Another day. Another story about state patients dying and suffering. Another distressed letter from desperate health workers. Another call for action and accountability from civil society. Another statement from government. Another day in Gauteng.
A week has hardly gone by in the past year without a media report detailing a horror in a Gauteng hospital or clinic.
These have included heartbreaking doctors' reports detailing newborn babies dying or being left brain-damaged at Chris Hani Baragwanath Hospital because of nurse shortages; doctors being forced to play God as they choose which patients to resuscitate and which ones they must leave to die at Charlotte Maxeke Hospital; cancer patients unable to access treatment at the same hospital due to broken equipment; drug shortages for life threatening paediatric illnesses at Rahima Moosa Hospital - the list is endless.
In an attempt to understand why Gauteng, considered the economic hub of South Africa, is unable to offer its citizens effective and accessible health care, Health-e spoke to a number of health workers, activists and government officials. None would be named but there was general consensus that the current crisis was the result of years of poor administrative and financial mismanagement, overseen by the provincial department and politicians.
"The Premier always reacts when there is an article in the newspapers, she stamps her feet and a week later nothing has changed and everything is quiet again, until the next article," said a frustrated activist.
SECTION27, the public interest law centre, agreed when it said in a statement: " each time a crisis hits the newspapers, instead of addressing the underlying issues related to overspending, the Gauteng Department of Health first denies that there is a problem. Then they shift spending from one area to another, effectively fighting fires rather than addressing the core issues with a structured attempt to develop a realistic needs-based budget that facilitates the delivery of healthcare services to the public."
After media reports about the situation at Charlotte Maxeke recently, Premier Nomvula Mokonyane reportedly swooped in like a superhero, holding a four-hour emergency meeting with her new Health MEC Hope Papo and staff. She apparently had harsh words, accusing her staff of making her look like a fool.
However, a couple of months ago, when a number of senior doctors tried to meet with Mokonyane and her then Health MEC Ntombi Mekgwe, they spurned them.
In fact, sources at the meeting reported that Mokonyane and Mekgwe were dismissive and refused to attend a meeting organised by the national health minister to bring the groups together.
This attitude permeated down to the administration, which has displayed a similar attitude and did everything in their power to sabotage meetings between the health department and clinicians.
The province's health woes have been building up for well over five years, with constant overspending, spending on unfunded mandates and the awarding of lucrative to government allies who have failed to deliver, being the order of the day.
At the same time, the money allocated for health historically has been inadequate to meet the needs of patients living in the province, and this has resulted in debt snowballing year after year.
Forensic audits pointing to corruption have not been followed up. However, the Hawks is investigating R1-billion worth of tender fraud, and the former head of department and chief financial officer have been charged with fraud.
Critical challenges facing Gauteng include:
- Continual shortages of essential medicines in health care facilities linked to non-payment of suppliers and poor supply chain management;
- Shortages of staff such as doctors and nurses as the system requires for the Gauteng Head of Department Dr Nomonde Xundu to sign off any new posts, a process which has reportedly caused huge delays;
- Severely curtailed laboratory services as the province fails to pay its bills and the National Health Laboratory Services is in turn forced to reduce staff, services and shifts;
- A break down of critical equipment for cancer, surgery, diagnostics and trauma linked to the non-payment of suppliers.
- The collapse of the Emergency Medical Services.
The Gauteng health department recently reported proudly that they had settled most accruals from previous financial years, hinting that a turnaround was underway.
However, what they failed to disclose is that to do this they used funds meant for service delivery this year, which has resulted in the department overspending on its 1st quarter budget.
The over-expenditures this early on in the financial year will repeat the annual cycle of improper utilisation of funds to settle debts and accruals. The effects of this approach are at the heart of the systemic crisis facing the province's health department and are devastating for the millions of patients who are dependent on public health care facilities.
There are also austerity measures in place, but these will only serve to compromise service delivery.
As each crisis pops up, the spin-doctors are quick to react and give assurances that the challenges are being addressed. It is helpful to take a closer look at some of the more recent ones:
- Shortages of medicines (including antiretrovirals and oncology meds): The health department recently reported that availability of antiretroviral medication has improved to 71 percent and stock levels are now up to three months and that communication has been sent to health care facilities to now start issuing between one and three month supplies to patients and increase as supply improves. However, activists point out that the 71 percent referred to was stock levels at depots and not at health care facilities. The majority of patients in Gauteng are therefore not experiencing an improvement in the availability of essential medicines. No proper explanation has been given for the disruption in oncology services.
- Shortages of staff: The department recently reported that there has been a moratorium on appointments to manage a shortage of funds in the budget, but it gave assurances that critical posts are now filled. This has not been the experience of hospital staff who continue to experience a shortage of personnel in critical positions, reporting massive bureaucratic hurdles when they attempt to fill these posts with candidates often leaving before the permission is finally granted.
- Improved turn around time for laboratory service results: The National Health Laboratory Services has restructured since the crisis in the last financial year. But health workers say that services remain dysfunctional and the turn-around times for results is still long.
- Emergency Medical Services: The health department has acknowledged that this service is in crisis, partly due to a failure to find someone to run this service.
"The chickens are finally coming home to roost," said a Treasury source, who asked to remain anonymous. "This is the legacy of years of poor management and corruption, which has created huge distrust between the provincial Treasury and the health department."
As with all such matters there is a lot of finger pointing at blame shifting, but ultimately there needs to be accountability.
The question has to be posed on where the Gauteng Legislature and, in particular, the provincial portfolio committee on health, chaired by Molebatsi Bopape, have been in all of this. Its silence is conspicuous and has been for a long time. When concerned parties have raised issues with them, the committee has said that they would follow-up but then nothing happened.
It has a constitutional obligation to hold the executive and administration to account for poor performance but has failed to do so.
Also of concern is that in several public statements, both the executive and the administration, have sought to shift the blame for many of the issues to the doctors by highlighting the issue of moonlighting and negligence.
This is disingenuous as there has been gross negligence on the part of the executive and administration for a long time. Civil society has warned of the impending budget crisis and doctors have repeatedly raised their concerns around funding but no proactive or meaningful action has been taken. Instead there have been denials and then claims that the situation with the budget shortfalls had been resolved.
Looming large in December is the ANC's elective conference in Mangaung.
The Gauteng Premier has the support of the ANC executive, and is a valuable Zuma ally in a province where support for the President is waning, hence Cabinet's reluctance to order a Section 100 intervention, which allows the national government to intervene in provincial matters, as has happened in Limpopo.
Gauteng has already pushed back against the national department and Treasury's attempts to intervene.
It thus appears that, in Gauteng, politics is preventing meaningful engagement and collaboration between national and province to solve the problems.
Simply put, this means for the foreseeable future, politics will remain the winner and the patients the losers.