An extended impasse over a vital agreement for training and improved hospital management between the Gauteng Department of Health and Wits University remains derailed, despite behind the scenes efforts to get it back on track.
A critical agreement between the Gauteng Department of Health and Wits University to bolster healthcare services in a province with the largest and busiest operating hospitals in South Africa hangs by a thread.
The memorandum of agreement (MOA) was signed over two and a half years ago in June 2022 but to date has been stalled and not implemented by the Gauteng health department. This is despite the fact that the last MOA between the parties expired in 2018. The MOA is needed since, among others, it helps to coordinate practical medical training in the province, defines the terms for joint appointments between the university and the department, and provides a structured framework for Wits to support the department.
The long delay spells potential crisis for a provincial healthcare system already in distress.
It is also not clear whether the Gauteng health department intends to revive the deal or whether they might decide to rescind it. Such a decision will be a blow to Wits University's Faculty of Health Sciences which is South Africa's biggest medical school with the highest number of graduating doctors, and comes with significant impacts for healthcare in the province, affecting students, and ultimately patients reliant on the public health service.
Spotlight understands that the health department has neither communicated why it's taken the position it has, nor what it wants changed, re-examined or re-negotiated. According to well-placed sources, attempts to break the deadlock in recent months through meetings between Wits and the health department have repeatedly been rescheduled, with no clear progress in sight.
Spotlight's questions to the Gauteng Department of Health at various points over the past months, with extended deadlines, reminders and prompts have gone acknowledged but unanswered.
Spotlight also reached out to the Public Service Commission (PSC), which became involved in the matter a month after the MOA was already signed. The PSC held a "Citizens Forum" at the time. "The session was informed by the PSC's observation on the shortcomings regarding accountability and governance in the implementation of the 2008 MOAs [with various universities, including Wits]", PSC Director of Communications Humphrey Ramafoko told Spotlight.
"The PSC advised the department to address the shortcomings identified in revising the MOA. The department subsequently advised the PSC that it is currently working with the medical universities to refine the MOA," he said.
The information at our disposal however suggests that this work to refine the MOA is not happening or has stalled.
If the MOA cannot be rescued, it is likely to have significant ramifications. These could include impacts on the practical training of medical students, which could throttle the supply of new doctors for the province and the country in years to come.
What the MOA is about
The five-year agreement, which has not been made public in full, includes aspects relating to the joint governance of staff recruitment, management, and discipline, as well as shared oversight of funding and financial arrangements between the Gauteng health department and Wits University.
Under the MOA, joint staff are paid through grants from the national departments of education and health. The monies are meant to be ringfenced specifically to support academic hospitals. The idea being to support more favourable staff ratios at academic hospitals so that 30% of the time of the staff can be dedicated to the training of students and university-related activities.
Without an MOA, medical staff who are employed in a joint appointment agreement - with 70% of their salaries paid by the health department and 30% paid by Wits - cannot be regularised. It means that appointed doctors doing private work instead of giving their full allotted hours towards public sector service delivery, training, teaching, research output, and research supervision of medical students can continue to flout their contractual obligations without being disciplined.
Without an MOA, which is part of the governance requirements between provincial health departments and academic institutions, Wits will not have sight of the likes of hospital budgets, to have a say on human resources processes, including on the process of appointing hospital CEOs and other heads of departments.
This is of critical concern because the appointment of senior staff has long been under scrutiny, but mechanisms to ensure better independent vetting and appropriate checks and balances have simply not been in place. This is captured in a recent report that explored critical governance issues impacting the country's health sector. The report highlights significant challenges, including leadership instability, lack of transparency, insufficient accountability mechanisms, and pervasive corruption.
"There are systemic problems and accountability cannot occur if we don't fix governance," co-authors of the report Professor Lilian Dudley and Professor Sharon Fonn told Spotlight. "A critical step is to ensure that the right people (ethical and with appropriate technical competencies) are appointed and to stop cadre deployment."
As widely reported, the Gauteng health department has faced intense criticism amid numerous reports of allegations of corruption, neglect, and malpractice within the province's public hospitals.
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On top of this, Gauteng hospitals recorded the most complaints, according to the Office of the Health Ombud's 2023/24 annual report that was presented to the Parliamentary Portfolio Committee on Health. It showed a cumulative 4 549 complaints coming from Gauteng in the last three financial years.
"Gauteng Province continues to have more complaints by far, whether this is taken as absolute figures or as per population size or number of hospital beds available. This might reflect the parlous state of complaints resolution mechanisms at the health establishments or provincial health department levels in Gauteng," states the report.
A loss of trust?
Part of the argument for the MOA is that it draws in support from Wits and provides additional oversight, which could help ease some of the management challenges haunting the province's public healthcare sector.
"For the Gauteng Department of Health to renege on the agreement makes no sense. It means that there is a substantial loss of trust and there are question marks around the motives for doing so because it appears as though there's a desire for the Gauteng Department of Health to unilaterally make decisions without any kind of additional oversight," said Professor Alex van den Heever from Wits' School of Governance. He is Chair of Social Security Systems Administration and Management Studies at Wits and his work has focused on health economics and financing, public financing and social security.
"You have to look at the inverse of what the MOA was trying to implement to understand what the Gauteng Department of Health is pulling back from. There should be scrutiny over the department's accountability structures," he said.
"Without explaining themselves, it means the Gauteng Department of Health wants to retain unilateral control; they want reduced visibility review and reduced transparency and accountability. But in a complex arrangement, you have to have more sophisticated governance structures. You require more transparency, more accountability, not less," Van den Heever added.
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Wits has around 1 300 staff members on clinical platforms including at Charlotte Maxeke, Chris Hani Baragwanath, Helen Joseph and Rahima Moosa hospitals.
The role of the university, Van den Heever stresses is "substantial in training the health professionals for the future" and is not that of a service provider, but a partner. "The purpose of the MOA was to establish a kind of framework where both parties have skin in the game," he added.
"The motivation for walking away from an agreement that you've [Gauteng Department of Health] signed is deeply problematic; this situation would normally be resolved in the courts, though in this case litigation is unlikely as it would only make the relationship more difficult," Van den Heever said. "There is a trust gap; and you can't have that between supposed partners," he added.
When the MOA was signed, both parties agreed to a three-month timeframe to set up committees that would develop governing schedules and management plans to put the agreement into action.
The MOA was signed by Dr Nomathemba Mokgethi who served as MEC from 2020 to 2022.
"We are committed to fostering a close, collaborative working relationship with Wits University, with the objective of enabling functional, agile, and well-managed academic health complexes that will deliver quality healthcare to the public", she was quoted saying at the time, adding that the partnership would "ensure the most efficient, cost-effective, appropriate and sustainable use of our joint resources".
Mokgethi has since been replaced as the province's MEC for health by Nomantu Nkomo-Ralehoko.
Wits is currently still working on a breakthrough, the university's head of communications Shirona Patel told Spotlight. "Discussions are underway, and the university will comment on the matter in due course," she said.
