The below talk was delivered by Sasha Stevenson on 25 May 2022 as part of a lecture series hosted by the Steve Biko Centre for Bioethics at Wits University. Stevenson is the head of health at SECTION27.
"This is a harrowing account of the death, torture, and disappearance of utterly vulnerable mental healthcare users in the care of an admittedly delinquent provincial government."
That was how former Deputy Chief Justice Dikgang Moseneke chose to begin his judgment in the Life Esidimeni Arbitration.
The admittedly delinquent provincial government was the government of this very province. The one that houses the City of Gold, national government, and the Constitutional Court. The one with a per capita GDP more than twice the size of the next richest province and a provincial budget to match. This is no back water, where it is difficult to get professionals to settle and make a life, but a province of opportunity. A prize posting for any politician or administrator.
And yet we have seen, for years, how disaster seems to court Gauteng health.
The most recent example, of course, is the glacially slow response to the fire at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). While the fire itself is a disaster, what is even more troubling is that it took almost a full year for any significant steps to fix it to be taken.
In April 2021, the fire whipped around Charlotte Maxeke causing significant damage.
It was reported that Gift of the Givers, toiling as ever in both war zones and plain dysfunctional provinces, offered help straight after the fire. They said that government officials could not be involved in the appointment of contractors. Their offers of help were not responded to.
Over the next few months, blame was placed at the doors of the City of Johannesburg, which was not allowing even partial reopening until full fire safety measures were put in place.
In May and June 2021, as surgical patients at Chris Hani Baragwanath were told to wait, Rahima Moosa Mother and Child Hospital doubled the number of babies delivered each day, and emergency departments in other tertiary and central hospitals were up 50%, various promises were made by provincial and departmental leadership.
Part of radiation oncology was opened in June 2021, as were some COVID beds.
After that, everything went quiet.
In December 2021, we are told that the Office of the Premier stepped in to mediate between the Gauteng Department of Health and the Department of Infrastructure and Development (DID).
In February 2022, the public was told about the issues between Health and DID, and management of the hospital repair was moved to the National Department of Health. We also found out that nine senior DID and Health officials in the province were suspended in connection with the R500 million allocated to upgrade the donated AngloGold Ashanti Hospital into a 181-bed hospital. That hospital never opened.
National Health is now relying on the Development Bank of Southern Africa to fund the rebuild.
The structural assessment report and fire report were only undertaken in April this year and a preliminary report is, I understand, complete. Though it has not been made public. Neither have details of contracts awarded during the ten-month period when Gauteng was in charge, or the police report of the fire, all of which we have sought access to in terms of a PAIA request. A request that has gone unanswered.
The three months since February have seen the development of a series of colour-coded diagrams and the definition and planning of work programmes. We have a partially re-opened emergency department and mostly re-opened oncology service. We are told that the project will be done by December 2023 (other than a few admin buildings) and that this should be considered an ambitious timeline. It seems that much of the work actually done so far has been organised and paid for by the Solidarity Fund, Gift of the Givers, and SPIRE Fund - a FirstRand fund.
In the course of a year of fumbling, healthcare workers across the province have been nothing short of heroic. At Helen Joseph Hospital, which has taken up much of the slack of the closure of Charlotte's psychiatry services, staff members were advised to avoid the psych waiting area (where mental health care users waited for up to 24 hours for a bed due to overcrowding) and to note down all assaults. Some psych referral services have now re-opened at Charlotte Maxeke but not enough to alleviate the pressure at Helen Joseph.
Health workers have been shuttling around the province trying desperately to maintain some level of service, against all odds.
And at the same time, with the inexplicable termination of some security contracts (and I would wager plenty of inside information), copper cable worth R30 million and equipment worth R200 000 at CMJ was stolen mid-repairs. The parallels with the Eskom saboteurs are irresistible.
As always, patients have been the ones to suffer.
Cancer Alliance reports an oncology waiting list of over 2 000 people. Expensive linac machines keep being bought for radiation treatment (at a cost of R100 million each) but without anyone to operate them and without the radiation-proof bunkers that are needed to render them safe. Currently, the linac machines for George Mukhari and Chris Hani Baragwanath hospitals sit in storage with the possibility, once bunkers are built, of staff being deployed from CMJ or Steve Biko's already overstretched units to operate them. In April, psych patients were still waiting more than a day for an emergency department bed. Surgeries have been delayed. Treatment has been interrupted. Where all the CMJ patients are, no one seems to know.
Just this past weekend, paediatrician Dr Tim De Maayer did what brave health workers in this province have always done. Having done everything in his power to care for the desperately ill children at Rahima Moosa Mother and Child Hospital, he raised issues with management and, having seen no change, he went public. He pleads with administrators in the province to come and see doctors trying unsuccessfully to intubate children by cellphone light because of loadshedding or the neonate whose incubator went cold for the same reason. He describes the hospital-acquired infections spreading through the neonatal wards because taps are dry, the slow return of blood test results, and the moral injury of counselling parents whose children shouldn't have died.
The @GautengHealth's response to the open letter a doctor at the @RahimaHospital penned about horrendous conditions at some GP hospitals.👇🏾👇🏾👇🏾@SECTION27news @DrMokgethi @PublicHealthSA @ShabirMadh @FrancoisVenter3 @SHA_ZAR @JackBloomDA @SAMedicalAssoc pic.twitter.com/NX65Z4nSGn
-- Spotlight (@SpotlightNSP) May 24, 2022
He makes the devastating statement "Children are dying and the horrendous conditions in our public hospitals are contributing to their deaths."
If history is anything to go by, Dr De Maayer will be accused of speaking out publicly, in violation of the public service regulations. He will be told to apologise and threatened with disciplinary action. Hopefully, the public support that he's receiving will help to protect him.
There has been some non-committal response from the department and the portfolio committee already, but we need much more. Much more than relying on hospitals themselves to make individual applications to avoid load shedding or to mitigate water cuts. Much more than the usual story about budget cuts. We need much more than the tired excuse that foreigners are somehow singlehandedly overwhelming the system. Given that approximately 7% of the population is foreign, the usual assertion that seven out of ten women giving birth in Gauteng are foreign is astonishing. And completely unsubstantiated. This is the number that has been trotted out for years but I have never seen any evidence of it. In fact, the department just a month ago said they are now going to conduct a study, after years of thinly veiled xenophobia and convenient excuses, and ignoring the law that entitles pregnant women to free health services.
READ: What the #law says about #medical #xenophobia in SAfrica. @SECTION27news @HealthZA @FoMohale @DENOSAORG @SAMedicalAssoc @HST_health @ANCParliament @Michele34297515 @IFPinParliament @NalediChirwa @RHAPnews @AlexvandeHeever @keymenthri @AkSafs https://t.co/nI2JkhhkrH
-- Spotlight (@SpotlightNSP) May 16, 2022
Providing health care services is the legal function of the health department. We need more than excuses for why that function is not being fulfilled.
This is, of course, a pattern in Gauteng health. We rely on health worker heroism while allowing leadership failure and failing to listen to those most invested in the system.
Who can forget Brian Hlongwa, MEC for Gauteng between 2006 and 2010 whose friend allegedly won tenders worth R1.2 billion during his tenure (and is meant to have returned the favour to Hlongwa through kickbacks)? If R1,2 billion is a familiar number, it's the amount that fixing Charlotte is now meant to cost. Unrelated but somehow even more galling. Hlongwa was elected to the ANC's provincial executive committee after the SIU report about his alleged corruption was made public by SECTION27. He finally resigned after public opinion seemed to sway the PEC to support his bar from public office.
Another Gauteng Health MEC who remained in the ANC inner circle after what should be a fall from grace (including remaining in the PEC and joining President Ramaphosa on public walks) was Qedani Mahlangu. Justice Moseneke found in his arbitration award that Ms Mahlangu, and I quote, "acted with impunity thinking that she will get away with murder because the users and their families were vulnerable and poorly resourced." At least 144 people died when Gauteng Health cancelled the Life Esidimeni contract. And they died emaciated, covered in septic bedsores, with plastic sheeting in their stomachs.
JUST IN: Policy Graveyard- where policies go to die. READ this interesting take on why our (health) policies fail or are poorly implemented. @SECTION27news @HealthZA @PresidencyZA @FoMohale @ygpillay @AlexvandeHeever @russ421 @schneider_helen @SHA_ZAR
https://t.co/uqOtzVhJ2L
-- Spotlight (@SpotlightNSP) May 20, 2022
In the past 10 years, Gauteng Health has had seven MECs and nine HoDs. In the past year, it has been sued for R1,6 billion in medico-legal claims. It has paid out around R300 million. There were 4701 serious adverse events in the province in 2020.
But they do tell a story. A story of unreliable and sometimes outright dishonest leadership. Of squandered budgets. Of people in the system not being listened to.
Of course, some of these events and some of the negligence claims are caused by just that: negligence. But consider Dr De Maayer's words "If health care workers are the centre of providing care, we cannot hold. Things are going backwards, fast."
Now, of course, these are examples of lowlights in the recent history of Gauteng Health. They don't reflect the excellent work done by many across the province. They don't acknowledge the life-saving care received by millions, the healthy babies born, and the ground-breaking medical research in the province. They also shouldn't be read to suggest that Gauteng is alone in its dysfunction. Most health departments across the country have horror stories of their own.
But they do tell a story. A story of unreliable and sometimes outright dishonest leadership. Of squandered budgets. Of people in the system not being listened to.
So what on earth do we do? How do we arrest the cycle of fires (and constantly putting out fires) and fumbles in Gauteng health? How do we put the needs of the people who are meant to be served by the system, at the centre of the system? How do we move towards healthcare with a more human face?
Of course, not everything is within Gauteng's control. There are national changes that could make health systems across the country work better, including, importantly, national-level decisions on budgets. But there are some things that are in the province's control and that continue to be neglected. For a province with myriad financial and social advantages, residents should expect the administration to do a whole lot better.
Putting the right to health at the centre of the health system
I suggest that we need to first start with an acknowledgement of what the health system in this province is meant to do. The system is no mere industry. It is not just a bureaucratic machine. It is a system that is meant to realise the constitutional right of access to health care services.
Alicia Ely Yamin describes health as "perhaps the most radical of subjects for human rights because, more than any other topic, it challenges the boundaries of what is 'natural'. There can be no right to be healthy... [b]ut much of population health is subject to social control through laws, policies, and programmes that influence exposures and mitigate effects... "
Our health system is meant to do something radical! Keeping people healthy and productive and capable of living a fulfilled life, of getting an education, and realising their potential. It is the foundation of so much of the potentially transformative power of the Constitution.
A health right in itself means little without a system to support it. The right to health requires that we adopt an understanding of the health system as a core social institution. Hunt and Backman compare an effective health system to a fair justice system. They say, "The right to a fair trial is widely recognised to have strengthened many court systems. It has helped to identify the key features of a fair court system [such as independent judges, legal aid, and trials without undue delay]. In much the same way, the right to the highest attainable standard of health can help to establish effective, integrated, and accessible health systems."
Acknowledging the right to health as central to the health system makes that system better. It requires that we put in place the leadership, programmes, budget, checks, and processes required to realise the right and attain the societal and individual benefits of realising the right.
Furthermore, it is not just the right to access health care services in itself that requires a health system that meets the needs of people. Section 195 of the Constitution provides that public administration be people-centred, development-oriented, accountable and that people's needs must be responded to. It is this people-centredness that must inform the way that the health system works.
This should be obvious in a country that so often, and rightly, touts its progressive constitution. But the reality of what it takes to make constitutional rights mean something seems to evade the imaginations of our leaders.
So the first thing, I would argue, is actually putting the right to health at the centre of the health system in this province. This means more than Batho Pele posters in clinics - displayed but generally ignored. It means making sure contraception is available to all. It means ensuring that when the Constitution says that everyone has a right to reproductive health care services, and the Choice on Termination of Pregnancy Act makes clear that this includes access to abortion, the response to illegal and unsafe abortion is not merely marches led by politicians but giving women real access to safe abortions at health facilities.
It means treating human rights not just as principles but as directives.
Health leadership
The second thing is getting leadership right. There is something terribly wrong when a province that should have it easier than most can barely hold on to a head of department for more than a year. Whether the reason is the MECs they serve under, the complexity of the system, the entrenched problems, or something else, the reasons need to be established and resolved. Are we not listening to people who have tried to do the job? Are we not putting in place the measures needed to make it possible for them to run the province? Or are we just choosing the wrong people, based on allyship rather than what the job needs?
One of the significant contributors to the failures in Gauteng health has been the blurring of lines between political and administrative leadership. The question of adequate independence was dealt with in the Constitutional Court decision in Glenister II where the court held that "independence does not require insulation from political accountability... but only insulation from a degree of management by political actors that threatens ... to stifle ... independent functioning and operations." So it is about keeping management of a department out of the realm of politics.
Such independence is in fact legislated in the National Health Act. The Act gives clear roles to the MEC and to the Head of Department. The PFMA specifies the weighty obligations of Heads of Departments as accounting officers. But politics in Gauteng seems to have overridden the law time and again, with disastrous consequences.
Health leadership, from MECs and HoDs to hospital managers, is acknowledged to be vital to the success of a system. It is one of the pillars of universal health coverage. It is referenced time and again in policy documents and as a success factor in other middle-income countries' health systems. We talk about it constantly and yet we are not getting it right.
An oft-mooted option is a national intervention under section 100 of the Constitution. This section provides for national executive intervention when a province cannot or does not fulfil an executive function under the Constitution. The intervention can take the form of a directive telling the province what it is doing wrong and how to fix it or national assuming responsibility for the province's obligations.
In theory, a section 100 intervention is a powerful safety switch. In practice, however, what is meant to be a temporary intervention is often prolonged and open-ended. There is no enabling legislation that ensures that national administrators can do what is needed to turn a province around - including to hire and fire or to appropriate dedicated resources. The Monitoring, Support and Intervention Bill (which was meant to do just that) has been in draft form since 2013 but never brought before parliament. There are reports that it will be sometime this year, but who knows. As it stands, capacity within the national department to step in and run failed provinces is limited. National intervention is a tool, but not a particularly effective one at this stage.
Leadership problems need to be resolved at provincial level and that requires diagnosis of the problems that may be contributing to the years-long failures, holding people to account for the political/administrative divide and for doing their jobs, and appointing the right people.
Lean on the experts (and get them into government)
Third, there is considerable wisdom in the health sector in South Africa and, more particularly, in Gauteng. We have some of the best people at our fingertips - working in the universities and tertiary and central hospitals in the province. We have scores of academics working on health policy and economics. We have researchers. We have activists with decades of health system experience and real knowledge and experience of the needs of health care service users.
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Why, then, is collaboration limited to anaemic consultation meetings? Why is the only example of working together on CMJAH when Solidarity Fund or Spire Fund pay for rebuilding of parts of the hospital? Why does most implementation capacity appear to be outside of government in this province?
Schneider, Lehmann, and Gilson reference "abundant global evidence that health systems function as complex adaptive systems" and are unlikely to "be controlled, let alone reoriented into completely new and better performance by strings pulled at the top, however necessary or well designed." The authors were referring to the wisdom of trying to create largescale health system reform under NHI through a legislative intervention without input from those on the ground, but the point applies to health system functionality in general.
Health systems need input! Look at our successful health programmes, including the HIV programme, that has been characterised by what the authors call relatively open systems of national programme leadership. This leadership has enabled participation and coordinated the actions of clinicians, managers, activists, and researchers. The leadership has enabled the development of communities of practice and supportive implementation processes that engage directly with frontline providers.
This is a lesson that needs to be learned in the province. People outside of the department are willing and available to assist. We saw this willingness by people at this university following the accord in 2013. At that time, there was real concern that the accord would amount to a papering over of the cracks between the university and the department. And unfortunately, it seems to have been just that.
But it is vital that the province leans on experts outside of government, and also gets the right people into the department. There must be, in the medium to long term, an intentional and serious attempt to build capacity within the department of health and to attract and employ skilled people.
The ongoing failure to value and lean on the collective wisdom in the province is absurd, it disempowers and embitters those who consistently offer their time and expertise, and it undermines the massive advantage that Gauteng could enjoy.
We can't stay in our lanes
Fourth and finally, those of us outside of government need to be better at working together.
We have hundreds of dedicated people in the province who pull off daily miracles to serve patients. The health workers in this province, in particular, are some of the best examples of health worker activists.
The alliance of health workers and health users in the fight for access to antiretrovirals was fundamental to winning that fight. The Life Esidimeni alliance of psychiatrists, activists, and affected families, while not successful in preventing the disaster, clearly warned of its likelihood (including litigating twice against government) and a less callous provincial government would have heeded the warnings and prevented it. The Open CMJAH Now coalition, a grouping of civil society and health workers is working to maintain careful focus on the ongoing disaster that is Charlotte Maxeke and to collaborate in pushing government to keep its promises to the people of Gauteng.
We cannot afford to stay in our lanes. Concerted action on matters of serious provincial concern is vital if we are to draw attention to them and to provide input. The media must be engaged to secure the buy-in of residents of the province and we are fortunate to have publications like Spotlight, the Daily Maverick, and Bhekisisa that represent some of the best in health journalism. We must recognise too that for advocacy in Gauteng to be effective it needs to be more organised and to be targeted. We must leverage the justified unhappiness and outrage to achieve specific changes. We cannot leave the decision on what happens following advocacy to the department to respond with the solution that suits it best.
Conclusion
In conclusion, this is a province of immense potential and tragic recent history. It is a province that has allowed politics to overwhelm the interests of patients. Without real focus on health as a right and what that means for the health system, on good and integritous leadership, and a separation between political and administrative functions, on collaboration both with government and between non-government actors, we stand little chance of changing this. The residents of this province deserve better.
NOTE: This is a speech delivered by an employee of SECTION27. Spotlight is published by SECTION27 but is editorially independent, an independence that the editors guard jealously.
