Vision
Consistent safe and quality healthcare for all.
Mission
We monitor and enforce health care safety and quality standards in health establishments independently, impartially, fairly, and fearlessly on behalf of healthcare users.
Values
OHSC has adopted the following corporate values, which serve as guiding principles around which its corporate culture and actions are governed and shaped. The OHSC’s values are grounded in strong ethical considerations. As a result, OHSC staff members are required to maintain the highest standards of proper conduct and integrity at all times and to ensure that there is no doubt as to what is required. To this end, the OHSC has developed a set of core values.
Mandate
The OHSC has been created by the National Health Amendment Act of 2013 and, in terms of section 78 of the Act, the objects of the Office are to protect and promote the health and safety of users of health services by:
- Monitoring and enforcing compliance by health establishments with norms and standards prescribed by the Minister of Health in relation to the national health system.
- Ensuring consideration, investigation and disposal of complaints relating to non-compliance with prescribed norms and standards for health establishments in a procedurally fair, economical and expeditious manner.
The term health establishment refers to both public and private healthcare services and facilities (see formal definition below). It includes hospitals and primary healthcare clinics and extends to emergency medical services, hospices, private medical practices and institutions offering frail care.
The functions of the OHSC are set out in Section 29 of the Act which states that the Office must:
- Advise the Minister of Health on determining norms and standards that are to be prescribed for the national health system and on the review of such norms and standards.
- Inspect and certify health establishments as compliant or non-compliant with prescribed norms and standards or, where appropriate, withdraw such certification.
- Investigate complaints relating to breaches of prescribed norms and standards.
- Monitor indicators of risk to develop an early warning system related to serious breaches of norms and standards and report breaches to the Minister without delay.
- Make recommendations for intervention by national, provincial or municipal health departments or by individual health establishments to ensure compliance with prescribed norms and standards.
- Publish information relating to prescribed norms and standards through the media and, where appropriate, to specific communities
- Recommend to the Minister quality assurance and management systems for the national health system.
The Act states that the Office may also:
- Issue guidelines to help health establishments implement the prescribed norms and standards.
- Request or collect any information on prescribed norms and standards from health establishments and health service users.
- Liaise with and exchange information with other regulatory authorities on matters of common interest and specific complaints or investigations.
- Negotiate co-operative agreements with any regulatory authority in order to co-ordinate and harmonise their work where their jurisdictions are closely related.
The OHSC is listed as a national public entity in terms of the Public Finance Management Act.
Definitions
In terms of the National Health Act:
The national health system is the South African system that comprises both public and private sector entities that are concerned with the financing, provision or delivery of health services.
A health establishment is a public or private institution, facility, building or place, or part thereof, that is operated or designed to provide in-patient or out-patient treatment, diagnostic or therapeutic interventions, nursing, rehabilitative, palliative, convalescent, preventive or other health services.
Main Areas of Work
The work of OHSC is structured around the following four key areas:
1. Compliance Inspectorate, Certification and Enforcement: This programme manages the inspection of health establishments to assess compliance with national health systems, norms and standards, certify health establishments as compliant or non-compliant with prescribed norms and standards and take enforcement action against non-compliant health establishments. This process will also consider information from the Complaints Centre and reports of the Early Warning System.
2. Health Standard Design, Analysis and Support: It provides a high-level technical, analytical and educational support to the mandate of the Office in relation to the research, development and analysis of norms and standards; and support, capacity building and establishment of communication networks with stakeholders.
3. Complaints management and Office of the Health Ombud: It aims to consider, investigate and dispose of complaints relating to non-compliance with prescribed norms and standards in a procedurally fair, economical and expeditious manner.
4. Corporate Services: it aims to provide the financial, human resources, IT and administrative support necessary for the OHSC to deliver on its mandate and comply with all relevant legislative requirements.
Organisational Structure
Early Warning System Indicators
History
The OHSC has its roots in the National Health Act of 2003 which recognised the need to foster good quality health services and made provision for an “Office of Standards Compliance” to be created within the Department of Health (DOH). It also provided for inspectorates of health establishments to be established in all provinces.
The Act envisaged that the office set up within the DOH would play a dual role: it would advise on how to improve quality of care as well monitoring and reporting on non-compliance with health standards. This office was established as a cluster of DOH in 2008 and played an active role in driving quality assurance systems in the public health sector.
This cluster also co-ordinated the development of a comprehensive set of National Core Standards for Health Establishments (NCS). The process involved extensive consultation and piloting of the NCS before they were finally adopted by the National Health Council as policy, applicable in all provinces. Detailed tools for measuring compliance with the NCS were subsequently developed and health establishments began to self-evaluate using these tools.
However, even as the Office within the department was taking shape and generating national standards, broader health policy evolved and it became clear that there was a need for an independent body to certify health establishments in both the public and private sectors. This was especially relevant in the light of the 2011 decision to introduce a system of national health insurance over the course of the next 14 years and create a national health insurance fund which would purchase services only from certified healthcare providers.
The internal office became the springboard for the creation of this independent regulator, the Office of Health Standards Compliance (OHSC). Drawing on international best practice and insights from various regulatory bodies in South Africa, the office assisted in the drafting of the relevant legislation and developed a business case for the envisaged OHSC.
In addition, a national inspectorate of health establishments was set up within the DOH in 2011. The intention was that members of the inspectorate would transfer to the OHSC once the legislative process had been concluded and the OHSC had been created as a public entity.
A dedicated training course was developed for inspectors, and senior members of the team had opportunity to undergo additional training at the Care Quality Commission in the United Kingdom.
From 2012 to March 2015, the inspectorate conducted over 1 000 inspections of clinics, health centres, hospitals and district health offices as part of their preparation and training. While relevant health establishments participated voluntarily in this process and the DOH lacked the authority to certify compliant establishments, the progress was extremely valuable because it:
- Provided an indication of the overall level of performance of health establishments in the public health system in relation to NCS.
- Produced extremely useful information on the adequacy of the NCS for measuring quality of care. This knowledge is being applied in the drafting of the first regulations on norms and standards.
- Gave health establishments a foretaste of the inspection process and how this could be used constructively to guide quality improvement.
The above developments ensured that, when the National Health Amendment Act was promulgated in 2013, giving birth to the OHSC, there was fairly widespread understanding in the healthcare sector of the concept of certification against prescribed standards.
OHSC Board
The OHSC functions under control of a Board appointed by the Minister of Health in terms of the National Health Amendment Act of 2013.
The Board is the accounting authority of the Office and is responsible for determining the policy of the OHSC and undertaking strategic planning for the functions of the Office.
The Act specifies that the Board should consist of seven to twelve members. Most members are selected on the basis of specific expertise and experience in various areas of healthcare, the law, finance and economics, the private and public healthcare systems, and quality assurance. One member represents organised labour and one is a representative of civil society organisations.
The Minister makes the final selection of members from individuals nominated by institutions of higher learning, civil society organisations, trade unions and other organisations in response to adverts in the Government Gazette and national press.
The Chief Executive Officer and the Chief Financial Officer of the OHSC are ex officio members of the Board.
Chairperson: Dr Molefe Kenoshi
Vice – Chairperson: Dr. Reno Morar
Board Members
Professor Mohambry Nadesan (Morgan) Chetty
Qualifications: MBChB (Natal), M Fam Med (Natal), FCFP (SA), MPH (USA), DTM&H (Wits), DOH (Wits), DHSM (Natal), PhD honoris Causa (NMU)
Prof Chetty is a registered Specialist Family Physician. He serves as Deputy Chairman of SAMCC.
Prof Chetty is the Chairman of the IPA Foundation of SA and Chairman of Kwa Zulu Natal Doctors Healthcare Coalition.
He serves as visiting Professor to the Department of Health Sciences, Durban University of Technology.
He was awarded the Fellowship of Family Physicians by the College of Medicine of SA – 2013 – FCFP(SA).
He has been awarded a PhD from the Nelson Mandela University in South Africa.
Prof Chetty was awarded the Fullbright – Humphrey scholarship to the USA in 1993 – 1994. He completed his MPH in the USA.
He has written two books on Managed Care and is a speaker at National and International Conferences on a regular basis and writes for the Medical Chronicle.
Prof Chetty was appointed on the NHI Technical Task Team [GP Contracting] in South Africa. He is now on the Board of OHSC (Office of the Health Standards Compliance) – appointed by the Minister of Health, Dr Aaron Motsoaledi.
Prof Chetty has been the recipient of a number of awards for leadership in Healthcare.
Amongst these awards are the Titanium Award by the BHF for Leadership in Healthcare and the Discovery Health Life Time Achievement Award for work on Quality of care.
Prof Chetty was elected onto the International Academy of Quality and Safety (IAQS) and as an ISQua EXPERT.
2018 – Appointed Interim Chairman of African Health Federation – South Africa.
Ms. Ritta Msibi
Dr. Maria Peenze
Prof. Lilian Dudley
Prof. Usuf Chikte
Ms. Palesa Santho
Mr. Rajesh Mahabeer
Mr. Anele Yawa
Ms. Sizeni Mchunu
OHSC Management
Dr. Siphiwe Mndaweni
Chief Executive Officer
She holds a BA Degree in Biology from Knox College, Illinois, USA; Masters in Medical Science Microbiology from Medunsa; MBCHB from Medunsa; Management Development Course for Healthcare Professionals from both Wits Business School and Duke University; Post Graduate Diploma in Health Systems Management and Executive Leadership from University of Pretoria.
Dr Mndaweni’s career and leadership journey is imbued and manifest itself in a number of entities she worked for. Her previous roles and positions include amongst others, Deputy Director-General: District Health Services, KwaZulu-Natal, Department of Health, Chief Director: Strategic Health Programmes, KwaZulu-Natal Department of Health; Chief of Party, URC USAID TB Programme and Deputy Chief of Party of the Right To Care EQUIP Programme.
Her professional accomplishments include amongst others, notable management of the overall implementation of the HIV, TB, Child and Maternal Health Programmes in KwaZulu-Natal Provincial Department of Health. She also brings over a wealth of experience from public health policy and program implementation from several African countries she supported.
Dr. Mndaweni’s commendable knowledge in public healthcare will contribute towards the OHSC accomplishing its mandate in ensuring quality and safety in both public and private healthcare establishments in South Africa.
Mr Siyabulela Tshefu
Director: Planning, Monitoring and Evaluation
Siyabulela Tshefu started his Public Sector career in 2004 and held various positions in the Eastern Cape Department of Health (2004-2013), Eastern Cape Provincial Treasury (2013-2021) and Department of Public Service and Administration (2021-2023) as the Director. He has been instrumental in institutionalising Monitoring and Evaluation as well as implementing various Planning Methodologies and Tools such as Scenario Planning.
He has massive experience and extensive knowledge in Strategic Management Monitoring & Evaluation. He produced a number of Evaluation studies reports such as Implementation Evaluation of Municipal Support Programme (2017), Implementation Evaluation of the Effectiveness of Cooperative Funding (2018), Impact Evaluation of Provincial Treasury’s Intervention in Eastern Cape Department of Health (2019) and Impact Evaluation Report of the Effectiveness of the HR Training Programme (2020).
Siyabulela Tshefu holds two master’s degree in Monitoring and Evaluation from the University of Stellenbosch (2021), a Master of Public Administration from Nelson Mandela University (2017), Post Graduate Diploma in Monitoring and Evaluation (Cum Laude) from the University of Fort Hare (2018), Bachelor Degree of Public Administration (Cum Laude) from University of Fort Hare (2015) and National Diploma in Taxation from Border Technikon (2003).
He has also obtained several certificates from different academic institutions namely Certificate in Monitoring and Evaluation (NQF LEVEL 7) from the University of Rhodes (2012), a Certificate in Monitoring &Evaluation from the University of Western Cape (2008) and a Certificate in Health Information Systems from University of Western Cape (2010).
Mr Julius Mapatha
Chief Financial Officer and Executive Manager: Corporate Services
Mr Julius Mapatha has over twenty-one (21) years working experience. During his working life he has occupied various technical and leadership positions covering the areas of finance, accounting, human resource and general management. This experience has been acquired in various sectors covering mining, FMCGs, NGOs, trade and investment promotion.
Ms Winnifred “Winnie” Moleko
Executive Manager: Health Standards Design, Analysis and Support
Winnifred Moleko, currently working in the Office of Health Standards Compliance (OHSC) as the Executive Manager: Health Standards Development Analysis and Support providing leadership in standards development and measurement tools; analysis of inspection data, development of guidance material and training on interpretation of standards and measurements. A highly experienced professional nurse with a Diploma in General Nursing and Midwifery (Chris Hani Baragwanath Hospital); holding degrees in Community Nursing Science, Nursing Education and Nursing Administration (MEDUNSA); Master’s in Education (MeD) for Primary Health Care (University of Manchester –UK); Post Graduate Diploma in HIV/AIDS Management (University of Stellenbosch); Advanced Course in Health Management (Foundation for Professional Development (FPD) and YALE University) and MPHIL (HIV/AIDS) with University of Stellenbosch.
Winnie worked at Wits Reproductive Health and HIV Institute (WRHI formerly RHRU) for 18 years and last position was Technical Head, Health Systems Strengthening. From May 2011 she was seconded to the National DOH as Quality Improvement: Senior Technical Advisor to assist with quality improvement/quality assurance work. In this, she had a critical role in the establishment of the Office of Health Standards Compliance as an independent entity, mandated to promote quality and patient safety. She gained extensive QI knowledge and expertise in coaching and mentoring with the Quality Assurance Project and Institute for Health Care Improvement.
During this period (2001 -2003), Winnie was actively involved in the organization and development of standards, training and facility self-assessment of Youth Friendly Services in Africa in Kenya, Ghana, Tanzania and Lesotho with International Planned Parenthood Federation of Africa Region (IPPFAR). This work included publication of Standards for Youth Care: A Guide to Youth Friendly Services with Dickson Tetteh K, W Moleko and Mpangile G, (2002). While at RHRU, published Quality of Care Self-Assessment Tool: Standards to improve the quality of HIV and related health services at primary health care facilities: Melanie Pleaner and Winnie Moleko (2010).
Director: Certification and Enforcement – Vacant
Mr Ricardo Mahlakanya
Director: Communications and Stakeholder Relations
Ricardo Mahlakanya is a qualified communications and media relations professional with a B-Tech Degree from Tshwane University of Technology. Over the years, he worked for a number of government and parastatals in areas such as communications, media relations, campaigns and stakeholder relations just to name but a few. He is currently pursuing his Honours Degree in Communications with University of South Africa.
Dr. Donna Jacobs
Executive Manager: Complaints Management
Dr Ziyanda Mgugudo-Sello
Director: Compliance Inspectorate
Dr Ziyanda Mgugudo-Sello qualified as a medical doctor at the University of Cape Town (UCT) in 2006. She completed her internship at King Edward Hospital in Durban and Community Service at Tintswalo Hospital, Mpumalanga. In 2011 she moved into the private sector where she worked as a general practitioner and Emergency Medicine Medical Officer for Cullinan Private Hospital and Netcare aeromedical emergency services.
She relocated to Cape Town in 2012 to work for COHSASA (The Council for Health Services Accreditation of Southern Africa) as an Assessor (Surveyor) and Quality Advisor where she implemented healthcare standards in public and private health establishments in South Africa and various African countries.
She left COHSASA in 2015 to pursue specialist training as a Public Health Medicine specialist at UCT. During her specialist training, she was an employee of the Western Cape DOH’s Health Impact Assessment and provided public health medicine expertise at Metro Health District Services, Epidemiology and Surveillance, Southern Western Substructure. During her final year of studies, she played a role as a Medical Manager for the Emergency & Covid-19 Testing Centres at Groote Schuur Hospital, Cape Town.
Ms Dikeledi Tsukudu
Executive Manager: Compliance Inspectorate
Mr Lehasa Moloi
Director: Finance and Supply Chain Management
Mr Jay Tulsee
Director: Information Technology and Document Management
Jay Tulsee joined OHSC in October 2014 as the CIO/Director of ICT. Tulsee has 25 years of health care IT experience. Prior to joining OHSC, Tulsee held a variety of senior positions in IT with several Health organisations. Tulsee holds a diploma in medical technology, information technology and a master’s degree in business management.
Mr Phillip Moholola
Director: Human Resources and Administration
Mr P Moholola joined the Office of the Health Standards Compliance in December 2014. He holds B Admin Honours degree, specialising in human resources management, from the University of the North (now Limpopo University). He is currently in the process of completing an MBA qualification with Tshwane University of Technology. He has extensive experience in all areas of human resources management, including ten years at senior management level.
Ms Kantha Padayachee
Director: Governance, Strategy and Board Secretariat
I qualified as an attorney in 1996 and went into private practice for a short period. I thereafter joined the RAF in 1998 and it was at the RAF that I developed my interest in medical law.
I then joined the HPCSA where I was actively involved in professional conduct matters. I served as legal advisor and pro forma complainant and as head of the Professional Conduct Section for a period of about six years.
Thereafter, I relocated to KZN in 2004, where I served at the Department of Health KZN, as Director and Chief Director: Legal Services.
The lure of private practice tempted me once more and I commenced practice for my own account in Pietermaritzburg in 2014.
In 2018, I accepted a position as State Law Advisor at the South African Law Reform Commission. My work here included research into possible legislative reform to address medical negligence claims.
From there, I moved to the South African Police Services Medical Scheme as Senior Legal Manager. This position comprised of Board Secretariat functions as well as contract management and litigation.
I have a keen interest in Medical law and hold an LLM degree in Medical Law from the University of KwaZulu Natal.
During my tenure at the DOH-KZN, I also obtained post graduate diplomas in Contract Management and Labour Law and a diploma in Legislative Drafting from the University of Johannesburg. In addition, I have a diploma in Business Management from Unisa.
I trained as a mediator focusing on medical negligence cases in a programme jointly coordinated by Mediation in Motion and the University of Cape Town.
In 2019, I completed a Trustee Training Programme at the Board of Healthcare Funders.
I am married and have 2 children. My hobbies include reading, cooking and hiking.
Ms Helen Phetoane
Senior Investigator: Healthcare Complaints
Mr Douglas Mapheto
Senior Investigator: Legal Issues: Complaints
I, Mpuru Douglas Mapheto was born and bred in the rural Sekhukhune area at Ga-Masemola village, in the Limpopo Province. I attended my Primary and High School studies in Ga-Masemola. After completing my matric in 1995, I took a gap year in 1996 before I enrolled with the University of Limpopo (UL), formerly knowns as the University of the North (UniN), in 1997. I studied a four-year bachelor’s degree in law, BProc degree, which I obtained in record time.
I completed a six (06) months Practical Legal Training (PLT) at the School for Legal Practice (SLP) in 2002 at EduPark in Polokwane, Limpopo Province. I was then appointed as an Article Clerk or Candidate Attorney at Dr TC Botha Incorporated in Ermelo, Mpumalanga Province between 2003 – 2004. Between 2005 and 2009, I joined a private company as a Claims Investigator and Legal Cost Consultant. This is where I developed a keen interest in investigation as a career.
Before I join the Office of the Heath Standards Compliance (OHSC) I was a Senior Investigator in the Public Protector South Africa (PPSA) between 2010 -2021. In that position, I was tasked with investigating rectifying and redressing any improper or prejudicial conduct in state affairs. I am currently a Senior Investigator: Legal Cases in the OHSC effective from 01 April 2021 (NB: not ‘April fool’ joke). My responsibilities include amongst others: To investigate healthcare complaints / legal cases investigations; to provide support to the Office of the Health Ombud (OHO); to manage investigations and reporting on complex cases regarding breaches of norms and standards etc.
I am looking forward to making a meaningful contribution in ensuring compliance by Health Establishments (HE) with the norms and standards and most importantly to protect and promote the health and safety of users of health services.
Dr Thokoe Thabiso Makola
Director: Health Systems, Data Analysis and Research
Dr Thabiso Makola qualified as a medical doctor from the University of Cape Town. He has extensive clinical experience working in both the public and private health sectors in South Africa and in the United Kingdom.
He went on to specialize in Public Health Medicine and holds an MMed (Public Health Medicine) from the University of Pretoria and also holds Fellowship in Public Health Medicine (FCPHM) from the College of Medicine of South Africa.
Dr Makola has experience of working within the health system in the area of Health Systems Strengthening, public health technical advisory, clinical risk management and academia. His special interests include Health Systems Strengthening, Health Economics and the overall Political Economy of Health.
Dr Thabiso Makola is a keen sports follower of soccer, athletics, tennis, and motor sport (formula one). His other interests include politics, economics and history. He lives with his family in Pretoria.
Ms Izelle Loots
Director: Health Standards Development and Training
Izelle is currently appointed Director: Standards Development and Training as of 1 September 2022. She holds a Master’s degree in Health studies (cum laude), a B Cur I ed A degree (cum laude), a 4-year integrated Diploma in nursing (General, Midwifery, Community, Psychiatric nursing), a post basic Diploma in Nursing Management and has furthered her studies as a Primary Healthcare nurse, post basic Pharmacology and post basic Community Health Nursing. She is currently enrolled as a PhD student in nursing.
Izelle has more than 20 years’ experience in the nursing fraternity. She has significant experience in nursing education and has been the former Chairperson, Vice Chairperson and Board Member for the Nursing Education Association and Pretoria Chapter. In addition, she is one of the founders and leaders of a movement called The Nursing Improvement Platform and is on the Advisory Board of the Occupational Guilds for Nursing.
Izelle is the recipient of three (3) Pacesetters Awards for Driving Excellence, three (3) Edge Runner Awards for Innovation and Change and, Night of the Stars Award for Nursing Excellence, the Great 100 Nurses Award for Compassionate Care and the Nursing Education Excellence Award.
She has been a presenter and moderator in both national and international nursing conferences. In addition, she is also a reviewer of academic articles in the fields of Nursing Management and Primary Healthcare.
Ms Nompumelelo Ndou
Director: Complaints Centre and Assessment
I am currently appointed Director: Complaints Centre and Assessment at OHSC as of 01 August 2022. I hold the following qualifications: Diploma in Nursing (General, Psychiatry, Community) & Midwifery from Chris Hani Baragwanath Nursing College, Diploma in Clinical Nursing Science, Health Assessment, Treatment and Care (Primary Health Care Nurse) from Ann Latsky Nursing College, Bcur Ed at Admin (Occupational Nursing Science) from the University of Johannesburg and a Post Graduate Diploma in Health Systems Management and Executive Leadership from the University of Pretoria.
My career started soon after completing my Diploma in Nursing, appointed as Professional Nurse in Primary Health Care Facilities, and later appointed as Primary Health Care Nurse and this was from 2004 to 2012 in Ekurhuleni Health District. In 2012 was appointed Operational Manager Nursing for Community Health Workers Programme and Expanded Public Works Programme in Ekurhuleni Health District, Coordinated the implementation of Ward based Primary Health Care Teams. In 2017 was appointed Deputy Director for Community Health Workers Programme/Wardbased Primary Health Care and Expanded Public Works Programme at the Provincial Office in Gauteng Department of Health. In 2019 was appointed Deputy Manager Nursing (Primary Health Care Sub-District Manager in Ekurhuleni South Sub-district) and I held this position till July 2022.
I have more than 18 years’ experience in nursing and 10 years’ experience in management within the public sector. I have extensive experience in Primary Health Care and District Health Services.