Free State province: Is there any hope left?
This story has been told countless times. Published in a stream of newspaper scoops. Handwritten on cardboard boxes carried by exasperated activists. In the anonymous letters of frustrated doctors. In the statements of concerned stakeholders. In the defence arguments of the so-called ‘Bophelo House 94’, convicted of attending a peaceful night vigil. In the reports of the South African Human Rights Commission. Most recently, through the piles of testimony heard and analysed by the People’s Commission of Inquiry.
The evidence is mounting and it cannot be ignored any longer. It certainly cannot be dismissed as ‘propaganda’ from the Treatment Action Campaign (TAC). It is the voice of the people who try to use clinics and hospitals every day, battling inefficiencies and negligence, in lengthy processes and undignified conditions. It is the voice of the healthcare professionals who no longer have the time, resources or support to provide appropriate medical care to patients. It is the voice of the 24 percent of doctors who stopped working for the Free State Health Department in the last year. The reality is that while some throw parties to congratulate themselves on ‘gains’, poor people across the Free State suffer frustrations, indignities and tragedies within the system.
The People’s Commission of Inquiry into the Free State healthcare system listened to these voices. It found that little has changed since the National Health Department investigated the province in 2008 – rather that the situation may even have worsened. Based upon their findings, clear recommendations have been outlined to address the crisis*.
One thing is certain, strong leadership and political will are needed to turn things around. The question now is whether the Free State government will hear the loud cries of this collective voice?
We know it is difficult to hear criticism. We know it is tough to be faced with frequent complaints. We know it is hard to b e told you are failing. But, remember: it is not as difficult as watching a loved one die on the side of the road waiting for an ambulance that never arrives. It is not as tough as being told to mop up when your waters break as you are going through a painful labour. It is not as hard as struggling to walk to the clinic on crutches, only to find that the stock of pain medication has run out.
Only time will tell if Premier Ace Magashule and MEC of Health Benny Malakoane hear these cries. But if they fall on deaf ears, if these issues are not addressed, if justice is not served, then we will be left with no choice but to return to the days of civil disobedience. Freedom or death, victory is certain.
Findings and recommendations of the People’s Commission of Inquiry
- Finding 1: The South African Government, in particular the provincial Free State government, is failing to assume its responsibility to protect access to healthcare services, especially for the poor in the Free State.
- A national task team should be established by the National Department of Health to investigate the findings of this report in the context of the 2007 Human Rights Commission report and the 2009 IST reports;
- The parliamentary portfolio committee on health must hold the national and provincial executives to account based on the commission’s findings and recommendations, and demand that the national task team completes its work swiftly and thoroughly, and without political interference;
- The South African Human Rights Commission should, as a matter of urgency, return to the Free State and investigate how the situation has changed since their 2007 report;
- The Free State Department of Health should establish a provincial task team to deal with the challenges outlined in the commission’s findings, and openly involve community and civil society in this process. The department must commit to fixed time frames for this process, and must respond comprehensively to the issues outlined in this document within a fixed period. It must show its commitment to move forward by setting transparent targets and deadlines to meet its goals.
- Finding 2: Shortages and stock-outs of medication and medical supplies are chronic, endanger the lives and health of vulnerable people across the Free State, and discourage people from accessing health care and trusting in the healthcare system;
The provincial Department of Health must implement the recommendations made in the 2014 Stock-Outs Survey in South African Second Annual Report. Namely, that:
- The provincial Department of Health follow the example set by the National Department of Health and the Limpopo, Gauteng, Northern Cape, North West and Western Cape provincial health departments, and engage with civil society on the causes of stock-outs and potential solutions to improve the supply chain.
- The department take urgent action to address those facilities in Fezile Dab Lejweleputswa District reporting ARV and TB stock-outs, where close to 42 percent (13/31) of facilities reported ARV/TB stock-outs.
- The provincial department develop and implement a provincial action plan to resolve and prevent stock outs in the province, with clear timelines and an evaluation of these action plans and provision for emergencies, and focus on the worst hit districts.
- The National Department of Health, in collaboration with the provincial Department of Health, establish and implement national minimum standards for supply chain management and the resolution of stock-outs.
- The provincial Department of Health, in collaboration with the provincial Treasury, must adequately cost the provision of pharmaceuticals in the province. According to the provincial Department of Health, the unavailability of medicines in the provinces is due to “declining provincial allocation and increasing price of medication, including the increasing patient numbers”.
- The department must, as a matter of urgency, address the current shortage of pharmacists in the province and ensure that it has the required funding to fill these positions in the province.
- Finding 3: The provincial emergency medical services and patient transport systems are characterised by long waiting times, unreliability and indignity – all experienced in the most vulnerable and frightening moments of life for people who depend on these services; and, many of the oral testimonies spoke of people having to make out-of-pocket payments for transport to health facilities.
- The Free State Department of Health, as a matter of urgency, must address the current shortage of ambulances in the province in order to meet the national norm of one ambulance per 10,000 population;
- The department, with the support of provincial Treasury, should undertake a full costing of the provincial EMS programme;
- The department must review its Planned Patient Transport programme to ensure that patients have access to transport to and from health facilities, to prevent unnecessary out-of-pocket payments. This will also help to strengthen service at the district level and ensure the referral system between facilities is accessible to patients, thereby effectively operationalising the primary healthcare approach;
- The department must take the necessary steps to address the shortage in emergency medical personnel by filling all vacant posts.
- The provincial Department of Health must cut red tape and bureaucracy – people are being shunted between one facility and the next unnecessarily because of processes that do not work, including a muddled patient referral process, poor planning for patient transport, and mismanagement of the deployment system for ambulances.
- Finding 4: Healthcare facilities in the Free State are often in disrepair and equipment is frequently broken or unavailable.
- In line with the recommendations made by the SAHRC in 2009, the department must ensure that there is adequate funding and personnel to properly maintain health facilities, including being fitted with the appropriate technology (medical equipment, ICT equipment, access to internet, etc.).
- The department, in conjunction with the Department of Public Works, must strengthen the infrastructure unit (engineers, maintenance crew, quantity surveyors, quality control) to address backlog maintenance, routine maintenance and the building of new health facilities, and to prevent any unnecessary under-expenditure of the Health Infrastructure Grant.
- Finding 5: Insufficient human resources and poor management of human resources prevent the fulfilment of the right of access to healthcare services.
The findings of the 2012 National Healthcare Facilities Baseline Audit (the ‘Audit’) corroborate the communities’ portrait of human resource shortages in the Free State. The Audit notes the ommission of national human resource norms as a major impediment to proper staffing and thereby the fulfilment of the right of access to healthcare services. The lack of national norms persists today.
At the provincial level, the Audit measured compliance with six ‘Priority Areas on Vital Measures’. Free State healthcare facilities were, on average, only 44 percent compliant with the priority area, measuring whether staff demonstrate a ‘positive and caring attitude’, and only 57 percent compliant with requirements related to ‘waiting times’.
- The Free State Department of Health, as a matter of urgency, must address the numerous human resource issues, problems and challenges, including those related to staff shortages and the impact thereof on the provision of quality health services;
- The department must address the Report of the Auditor General year ended 31 March 2013 and ensure that there is a human resource plan in place, that vacant posts are filled within 12 months and that an organisational structure be in place based on the department’s strategic plan;
- The provincial Department of Health should carry out investigations into each allegation made in the verbal and written testimonies with regard to health personnel failures – including neglect and bad attitudes – and that, following this investigation, disciplinary action be taken where appropriate and compensation be paid out to victims of neglect or ill-treatment;
- Leaders at the provincial Department of Health must pay attention to staff complaints – working conditions for nurses, doctors, paramedics and ambulance drivers are far from ideal. Senior officials must communicate with staff on the ground to understand the failings in the system and to rectify these with better planning, on-going training, support, and provide adequate facilities and supplies in the clinic and hospitals where they work;
- Improved staff support systems should be put in place by the provincial Department of Health. Staff are aware of the constant projection of failure in the health system and are sensitive to the fact that, ultimately, healthcare workers themselves become victims to the system and are alienated from what they know to be proper professional conduct. Healthcare staff choose this vocation because they care about individuals. However, they are constantly susceptible to failure because they do not have the time, tools, or medicines to do their job properly. Support systems must urgently be put in place to deal with the systemic psychological and social malfunctioning of the entire system of healthcare in Free State. Stress, exhaustion, and burn out as a result of the malfunctioning system can manifest in the mistreatment of patients by staff. Wellness sessions and psychological evaluation relating to individual suitability to work in this sector should be established;
- The National Department of Health must rapidly finalise and clarify its national community healthcare workers’ policy, and the provincial Department of Health must set in place a transparent plan to re-employ the Free State community healthcare workers under dignified and formalised working conditions.
- Finding 6: Whistleblowing and candid engagement with the provincial department by healthcare personnel and/or the public is discouraged and at times met with severe intimidation.
- The National Department of Health must ensure that safe mechanisms are in place within the provincial Department of Health for staff and patients to communicate their experiences of the healthcare system in the Free State;
- That the provincial government must create a system whereby management teams regularly visit communities to see and hear the needs and concerns of citizens first-hand.
- Finding 7: There is ineffective, unresponsive and unaccountable leadership, particularly from senior officials in the provincial department.
- That the MEC for Health and other responsible individuals be held accountable for the failings in the healthcare system in Free State. It is essential that those in positions of power set higher standards of professionalism and respect for patients.
- Finding 8: The provincial health department has a history of poor planning, budgeting, expenditure and oversight.
- That the Free State Department of Health must communicate what the annual budget is per clinic and facility. This information should be displayed clearly at all facilities, to be monitored by those who use it;
- The department must ensure that clinic committees and other structures understand that their responsibilities include monitoring the resources that ensure the proper running of health facilities, and that these structures are supported by the provincial department.
Interviews by Ufrieda Ho
Betty Mabuza, Welkom
Talking about the child she lost isn’t easy for Betty Mabuza. The 31-year-old says some days she manages to talk about the baby boy, who would have been her second child, without a tear falling. Most days, though, she crumples in a heap of heartache and despair.
‘Sometimes I am at the PEP Stores and I see all the baby clothes they have and I can’t help thinking about him,’ says Mabuza, breaking down. It’s only five months since the ordeal of losing her child. Mabuza gave testimony even though she knew it would stir up raw emotions; she wanted to be heard. She says she knows she should have been given better care and she knows that, had nurses and doctors done better, her boy would have had a fighting chance.
Mabuza arrived at the commission as part of the Welkom delegation giving testimony on day one. She’s a resident in Tshepong, near Odendaalsrus. Speaking through an interpreter, she said: ‘I fell pregnant last year and by February this year I had done my whole nine months. I was last at the Tshepong Clinic in February with pains but the sister told me she couldn’t transfer me to Bongani Hospital because my tummy was inconsistent – sometimes big and sometimes small. They just gave me medication and told me to go home.’
Days later though, she felt pains she couldn’t understand so she returned to the clinic, where she was made to wait before nurses told her her appointment dates were wrong and that she should walk to the hospital if she wanted help.
‘I started to walk home. On the way I did a call-back to my mother and, when she phoned, I said to her: “Mama I think I’m about to give birth, but I’m still walking.” I just had to walk and pray. I begged God,” she says. Tears roll down Mabuza’s cheeks. She made it home and got to the Bongani Hospital that morning. But there she would undergo more humiliation and maltreatment, she says.
‘When I got to the hospital, the sisters told me to sit and wait, and I waited for hours in pain. It was after 3 pm in the afternoon when they took me to a bed and they told me to sit upright. I was checked by more than 10 nurses and they all said they could feel nothing, and said there weren’t any problems and I should wait for the doctor,’ says Mabuza.
When the doctor arrived though, he had the most devastating news for her. ‘He looked at me and told me to just rest and sleep on the bed. Then he examined me and he looked me in the eyes and said angrily: “What does it mean if the baby’s heart is not beating?” I just kept quiet,’ she remembers.
Then the doctor said to her: ‘This child you are carrying has been dead since January.’ Repeating these words leaves Mabuza sobbing. It wasn’t the end. She was left in the room alone, even as labour had started. She says: ‘A nurse came in and just said, “Are you able to give birth on your own?” I knew I couldn’t but only later, when I looked down and the head of the baby was already coming out, did the nurses come to help me.
‘I pushed so hard I thought I was going to die. They showed me my baby. It was terrible, my child was rotten,’ says Mabuza, choking back tears.
Worse still, straight after this traumatic process, the nurses made her wait in the corridors, without counselling, a kind word, or bathing her. It was only when the nightshift nurses arrived on duty that she was bathed.
That day in hospital was months ago, but the sadness hasn’t left her. Her pain and trauma remain. She says: ‘I don’t eat a lot, I think about him a lot. I think that if my child could be dead inside of me for so long then I should die too.’
Interviews by Ufrieda Ho
Vele Gadebe, Harrismith
Vele Gadebe is a doting grandfather; he loves two-year-old Melokuhle. But much as he wishes all that’s wonderful in the world for her, he knows she will never have one of the most precious things: she’ll never know her mother, Thandeka.
Thandeka died when Melokuhle was just three months old. Gadebe will never forget the days leading up to his 22-year-old daughter’s death. It’s what’s brought him to the People’s Commission of Inquiry.
The Harrismith local’s testimony is of the callous attitude of nurses, ‘too busy to give his child oxygen’, ambulances that never arrive, bureaucracy, bullying, and no one with answers or willing to take responsibility.
It started after his daughter had a caesarean section. Thandeka started coughing badly and Gadebe ended up taking his daughter to the Thebe Hospital near their home. But doctors there only see patients between about 8 am and 1 pm, says Gadebe, despite the fact that people arrive hours earlier to queue and that there are still people in the queue after lunch hour.
‘The nurses just told me, “you can write your complaints in the book” when I complained,’ says Gadebe. He took his daughter to a private doctor, someone he identified as ‘Dr Lucky’. By this point Thandeka was weak, unable to walk or to lift herself from a prone position.
‘Dr Lucky told us to take her to the hospital and said we should call an ambulance, but the ambulance never came. In the end Dr Lucky took us there himself because he knew that she might die,’ says Gadebe.
He adds: ‘When we arrived at the hospital I asked for a wheelchair and some help to carry my daughter from the car. The nurse pointed to the wheelchair and told me I had to abide by her rules or leave the hospital.
‘When I asked her for something to help my daughter breathe, she said she was busy and I would have to wait – she was too busy to give oxygen for my child to breathe.’
Finally a doctor appeared. Gadebe complained to him and all he did was to give him a number for the hospital where he could lay a complaint. While the doctor saw to Thandeka, Gadebe tried to lay a complaint, and the supervising nurse who was had bullied Gadebe disappeared.
Moments later, though, the doctor reappeared. ‘He said, “Who is the father of this child?” and when I said it’s me, he told me he wanted to talk privately with me. My daughter had passed on. That is how it ended.’