A timeline of collapse
To understand what led to the crises in the Free State it is helpful to backtrack to 2005 when the provincial scale-up of antiretroviral therapy (ART) programmes across South Africa’s nine provinces began in earnest. In the absence of guidelines, norms or standards issued by the National Department of Health, the Free State had developed its own systems for scale-up. The province struggled to initiate patients onto ARVs quickly enough to meet the high demand for treatment, and its model of ARV provision through a small number of centrally located clinics meant that treatment remained inaccessible for many who lived outside the few urban areas.
This was partly the result of the laborious accreditation process before ARV sites were allowed to dispense the drugs, and partly because of human resource shortages and infrastructural constraints. The concentration of services in urban centres meant that many patients had to travel long distances to access care, and lengthy waiting lists at central facilities indicated the high unmet demand for ARVs. Between May 2004 and December 2007, one quarter of patients on the province’s ARV waiting list died before accessing treatment.
President Thabo Mbeki resigns and Kgalema Motlanthe assumes the presidency of South Africa for the remainder of the parliamentary term. Almost immediately Motlanthe replaced Health Minister Dr Manto Tshabalala-Msimang with Barbara Hogan, who was known for her financial acuity and her support for evidence-based health interventions.
Despite Hogan’s commitments to better financial oversight and to the expansion of antiretroviral (ARV) coverage, a moratorium on initiating new patients onto ARVs was ordered in the Free State province by the Free State head of the HIV/ AIDS department.
At the time the province had no methodology by which it set treatment targets and aligned these with budgets. At the time, the Free State also had the lowest rates of provincial ARV treatment coverage, at only 25% of those eligible for treatment was accessing it.
3 November 2008
The head of the Free State’s Comprehensive HIV and AIDS Management Programme emailed the provinces Chief ARV Pharmacist with an instruction in the subject line to stop putting new clients on ARVs The email stated: “This province (Free State) is experiencing an acute shortage of antiretroviral drugs…This will lead to clients on treatment defaulting not because of their own fault. The only way to avoid this is by keeping the remaining ARVs for the exclusive use of those on treatment already with the exception of clients on the PMTCT program (pregnant women). In the meantime the FSDoH (Free State Department of Health) will be trying to find ways to remedy this situation”.
The Chief ARV pharmacist forwarded this email to healthcare workers and facility managers, acknowledging its serious implications: “We are facing a difficult period. You at the sites are faced with an even worse situation whereby you have to turn patients away because of the present circumstances. The same patients who look at you as their last hope in life.” The ARV moratorium was the forerunner in a series of cost curtailment measures, which were implemented by all 31 public healthcare facilities in the Free State on 24 November 2008. These reduced the services available by drastic measures, and terminated all outreach services (with the exception of oncology). Clinical admissions were limited to “dire need only”, and at one hospital patients were instructed to “go home and phone to hear if a bed is available”.
Hogan reacted to the Free State’s ARV moratorium, committing additional funds to replenish drug stocks and dispatching health systems experts to the province. The minister arranged for the transfer of R9.5 million in emergency funds to the province to purchase ARVs. The moratorium, which was part of a series of cost curtailment measures, lasted for four months. During this time, an estimated 30 additional patients in the province died from AIDS each day.
The moratorium contradicted national government’s commitment to the scaling-up of antiretroviral (ARV) treatment to 80% of those in need by 2011. As the first official cessation of provincial rollout, the moratorium served as a litmus test for government’s reaction to critical challenges in the expansion of the ARV treatment programme at both national and provincial levels. It therefore provides a valuable case study for the state’s response to some of the systematic and health infrastructural problems that have characterised South Africa’s ARV rollout since its inception. It was also the first litmus test for the post-Mbeki government, even thought it was very much as a result of and a legacy of that period. Contributing factors to the Free State ARV moratorium were
(Source: Hodes, R., & Grimsrud, A. 2011. The antiretroviral moratorium in the Free State province of South Africa: Contributing factors and implications. Centre for Social Science Research, University of Cape Town, Working Paper No. 290)
19 June 2014
The TAC and SECTION27 release a media statement revealing the extent of the crisis in the Free State.
27 June 2014
Community health workers gather at Bophelo House in Bloemfontein, the headquarters of the Free State Department of Health. Their contracts had not been renewed and they had not been offered an explanation. A meeting with a health official leads to an agreement that a meeting with Health MEC Benny Malakoane will take place within seven days.
3 July 2014
The Treatment Action Campaign (TAC) releases the results of a fact-finding mission across the province. It is established that there is a health care moratorium in the province with massive stock-outs, shortages and system collapse. There is a call for the Health MEC to be fired. In addition the TAC make the following demands:
Premier Ace Mashagule must remove Benny Malakoane from his position as MEC of Health in the Free State. If Mashagule is not willing to do this, we call on the ANC’s national leadership to intervene.
Recently dismissed community healthcare workers must be reinstated with immediate effect.
A turn-around plan for the provincial health system must be developed as a matter of urgency. It is essential that this turn-around plan be led by committed and qualified people – and not the current MEC.
The secretariat of the Provincial AIDS Council must be moved out of the Department of Health so as to ensure independence and more effective civil society engagement.
The Free State Department of Health must come clean about its financial problems. The public has a right to know how the Department is spending money – especially in the midst of a crisis like the current one.
The Mail & Guardian publishes a feature further exposing the health system collapse in the province and makes allegations implicating the MEC in a “ICU bed for pal” scandal.\
9 July 2014
Over 100 community health workers (CHWs) and TAC activists from across the province start a peaceful vigil outside Bophelo House in an effort to draw attention to their plight. The TAC announces the commencement of a civil disobedience campaign.
Reports emerge of MEC Malakoane phoning CHWs, warning them that they will be arrested if they participate in the protest action. He demands the names of those attending the protest. Police presence increases significantly and they start negotiating with CHW and TAC leadership.
Media statement: http://www.tac.org.za/news/tac-embark-civil-disobedience-free-state
10 July 2014
Further police back-up arrive on the scene and protesters are ordered to disperse or face arrest. Police tell protesters they have been sent by the Health MEC Benny Malakoane. Police move in and start arresting male CHWs and male TAC activists. Arrested protesters are taken to various police stations where they are locked up.
Protesters are told they are being charged for taking part in an illegal gathering.
Later in the day another 50 TAC members are arrested for picketing outside Bophelo House and taken to Park Road police station. They are forced inside police vans.
TAC General Secretary Anele Yawa contacts ANC General Secretary Gwede Mantashe who indicates that he does not see it as his responsibility to deal with the ANC leadership in the Free State.
11 July 2014
All those arrested appear in court and are told to again appear in court on September 1.
16 July 2014
Press statement sent out notifying the press about the continuation of peaceful night vigils.
17 July 2014
About 1 000 activists march to Bophelo house, the Free State Department of Health headquarters
The activists demand the immediate dismissal of Free State Health MEC Benny Malakoane, the reinstatement of recently dismissed community health workers on new terms, and a clear action plan to fix the Free State health system. The group also marches to the Provincial AIDS Council to give the council’s secretariat a memorandum to acknowledge the failing provincial health system and call for the MEC’s resignation.
Mail & Guardian coverage on march: http://mg.co.za/article/2014-07-17-free-state-healthcare-workers-march-for-malakoanes-head http://mg.co.za/article/2014-07-17-free-states-malakoane-calls-activits-slogans-insulting
eNCA interview: http://www.eNCA.com/media/video/tac-vigils
18 July 2014
TAC General Secretary Anele Yawa and TAC leaders meet with Tefo Tabi, the head of the Free State Provincial AIDS Council secretariat to discuss the crisis.
22 July 2014
Free State health department offers two-month contracts to the CHWs.
23 July 2014
TAC meets with NUMSA leadership.
24 July 2014
TAC meets with COPE leadership.
25 July 2014
Student nurses embark on a strike at Bongani regional hospital. 300+ TAC members attend another night vigil
01 August 2014
MEC Benny Malakoane appears in Welkom Magistrate’s court on charges of fraud and corruption from his time as Matjhabeng municipal manager between 2007 and 2010.
The case is transferred to Bloemfontein Regional Court and postponed until the 27th of August.
A TAC night vigil continues into the morning and 30 TAC comrades picket outside the court.
8 August 2014
The Stop Stockouts Project (SSP) published a report that indicated there is no improvement in the availability of essential medication in the Free State.
11 August 2014
The student nurses strike at Bongani Hospital grows into a massive campaign; they stated that no one will be working until their demands are met.
14 August 2014
Free State TAC meets with the public protector. She says they are aware of allegations of corruption against Benny, but her office needs more facts in order to investigate.
The new doctor appointed head of the HIV program in FS requested to meet with TAC and wanted to create a platform to have monthly meetings.
19 August 2014
21 organisations attended a TAC partners meeting in Johannesburg on the state of healthcare in Free State.
27 August 2014
MEC Malakoane appeared in the Bloemfontein Magistrate’s court on charges of fraud and corruption relating to his time as Matjhabeng Municipal Manager. The case was postponed until November.
1st September 2014
All those arrested appear in court and are told to again appear in court on October 2.
TAC brings charges of corruption against Free State MEC for Health Benny Malakoane, Head of Free State Health Department Dr David Motau, Free State Deputy Director General for Health Teboho Moji and senior officials in the provincial Department of Health at the Park Road police station in Bloemfontein.
The charges relate to the matter reported in the Mail & Guardian newspaper on July 4 2014. The article titled “How a dying women’s bed was taken by an ANC official” states that MEC Malakoane had ordered that an ICU bed at Dihlabeng Regional hospital should be made available to an ANC official – even though clinical guidelines did not indicate that the official should be given a bed. The Mail & Guardian quotes doctors indicating that other patients would have benefited more from access to the ICU bed. One of these patients died shortly after.
4 September 2014
The corruption case transferred to Bethlehem Police Station – case number 219/9/2014. No investigating officer had been assigned due to the absence of a hard copy of the docket.
2 October 2014
All those arrested appear in Bloemfontein Magistrate’s Court. The case was postponed to the 29th of January 2015. The postponement was meant for the prosecution to provide the CHW’s the evidence against them and for the CHW’s to make representations to the National Director of Public Prosecutions, Mr Mxolisi Nxasana.
11 November 2014
CHWs make formal, written representations to the National Director of Public Prosecutions (NDPP), Mr Mxolisi Nxasana. Their representations call upon the NDPP to unconditionally withdraw the charges against them.
27 January 2015
The NDPP responds to the written representations made by the CHWs that the case would not be withdrawn.
29 January 2015
All those arrested appear in Bloemfontein Magistrate’s Court for the fourth time. The prosecutor offered a settlement in order to drop the charges with conditions attached. The settlement amounted to an admission of guilt that “the gathering was illegal” and that they will not partake in any “unauthorised” gathering in the future. Failure to comply with this could amount to the charges being reinstated. The admission of guilt was found by the vast majority of CHWs and TAC members to be unacceptable. The settlement was rejected by 118 and accepted by 11. The 118 were told to re-appear at court on March 30.
12 February 2015
TAC releases a satire newspaper with the headline “Benny Fired – Incompetent Free State Health MEC Dismissed”. Amongst others the newspaper featured an article detailing Premier of Free State, Ace Magashule’s plan to turnaround the crisis in the Free State health system, and a job description for a new MEC of Health in Free State. The newspaper was distributed inside the State of the Nation at Parliament. In addition banners were held stating “ANC fires Free State MEC – Viva!” along the highway.
13 February 2015
TAC gathers outside Bloemfontein Regional Court where MEC Malakoane is due to appear on charges of corruption. The case is postponed to June 5. TAC distribute newspapers outside Bophelo House, the Free State Department of Health in Bloemfontein.
17 February 2015
ANCYL FS, NAPWA FS, Free State Men’s Sector hold a press conference in defence of MEC Benny Malakoane and the ANC, and against TAC at the ANC Provincial Office.
19 February 2015
TAC issue statement on the planned march to TAC offices in Bloemfontein to call for TAC de-registration http://www.tac.org.za/news/tac-continue-call-dismissal-mec-health-free-state
20 February 2015
ANCYL FS, ANCWL FS, NAPWA FS, and SANAC Men’s Sector Free State, march for the de-registration of TAC. Reports suggest 200 people attended. Statements issued by various organisations in support of TAC:
Equal Education, Social Justice Coalition and Ndifuna Ukwazi: http://www.equaleducation.org.za/article/2015-02-20-no-to-political-intimidation-no-to-corruptionwe-call-on-organisations-not-to-march-against-tac-in-bloemfontein
United Front: http://www.tac.org.za/news/united-front-response-free-state-ancyl-march-against-tac
SANAC Civil Society Forum: http://www.tac.org.za/news/sanac-csf-response-ancyl-march
Sonke Gender Justice, Grass Root Soccer, AIDS Accountability International: http://www.genderjustice.org.za/news-item/tac-and-south-africa-civil-society-under-attack/
SANAC Men’s Sector: http://www.genderjustice.org.za/news-item/sanac-mens-sector-media-statement-hands-off-the-treatment-action-campaign-tac/
People’s Health Movement South Africa: http://phm-sa.org/press-statement-phm-supports-tac-condemns-free-state-ancyl-intimidation/
23 February 2015
TAC leadership meet with Minister of Health, Dr Aaron Motsoaledi to discuss the problems in the Free State amongst other priorities.
31 March 2015
The National Prosecuting Authority continues to prosecute 117 community health care workers and TAC members in the Free State who were involved in a peaceful night vigil on 10 July 2014. Court adjourned late and after deliberations, the trial was postponed until 6 July 2015.
4 March 2015
On 27 February, the GroundUp website published a letter from doctors in the Free State. This letter listed several serious allegations regarding the collapse of the Free State healthcare system. On 28 February, GroundUp published a response from the Free State Department of Health that does not address any specific concerns raised in the doctors’ letter and down-plays many of the allegations. In response, TAC made several demands of the Free State: that MEC Malakoane be dismissed or suspended, that a provincial consultative forum be convened, and that the SA Human Rights Commission should launch an investigation into the doctors’ allegations.
1 April 2015
TAC is notified of Zwelinzima Vavi’s expulsion from Cosatu and his subsequent absence from the Cosatu Central Executive Committee meeting.
11 June 2015
TAC General Secretary, Anele Yawa, gives a speech at SA AIDS 2015 Plenary focusing on the political issues in the health care crisis. His speech emphasizes the issues of staff shortage and the lack of resources and services in the Free State and lays blame on MEC Malakoane. Yawa explains the steps TAC has taken to address the issue with no progress and then call upon all listening to make the struggle against HIV and TB a political fight and hold the provincial MECs for health accountable.
15 June 2015
1120 delegates from the 7th South African AIDS conference in Durban signed a petition to drop charges against the 117 community healthcare workers in the Free State who were arrested for a peaceful protest against their unfair termination of employment and the state of the healthcare system in the province.
7/8 July 2015
An independent commission of inquiry conducted public hearings into the state of public healthcare in the Free State. Bishop Paul Verryn, Thembeka Gwagwa, and Thokozile Madonko investigated the situation of healthcare in the process, hearing from healthcare providers and users.
1 October 2015
94 community healthcare workers from the Free State who were arrested for a peaceful night vigil in July 2014 are found guilty of attending a prohibited gathering in the Bloemfontein Magistrate’s Court. The court did not find that the vigil posed any threat to public safety or property; the ruling is based on the fact that no notification about the vigil was given. Regarding this ruling, Yawa stated, “This prosecution is not about justice. Instead, this case is about punishing those who dare speak out and challenge power.”
21 October 2015
The 2015 South African Health Review is released citing that the number of doctors working in the public healthcare system in the Free State has dropped from 716 in 2014 to 539 in 2015. The loss of 177 doctors represents a 24% reduction giving the province a ratio of 23.3 doctors per 100,000 patients. This is one of the worst ratios throughout the country.
10 November 2015
The report of the People’s Commission of Inquiry into the Free State Healthcare System was launched at an open dialogue in Bloemfontein. The report makes the following key findings: the provincial Free State government is failing to assume its responsibility to protect access to healthcare services; the shortages and stockouts of medicines and supplies are chronic in the Free State; emergency medical services are unreliable and are characterised by long waiting times; healthcare facilities in the Free State are poor and equipment is often broken or unavailable; and there are insufficient human resources and poor management in the province.
The report lists several recommendations for the Free State. The report recommends that the findings of the report be investigated by several different agencies and that the Free State Department of Health create a task team which involves community members to deal with these findings. The report also recommends that the Free State Department ensure that there is adequate funding and personnel to update and maintain health facilities and medical supplies. The Free State Department of Health must also address human resource issues including staff shortages, mismanagement, and poor working conditions.
6 April 2016
TAC releases a statement following the National Council meeting at the end of March. The statement recounts topics discussed at the meeting including the shortage of healthcare workers, specifically in provinces like the Free State. The statement also mentions TAC’s plan to use the Free State as its centre for advocacy at the International AIDS Conference to focus on issues of mismanagement and dysfunctional healthcare systems. Several resolutions regarding the Free State were made at the meeting: TAC resolved to send a team to the Free State to gather new evidence of the situation in the Free State public healthcare system and to organise a march in May 2016 to the Free State office of the National Prosecuting Authority and provincial police commissioner to call for all charges against MEC Benny Malakoane not to be delayed any further.
12 May 2016
TAC and others, 500 people total, marched to the Park Road police station and the Free State Prosecuting Authority in Bloemfontein to demand that the charges TAC laid against MEC Malakoane regarding a political favour for an ICU bed be investigated faster so that the prosecution of MEC Malakoane can begin. Two years ago Malakoane allegedly stole an ICU bed from someone in need to give it to a relative of a political friend in exchange for a political favour. Evidence against Malakoane in this case is overwhelming and yet investigations are ongoing.
20 May 2016
TAC writes a letter to the National Prosecuting Authority regarding delays in two trials against MEC Malakoane. The letter outlined concerns regarding the delays and the implications that these delays have on the justice system and on citizens. The letter also requests action in investigating and prosecuting Malakoane and a response which properly outlines reasons for delays.