Not so long ago, in mid 2017, I was part of a team evaluating a system-wide initiative in Nelson Mandela Bay Metropolitan (NMBM) health district to improve the quality and accountability of its primary health care services and district hospitals. Our independent assessment was overwhelmingly positive. We documented an integrated system of problem analysis and response in frontline health services, engaging providers and their immediate supervisors in a manner that was both generative and meaningful to them.
These successes occurred under the stewardship of an experienced health district manager in the metro, whose achievements included the successful amalgamation of previously separate local and provincial primary health care services. This required complex transfers of assets and staff across the two spheres of government, a task yet to be achieved in other metros.
The manager was supported by an energetic and likeable district team, overseeing the new system of quality management and ensuring accurate and up-to-date health information (readily shared with us). The district's Ward Based Outreach Team (WBOT) (community health worker) model also offered significant lessons, prompting a follow-up case study of the programme in early 2018 as part of a national investment case for the WBOT programme.
These engagements with the metro were a reminder, once again, of the latent potential of the public health system, revealed sometimes in the most unexpected places. In this regard, a visit to one of the smaller clinics in Motherwell stood out for its people-centred approach - its low fence, relaxed security, burgeoning food garden, organised care systems and motivated manager - all of which spoke volumes about relationships of trust and respect with the surrounding community.
Things fall apart with COVID-19
Fast forward to 2020 and COVID-19. Nowhere in South Africa has the havoc of the pandemic and a dysfunctional public health system been more evident, and its impacts more devastating than in the Eastern Cape, now in its second wave. News reports since the early days of the pandemic in Spotlight and other publications have documented the unfolding calamity in the Eastern Cape. Nelson Mandela Bay Metro has been its epicentre - a seemingly rudderless health system in the Metro with its 'hospitals of horror', closed clinics and emergency services, lack of PPE, patients competing for oxygen, mothers and infants dying in maternity wards and distressed health workers downing tools.
The toll has been massive.
This is most evident in data on excess mortality provided by the South African Medical Research Council (see figure). This metric reports on all deaths in 2020 over and above and above expected deaths based on the trends of the prior two years. The Eastern Cape has experienced by far the highest excess death rate relative to other provinces, although rivalled closely by the Free State.
Failings of leadership
How and why, then, did things unravel so fast and so spectacularly in Nelson Mandela Bay's public health services?
Both the successes and failings of the metro provide a textbook case of the critical role of leadership.
Shortly after we completed our research in 2018, the respected district manager of NMBM retired. Two years later, she had still not been replaced. According to a colleague in the province, members of the existing team were first tasked with rotating in the position. An external acting manager was eventually assigned to the district but acting managers lack formal mandates and are generally weak caretakers.
Compounding this, in November 2018, the CEO and senior management team at one of the largest facilities in the metro, Livingstone Hospital, were suspended and the complaints against them still not resolved some 18 months later. In 2019, the chairperson of the Portfolio Committee on Health in the Eastern Cape legislature was moved to declare the (previously model) NMBM Health District the worst in the province. This might not have been the case had the original district manager still been in place.
These are just two high-profile instances of a chronic inability to secure staff appointments by the Eastern Cape's Health Department.
COVID-19 thus hit an already fragile system, and it did not take much to reach a tipping point in NMBM. At the height of the crisis in July this year, Livingstone Hospital's Emergency Department and COVID-19 management site shut down when support services ground to halt and PPE stocks ran out. A competent leadership team in this hospital could have prevented this and no doubt saved lives.
The minister of health and civil society intervene
These and other failings in the public health response to COVID-19 in the Eastern Cape, including the inability to provide accurate reports on infections and deaths, prompted forceful intervention by the national Minister of Health, Dr Zweli Mkhize. In a series of high profile visits to the province, the minister did not mince his words on the problematic political leadership in the Eastern Cape's health system, and reportedly 'lambast[ed] the Eastern Cape Health MEC Sindiswa Gomba for failing to fill critical posts'.
Showing a rare willingness on the part of the national sphere to intervene at high levels in this Province - the health minister wasted no time in ensuring that a new and experienced district manager was appointed in the metro and allocated a senior provincial manager to provide oversight of the district.
Over the ensuing months, civil society and private sector actors in the province also became increasingly vocal. The Dean of Health Sciences at Nelson Mandela Bay University, Professor Lungile Pepeta, emerged as a key voice for concerted and collaborative action in this period, before tragically dying of COVID-19 himself. In late July, members of the Treatment Action Campaign (TAC) staged a picket at the NMBM District offices demanding accountability for the critical lack of access to chronic services, ambulances and primary health care services. The TAC and Eastern Cape Health Crisis Action Coalition (ECHCAC) were subsequently invited to conduct joint oversight visits with the Eastern Cape Health Department to the 48 primary health care facilities in the metro.
The longer history
COVID-19 has revealed in a stark manner what has been known about the Eastern Cape's public health system for many years, documented amongst others, by the ECHCAC. As Livingstone Hospital was closing its doors, one NGO in the district declared that 'health services were circling the drain for 10 years. Now they've collapsed'.
The problems in this province run wide and deep - affecting every conceivable component of the health system. This is apparently rooted in a civil service and political culture, where a lack of accountability and oversight appears the norm, where patronage and factionalism run deep, and political interference in administrative functions is routine.
These troubles, of course, have a longer history in the Eastern Cape's complicated past of inherited homeland administrations and the nature of politics in the province. In a wide ranging radio interview on the legacies of the Eastern Cape, Tshepi Mothlabane of the organisation Equal Education, highlighted the post-Polokwane era, where 'professionalism and excellence is not just a source of suspicion, but otherwise a threat to increasingly incompetent politicians'.
Reimagining health and health care in the Eastern Cape
Numerous reports, interventions and initiatives have done little to address a fundamental crisis of governance in the province. The more the task teams and comprehensive diagnostic exercises point to the scale of the reset required, the more intractable the problems seem. As pointed out in an article published in Daily Maverick, there is little to be gained in exhorting a dysfunctional system to change when it does not have the will and capability (political or administrative) to do so. Piecemeal efforts will work in certain places and times but easily fall apart, as the case of NMBM illustrates.
It is also hard to see how the top down legislative reforms in the National Health Insurance (NHI) Bill - despite the hopes of many - can engineer a comprehensive turn around. Indeed, the much vaunted 'purchaser-provider' split and new contractual arrangements may simply create new opportunities for corruption. Such market-inspired measures are seldom the answer to public sector failings, and if anything, COVID-19 has emphasised the critical role of a capable public health system.
How then, can we reimagine a future of access, equity and justice in health and health care in the Eastern Cape?
One way to approach this question is to consider change in a more targeted and modest but strategic manner. This involves identifying the 'leverage points' and focusing on particular nodes within the system that have wider influence. Action on these nodes, starting with manageable gains ('small wins'), could lay new positive feedback loops that, with time, begin to have systemic effects. Seeking gains focused on specific nodes (even while holding long-term transformative visions) is easier to imagine and organise than tackling all the problems simultaneously.
One such node is the district manager and their core team - posts which are key to the decentralised governance arrangements proposed in the future NHI. If this is the case, would it be possible to envisage the mobilisation of collective action where we - activists, NGOs, researchers, organised labour, media, national and provincial policy makers and others - jointly make it our business to place a spotlight on district managers?
The immediate goal could be to ensure that every health district (the eight in the Eastern Cape and the 44 in the remainder of the country) is led by a competent manager invested in the public interest, and is supported by a capable team. This could be achieved by campaigning for transparent appointment processes, open to scrutiny by the public and media, and regular monitoring and reporting (through the media avenues such as the South African Health Review) of filled and vacant positions.
The experiences gained in such a campaign could point to the next 'small win', whether in the appointment of other senior managers (such as hospital CEOs) or open procurement systems, as proposed by some experts in local government law. Seeds of this approach have already been planted in the monitoring partnership between civil society players and the new NMBM district manager and the willingness of the Minister of Health to call politicians to account at provincial level.
The approach rests on the recognition that bottom-up institution-building is as crucial as top down legislative, budgetary and other reforms, and that involvement of civil society in such processes is key. As pointed out in Daily Maverick editorial, change will come from 'a system of co-governance with civil society organisations that can make transparent, informed decisions that ensure the rapid deployment of resources to the right places at the right time'.
*Professor Schneider is from the School of Public Health, University of the Western Cape. She holds a SARChI Chair in Health Systems Governance.
*This article is part of Spotlight's 'Reimagining health in the Eastern Cape' series - in which activists, healthcare workers, policy-makers and others are asked to reflect on how access to healthcare in the province can be improved.