There are over 100 clinics in Mpumalanga without visiting doctors, hundreds waiting on surgeries in hospitals due to a lack of surgeons and specialists, and only 60 working ambulances meant to service a population of over four million healthcare users.
These are some of the human resource challenges highlighted in a third-quarter health committee report tabled in Mpumalanga's provincial legislature in February.
Bar for 16 senior managers, including a new head of the health department - Dr Lucas Khetani Ndhlovu - who were all appointed at the tail-end of the last financial year, the Mpumalanga health department's response to the health worker shortages was mostly to kick the can down the road to the current financial year.
Healthcare worker shortages
Despite these shortages and a clear need for extra hands in public health facilities in the province, the report shows that the provincial health department underspent its budget for employee costs by about 30%. This, the department states, was due to the "challenges of attracting new health workers across categories to the province".
The department also did not spend about 30% of its NHI grant allocation - they say also due to recruitment challenges. They also did not spend about 30% of the Human Resources Training grant but did, by January, appoint 13 registrars.
The report shows that 25 of 28 district hospitals had a full complement of executive management, but the Piet Retief Hospital, for example, did not have a CEO. According to the department, the post was advertised and the selection process was underway. The Sabie Hospital did not have a CEO or a finance manager, but interviews and shortlisting processes were underway. The Rob Ferreira Hospital was also without a CEO.
There were also 34 primary healthcare (PHC) facilities without operational managers and a shortage of senior nurses. "In some cases, you find that operational managers cannot execute their duties because they have to do a lot of clinical work due to staff shortages," the report states. "Departmental requirements stipulate that they should do 20% clinical work and 80% administration work, but they do more than 20% clinical work. Some of these operational managers do not even have laptops." The department undertook to fill these posts and said recruitment processes are underway to fill operational manager posts and R14 million has been allocated in their Ideal Clinic programme to ensure that they have equipment to carry out their duties.
In total, there were 180 clinics in the province that needed extra health workers across the various categories. According to the report, there were 5 581 community health workers who are part of the ward-based outreach teams, but the number of teams "are inadequate to cover all 402 wards in the province".
The department said there is a high turnover of contracted doctors which impacts the number of primary healthcare facilities that are supported by visiting doctors.
The province's district specialist teams are also not at full capacity. In Gert Sibande District, for example, the team did not have a single specialist, including a gynaecologist, paediatrician, anaesthetist, or a family physician, according to the report. These district clinical specialist teams are an important lever to improve access to quality care and health outcomes at district level, especially for mothers, newborns, and children and usually include "seven specialists in each district, comprising three medical and three nurse specialists from obstetrics and gynaecology, paediatrics, and family medicine/PHC, and one anaesthetist". Recruitment to fill these positions, the department says, is subject to funding.
The Mpumalanga Department of Health is expected to table its budget for this financial year next month and this will provide some insight on how and when, if at all, these vacancies will be filled. Yet, when Spotlight asked the departmental spokesperson Dumisane Malamule about this, he said - referring to the visiting doctors supporting clinics - they "only have 114 out of 292 clinics that are not supported by a doctor". Malamule says more sessional doctors will be recruited.
Creating an enabling environment
Professor Andrew Ross, founder, and trustee of Uthombo Youth Development Foundation, a non-profit organisation which supports the training of doctors from rural areas, tells Spotlight that getting rural doctors to visit clinics while there is a shortage of doctors at district hospitals is a challenge.
"It is important that you have enough doctors at a district hospital first so that they will be able to visit a clinic in the outlying areas. If, for instance, you are supposed to have ten doctors at a hospital and you only have three, then they are definitely not going to visit an outlying clinic. It is important to have trained locals as medical officers, then there is a possibility that they might work at a rural facility."
Ross says hospital management has a huge responsibility of creating an enabling environment for doctors to work and stay at certain facilities.
"If there are supposed to be ten doctors at a hospital and there are only two, the two doctors will not stay because they are overworked. Senior management needs to provide a conducive environment for doctors to work there, which means that there must be enough resources and proper accommodation."
According to Sifiso Nkala, a field researcher at SECTION27, creating an enabling environment also extends beyond the clinical contexts and the health department. "I strongly believe we must see a role of municipalities in attracting experts, as we lack proper roads, dumping sites, parks, clean water, and elimination of slums or informal settlements, to mention a few things. The health department can never work alone in attracting experts into the province." He says he hopes to see a strategy that will tackle this.
"Providing adequate human resources for health is a major challenge, as the state is limited by the available funding," says Russell Rensburg, director of the Rural Health Advocacy Project (RHAP). "Salaries or employment costs are the highest cost in most provincial budgets since provinces are the main service delivery agents. Despite increased population numbers, the number of healthcare workers has not increased significantly since 2012. This is despite South Africa doing well in producing new healthcare workers. In the last year, over 2 200 new community service doctors were added but less than 10% will be employed in the public service after their community service year."
Rensburg argues that budget and staffing structures should be reviewed according to the greatest need. "South Africa has good routinely collected health management information. Our budget allocations and staffing structures should be reviewed and reorganised toward the greatest need with strong investment in district health services," he says.
Impact on services
The Democratic Alliance's spokesperson for health in the province, Jane Sithole tells Spotlight she visited the Witbank Hospital on 25 April. According to her, the hospital has a vacancy rate of 37% and oncology services are lacking because there is no oncologist on site.
The shortage of specialists is not just affecting services at Witbank Hospital. The health committee report shows that there is a shortage of 19 specialists at Mpumalanga's tertiary hospitals, which also affects surgery turnaround times.
Malamule says the department is engaging with several universities to ensure that they can train doctors to specialise in various fields with the hope that they will work in the province.
"Mpumalanga province, like any other rural province, is experiencing a shortage of specialists due to difficulty in attracting and retaining specialists. The planned intervention is to increase the intake of registrars by an additional ten over the next three academic years. For the 2023 academic year, a total of 14 registrars have been offered bursaries to train as specialists in different universities across the country, bringing the cumulative total to 48 registrars. In the 2024 academic year, provision will be made to increase the intake by an additional ten to increase the pool of specialists trained in the province," says Malamule.
But according to NEHAWU's provincial secretary, Welcome Mnisi, the provincial health department needs to do more to ensure that nurses and doctors who have left the system are replaced in time.
"Management has to ensure that whenever a doctor or nurse has left the system they are replaced in time," he says. "You cannot have a vacant position for over six months while the human resources department knows that someone has retired or resigned. The human resources department knows when somebody is leaving the system, but they are taking long to fill some positions that are already funded."
Slow turnaround in disciplinary cases
Another snag in the chain of human resource challenges in Mpumalanga's health department is the slow turnaround times in disciplinary cases. According to the health committee report, there were 30 cases under investigation that were delayed for up to one year, 20 cases were delayed for three months and are awaiting disciplinary hearings, 12 employees are yet to be charged, and three cases were delayed for one year and six months but are currently being handled in consultation with the Special Investigating Unit (SIU). Some of these cases will have proceeded further since the tabling of the report in February.
The department attributes the delays to budget constraints that prevent it from appointing investigators to deal with disciplinary cases. The department says it will establish a multi-disciplinary team and train more presiding officers for these processes, but gave no clear timelines.
EMS shortages
The province's Emergency Medical Services (EMS) is also not spared health worker and vehicle shortages. According to Sithole, ambulance shortages are "killing" the people of Mpumalanga.
"The harsh reality is that the department lost a further 12 ambulances within three months. The department reported in the third quarterly report that they had between 60 and 72 ambulances operating on a daily basis. In the fourth quarter, the department had only 60 working ambulances for a population of 4.7 million, which is far below the recommendations of the Emergency Medical Norms and Standards," Sithole says.
According to the National Department of Health's Emergency Medical Norms and Standards, there should be one ambulance per 10 000 people, which means that Mpumalanga should have 474 fully operational ambulances.
In her budget speech in June last year, health MEC Sasekani Manzini announced that R60 million would be set aside to prioritise EMS and procure additional or replacement ambulances, equipment, and appoint advanced life support personnel.
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But according to the report, the department had only procured ten ICU ambulances and due to financial constraints, no new staff were employed, although the moratorium on posts was lifted. No new EMS stations were established, and no obstetric ambulances and no emergency response vehicles were procured.
According to Sithole, the procurement of ten ambulances and the appointment of skilled EMS staff members have been shifted to this financial year, as well as the procurement of the long overdue Emergency Management Centre System, which will improve call-taking and dispatching of ambulances. Sithole says the department is still using a paper-based system to monitor the time taken to respond to a request for an ambulance, which makes data less reliable compared to a digital system.
"Ambulance shortages and shortage of EMS personnel mean that patients have to wait longer hours for an ambulance to arrive and provide health care service. Patients are denied treatment because they have to be transferred to other healthcare facilities and there are limited ambulances available," says Provincial Chairperson of the EFF in Mpumalanga, Collen Sedibe.
Sedibe says the solution is for the department to train more EMS staff and to have more ambulances available.
"The department must bear in mind that the dominant population of the province is the disadvantaged residing in rural areas and are highly reliant on the provincial public health services as they cannot afford private health care services. The department also needs to provide regulations and resources for paramedics and emergency service employees to ensure their safety," says Sedibe.
When Spotlight asked the department about the ambulance shortages, Malamule said, "The department will be introducing ten dedicated inter-facility mobile ICU units to cater for the ever-increasing patient transfers within and outside of the province, three dedicated ambulances for mental health patients (one for each district) in the next two months, and operationalise the referral and handover policy to minimise the turnaround time for ambulances at facilities and free them up for other call-outs." He also said they plan to introduce rapid response vehicles to respond to calls to triage and initiate treatment and will also replace aged (high mileage) and written-off ambulances.
NOTE: Sifiso Nkala from SECTION27 is quoted in this article. Spotlight is published by SECTION27 and the Treatment Action Campaign, but is editorially independent - an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
