PRESENTATION : PORTFOLIO COMMITTEE ON CORRECTIONAL SERVICES Building a caring correctional system that truly belongs to all PRESENTATION : PORTFOLIO COMMITTEE ON CORRECTIONAL SERVICES 2007/06/10 HEALTH CARE DELIVERY AND MANAGEMENT IN THE DEPARTMENT OF CORRECTIONAL SERVICES

The purpose of the presentation is to provide the Portfolio Committee on Correctional Services with an overview of health care delivery, management and challenges faced within the Department of Correctional Services. 2

INTRODUCTION According to international norms and standards, “offenders must have access to the same quality and range of health care services as the general public receives from the National Health Services”. A person’s capacity to access health services should not be compromised by reasons of incarceration since all people have a basic right to health. 3

INTRODUCTION (cont) Dr Manto Tshabalala – Msimang, Minister of Health in the National Human Resource Plan for Health 2006 “However, an overall shortage of health personnel as well as an inequitable distribution between urban and rural areas and between the public and private sectors remains a challenge”. “South Africa identifies with the global health community concerns regarding the crisis with regard to human resources for heath”. 4

INTRODUCTION (cont) Dr Percy Mahlathi- DDG Human Resources in the Department of Health in the National Human Resource Plan for Health 2006. “In this context , development of a country HRH Plan was prioritized in an effort to address the numerous HRH challenges that the health system is grappling with, amongst these being the high rate of attrition of personnel to the private health sector as well as migration out of the country to wealthier countries, retirement of skilled experienced professionals and career switching by young professionals to other sectors”. 5

INTRODUCTION The Department has also been faced with a number of challenges with regard to the provision of health services to offenders, and this is a product of historic legacy. Instead of these challenges being reduced, they are escalating. These challenges are not only unique to the Department and the country, there is unprecedented international migration of health professionals. The crisis currently experienced by the Department is in respect of the following health professionals: Professional Nurses Medical Practitioners Psychologists Pharmacists 6

INTRODUCTION (cont) The Department acknowledges the findings of the inspecting judge and some of our own inspections and audits with regard to the challenges facing health care delivery. Sometimes some of the initiatives taken by Department do not show positive results that we want for example: Headhunting processes. The increase in the establishment does also not show positive results. 7

FINDINGS AT POLLSMOOR Facilities Availability of clinic, one consulting room and no dispensary. Inadequate facilities to manage mental health care users. Limited isolation facilities for communicable diseases. Equipment Outdated equipment. Lack of delivery packs for emergency cases Pharmaceutical Services Expired medication Unavailability of treatment protocols 8

FINDINGS AT POLLSMOOR Services and Programmes No records of communicable diseases (TB). Inadequate management of health conditions e.g. (TB). Inadequate management of integrated management of childhood diseases. Poor implementation of EPI. Poor record-keeping: No available statistics for TB, no patient’s file. Security versus programmes. Offender’s health compromised. Increase work load versus the available nurses. 9

FINDINGS AT POLLSMOOR Human Resource Inadequate health professionals. Some professionals functioning beyond their scope of practice. Over burdened and over stretched health professionals. Lack of employee wellness programmes for health professionals. Limited supervisory capacity. Miss use of health professionals (escorts) No regular meetings to address health issues. 10

FINDINGS AT POLLSMOOR High turn over of health professionals is exacerbated by removal of weekend overtime and introduction of 7 day establishment. In competitive markets institutions introduce methods and incentives to recruit health professionals to recruit and retain health professionals. 11

INTERVENTIONS BY REGION Regional task team established. Deployment of health professionals from the region to assist Pollsmoor management area. Procurement of some of non-available items and equipment. Removal of expired medication. Discussions of the provincial Department of Health (Valkenberg Hospital) to assist. 12

PURPOSE OF HEALTH CARE IN DCS Health care services in Correctional Centers should promote the health of offenders; identify offenders with health problems; assess their health care needs, provide treatment and/or refer to other specialist services as appropriate. Should also continue any care started in the community contributing to a seamless service and facilitating after care (through care) on release. Majority of health care services in Correctional Centers is therefore of a primary care nature. However, healthcare delivery in Correctional Centers faces a significant number of challenges not experienced by primary care in the wider community as indicated below. 13

LEGAL MANDATES Constitution of the Republic of South Africa Standard Minimum Rules on the Treatment of Prisoners White Paper on Corrections in South Africa Correctional Services Act White Paper on the Transformation of Health Services in SA Nursing Act Health Act Mental Health Act Pharmacy Act Medicine and Related Substances Control Act Other applicable legislation 14

HEALTH CARE SERVICES AND PROGRAMMES The Department ensures access to and provide comprehensive primary health care services on a 24 hour basis which include: Preventive and promotive care Curative services for acute and chronic communicable and non-communicable diseases. Rehabilitative services. Referral services for secondary and tertiary levels of care. 15

CHALLENGES Healthcare delivery in Correctional Centers faces a significant number of challenges not experienced by primary care in the wider community. The offender population is as follows: : 185 783 : 186 468 : 169 459 : 158 858 : 161 194 16

CHALLENGES Legislation: Impact of new health legislation onto the Department, e.g Pharmacy Act and Mental Health Care Act. Poor compliance and inability to ensure compliance to legislation, policies, procedures and protocols due to lack of adequate resources. Requirements for the accreditation of the Department of Correctional Services as sites for the roll-out of Antiretro-viral therapy. Lack of clear policy (roles and responsibilities) by the National Department of Health and Provincial Departments of Health with regard to Correctional health care issues. 17

CHALLENGES Target Population : Overcrowding undermines the rights of offenders to conditions of detention which are consistent with human dignity (violation of privacy, spread of communicable diseases, etc). Participation of offenders in high risk behaviors and practices. Increase in the youth population due to the type of aggressive crimes they commit and increase in lengthy sentences passed by the courts. High turnover of awaiting trial detainees contributes to the inadequate management of diseases. Limited self care opportunities 18

CHALLENGES Services and Programmes: Inadequate management of acute, chronic and communicable diseases such as diabetes, tuberculosis, mental illness and HIV and AIDS, provision of appropriate nutrition for HIV and AIDS patients. Difficulty in maintaining positive clinical improvement in order to strengthen the quality of care, and enhancing disease prevention strategies. Inability to increase focus on outcome based health care. The increase in the burden of disease which are becoming complex. 19

CHALLENGES Health Human Resources : The key to successfully retaining staff lies in amongst other things, a generous and market related salary package. In the various identified scarce skill categories of the Department, the two key factors influencing personnel recruitment and retention are non competitive salaries and the unique and stressful working environment. This impacts directly on: Inability to recruit and/or retain health care professionals (nurses, medical practitioners, pharmacists, psychologists). High turnover of health care professionals. 20

CHALLENGES Limited strategies within the public sector to address the shortage and empowerment (Primary Health Care, Dispensing) of health care professionals (pharmacists, registered and psychiatric nurses, pharmacy assistants, dieticians, medical practitioners, food service managers). Implementation of an effective recruitment and retention strategy for the above officials. Lack of wellness programmes for the care givers. Lack of mechanisms to address training needs for emerging diseases and new treatment guidelines. 21

ESTABLISHMENT GROWTH 1 APRIL 2005 TO 31 MAY 2007 OCCUPATION 2005 2006 2007 VACANY RATE Financed Actual Vacant Professional Nurses 1 026 680 346 1 027 652 375 1 036 694 342 (33%) Vacancy Rate 33,7% 36,5% 1% Growth 2% Growth 1,2% Growth Medical Science & Support Personnel 156 62 94 157 66 91 195 69 126 (64%) 60,3% 58% 20% Growth 10% Growth 25,4% Growth The growth at this stage reflects funded posts out of the funds allocated for the implementation of the White Paper on Corrections. Project Re a Lokisa has also been activated from March 2007 and the impact will be as follows: 22

POSTS FUNDED: PROJECT RE A LOKISA Commenced on 16 March 2007 OCCUPATIONAL CLASS NEWLY FINANCED POSTS PROFESSIONAL NURSES 27 PSYCHOLOGISTS 3 PHARMACISTS 1 MEDICAL PRACTITIONERS TOTAL 32 23

APPOINTMENTS TERMINATIONS 2005 2006 2007 2005 2006 2007 1 APRIL 2005 TO 25 MAY 2007 OCCUPATIONAL CLASS 2005 2006 2007 2005/4/1 to 2006/3/31 2006/4/1 to 2007/3/31 2007/4/1 to 2006/5/30 NURSING AND SUPPORT 33 128 24 MEDICAL SCIENCE AND SUPPORT 5 40 2 TOTAL 38 168 26 TERMINATIONS 1 APRIL 2005 TO 25 MAY 2007 OCCUPATIONAL CLASS 2005 2006 2007 2005/4/1 to 2006/3/31 2006/4/1 to 2007/3/31 2007/4/1 to 2006/5/30 NURSING AND SUPPORT 80 93 8 MEDICAL SCIENCE AND SUPPORT 27 21 6 TOTAL 107 114 14

MEDICAL PRACTITIONERS HEAD HUNTING ACTIONS: 1 APRIL 2006 TO 30 MAY 2007 REGION MEDICAL PRACTITIONERS PHARMACISTS PROFESSIONAL NURSES PSYCHOLOGISTS FREE STATE/NORTHERN CAPE 1 27 GAUTENG KWAZULU/NATAL 8 WESTERN CAPE 4 EASTERN CAPE 2 50 LIMPOPO/MPUMALANGA/NORTH WEST TOTAL 85 25

COUNTER OFFER ACTIONS: 1 APRIL 2006 TO 30 MAY 2007 REGION MEDICAL PRACTITIONERS PHARMACISTS PROFESSIONAL NURSES PSYCHOLOGISTS FREE STATE/NORTHERN CAPE 3 1 GAUTENG KWAZULU/NATAL WESTERN CAPE EASTERN CAPE 2 LIMPOPO/MPUMALANGA/NORTH WEST TOTAL 26

PROFESSIONAL NURSES AND MEDICAL PRACTITIONERS EXTERNAL ADVERTISEMENT: MARCH 2007 TO DATE REGION PROFESSIONAL NURSES MANAGERS MEDICAL PRACTITIONERS WESTERN CAPE 95 1 EASTERN CAPE 2 KWAZULU/NATAL 9 FREE STATE/NORTHERN CAPE 7 GAUTENG LIMPOPO/MPUMALANGA/NORTH WEST 37 TOTAL 150 3 5 27

STATUS : PROFESSIONAL NURSES AVERAGE SALARY (PER ANNUM) LEVEL FINANCED POSTS FILLED POSTS VACANT POSTS AVERAGE SALARY (PER ANNUM) 6 787 489 298 125 217 7 71 55 16 152 065 8 132 111 21 183 462 9 27 24 3 217 683 10 1 264 248 11 12 314 395 1 036 694 342 28

MEDICAL PRACTITIONERS LEVEL FINANCED POSTS FILLED POSTS VACANT POSTS 11 13 5 8 TOTAL 29

PSYCHOLOGISTS LEVEL FINANCED POSTS FILLED POSTS VACANT POSTS 8 80 32 48 9 7 3 4 10 1 11 12 TOTAL 90 38 52 Out of 38 filled posts, 13 posts are filled by Community Service Psychologists. 30

PHARMACISTS LEVEL FINANCED POSTS FILLED POSTS VACANT POSTS 7 30 20 10 8 4 9 1 11 TOTAL 40 26 14 Out of 26 filled posts, 22 posts are filled by Community Service Pharmacists. 31

CHALLENGES Facilities : Lack of adequate primary health care clinics and in-patient facilities. (equipped clinics, in-patient facilities and isolation cells). Current health facilities and food service units do not complement health care delivery - Correctional facilities were built for security purposes. Some facilities are dilapidated. The Correctional facilities do not promote a therapeutic milieu. 32

CHALLENGES Budget : The Department is unable to implement most programmes and services adequately due to budget limitations. The training of health care professionals is also delayed by the lack of sufficient budget and internal capacity. Information : The Department’s health information system is not aligned to the National Health Information System of South Africa thus inadequate information management. 33

MEASURES TO IMPROVE THE SITUATION Legislation Continuous interaction with the Department of Health at National and Provincial levels and the different statutory bodies to provide support to the Department w.r.t providing assistance and capacity building in the implementation of health related legislation. Target population The issues of overcrowding and awaiting trial detainees are being addressed within the Justice Cluster. Where capacity exists the necessary health intervention are provided. In some instances public and private external stakeholders are rendering preventive and promotive health services. 34

MEASURES TO IMPROVE THE SITUATION Services and Programmes: Where capacity exists the necessary health interventions are provided. Patients are referred for further management at the different health facilities within the different districts. In some instances public and private external stakeholders are rendering preventive and promotive health services. Outsourcing of pharmaceutical services to improve access to essential drugs. Exploring the creation of centers of expertise to improve working conditions and utilizing the limited resources optimally. 35

MEASURES TO IMPROVE THE SITUATION Implementation of correctional center base care by rendering some of the elementary aspects of palliative care. Exploring the use of volunteers from the communities. 36

MEASURES TO IMPROVE THE SITUATION In order to curb the outflow of health professionals and attract suitable candidates the following interventions have been developed by the Department: The implementation of a new Occupational Specific Dispensation for Nurses is on the table which will improve salaries as well as career progression . Concurrently the upgrading of post levels where the largest gaps exist. This is being consulted with DPSA for implementation from 1 August 2007. Providing counter offers to retain health professionals. 37

MEASURES TO IMPROVE THE SITUATION (cont) The implementation of a head hunting framework for Professional Nurses with effect from 6 April 2006). The Department intends utilizing Placement Agencies to accelerate the availability of professional nurses at areas where they are urgently required (e.g. Pollsmoor and Durban Westville) . This will be a pilot project and if successful the possibilities exists for a roll out to the other Management Areas. The Department has also registered a need with the Department of Health for the allocation of Community Service for nurses as from 2008. 38

MEASURES TO IMPROVE THE SITUATION (cont) The performance assessment procedures for professionals has been amended to ensure that professionals are assessed by colleagues in their own profession. This will create a fair system for all the professionals. As an attraction strategy to upgrade all Medical Practitioners’ posts from Level 11 to Level 12 is also being considered. Exploring the re-introduction of nursing assistants and enrolled nursing assistants. (COREs have been finalized.) 39

MEASURES TO IMPROVE THE SITUATION (cont) PSYCHOLOGISTS AND PHARMACISTS The following interventions have specifically been implemented for the Pharmacists and the Psychologists: The entry level posts for Pharmacists has been upgraded from Level 7 to Level 8. The post levels for intern Psychologists have been upgraded from Level 3 to Level 7. The allocation of Community Psychologists and Pharmacists into existing vacant posts to improve the availability of these professionals. 40

MEASURES TO IMPROVE THE SITUATION Facilities: The new Correctional facilities are designed to complement health care delivery and other rehabilitation programs. Budget: The department is receiving fund from Presidential emergency funds for the relief of HIV & AIDS (PEPFAR) to accelerate the implementation of some of the programs. Information: The department with the assistance of the Department of Health is aligning the Departmental Health Information System to the NHIS-SA. 41

CONCLUSION In collaborations with community organizations, the Department remains committed in improving the health situation of those entrusted to its care despite the numerous challenges it is faced with. It needs to be mentioned that each intervention mentioned above has a financial implication which can only be managed within a limited personnel budget. A policy decision needs to be taken on the role and the responsibility of the Department of Health w.r.t health care to the offenders as citizens of the country. The sharing of the already exhausted resources may alleviate some of the challenges the Department is faced with. 42

CONCLUSION The unique conditions within the Correctional environment under which our staff perform their duties are also a contributory factor to the high turn over of health professionals. It needs to re-emphasis that the above mentioned challenges are not only unique to the Department and the country, there is unprecedented international migration of health professionals, and this has a huge impact on the delivery of health services in the country. 43

Building a caring correctional system that Thank you Building a caring correctional system that truly belongs to all