Crumbling Provincial Health Departments Cost Lives and Will Affect NSP Outcomes

Over the last year reports to TAC and SECTION27 of drug shortages, vital medical equipment breakdowns, staff shortages, corruption and mismanagement have become almost a daily occurrence. Often these breakdowns bring tragic consequences, such as the preventable deaths of women and infants kept waiting too long for caesarean operations, or people dying of cancers because of the failure of oncology services.

However, less understood is the impact of the health systems crisis on people who for example, require antiretrovirals (ARVs), tuberculosis (TB) medicines and drugs for chronic conditions; people who tire of getting short supplies or no supplies, and become non-adherent or stop taking their medicines altogether. It is unfortunate that the Department of Health has no systems for monitoring the quality of its health services, rather than just their quantity. If we did we might see a different story from the official version.

The tragedy is that this crisis has been anticipated for a long time. The harbinger was the Free State ARV moratorium in 2009, when ARVs stopped being provided to new patients for over three months.

As a result of that crisis the government undertook various interventions and analyses of the health system. The most important of these exercises was the Integrated Support Teams (ISTs) set up by former Minister of Health Barbara Hogan, which undertook an analysis of the budgeting and management procedures of each provincial health department, as well as the national department. The IST teams produced detailed reports and recommendations which were made public in 2010 by Minister of Health Aaron Motsolaedi. But these reports, or at least their recommendations appear to have been forgotten. (See the reports online here)

Since that time Motsoaledi has promised a major revamp of the health system. This overhaul would be a vital part of preparing the ground for a system of National Health Insurance (NHI). A new National Strategic Plan on HIV, TB and STIs has been agreed featuring ambitious targets of over three million people on treatment by 2016. But neither the NSP nor NHI can succeed outside of a functional health system. And the great plans for the future have not stopped the disastrous crumbling in the present.

The crisis we declare has nothing to do with Dr Motsoaledi’s heroic efforts and vision. Yet it cannot be separated from a political crisis that pays loud lip service to efficiency and accountability, but which for self-serving reasons is unwilling and unable to enforce the standards required for an effective health system. These standards are also demanded by our constitution.

In 2012 it has become clearer than ever that the crisis is overwhelmingly one of management rather than a shortage of funds. Corruption and nepotism join forces with a lack of accountability and oversight to give most officials apparent de facto tenure in their positions, able to destroy hopes and lives with impunity. Rarely are health officials held accountable or interventions launched to stem the crisis.

In this context TAC and SECTION27 welcomed the use of Section 100 powers in the constitution over the Limpopo Department of Health in December 2011 (see article by David McNaught on p 18). However we have still to question whether a Section 100 intervention – which gives the national department short term powers to take over a provincial department in order to maintain essential standards – is really suitable for fragile ecosystems such as our health system. It seems self-defeating for the National Department of Health to observe the system being weakened and wait for it to break – for the rot to really set in – and only then try to fix it.

There is also reason to be sceptical about whether the powers of the constitution are really being used to protect and advance health, or whether there is underlying political agenda behind their deployment.

For example, whilst Section 100 has been used in Limpopo, other provinces with health systems in a similar state of cardiac arrest appear – for political reasons – to be untouchable. Thus, despite rumours of massive corruption in the Gauteng Department of Health, combined with the actual collapse of parts of the health system to the level where there are no vaccinations for children in some areas of the province, there has been no action in Gauteng. In the last three years there have been three Health MECs and Heads of Health. Yet in this time nobody has been found accountable for health service failures or held criminally responsible for corruption.

For this reason in October 2012 TAC and Corruption Watch jointly launched an official request under the Promotion of Access to Information Act (PAIA) for access to a report by the police Special Investigating Unit (SIU) into corruption in the Gauteng Department of Health.

A similar situation exists in the Eastern Cape. In this poor and predominantly rural province of 6.8 million people public-minded doctors and nurses are deserting health facilities because they cannot work under the unbearable pressures of staff, medicine and equipment shortages. Unusually, the provincial department has a Head of Health, Dr Siva Pillay, who has integrity and qualifications to run the department. But he is unable to do so without political interference. Once again, despite the evidence of collapse, despite suggestions that corruption may cost the province as much as R800m per annum, there has been no action. No measures have been taken against the Eastern Cape MEC for Health or other officials tainted with corruption directly or a failure to fulfil their legal duties to report and act against graft. In this respect, TAC and SECTION27 are in possession of official documents detailing the corruption. They have decided to launch a campaign of community mobilisation and litigation to rescue some of the province’s ailing hospitals from the crisis of insufficient health workers.

For these reasons, we believe that more important than emergency interventions will be the Office of Health Standards Compliance (OHSC), an independent statutory body that has been agreed to by Parliament in 2012. The OHSC will create a system allowing anyone to report failures and poor quality services in the health system. The question is: will they be acted upon?

Faced by the evidence, and hearing the cries of people denied the health services they are entitled to by law, we cannot help but believe that many essential parts of the public health system are in a near-fatal condition. TAC and SECTION27 offer our full support to the vision, passion and plans of Dr Motsoaledi. But more is needed than a good Health Minister and Director-General. We need all the decent and honest people in the health system to stand up and work for the constitutional right to health and dignity. We need all those who steal and sleep on duty to be removed. We need a demonstrated political will from the President and his Cabinet, that brings action, inspires trust and encourages effective managers to return to advancing the public good through public health.

Mark Heywood, Executive Director, SECTION27