 2015).

10. CONCLUSION

The PSC’s inspections on availability of medicines and medical equipment have found that

there were challenges of availability of medicines at the visited health facilities. With regard

to medical equipment, it emerged that most of the inspected health facilities had the

necessary medical equipment to ensure sustainable service delivery. However, it was found

that the support of the District Offices was not in all instances sufficient. For instance, it was

observed that District Offices did not sufficiently conduct monthly visits, especially to clinics,

as required by the Handbook for Clinic/CHC Managers. As a result, key challenges

experienced by the health facilities such as poor quality and maintenance of medical

equipment, shortage of staff, condition of buildings, were not timeously addressed. It is,

therefore, hoped that the recommendations will assist the NWDoH in ensuring that quality

health care is provided at the inspected facilities.

11. ACKNOWLEDGEMENT

The PSC would like to express the 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 District Hospitals and Clinics regarding availability of medicines and medical equipment and the role of Health District Offices in the Department of Health: North West

Province

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

Bojanala District Office Ms Mirriam Mabe, Manager T. Motladiile, Manager

Commissioner Sejosingoe Ms Thato Mohapi Mr Martin Chale Ms Mmapeu De Jenga Mr Patrick Funani Mr Lebogang Mautlwa Ms Mpho Kuane

Tlapeng Clinic Sister Montsho, Nursing Sister

Unit 9 clinic Sister Wechoemang, Nursing Sister

Brits hospital Dr. Pooe, Clinical Manager Ms Heidi Van Rooyen, Pharmacy Manager

Kenneth Kaunda District Office Ms N Mojanaga, Chief Director J. Mbele, Finance Manager

Commissioner Sejosingoe Ms Thato Mohapi Mr Patrick Funani Mr Patrick Funani Mr Lebogang Mautlwa Ms Mpho Kuane

DryhartsClinic Sister Mkenku, Nursing Sister Mr Patrick Funani Mr Lebogang Mautlwa Ms Mpho Kuane Ms Thato Mohapi

Taung Station Clinic Sister Vanqa, Acting Sister-in-Charge Mr Patrick Funani Mr Lebogang Mautlwa Ms Mpho Kuane

Klerksdorp Hospital P. Mokatsane, CEO M Dikging, Manager

Commissioner Sejosingoe Ms Thato Mohapi Mr Patrick Funani Mr Patrick Funani Mr Lebogang Mautlwa Ms Mpho Kuane


Province

ANNEXURE B: ANNOUNCED INSPECTIONS ON AVAILABILITY OF EMCICINES AND MEDICALEQUIPMENT IN THE FACILITIES

VISITED

Availability of medicines at inspected clinics

√ Norms and standards adhered to

X Norms and standards not adhered to

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L fo

r P

HC

√ √ √ √ √


Province

Dryharts Clinic

√ √ √ √ √


Province

Availability of medicines at inspected hospitals

Brits District Hospital

Me

dic

ine

s

Me

dic

ines s

up

ply

acco

rdin

g to

ST

G

an

d E

DL

: H

osp

ita

l le

ve

l

Me

dic

ines s

up

ply

acco

rdin

g to

ST

G

an

d D

L: P

rim

ary

Ca

re leve

l

Me

dic

ines a

nd

su

pp

lies a

lwa

ys in

sto

ck.

Tro

lleys w

ith

em

erg

ency d

rug

s a

nd

resu

scita

tio

n e

qu

ipm

en

t

Ph

arm

ace

utica

l T

he

rap

eu

tic

Co

mm

itte

e in p

lace

√ √ √ √ √

Klerksdorp Hospital

√ √ √ √ √


Province

Availability of medical equipment at the inspected hospitals



Brits District Hospital*

Me

dic

al e

qu

ipm

en

t

Ba

sic

eq

uip

me

nt fo

r

exa

min

atio

n o

f p

atie

nts

in

OP

D a

nd

wa

rds

Ad

ult a

nd

ch

ild e

lectr

on

ic

we

igh

ing

sca

les, m

easu

ring

rods a

nd

pe

dia

me

ters

Pro

cto

sco

pe

s

La

rynsco

pes

Pe

ak f

low

mete

rs

Glu

co

me

ters

He

am

og

lob

ino

me

ters

Lu

mb

ar

pun

ctu

re k

its

Ca

rdia

c m

on

ito

rin

g u

nit

Ge

ne

ral X

-ra

y r

oom

with

su

pin

e &

bucky u

nit w

ith

scre

en

ing

& ta

ble

ma

ttre

ss

Sn

elle

n c

hart

Ve

no

-pu

nctu

re s

et

Flu

id g

ivin

g s

et

A c

linic

al w

aste

sto

rag

e

Fix

ed

an

d/o

r m

ob

ile o

xyg

en

su

pp

ly

A p

riva

te a

rea

fo

r cou

nse

ling

(e.g

. H

IV/A

IDS

)

Ba

sic

eq

uip

me

nt to

co

ndu

ct

no

rma

l d

eliv

erie

s

EC

G

Em

erg

en

cy e

qu

ipm

en

t fo

r

tra

um

a a

nd

em

erg

ency

Tro

lleys w

ith

em

erg

ency

dru

gs &

re

suscita

tion

eq

uip

me

nt

√ √ √ √ √ √ √ √ √ x √ √ √ √ √ √ √ √ √ √

General X-ray room: Although the X-ray equipment was found to be working, the hospital was concerned that it had almost reached

the end of its lifespan and, therefore, needed to be replaced.

Klerksdorp Hospital

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √


Province

Availability of medical equipment at inspected clinics



Med

ica

l e

qu

ipm

en

t

Tlapeng Clinic

Dia

gn

ostic s

et

Blo

od

pre

ssure

mach

ine

s

Ste

tho

sco

pe

Sca

les f

or

adu

lts &

yo

un

g

ch

ildre

n

Me

asu

rin

g tap

es

Sp

ecu

lum

s o

f d

iffe

ren

t

siz

es

He

am

og

lob

ino

me

ter

Glu

co

me

ter

Pre

gna

ncy test

str

ips

Em

erg

en

cy tro

lley

Oxyg

en

cylin

de

r a

nd

mask

Te

lep

ho

ne

/ tw

o w

ay r

ad

io

Tw

o w

ork

ing

re

frig

era

tors

Sh

arp

s d

isp

osa

l syste

m

Ste

riliz

ation

syste

m

Eq

uip

men

t &

co

nta

ine

rs

for

takin

g b

loo

d &

oth

er

sa

mp

les

Co

nd

om

dis

pe

nse

r p

lace

d

wh

ere

easily

accessib

le

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

Unit 9 Clinic

√ x √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

Blood pressure machines: Gets overheated after prolonged usage then produce incorrect readings.

Taung Station Clinic


Province

Dia

gn

ostic s

et

Blo

od

pre

ssure

mach

ine

s

Ste

tho

sco

pe

Sca

les f

or

adu

lts &

yo

un

g

ch

ildre

n

Me

asu

rin

g tap

es

Sp

ecu

lum

s o

f d

iffe

ren

t

siz

es

He

am

og

lob

ino

me

ter

Glu

co

me

ter

Pre

gna

ncy test

str

ips

Em

erg

en

cy tro

lley

Oxyg

en

cylin

de

r a

nd

mask

Te

lep

ho

ne

/ tw

o w

ay r

ad

io

Tw

o w

ork

ing

re

frig

era

tors

Sh

arp

s d

isp

osa

l syste

m

Ste

riliz

ation

syste

m

Eq

uip

men

t &

co

nta

ine

rs

for

takin

g b

loo

d &

oth

er

sa

mp

les

Co

nd

om

dis

pe

nse

r p

lace

d

wh

ere

easily

accessib

le

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

There is atelephone; however, a two-way radio is required as indicated by the Head of clinic for usage as backup.

Dryharts Clinic

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

There is a telephone; however, a two-way radio is required as indicated by the Head of clinic for usage as backup.


Province

ANNEXURE C: UNANNOUNCED INSPECTIONS NORTH WEST CLINICS AND DITRICT HOSPITALS

X Batho Pele requirement adhered to

0 Batho Pele requirement not adhered to

* No fees payable at clinics.

Batho Pele requirements

Re

ce

pti

on

Ou

tsid

e s

ign

Ins

ide

sig

n

Bu

sin

es

s h

ou

rs

Pri

or

req

uir

em

en

ts

Co

st

of

serv

ice

s

Bu

ild

ing

in

go

od

co

nd

itio

n

Ra

mp

s

Cle

an

lin

ess

Sta

ff t

o g

uid

e p

eo

ple

Se

rvic

e c

hart

er

Se

rvic

e c

hart

er

in lo

ca

l

lan

gu

ag

e

vis

ibilit

y o

f se

rvic

e

ch

art

er

Info

rma

tio

n d

es

k

De

sk

wit

h m

ate

ria

l

De

sk

sta

ffe

d

Su

gg

esti

on

bo

x

Co

mp

lain

t p

roc

ed

ure

Na

me

ba

dg

es

Na

me

ba

dg

es

of

ba

ck

off

ice

sta

ff

frie

nd

lin

ess

Pro

fess

ion

alis

m

Air

-co

nd

itio

nin

g

sy

ste

ms

Pa

rkin

g

Dryharts Clinic 0 X X X X -* X X X X X X X X X 0 X X X X X X X X

Taung Clinic 0 X X X X X X X X X X X X X 0 X X X X X X X X

Brits District Hospital

X X X X X X 0 X X X X X X X X 0 X X X X X X X X

Klerksdorp District Hospital

X X X X X X 0 X X X X 0 X X X 0 X X X X X X X X

Tlapeng Clinic X X X X X - 0 0 X 0 X X X 0 0 0 X X X X X X X X

Unit 9 Clinic X X X X X - 0 0 X 0 X X X 0 0 0 X X X X X X X X


Province

ANNEXURE D: STATUS OF IMPLEMENTATION OF PSC RECOMMENDATIONS EMANATING FROM INSPECTIONS CONDUCTED IN

2009

The status on the on the implementation of recommendations that was done by the PSC in 2009 is as follows:

Details of the clinic Recommendations Implemented Not implemented

Tlapeng Clinic Ramps for people with disabilities should be erected. (In

this regard a plan of action should be in place by April

2010).

No Not yet implemented.

Demarcated parking areas should be made available (In

this regard a plan of action should be in place by April

2010).

No (District lack capacity).

Not yet implemented.

clinic building should be properly maintained Yes

Reception areas should be erected (In this regard a plan

of action should be in place by April 2010).


Service Charter should be translated into the local

language (In this regard a plan of action should be in

place by April 2010).


Staff should be provided with name tags by April 2010

and they must wear them

Yes

Manager should immediately arrange for proper removal

of medical waste

Yes

Clinic should be provided with functional computers, fax, and photocopy machine. (In this regard a plan of action should be in place by April 2010).

Only have functional computer.

Provision of Fax and photocopy

machine still not implemented.

Dryharts Clinic Service Charter should be translated into the local

language (In this regard a plan of action should be in

place by April 2010).


Clinic should be provided with functional computers, fax,

and photocopy machine. (In this regard a plan of action

Only have functional computer.

Provision of Fax and photocopy


Province

Details of the clinic Recommendations Implemented Not implemented

should be in place by April 2010). machine still not implemented

Clinics should be immediately be provided with sufficient

diesel for generator to ensure that the clinic functions

properly even when there is power failure.

Yes

Clinic should ensure that the clinic facilities remain clean

at all times. This should be done immediately.

Yes

report on a service delivery inspection of district

Documents