Health-e (Cape Town)

South Africa: Battle to Stop the E Cape Rot

He cuts a lone figure in the fading dusk light, clutching a laptop bag in one hand and an oversized grass basket in the other. His salt and pepper hair slightly disheveled after a long day, the Eastern Cape health's head honcho Siva Pillay looks over his shoulder and grins: "I should have come in my other bakkie, I could have shown you those bullet holes".

He scurries across the road and melts into the early evening East London ocean mist, his shoulders slightly hunched, but his gait resolute.

An hour earlier, after an intense discussion on his attempts to root out the deeply embedded fraud and corruption and the subsequent three attempts on his life, one of those attending the meeting quizzed Pillay if he was not afraid of dying. He smiles and leans back in his chair: "I am a Buddhist, I am not afraid of dying."

Pillay's deployment as Secretary-General to the Eastern Cape health department in March 2009 was applauded by all those who had for years unsuccessfully tried to turn the spotlight on the unrestrained looting that was happening in the poverty stricken province.

Pillay is a medical doctor with impeccable struggle credentials who for years served the poor in the Eastern Cape, had a stint as Mayor of Uitenhage and whip of Parliament's powerful State Enterprises committee.

His latest role is close to seeing him throw the towel in as he alludes to resistance from the highest levels to his investigations.

The bespectacled Pillay is a no-nonsense person who has one goal: To expose and root out corruption and get on with the job of delivering good health services to the province which has huge swathes of rural settlements where accessing healthcare is often an impossible physical and geographical challenge.

However, Pillay's crusade has exposed the ugly underbelly of a province where fraud and corruption has spread like an incurable virus which has infected every level of the health department, from small, rural clinics right up to head office in Bisho.

Several investigations by Pillay and a small team of confidantes have exposed intricate webs linking health department employees to companies that have successfully tendered for various services from catering and stationary provision to more sophisticated contracts involving the revitalization of hospitals and the provision of equipment.

A number of employees have been charged and fired, but the rot is so deep that there is still much work to be done.

Pillay's battle is slowly, but surely gaining support with among others Corruption Watch, SECTION27, the Legal Resources Centre (LRC) and the Treatment Action Campaign getting involved on various fronts.

A number of investigations and forensic audits have revealed the extent of the corruption, although there is a belief that it is only the tip of the iceberg.

Looming litigation, led by the LRC, to address critical staff shortages at two Eastern Cape hospitals - Madwaleni and Livingstone - has also returned the spotlight to the beleaguered province.

However, the current crisis in public health in the Eastern Cape is not new and has its origins in more than a decade of poor management and an inability to appropriately use and account for resources made available to public health.

In the last 10 years, the Eastern Cape Department of Health has only received one clean audit and 7 adverse opinions from the Auditor General. This high number of adverse opinions clearly demonstrates that the Department has been unable to account for how its budget is being used and reveals a system that is unable to fully perform even basic public finance management functions.

However, more recently a shortage of funds has seen Treasury place the brakes of spending by the health department, basically instituting a moratorium on the filling of critical posts. This moratorium has seen Madwaleni, which should have 14 doctors, reduced to one doctor. At Livingstone critical specialist posts have also not been filled.

A 90 minute drive to the east of Mthatha, mostly along a challenging, potholed dirt road, leads to Madwaleni Hospital.

Here, as Rural Doctors Association chairperson Dr Karl Roux says, is a classic example of how the moratorium destroyed a hospital.

Three to four years ago, the former mission hospital set amid rolling hills in arguably some of the most breathtaking scenery in the world, had an excellent and experienced team of doctors and administrators.

However, once some of the doctors and health workers indicated well in advance their intention to leave, crippling bureaucracy led to the 180-bed hospital now being served by a lone German doctor who can understandably only cope with complex HIV and TB cases, in an area where the infectious disease burden is already high. She specialises in HIV and TB, which is why she applied for the position, and has not done paediatrics, obstetrics or emergency for many years.

The 180 bed hospital has almost half the beds occupied by HIV/TB patients.

The deputy nursing manager has been the acting head of the hospital since 2009 and the hospital has had no clinical manager since September 2011. The only pharmacist will be leaving at the end of October, the head of rehabilitation has not been paid her full salary since the beginning of last year, the x-ray machines have either been condemned or are broken, meaning the radiologists have no work other than ensuring those patients lucky enough to get a spot on the weekly minibus shuttle to Mthatha, are seen to.

Emergency and trauma cases, including complex pregnancies, are subjected to long waits for an ambulance which transports them to Mthatha Hospital, 100km away.

The lone doctor has confirmed that there has been a noticeable spike in death certificates she is requested to sign.

Another health worker, burst into tears, as she recalled trying to assist a woman to get out of her bed after she had been sedentary for a week with no intervention.

"She just crashed (stopped breathing) and as I turned around to call for help and oxygen, I realized there was none and the only thing I could do was hold her hand and assure her it was going to be okay, while she struggled to breathe. She died while I held her hand."

Two Clinical Associates, basically auxiliary health workers supposed to work under strict supervision by a doctor, were working unsupervised at the hospital.

"It's all risk risk," sighed a nurse.

The maternity section, which is supposed to have 42 nurses, currently has 10 with the nursing accommodation consisting of empty garages and rondawels with no bathroom facilities. A double-storey residence, housing most of the nurses, resembles a condemned building with paint peeling, doors falling down and toilets blocked.

Madwaleni's antiretroviral treatment outreach programme, at one stage considered one of the best in Africa, is now being run without doctors.

The more than 6000 patients, of which over 3 000 are on antiretroviral treatment, are relying on the nurses to initiate and manage complicated cases in the outlying clinics.

"They have destroyed years and years of good work," said Le Roux.

Dr Tom Boyles, an infectious disease specialist who worked at Madwaleni as a Senior Clinician for a number of years, says that even if doctors arrived tomorrow the fundamental problems that have lead to the crisis at Madwaleni remained.

"Until there is a stable hospital manager and clinical manager the recruitment and retention of staff will continue to be hugely problematic. Even if the current staffing crisis is solved the hospital is likely return to its current state within a year if the positions remain unfilled.

"The most important action is that competent people are recruited and retained in these vital positions," said Boyles.

Since the crisis at Madwaleni has received increasing attention, rural health recruitment specialists Africa Health Placements received job offers for three doctors.

Lynne Wilkinson, who was key in establishing and managing Madwaleni's ART programme for a number of years, cautions that it is vital that the process does not stall and that these doctros are provided with contracts of employment as soon as possible.

Three doctors have also applied to do Community Service as well as the partner of one of them, a qualified occupational therapist.

Boyles and Wilkinson, who have tirelessly petitioned for the crisis at Madwaleni to be addressed, said it had been a disaster for the hospital that no community service doctors were allocated last year.

"This group of enthusiastic doctors would be a huge asset to the hospital and it is vital that they are all placed there together," said Boyles.

There is currently no head of administration. There previous one was removed from his post under suspicion of fraud but remained in the post for many months. This is a critical position at the hospital.

Back in East London Pillay slowly shakes his head. "Everything is going haywire. Thieves have hijacked the process. All the gains we made are slowly being reversed. We are bleeding everywhere."

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