Despite some interventions by Mpumalanga's health department, a litany of challenges at hospitals in the province continue to hamstrung quality patient care in the province. Healthcare users who depend on ambulances, for example, have to make do with only 58 of 98 ambulances that are in working condition. Other concerns flagged include doctors who do not show up for duty, poor administration, staff shortages, and persisting security challenges.
Both the health and social services committee of the Mpumalanga Provincial Legislature and the South African Human Rights Commission (SAHRC) have highlighted and investigated various challenges in Mpumalanga's public sector health facilities and at least one doctor spoke out about conditions at some hospitals.
"Doctors not showing up for duty"
Spotlight spoke to a doctor who worked at the Piet Retief hospital. The doctor says some doctors who run private practices often fail to show up for duty. This results in patients waiting for long hours and sometimes going home without receiving medical attention.
The doctor says some doctors are also performing Remunerative Work Outside Public Service (RWOPS) without approval.
The doctor asked not to be named for fear of reprisals.
The lack of services available in Mpumalanga is shocking. There are also doctors on the payroll for overtime, but they do not ever work at the hospital - a doctor
The provincial health department's audit and risk committee also flagged this issue of employees performing remunerative work outside public service without approval. The health and social services committee in its draft report on the department's performance notes that training will now be conducted for all employees to ensure compliance with the RWOPS policy.
"I was shocked at the discrepancy in the standard of care between Gauteng and Mpumalanga provinces," says the doctor, who previously worked in Gauteng. "The lack of services available in Mpumalanga is shocking. There are also doctors on the payroll for overtime, but they do not ever work at the hospital. Management is aware of this issue and some participate in this kind of behaviour, so there is no one to report this to."
MEC for Health,Ms Sasekani Manzini currently visiting Ermelo Regional Hospital unannounce to Monitor the provision of Health care service and interact will patients regarding services,this is to ensure that quality health services continue to benefit Community members. pic.twitter.com/lQ3mSkPoe2
-- Mpumalanga Health (@MpuHealth1) October 11, 2022
The doctor went on to say that there is a severe lack of human resource management as well as strong, disciplined management at most hospitals. There is no consequence management or follow-up when doctors are negligent, says the doctor.
Dumisani Malamule, Mpumalanga health spokesperson, responded by saying that the department has developed a monitoring tool to track doctors who have been given permission to do RWOPS.
"The condition of the RWOPS approval is that if the doctor is found to be non-compliant with the conditions, the approval is reversed immediately. There is a committee that has been established to deal specifically with the issue of doctors and other health workers that has been given approval to perform RWOPS. The department is open to receiving anonymous tips to follow up on doctors abusing the RWOPS approval and doing private work during their normal working," says Malamule. He says the department will train all employees to ensure the RWOPS policy is successfully implemented.
The department is open to receiving anonymous tips to follow up on doctors abusing the RWOPS approval and doing private work during their normal working - MP Health spokesperson
High vacancy rates
Part of the case for allowing RWOPS in the first place is that it is seen as part of the solution to the problem of staff shortages.
During an oversight visit to Witbank Hospital in July, the legislature's health committee found the hospital has a vacancy rate of between 11% and 34%. When asked what the department is doing to address this, Malamule said, "At the beginning of each financial year the department compiles a list of priority posts to be filled to ensure that all critical areas are adequately staffed based on the available budget.
In the committee's report, the department stated that various advertisements have been placed in the last few months to fill key management positions in at least seven hospitals, including corporate managers, finance managers, nursing managers, and a clinical manager. There's also one CEO position at Matikwana Hospital that is vacant and recruitment processes have begun, according to the department.
There are also specialist vacancies that add to cataract surgery backlogs at some hospitals, which already hit the 8 500 mark. Malamule told Spotlight that Mpumalanga is a rural province and as a result, it is a challenge to attract specialised ophthalmic staff (eye surgeons). "Specialised staff shortages make it challenging to reduce the backlog. However, the department is doing everything in its power to recruit ophthalmic staff to reduce the backlog. We are also in the process of signing an agreement with both the Tshemba Foundation and the Council for the Blind to address the backlog."
He said the department is now putting in place measures to ensure that weekend operations in Tonga Hospital and the other hospitals conducting cataract operations are taking place.
More backlogs
During another oversight visit at Kwa Mhlanga Hospital, also in July, the committee found, among others, a backlog of orthopaedic patients, psychiatric patients staying beyond 72 hours because of lack of space at Witbank Psychiatric unit, and patients bypassing primary healthcare facilities which leads to overcrowding at the hospital.
According to Malamule, the backlog of orthopaedic patients is a result of increased trauma cases due to the high number of motor vehicle accidents and violence and is compounded by population growth and increased life expectancy that results in an increasing number of pathological fractures.
"Witbank Hospital has recruited more orthopaedic surgeons. They have three full-time orthopaedic surgeons and are sending others to train at Steve Biko Academic Hospital to increase capacity. Theatre time has been increased with orthopaedic surgeons operating almost every weekday," says Malamule.
Mental health challenges
Malamule told Spotlight that the province does not have a psychiatric hospital, so mental health patients are admitted to the designated mental health units in hospitals. Aggressive, high-risk psychiatric patients are admitted to both Witbank and Rob Ferreira hospitals. If there is no space at Witbank, patients are also referred to Rob Ferreira Hospital.
"To address this challenge plans to construct a psychiatric hospital are at an advanced stage and this will greatly improve the care provided to mental health users in the province," he said.
He said plans are underway to renovate and expand the psychiatric unit in Witbank Hospital. They are also working together with Ermelo Hospital to increase the number of beds.
Security issues persist
In June, Democratic Alliance provincial health spokesperson Jane Sithole sound the alarm after she found two security companies working in health facilities across the Nkangala District. According to the department, one security company, Mafoko Patrols did not want to vacate the premises after their contract had ended and the owner had told workers to remain on site. The situation has since been resolved.
Spotlight previously reported on security issues at health facilities in Mpumalanga. In some instances, doctors and nurses were robbed of their personal belongings. In February, a woman doctor was hijacked at gunpoint and almost raped after completing her shift at Mapulaneng Hospital in Bushbuckridge.
According to the provincial health department, security at hospitals and clinics is the mandate of the Department of Community Safety and Transport.
Waiting on ambulances
The health and social services committee's draft report notes that only 55 ambulances out of a fleet of 98 are working. There is also a shortage of life support staff in the province. The report also notes that the department used (leased) an air ambulance (helicopter) and transported 71 patients at a cost of over R4.1 million in the first quarter of this financial year.
While tabling her budget speech earlier this year, Mpumalanga's Health MEC Sasekani Manzini said her department plans to procure 10 new ambulances this financial year.
"The Department has put a plan in place to improve the EMS in the province. In the past financial year, the department introduced Planned Patient Transport (PPT), which is part of EMS. PPT is transport that is aimed at transporting stable patients between health facilities. This relieves the operational ambulances to attend only to emergency cases," says Malamule.
But patient transport and referrals remain a problem according to the Piet Retief doctor. "It was extremely difficult trying to refer a very sick patient to the next level of care from the Piet Retief Hospital. If it was eventually arranged with the referral hospital, the EMS services are not coping and take many hours to arrive to take the patient," says the doctor.
"If a patient had to be transferred to another hospital, you would have to call the referral hospital numerous times to discuss the patient for transfer. Only once the doctor on the other side is satisfied that the patient needs to be transferred, can EMS be contacted to send an ambulance. When such a problem is highlighted to senior management, they just tell the doctors to keep writing in the file that they are waiting for transfer or if the patient was not accepted for transfer to just document the situation in the file."
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Medicine availability
The report also notes that the provincial health department has "consistently failed to ensure the target of 95% availability of medicine and surgical sundries at the medical depot". The average stock availability of essential items at the depot during the first quarter was 84%, which included ARVs (94%), TB medication (93%), and chronic medication (95%) (this is for diabetes, hypertension, anti-psychotics, etc.) EPI (vaccines) was at 86% and Surgical Sundries (61%).
The department attributed this to the fact that their medicine supply management systems are not interlinked to increase stock visibility at all levels and improve efficiencies. In the report, the department undertook to "work tirelessly to innovate medicine supply management systems to enhance operations and improve stock availability" in the province. "The province has engaged in a process of aligning the provincial medicine formulary (database) with the National Medicine Master Database Systems. This is the first phase of the provincial project to innovate the systems and increase stock visibility all the way from the suppliers to depot and eventually the patients at facility level."
Human Rights Commission also monitoring
Meanwhile, the SAHRC told Spotlight some progress has been made after it investigated three hospitals in Mpumalanga last year. The hospitals investigated for alleged lack of medical services were the Standerton Hospital and Bernice Samuel Hospital in Delmas, while Mapulaneng Hospital in Bushbuckridge was investigated for alleged water shortages. When the DA's Sithole visited the Mapulaneng Hospital in September last year, she says she found that there was no water and toilets were full of human waste.
The SAHRC's provincial commissioner, Eric Mokonyama, told Spotlight they are finalising their report on the Bernice Samuel Hospital.
"In Mapulaneng Hospital, the SAHRC engaged the Mpumalanga health department, conducted a site inspection, and resolved that the measures taken by the department to address the issues raised were reasonable. This was communicated to the complainant in February 2022 and the SAHRC is continuing to monitor these and other healthcare institutions in the province," says Mokonyama.
In Standerton Hospital, Mokonyama says the SAHRC assessed the complaint against the provincial health department based on allegations of mismanagement and unsatisfactory medical healthcare services. He says the issues have been referred to the Office of the Health Ombudsman.
