MINISTRY OF HEALTH AND QUALITY OF LIFE
13.1 Pharmacy
The Commission for Health at Rodrigues places orders of drugs with the Central Supplies Division of the Ministry of Health and Quality of Life. These drugs are to be used for the next three months and thus issues should be effected with appropriate shelf life.
In my previous audit reports, I commented on the presence of expired drugs or drugs nearing expiry on shelves. These items had to be either returned to Mauritius or disposed of.
Observation
Drugs nearing expiry dates and with even less than one month shelf life were being sent to Rodrigues.
Implication
Rodrigues has limited care centres and in the event of receipt of drugs nearing expiry they have no other alternatives than to dispose of them or send them back to Mauritius.
This eventually involves additional administrative work as well as cost.
Recommendation
Taking into consideration the specificity and remoteness of RodriguesIsland, the CSD should supply drugs with reasonable shelf life or with a minimum of a specific shelf life. In the event that they are not available, the Pharmacy Unit of the QueenElizabethHospital should be informed of the expiry dates and clearance be obtained before sending them to Rodrigues.
13.2 Lithotripsy Machine at VictoriaHospital
In 2000, the Ministry purchased one lithotripsy machine (Model Econolith 2000) for
Rs 6,650,000. The machine was installed and commissioned on 13 January 2000, by the supplier. Since its acquisition, problems have been encountered with the machine.
As per logbook, the machine was out of order frequently as shown in Table 49.
Table 49 Frequent Machine Breakdown
Year / No. of days machine breakdown2000 / 43
2001 / 74
2002 / 96
2003 / 105
No maintenance agreement was entered with the supplier after the end of the warranty period.
Repairs have been effected on the machine. However, the Biomedical Unit did not exercise proper control over the use of the equipment.
In April 2004, the Consultant reported that he has been using the machine for the past 18 months and the result obtained from the machine was not satisfactory, that is no ureteric/kidney stones could be broken. Same was confirmed by a medical officer who has used the machine.
In several cases patients had to come to hospital at least four times for stone breaking without success.
Patients are no longer given appointment for stone breaking. In April 2004, 24 patients were on the waiting list for stone breaking, some dated as far as back as February 2003. I have been informed that these patients are being sent to J.NehruHospital.
To the National Audit Office the frequency of breakdown of the machine appears to be abnormal. The Ministry should investigate into the causes.
13.3 Infrastructural Problems at Hospitals
13.3.1 Dr A.G.Jeetoo Hospital
In line with the National Health Plan (NHP) designed to improve and sustain the quality of life in Mauritius through strengthened health care delivery system, Government initiated a project to upgrade Dr. A.G Jeetoo Hospital.
This project originated with the visit of a representative of African Development Bank (ADB) in April 1991. The Project was approved by ADB in 1993. However, the loan agreement was cancelled as Government took the decision to construct a new regional hospital on a different site. In 2000, Government approached ADB for the financing of the construction cost. The loan agreement was signed in August 2002. The ADB will finance around 83 percent of the project value (Rs 660 million) and the remaining balance will be funded by Government.
More than thirteen years since its inception, the project is still at the embryonic stage. The Central Tender Board’s approval has just been obtained for consultancy services. Further, the Ministry decided in June 1998 that no renovation work would be effected as there was a project in the pipeline for the construction of a new hospital.
On one hand the project for the construction of the new hospital is not being implemented, while on the other hand, major repairs are not being carried out to existing infrastructure. Meanwhile the infrastructural conditions at Dr Jeetoo Hospital are deteriorating.
Observations
Infrastructural problems are adversely affecting the level of health care delivery. In several units, the lack of space is causing much inconvenience to both patients and staff. Further, difficulties are being encountered for the installation of bio-medical equipment.
Accident and Emergency Department & Out-Patient Department(OPD)
Accident and emergency cases as well as out-patients are being attended to in the same area. Some 800 – 1,000 patients attend the hospital daily. The following clinics are held daily at the OPD:
Paediatrics
Medical
Gynaecology
Antenatal
Cardiac
Physical medicine
All the above-mentioned clinics are held in the same area, with one to two consultation rooms for each clinic. This area is overcrowded nearly at all times. At times it is so crowded that it is hardly possible for patients to move freely. It is even more difficult for patients in wheelchair and on trolleys to move.
Medical records staff are accommodated in a small corridor. Sometimes three to five staff work with two office desks, in a single office. Other office equipment, computers and patients’ cards render these small offices cumbersome and thus difficult for officers to operate more freely.
Ministry’s Reply
At present, the Ministry has to manage with what it has at this old infrastructural set-up. With the coming of the NewJeetooHospital, more space would be made available.
Wards
Most of the wards are in a bad state. Although a huge sum of money is being spent under the item ‘Repairs & Maintenance of Buildings’, still much need to be done because of the state of the building. The wards and other areas continue to leak. Some need major repairs, namely Wards 3 and 10 have been condemned for the time being.
Repairs and maintenance for the previous four financial years are shown in Table 50
Table 50 Repairs and Maintenance of Buildings
Year / Budgeted Amount(Rs) / Actual Amount
(Rs)
2000-01 / 3,720,000 / 3,642,237
2001-02 / 3,950,000 / 3,933,902
2002-03 / 4,000,000 / 3,996,624
2003-04 / 3,600,000 / 6,034,760
15,270,000 / 17,607,523
For the previous four years, some Rs 18 million have been spent. Expenditure under this item is increasing year by year, and will continue to increase due to the state of the hospital.
Ministry’s Reply
The Ministry is contracting out major works such as leakages and upgrading of wards.
Operations Theatres
The physical conditions of the operating theatres are worsening. Though repairs had been carried out on the roof of the building in the past, yet it continued to leak during periods of heavy rain. Sometimes operations had to be postponed in the Ortho theatre due to risk of electrical failure.
There was inadequate space to move in the offices, which accommodate staff of the theatre. The offices are crammed, accommodating staff, furniture, surgical items, solutions and drugs.
Ministry’s Reply
The Ministry has already reported the problem to the Ministry of Public Infrastructure (MPI). MPI is currently finalizing a survey.
Installation of bio-medical equipment - C-Arm Image Intensifier
The request for the purchase of a C-Arm Image Intensifier for the implementation of pacemakers was made since February 1999. The quotation was finalised in April 2001. The order for the equipment worth some Rs 10 million was placed on 28 January 2004.
As at September 2004, the equipment has not yet been delivered due to non-finalisation of infrastructural works, with the consequence that treatment for cardiac patients are being delayed.
Recommendations
The project for the construction of the new Dr. Jeetoo Hospital be given due consideration. The implementation of the project may also have the following benefits:
The high cost of repairs and maintenance could be reduced, if not eliminated.
A better and enhanced working environment could be provided to medical, paramedical and other staff of the hospital.
The new hospital can house new high tech and up to date equipment that are being deprived for the time being because of space problem.
The early implementation of the project is desirable, as construction cost tends to increase with time.
13.3.2 ENTHospital
Tests performed by the Environment Health Unit, in January 2000 and September 2003, have revealed the contamination of the water supply. Biological growth from internal corrosion deposits and encrustation in water pipes had resulted in bacteriological water quality deterioration and this represented a public health risk. The metal water tanks have been replaced but still water pipes of the whole system have not yet been replaced.
The MPI has appointed a private consultant for upgrading of water reticulations, but no survey was carried out yet to establish the scope of works involved.
Leakage of Water in Wards
In the three wards of the Hospital, water leakages have been noted during periods of heavy rain. During visits effected in the wards, it was observed that rain water drops directly onto beds in the Paediatrics Ward, whereas in the Female Ward, one patient even complained that rain water splashed onto her.
Acute space problem in Medical Records Department
The Medical Records Department is facing acute space problem for more than five years. The Officer in Charge has in each monthly report submitted at Management Meetings informed the Ministry of the problem. Temporary measures have been taken but the problem was still as acutely felt as before.
Evoked Response Audiometer
The Evoke Response Audiometer is an essential instrument enabling the diagnosis of hearing loss among children under three years old. The equipment was purchased in 1997-98 at a cost of Rs 605,958. The equipment, which was ready for delivery has been dormant in the stores of the supplier for two years and could not be installed since the audiology room was not ready to house it.
The equipment was finally delivered on 13 March 2000 and the acceptance test certificate signed on 18 May 2001 with the remarks that two weeks training was not provided to the user and that the ECOG and CERA functions were not tested due to lack of training. As at September 2004, after four years, no training has yet been provided. Thus, only one test, instead of three available on the equipment, could be effected.
13.3.3 Brown Sequard Mental Health Care Centre
The completion date for the new psychiatric hospital, which was scheduled for 26 January 2004 has been revised to 26 May 2004. A further request has been made for an extension of 220 days, thus delaying the construction works by another year.
Meanwhile patients continue to be accommodated in the existing buildings at the Centre. Several wards were in a deplorable state. Roof leakage was noted in four wards in the Out-patient Department and in the newly relocated Occupational Therapy Unit. The roof was covered with tarpaulin in one ward. During rainy periods, electrical installation is subject to power cut. There was also no emergency exit in two wards on the first floor. This is against the recommendation of the Fire Services.
Ministry’s Reply
The new psychiatric hospital is scheduled for completion in December 2004.
Effects on the level of service
The above situation has resulted in several wards being overcrowded. A survey carried out by my officers revealed that almost all wards were accommodating patients over and above their bed capacity. No official record was available for the bed capacity, of wards of different sizes. I was informed that in general, an average of 25 patients per ward was acceptable. Actually in some 12 wards, it was noted that the number of patients was around 40. Hence, beds were even placed in the middle of the corridor, or wherever space was available. There was only a half-metre distance between beds in some wards resulting in limited available space.
It is to be noted that in general, these patients are not bed-ridden, whereby the need to move about freely in wards.
Ministry’s Reply
Adequate space is available in the yard for patients to move around freely. With the foreseeable completion of the NewPsychiatric Hospital, patients would receive health care in a state-of-the-act environment.
13.4 Dental Services
In Mauritius, dental services are being provided by both the public (free service) and private sector. It is characterised by a predominance of 104 private practitioners compared to 54 dentists in the public sector, (ratio 2:1). Still, the Public Dental Services are fast expanding. In fact, the number of dental clinics is almost two fold compared to some 15 years back. In addition, Government provides specialised services such as Orthodontics and Oral Surgery.
Below are the various problems identified in respect of the services provided.
Physical Working Environment
Visits were effected at 16 clinics.
Observation
The physical infrastructure and facilities were satisfactory in most of the clinics, except in some cases where space was too limited, namely Eastern Suburb, Oral Surgery Unit at JNH, VH clinic and the Public Health Dentistry Unit. It was difficult for both staff and patient to move around.
Equipment
(i) Records
Fixed assets records were not available at the Ministry in respect of dental equipment. Such records not only serve as a tool to exercise proper control over equipment but also help management to derive valuable information for acquisition planning.
In the absence of the above records, it was therefore not possible for my officers to ascertain the completeness of dental equipment.
Recommendations
The Ministry should carry out a survey of dental equipment in all clinics and compile a master record. Relevant information such as date received, serial number, make, cost of equipment together with list of accessories and tools inserted for each clinic within the inventory records.
Ministry’s Reply
A master record is being compiled for dental equipment.
(ii) State of Dental Equipment
Several dental equipment are quite old and are subject to breakdowns. This hampers the smooth running of the service.
Dental Consumables
Expenditure incurred under item Dental Materials, Equipment & Stores, amounted to Rs 4.1 million as at 31 May 2004.
Observations
Some items are recommended for purchase on the basis of samples. However, these samples were not sent to Central Supplies Division (CSD) for delivery purposes.
Storage conditions were not satisfactory. Dental materials were stored in different locations. Further, due to lack of space, dental consumables were seen kept together with other surgical items.
Some items have been purchased in spite of adequate stocks. Based on the trend of issues, it appears that available stock represents several years’ consumption.
Braided suture worth some Rs 900,000 was lying dormant.
Human Resources
The Dental Services have been fast expanding, with a total of 35 dental clinics, and three new clinics are to be set up. However, there are eight dental clinics, which operate on a part-time basis due to a shortage of staff.
Dental Surgeon
Despite the recruitment of four dental surgeons in April 2004, there is still a shortage of staff for the time being, as two dental surgeons are on study leave and staff are needed for replacement during leave period.
Dental Assistants
There are actually 45 dental assistants in post against 53 established posts. However, after three years, vacancies have not yet been filled in due to the inordinate length of time to amend the scheme of service.
Post of Dental Technician
The post of dental technician has been created since financial year 1999-00. But it was not until October 2003 that the Ministry worked out a proposed scheme of service for submission to the Ministry of Civil Service Affairs. After three years, this scheme of service has not yet been finalised.
Delivery of Service
Dental Clinics
The MOH provides curative services to the public in 45 dental clinics and one mobile dental clinic. 37 dental clinics operate on a full week basis and eight clinics work on a part-time basis. Morning sessions are reserved for out-patients and afternoon sessions for appointments. Emergency cases are also attended to in the afternoon. Visits at the dental clinics revealed the following problems:
Heavy Workload for Morning Sessions
In general, the morning sessions were quite heavy. In fact, in regional hospitals such as VictoriaHospital, JNH and FlacqHospital, where there is only one dental clinic, the working sessions were much heavier compared to those at JeetooHospital and SSRNH, where two clinics are in operation.
At five clinics, namely Curepipe, Victoria Hospital, Mahebourg, E.Suburb and Flacq, the number of outpatients was very high.
Afternoon Sessions
The following unsatisfactory features have been identified:
At Petite Rivière and Flacq Clinics the number of appointments was less than 10 and appointment was given after longer intervals.
There is a high percentage of patients who did not turn up on appointment – up to 58 per cent. This might be attributed to the fact that appointments were given after long intervals (ranging from two to four months), The National Oral Health Survey carried out by WHO in 2001-02 indicate that less than 50 per cent of the public were satisfied with the public dental services.