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The DPSA Review of Provinces
DEPARTMENTAL REPORT:
Province: KWAZULU NATAL
Department: HEALTH
Annexure: J
Date: 6 FEBRUARY 1997
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ANNEXURE J
DEPARTMENT OF HEALTH
1. Vision & Mission
(a) The vision of the department is as follows:
To develop a single co-ordinated, comprehensive and integrated health
system at all levels of care based on the principles of primary health care
approach through district based health care.
(b) The mission, in order to realise this vision, is the following:
1. To meet the needs of individuals.
2. To be accessible and acceptable to our public.
3. To inculcate a sense of ownership and participation by all our
stakeholders.
4. To provide an efficient and effective service.
5. To ensure co-operation between provider, consumer and policy-
maker.
6. To ensure versatility, sustainability and measurability in all our
endeavours.
7. To provide a comprehensive, caring and compassionate service from
point of entry to point of exit.
8. To provide quality service as judged by our customers.
9. To keep our vision alive and owned by all.
10. To maintain inter-sectoral collaboration.
In addition the department is one of the piloting departments in the good
governance programme of the province. This programme is aimed at
creating a positive work culture and ethos in the province.
2. Strategic Planning and Management
2.1 Departmental Plans
Although the senior management team of the department developed the
above vision and mission, a strategic plan for the department is not yet in
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place. A health plan for the province, linked to the national health policy,
is however in place and has been properly communicated to all the
regions of the department.
2.2 Purpose and Functions
Purpose:
To satisfy the health care needs of the people in KwaZulu-Natal.
Functions:
1. The rendering of comprehensive health care services.
2. The rendering of strategic and logistical support services.
2.3 Policy decisions, planning & action
Policy at provincial level is well aligned with national policy, especially in
respect of primary health care. The department influences national policy
by attending and participating in the Consultative Health Forum at national
level. The department has decided to institute a similar forum at provincial
level with unions, NGO’s and other stakeholders attending.
3. Leadership and Management
Regular meetings of the senior management of the department are held.
Everyone is invited to add matters to the agenda and matters remain on the
agenda until they are finalised. Minutes are kept of these meetings and are
then distributed to all members. The same procedures apply in respect of
middle management.
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4. Structure
AMALGAMATED STRUCTURE
SUPERINTENDENT GENERAL
DDG: Health Care DDG: Support Services Ministerial Support
Component
CD: Regions 1-4 CD: Management
Support Services
CD: Regions 5-8 CD: Administrative
Instructive Support
Services
CD: Programme Development
and Professional Service
Support
PROPOSED RATIONALIZED STRUCTURE
SUPERINTENDENT GENERAL
DDG: Health Care DDG: Support Services SG’s Support
Services
CD: Regions A, B, C
CD: Management
&F
Support Services
CD: Regions D, E,
CD: Administrative
G&H
Instructive Support
Services
CD: Programme Development
and Professional Service
Support
The rationalisation of the department has not been finalised yet, although an
interim amalgamated structure was approved by the Provincial Service
Commission. This structure is seriously flawed as it does not provide for some
of the new functions added to Health, such as finance, labour relations, and
communication. Although the proposed rationalised structure was approved by
the DG and submitted to the Provincial Service Commission in October 1996,
the matter has not been finalised yet and the Commission has indicated that
departments in the province must operate on their amalgamated structures for
at least a year before the rationalised structures can be considered.
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5. Service Delivery Activities
5.1 Performance
Not all clients are satisfied. In some areas the department simply does not
have the necessary staff and resources. The attitude of staff is also a
problem. The accessibility to health services has however improved
dramatically since the new government came into power. In the case of
the primary health care the performance of service delivery is measured
by means of a checklist which measures the performance of the workers.
Questionnaires have also been developed which help with the
measurement of service delivery. The response times in emergency
cases is also measured and recorded. There has however been no full or
formal performance audit. The necessary capacity needs to be built in this
regard.
5.2 The service providers
The catering services at hospitals have been outsourced. The catering
services seems to be comparable with those provided before by the
department. There is, however, a lack of capacity to measure whether the
outputs are still of the necessary quality after being contracted out. The
privatisation of activities has generally been successful because staff are
overburdened and does not have the time to provide quality services in all
respects.
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Administrative activities
6.0 Personnel
Most appointments, promotions, etc., are currently done at Head Office. The
six institutions under the old NPA administration had many personnel
delegations, whereas personnel matters under the old KZN administration were
handled at Head Office in Ulundi. Personnel files are kept at Head Office
(Natalia), Ulundi and Durban. Dummy files for personnel are also kept at Head
Office.
The department went live on PERSAL in October 1996. The finer personnel
details are currently being entered into the system on a continuous basis
whenever the staff finds the time for this.
No of Filled Funded Unfunded Number on Not
posts Vacant Vacant payroll absorbed
Provincial DG’s Office
PERSAL 58 000 51 000 - 7 000 51 000 -
Department
6.1 Rationalisation
The fact that the amalgamated structure has not yet been replaced by the
proposed rationalised structure is causing great uncertainty of personnel in the
department. The policy is to fill those posts on both the amalgamated and
proposed rationalised structures, whose contents have not changed
appreciably. There has however been administrative delays in filling posts in
the amalgamated structure. Because there is not enough senior personnel to
drive health policy and health and financial planning, this had led to low staff
moral. The department indicated that there has been no supernumerary staff
so far.
There was 1287 applications for the voluntary severance package in the first
group to be processed, of which 231 were approved. The reasons for the low
approval rate was the already high vacancy rate in the department, the fact that
doctors could not be considered and the fact that a large number of nurses
applied which could naturally not all be approved. A second group of 569
applications has not been finalised yet.
6.2 Recruitment & appointment of staff
All entry grade posts except in respect of medical and paramedical staff, have
been frozen, until 31 March 1997 to save funds. Staff are being trained in
especially the ex-KwaZulu hospitals in recruitment and interviewing procedures.
Posts take two to three months to fill. This is due to a shortage of staff,
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interference by the Provincial Service Commission and the fact that there are no
effective delegations in place in respect of promotions. Another problem is that
Public Service Vacancy Circulars are not being circulated properly in the
province because of logistical problems.
6.3 Leave
This is administered an institutional level. Head Office keeps the master files
for the top structure. The planning and checking of leave are done at
institutional level. There are reports of problems with leave being taken without
being properly recorded. This is being addressed by means of spot-checks and
internal audits. The personnel records of ex KwaZulu are generally not of the
same quality as those of ex NPA. This is largely due to a lack of training.
6.4 Misconduct
Misconduct is managed at Head Office. 1032 cases were reported in 1996 of
which 10 have been finalised. 67 cases have been reported so far in 1997.
The nature of cases range from fraud, theft, and AWOL to substance and
alcoholic abuse. Frustration because of staff shortages leads to lack of
discipline among personnel. A huge backlog has developed in the finalisation
of cases because there is a shortage of personnel and a lack of personnel with
legal expertise to undertake investigations. There is an effort to get staff trained
for this purpose. The procedure is also cumbersome and highly centralised and
should be decentralised.
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7. Finance
The Superintendent-General is the accounting officer for the department. The
Superintendent-General is also the programme manager for the department.
Responsibility managers are currently being appointed. There are problems
because PERSAL and FMS do not allow proper monitoring. The 18 people in
the department responsible for finance are mostly inexperienced but are
developing themselves.
The 1994/95 budget was basically a rule of thumb effort, based on history. In
1995/96 the various budget were amalgamated and co-ordination began with
other provinces and the national Department of Health. In 1996/97 the
department did their first proper budget but was allocated less than they
budgeted for. At that stage they foresaw a shortfall of R200 million, but this has
since grown to a projected shortfall of R400 million. Certain control measures
have been introduced to combat this, but this is not expected to make such of a
difference.
7.1 The Budget and Expenditure
The total budget for the 1996/97 financial year is R3,5 billion. The year to
date expenditure as at the end of January 1997 is R3,3 billion. As already
mentioned above, the expected shortfall for 1996/97 will be ± R400 million.
This is due to the fact that the department received less than they
budgeted for to start with and because more functions were added, such
as the primary school nutrition programme, without additional funding.
The July 1996 improvement in conditions of service (new salary grading
system) also put a further strain on the department’s financial resources.
Personnel expenditure accounts for 61% of the budget, whilst only 2% is
available for capital expenditure to develop infrastructure.
The department has outsourced catering, security, cleaning and gardening
services, as well as the transportation of patients, although the latter is
being revisited because of abuse of the system. The services are
monitored by the hospitals who have to determine whether the companies
are delivery according to the terms of the various contracts. The oversight
is however inhibited by shortages of staff.
R362,646,000 million is paid in the form of transfer payments to local
authorities and mission hospitals (R114 million for the primary school
nutritional programme alone.) These institutions have to provide audited
statements to the department at the end of each year. These statements
are however not always submitted timeously. The accounts of the
department are being handled centrally by the Department of Finance of
the province.
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7.2 Spending Approval/Delegations
Most expenditure is approved at institutional level by hospitals. Each
hospital has a responsibility manager. Hospitals can invite tenders of up
to R250 000 to buy new equipment, although the Tender Board procedure
can take up to 2 months to finalise. The department can also invite
tenders of up R10 000 without the intervention of the Tender Board.
Cheques in the department are generated in Pretoria through the FMS
system and then sent to Pietermaritzburg via counter services, from where
it is then posted to the various institutions. Hand-written cheques are also
sometimes issued by the Department of Finance in Ulundi.
The department has 530 paypoints.
7.3 Provisioning
The department makes their recommendations, but tenders have to be
approved by the KZN Tender Board. Pharmaceuticals are purchased
through a national contract in Durban.
7.4 The financial management system
The FMS system is being applied with mixed results that there is a need to
build staff capacity to enable the department to get accurate and timeous
information from the system. According to the department’s experience
FMS and PERSAL are compatible, but there are however problems with
interpreting reports. One of the weaknesses of the FMS system is that it
lends itself to fraud.
7.5 Management of Assets
Inventories of assets are being kept at institutional level. There is no
central record of assets at present but the department indicated that it is in
the process of creating this. There are major problems with the
management of state vehicles. The Department of Transport controls
ordinary vehicles, whilst the department controls vehicles in hospitals.
The department has a total of 3 165 vehicles at its disposal, of which 357
are ambulances. Of the department’s 2708 ordinary vehicles, 265 were
lost in 1996; 21 were stolen, 3 were hijacked, 185 withdrawn for various
reasons and 56 involved in accidents. Of the department’s 357
ambulances, 96 were lost in 1996; 16 were stolen, 3 were hijacked; 45
were withdrawn and 32 were involved in accidents. The Wesbank Auto
cards (for petrol) and the service contracts for government vehicles are
also being heavily abused at great cost to the department. The only real
attempt at that stage to address these problems is the fact that all vehicles
are being fitted with gearlocks.
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The department seems to feel itself unable to cope with the other
problems surrounding state vehicles.
8.0 Information Systems
The NHIS Committee at national level determines IT policy. There is also a co-
ordinating IT committee between departments in the province and a
departmental IT committee. The department faces serious constraints in terms
of IT because of a lower budget and a loss of skilled staff to the private sector.
In the previous they have different computer systems and programs in the
hospitals. A patient can have a different number if he visits different hospitals.
The don’t have a unique number of each patient. There is no link between the
hospitals computer systems. They are now working on it to have the same
hardware and software.
Training is also a major problem in that there are often computers and printers
available, but with no staff with the necessary skills to utilise them. People also
need to be trained to appreciate the value of IT. But they have a Health-Net for
13 hospitals.
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Provincial Staff Interviewed
Name Rank Responsibility
Prof RW Green Thompson SG Health
Mrs S Skweyiya DDG Management/Administration
Mr GE Mkhize CD Administrative Support
Mr H Conradie CD Support Services
Mrs DN Hook Control PO Services
Mr B Gray AD: PM Personnel Provisioning
Mrs EMR Durandt PPO Personnel Establishment &
Salary
Mrs TT Hlongwa Control PO Personnel: Discipline Merit &
Promotion
Ms PR Bailey AD: PM Personnel: Conditions of
Service, Registry & Pensions
Ms R Kara Sen. Personnel Personnel: Conditions of
Practitioner Service
Mr LWE Jones Chief Work Study Work Study
Officer
Mr EP Motha DD Labour Relations and Legal
Services
PA Allwright SAO Financial Management –
Health
NRR Radebe DD Financial Management &
Logistics
RF Kitching AD Fin. Management
TZ Chili SAO Financial Management
CA Coleman Act. SAO Assets Administration
O Baloyi DDG Health Care
D Hackland DG Health Care
A Chathury CD Health Care
JE Stewart CD Programme Development
Professional Support Services
MG Hlongwane Director Regional Director
MR Bouwer RD Health Services
AD Mitchell RD Health Services (Region A)
ML Mhlongo RD Health Services (Region H)
P E Emerson Director: Prof. Health Services
Ms I Mustard Chief Admin. Office Services
Clerk
MJE Mkhize Chief Director Support Services
M Zwane DD (Acting): D Support Services
Mr GC Van Der Merwe DD Health Informing
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General Issues / Constraints
1. The department has been experiencing major problems because the Provincial
Service Commission has been delaying for ± 9 months now in approving the
proposed rationalised structure after approval by the DG. This has led to low
staff moral.
2. Because of a general lack of delegations and the inability of Head Office to
provide adequate support, the department has been unable to fill key positions
at both the senior and middle management levels. This has led to people being
overworked and low staff morale.
3. The Tender Board’s procedures are causing great delays in purchasing
equipment, particularly emergency equipment for hospitals. A moratorium
placed on period contracts has also halted the whole process.
4. Because of the fact that allowances have been stopped in terms of the new
salary grading system, some doctors are receiving up to R3 000 less per month.
Allowances for nurses in trauma wards have also been stopped. These nurses
are now requesting to be moved to less stressful jobs. There has also been
consistent problems regarding overtime payment for doctors and nurses.
5. The department is experiencing problems in placing personnel on the second
and third notches of the new salary scales. This is causing frustration amongst
personnel.
6. The department is of the opinion that Gauteng and the Western Cape is being
favoured as provinces in terms of their health budgets as percentages of the
total national health budget.
7. There is a very high level of violence prevalent at clinics, which has caused
problems for some of them to render proper services and to stay open as long
as they should.
8. The department is experiencing serious resistance to change amongst its
personnel and their uncertainty concerning the province’s capital is also causing
problems.
9. There are problems with the FMS and PERSAL systems in that personnel are
not properly trained to use these systems and that there are problems in
interpreting the information provided by the FMS system.
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Recommendations
1. The province will have to address the finalisation and approval of rationalised
organisational structures as a matter of the utmost urgency.
2. The department should be enabled through proper delegations to fill key vacant
posts, especially those appearing unchanged on both the amalgamated and
proposed rationalised structures.
3. The ability of the Tender Board to deliver services efficiently and timeously will
have to be revisited.
4. The financial, human resource management and IT functions in the department
need to receive serious attention in terms of capacity building of staff.
5. The problems regarding allowances and overtime for doctors and nurses will
have to be revisited urgently at national level.
6. Clear guidelines should be put in place at national level to facilitate the
placement of personnel on the second and third notches of the new salary
scales.
7. The equity of spending on health in the various provinces as a percentage of
the national health budget should be revisited.
8. Better security should be provided at clinics of the department to enable them to
provide better quality services and stay open for longer hours.
9. Personnel in the province should be kept abreast of changes and progress with
the rationalisation process in the province by means of proper communication
and training programmes.
10. Personnel in the department must be properly trained in the use of the FMS and
PERSAL systems as a matter of urgency.
11. The department needs capacity building in IT.
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