In this analysis, Luvuyo Mehlwana looks back at the performance of public healthcare services in the Eastern Cape over the last five years - a term characterised by leadership instability, infrastructure problems, financial short-falls, and of course the COVID-19 pandemic.
In South Africa, the right to access basic healthcare services is a fundamental right guaranteed by the Constitution. For residents of Xhora Mouth in the Eastern Cape, that constitutional right in some respects remains a mirage.
Almost four years ago, in her May 2020 budget speech, the then MEC for Health, Sindiswa Gomba, promised the community a clinic. The Xhora community consists of villages such as Nqileni, Tshezi, Folokwe, and Mgojweni about 100 km from Mthatha. Villagers have to walk long distances, including crossing the Xhora River and navigating through thick bushes to get to the nearest clinic in Nkanya Village, which is about 15km away. When Spotlight reported on their plight in 2019, they had already been campaigning for a clinic of their own for more than a decade.
That there would after all not be a new clinic in Xhora Mouth under the current administration became clear when Nomakhosazana Meth took over from Gomba as health MEC in March 2021. Meth made it clear in her first budget speech that the department would focus on maintaining existing infrastructure instead of undertaking new construction. The community of Xhora Mouth will thus have to wait even longer.
Spotlight looks at what else has, or has not, changed in the province's healthcare system since the last national and provincial elections in 2019, focussing on leadership, infrastructure, medico-legal claims, and emergency medical services. COVID-19 was obviously a big part of the story of the last five years, but we don't focus on it here - much has been written elsewhere about the severe short-comings in the province's response to the pandemic.
Leadership instability
Meth's appointment is emblematic of the leadership instability that has plagued Eastern Cape health over the last five years. To what extent this instability has contributed to the province's health problems is unclear, but it couldn't have helped.
Meth replaced Gomba after Premier Oscar Mabuyane fired the latter in February 2021. It followed Gomba being charged along with several others in a case of alleged fraud relating to the funeral of former president Nelson Mandela. Meth herself seems likely to vacate the position of MEC in June given that she is high on the ANC's national candidate list for the upcoming elections and is very likely off to serve in the national parliament.
The province's health department is currently on its fourth departmental head since South Africa's last national and provincial elections. Dr Thobile Mbengashe started the term as head of department but resigned in the wake of a controversial scooter ambulance tender that was eventually set aside by the corruption-busting Special Tribunal - a niche court (Gomba was also implicated in the affair). Mbengashe now serves as an advisor in the Premier's office.
After Mbengashe's departure, Dr Sibongile Zungu, former head of the KwaZulu-Natal health department, was roped in to serve as the acting head of the Eastern Cape health department. Prior to that, Zungu had been called on to assist with the province's response to COVID-19, which was widely reported to be severely dysfunctional. Zungu would later also serve as head of the Gauteng health department in an acting capacity.
Zungu was followed by Dr Rolene Wagner, who was appointed as head of department on a full-time basis in August 2021. There was initial optimism about Wagner's appointment given her mix of public and private sector health experience. But just over two years after her appointment, Wagner was controversially moved out of the position by Mabuyane.
Wagner in turn was replaced as head of the health department by Sindisiwe Gege.
This leadership instability is linked to what he sees as the department's poor performance, says EFF MPL and provincial health portfolio committee member, Simthembile Madikizela. "In addition to the previous MECs not doing justice to the department, the current MEC too has issues with Wagner, who happened to be transferred to the Premier's Office. That alone created another instability in the department, the current acting head of department [Gege], does not appear confident or capable of resolving the department's challenges," says Madikizela.
And as the Xhora Mouth example reminds us, infrastructure and staffing at health facilities is one of those challenges.
Hospital and clinic problems
In the last five years health facilities in the province have been the subject of several investigations and damning reports. A report published by the Public Protector in June 2021 found that the administration of health by the Eastern Cape Department of Health at several health facilities does not accord with the obligations imposed by the Constitution and the law. The Public Protector also pin-pointed several instances of improper conduct and maladministration.
A broader Public Protector report into service delivery in the province, published in 2023, concluded that "the delivery of healthcare services by the Eastern Cape Department of Health, is prone to being ineffective and/or unreliable, as a result of various challenges caused by poor contract management which contributes to delays in finalising infrastructure projects, backlog in upgrading health facilities and defective infrastructure". It also found that "the shortage of staff at most health facilities hampers the effective provision of services". Oversight visits and reports by the provincial legislature's Portfolio Committee on Health have also flagged serious infrastructure problems at health facilities in the province.
Mud clinics remain a reality in the province. As MEC, Gomba three years ago vowed that clinics with elements of mud would be made a thing of the past and committed to the rebuilding of community clinics. But, of the 13 healthcare facilities in the province identified to have elements of mud structure, only 5 were included in the R492 million allocated for refurbishment over the 2023/2024 medium-term expenditure framework. This indicates that at least some mud clinics will remain in use for the foreseeable future.
Yet, despite the bleak situation with infrastructure, healthcare worker to patient ratios in the province appears to be improving. According to the latest figures from the District Health Barometer, the number of medical practitioners per 100 000 people in the province has increased from 33.5 in 2019 to 39.9 in 2023, pharmacists increased from 14.1 per 100 000 to 16.4 per 100 000, and professional nurses from 186 per 100 000 to 197 per 100 000, over the same period.
Critics however complain about management at health facilities.
"The lack of management in our hospitals is another problem because everyone does their own thing since there is no clear direction. Hospital boards are not functioning, and those who are functioning are not receiving their stipends. Almost all hospitals are run by acting CEOs, that show a lack of leadership and a lack of visionary lead to such situations. It is not necessary for the hospitals to perform any magic, but a visionary in the form of MEC is essential," says Madikizela.
Money and medico-legal claims
The Eastern Cape have also been in the headlines in recent years for the high number of medico-legal claims against the province's health department. Partly due to this, the department have slipped into a pattern whereby it starts every financial year with a substantial amount of accrued debt from previous years. There also appears to be a pattern of salary costs, and paying for salary increases, being prioritised over other health costs. These financial troubles have at times contributed to the late or non-payment of service providers, which have in turn disrupted service delivery.
Though the Eastern Cape often ranks at or near the top when it comes to the number of and value of medico-legal claims against health departments, the high number of these claims is a national problem. As the Auditor General has pointed out in parliament, government has failed to meet its target of reducing contingent liability from medico-legal claims by 80% from the 2018 baseline of R70 billion - in March 2023 it stood at R77 billion, a 10% increase. Contingent liability refers to the amounts claimed, the actual amounts paid out are much lower.
In one of the most important recent legal developments in this area, the Eastern Cape Department of Health won a significant victory in February 2023. Judge Robert Griffiths, of the Bhisho High Court, ruled that the department no longer has to make upfront lump sum payments in certain medical negligence claims and may provide the necessary medical care instead of paying for future medical costs.
The Eastern Cape health department has been granted a reprieve after Judge Robert Griffiths, of the Bhisho High Court, ruled on Tuesday that it no longer had to make upfront lump sum payments in medical negligence claims https://t.co/3xDTj3LTwu. pic.twitter.com/BZ47lmzfqz
-- City Press (@City_Press) February 8, 2023
A reduction in the amount of lump-sum payments it has to pay could provide a significant boost to the province's health budget. Spotlight asked the department for the latest data on medico-legal claims in the province, but did not receive a substantive response. We thus don't know whether the ruling has so far had any beneficial impact on the department's finances. It probably hasn't, given that as recently reported by the Daily Maverick, the department started the current financial year with a massive R4.8 billion in unpaid bills.
Jane Cowley, DA MPL and shadow MEC for health in the province, says the department is in deep, deep trouble. "All these years we have been calling for an urgent review of the Eastern Cape Department of Health's budget, which has been pushed through with no consideration of its disastrous implications for residents in desperate need of healthcare services. Every single financial department starts with billions of accruals. The Department, along with the Office of the Premier have not been able to halt the tsunami of medico-legal claims against the department, which continue to decimate their finances," she tells Spotlight.
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"It is outrageous that patients must suffer because of years of historical financial mismanagement by the department. The critical shortfall of funds has already resulted in services at hospitals and clinics deteriorating dramatically over the past few years. High vacancy rates amongst doctors and specialists, coupled with a bloated and inefficient administration, have left hospitals and clinics reeling without budgets," she says.
Ambulance shortages
A lack of quick and reliable emergency medical services (EMS) is also a long-standing problem in the province, especially in rural areas. The situation triggered the South African Human Rights Commission (SAHRC) in 2015 to investigate and produce a report with detailed recommendations. Meth, in her 2022/23 budget speech, acknowledged that the department has not yet addressed the gaps identified by the SAHRC.
Although the ambulance fleet increased from 306 in 2018 to 439 ambulances in 2023, out of these, approximately 190 ambulances are grounded for repairs and services. The department spokesperson, Sizwe Kupelo, confirmed in November 2023 that the province is not meeting the national target of at least one operational ambulance per 10 000 people - or roughly 650 operational ambulances.
The situation was further complicated when EMS workers from Amathole and King William's Town went on strike from April to November 2022, alleging that the equipment they were provided with is inadequate. There has been no resolution to the situation, as the department is now seeking to fire 224 workers who participated in what it described as an unprotected strike. Apart from the strike's direct impact on healthcare services, it also underlines the fact that disputes between workers and the Eastern Cape Department of Health has been a constant feature of health politics in the province under this and previous administrations.
Kupelo, was contacted for comment on this story on 15 March 2024. He responded that he was on leave and referred Spotlight to the health MEC's spokesperson Mkhululi Ndamase. Spotlight sent questions to Damas on 19 March 2024, but did not receive a response despite several further reminders.
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