#Vote4Health: Health in the Northern Cape: Disturbing visions from SA’s forgotten province

Waiting for healthcare at Augrabies Health Care Clinic outside Kakamas. PHOTO: Thom Pierce/Spotlight

By Anso Thom, Marcus Low, Nomatter Ndebele and Thom Pierce (all photographs)

Health services in large parts of the Northern Cape have virtually collapsed with communities mostly being served by overstretched nurses struggling to cope with the disease and injury burden. The challenges are overwhelming. Qualified doctors, specialists and professional nurses are as scarce as water in this arid province. Health facilities are poorly serviced with basic services such as emergency medical services, cleaning and infection control, drug and basic medical supply stocks, mortuaries, standard operating hours, trauma and mental health services virtually non-existent in most towns.

In a particularly shocking instance Spotlight was shown frozen, bloody medical waste in a chest freezer which was by all accounts tissue from abortions or stillbirths. Keimoes Hospital mortuary is locked up and abandoned. Instead community members and some health workers told us that bodies are collected by a nearby undertaker who then in turn negotiates the funeral or transport arrangements with families. On a walkabout through the hospital Spotlight was taken into a room a few steps from the bare maternity ward where a household chest freezer contained buckets of bloody tissue leftover from abortions and/or stillbirths. “Keimoes Hospital” forms to report “nie leefbare fetus (non-living foetus)” were openly displayed on a table next to the freezer detailing the birth mother’s name, contact details, weight of the “fetus” and signature of a nurse and two witnesses. Dates on the forms indicated that the tissue had been in the freezer for some weeks.

But we are getting ahead of ourselves.

Concerning reports from whistle-blowers meant that the Northern Cape had long been on Spotlight’s to do list. Late in 2018 a team of writers and a photographer finally took on the long roads of the country’s largest, but most sparsely populated province. The Northern Cape mostly operates under the radar, but once you pull the curtain back the picture is grim.

We travelled a circular route through the province and clocked up about 2 000 kilometres of mostly dirt and some tar road visiting doctors, healthcare workers, patients and some of the very few activists in the province. We passed through towns and small outposts, some just blips on the radar long past their heyday. Signposts hinting at suffering whizz by – Sweetfontein (Perspiration Fountain), Omdraaisvlei (Turnback Vlei), Uitlvlug (Flee Away) and so on. We slowed and at times paused in Middelpos, Sutherland, Fraserburg, Loxton, Victoria West, Britstown, De Aar, Prieska, Groblershoop, Upington, Keimoes, Kakamas, Kenhardt, Brandvlei, Calvinia and Nieuwoudtville.

In the months since the trip we have maintained contact with the many people we met on the road. We have given the Northern Cape government the benefit of the doubt and tried time and time again to show us what they are doing to address the shocking dysfunction in the province. As we explain later on, government has been less than forthcoming.

Based on what we’ve seen ourselves and what we have been told by various sources, we feel confident in making the following 10-point diagnosis of the public healthcare system in the Northern Cape.

1. There are critical doctor and nurse shortages in the province

Almost all the hospitals or health facilities visited by Spotlight had no doctors or were in the process of losing the doctors they had. Calvinia had two community service doctors working without supervision (they now have three community service doctors, two sessional doctors in private practice and one Congolese-qualified doctor), Sutherland and surrounding areas were set to be without a doctor by the end of 2018 (a recent update confirmed that Sutherland has no doctor and was being served by a community service doctor from Calvinia for a few hours every second week), De Aar reportedly had a few doctors – most of them foreign qualified (a visit to the new hospital revealed that the trauma unit was being run by nurses-only), Kakamas had no state doctors and Keimoes had no state doctors. Most community service doctors also work without any supervision.

We spoke to one doctor and one experienced nurse who quit their jobs because of the difficult working conditions and lack of support in the province. According to these two healthcare workers, the provincial department of health made no effort to convince them to stay – in fact, the impression was created that those who ask too many questions would be worked out of the system.

2. There are often no ambulances to deal with emergencies

Emergency Medical Services are virtually non-existent in some areas in the Northern Cape with the few ambulances that were still in running order mostly used to ferry patients to Upington and Kimberley. One ambulance manager reported that very few ambulances were on the road with the bulk of the vehicles not being in running order. Spotlight was also told that most of the ambulances are run by Basic Life Support staff and that there are literally just a handful of Intermediate or Advance Life Support paramedics in the entire province. We spoke to one mother who lost her baby – possibly due to the fact that an ambulance was not available to transport her from Keimoes to Upington.

There are also serious questions around the awarding of the aeromedical ambulance service contract in the Northern Cape which has gone to a company that by all accounts failed to conduct outreach services in the province when it had the previous contract. For many years such aeromedical outreach programmes were an effective way to get specialist care to various outposts in South Africa’s largest province

3. The Northern Cape is a province of ghost hospitals

Many “hospitals” in the Northern Cape have been downgraded to Community Health Centres, which is just a fancy term for hospitals with no doctors. In Kakamas and Keimoes nurses are left to run “Community Health Centres” with overnight beds…family members and friends are asked to look after patients in the overnight beds as nurses try to work through the queues in the outpatient departments.

When Spotlight visited the brand new De Aar hospital it felt like an empty shell with only a few wards operational. During the 7pm shift change Spotlight also observed very few health workers arriving and few leaving for such a big hospital. We were told the TB ward is still not open with no beds – we were also told that the TB ward was one of the reasons why the new hospital was built in the first place. Democratic Alliance counsellor Kobus Rust told Spotlight they were aware of the new hospital often having no hot water, a massive shortage of critical staff, posts not filled as disciplinary processes dragged on for very long, ambulance services not functioning, cash flow problems and poor workmanship at the new site. Rust claimed there was also no functioning TB facility in the province and that political interference was hampering service delivery.

4. The province has a problem with vacancies and political appointments in the healthcare system

The Northern Cape public healthcare system has large numbers of vacancies with very little evidence that there have been serious attempts to attract qualified people. Instead the province places “block ads” which means they on a few occasions invite people to send their CVs to head office which are then placed on file. Spotlight was given information of administrative appointments made based on political affiliations and people without the proper qualifications being appointed or administrators being appointed at facilities without there being vacancies or communication with facility managers. We put some of these allegations to the province – they did not respond.

5. There are question marks over the appointment of the Head of Department

The appointment of the Head of the Northern Cape Department of Health Dr Steven Jonkers is mired in controversy. The province failed to produce the advertisement for the job when asked. Media reports indicate that Jonkers received a “golden handshake” in 2016 from the Northern Cape Department of Transport. At the time of his appointment to the health department Jonkers was reportedly facing charges of corruption. Neither Jonkers nor the Department of Health responded to questions on these allegations. The department also failed to share an organogram of the department with the latest document we could find dating back to 2016/7 only containing the name of the MEC at the top.

6. There are stockouts across the board

Health facilities in the Northern Cape regularly face stockouts and shortages of basic medical supplies, drugs, food and stationary. When Spotlight for example visited Kakamas the hospital had among others no intravenous drip bags. Basic infection control was absent in Kakamas with no cleaning services over weekends and cleaners only working from 7am to 12 noon in the week. We received similar reports at a number of other facilities with various different medicines and other essential supplies being reported as being out of stock.

7. The central hospitals are taking strain

A key hospital in the province, Dr Harry Surtie in Upington has severe staff shortages with health workers and patients who spoke to Spotlight claiming the hospital has high death rates. According to news reports the Democratic Nursing Organisation of South Africa late last year downed tools at Harry Surtie mainly due to staff shortages and the fact that it was endangering lives. The Democratic Alliance has also been sharing figures of vacancies in some departments in the hospital claiming that only 228 of 327 hospital beds could be used because of staff shortages.  Patients are fearful of being referred to this hospital saying too many people return home in coffins. Some healthcare workers told us that people go to Upington to die. This could of course be because only the sickest people are sent to Upington, but most people seem convinced there is more to it.

8. Some facilities are downgraded to Community Health Centres, but forced to operate like hospitals

Keimoes and Kakamas Community Health Centres are buildings posing as health facilities. When Spotlight visited the two health centres it was being run by only a handful of nurses trying to hold the fort, basic medical supplies were out of stock, a long list of drugs were out of stock and some hospital board members were being accused of illegally receiving government tenders. The understaffing and horrible working conditions we saw for ourselves – while we cannot confirm that there is substance to the allegations of corruption, we can confirm that many healthcare workers believe there to be corruption – which is serious in itself.

9. Many primary Health Care clinics are virtually non-operational

Around Kakamas and Keimoes, several primary healthcare clinics such as Augrabies, Alheit, Marchand and Lutzburg had patients sitting outside when Spotlight went there, waiting for a nurse to arrive, hours after the clinics were supposed to open. Patients spoke of stockouts of basic medicines, having to wait long hours to see a nurse and health workers often not pitching. Mothers with newborns said they were also turned away to return at a later date for immunisations.

10. The Northern Cape government couldn’t care less about accountability

There is very little effort by those in power in the Northern Cape to show any accountability. For several months, Spotlight’s efforts to elicit any comment, explanation or meetings with the MEC, her advisor, the head of department or any other people in decisionmaking positions came to nothing. Promises of interviews and meetings came to zero, while all questions or requests via the media office or the HOD’s office were simply ignored. Almost 70 questions were sent to the MEC, the HOD and the head of Communications at end of 2018. These questions were resent in early 2019 with several follow-ups. There was no effort to engage or answer the questions other than the MECs advisor making some promises regarding a “no holds barred” interview which came to nothing.

Spotlight tried to get comment from the National Department of Health and was told that this was a matter for the health minister. However, we were later informed that the Minister was not able to comment as he had been busy with elections.

The Democratic Alliance in the province also expressed interest in commenting and said they had lots to say, but later indicated they were also busy preparing for the elections.

For many in the Northern Cape, once the razzmatazz of the elections has come and gone, their living hell will continue.

• Below we include the full list of questions we sent the Northern Cape Department of Health including the MEC, the HOD, the MEC’s advisor and the head of Communications. As explained above, the Department undertook to answer the questions, but never did so despite repeated extensions and reminders. These questions were also shared with the National Department of Health in February. They have also failed to comment.

Please provide us with answers to the below questions no later than close of business on 6 December 2018. We have visited a number of healthcare facilities in the province and interviewed a wide range of people. With the below questions we are giving the NC DoH an opportunity to respond to many of the very serious issues we have picked up. Should the department fail to respond by the given deadline we will go to press with the information we have at our disposal and state that the department declined to comment. We recognise that this is a long list of questions – which is why we are providing more than a week for the department to comment.

General Human Resources

1. Can you supply us with a logsheet of advertisements for vacancies in the health system over the past 12 months? If you are not able to do so, can you please indicate where you have advertised posts over the past two years.
2. Can you confirm that the province mostly relies on “block ads” where you put out a general call for CVs, place those on file and select CVs when you have vacancies.
3. Does the province struggle to recruit and retain healthcare workers such as nurses, doctors and specialists? Please explain.
4. How are admin clerks recruited and placed in clinics? Is this done in consultation with the facilities where they will be placed?
5. What steps has the department taken to avoid appointments in the province’s healthcare system being made on the basis of political affiliations?
6. What is the vacancy rates in your funded posts for nurses, doctors and specialists?
7. Please supply a breakdown of full-time doctors, specialists and nurses employed by the province and which facilities they are placed?
8. How many doctors and specialists are RWOPS? How is this monitored to limit abuse?
9. Are there any ComServ doctors in the province who are working without the required supervision?
10. Can you please supply us with the copy of the advertisement for the current Head of Department?
11. Can you confirm and explain why at least 28 admin clerks were appointed in Namakwa District facilities shortly after the local government elections?
12. Can you confirm that most facilities were not informed of these appointments?
13. Are you aware of reports that the current HOD Dr Steven Jonkers received a “golden handshake” in 2016 from his former employer, the Department of Transport before he was appointed to the health department? Were you aware of the pending charges of fraud and corruption at the time of his appointment? Has this investigation been completed and has the Department or Transport been able to provide an update on these charges and the investigation to the Department of Health?
14. Can you please share the current organisational structure of the Northern Cape health department? We note the one we were able to access from the 2016/7 annual report only has the name of the MEC.
15. Are there instances where people are appointed without any job interviews conducted?
16. Are line managers involved in recruitment or is it all done centrally?
17. Can you confirm how many foreign qualified doctors are employed by the NCape DOH? How many qualified in Cuba?
18. Does the NCape DOH currently have a doctor or nurse employed in a facility with a track record of substance abuse? Including a criminal record?
19. Does the NCape DOH have a website? What is the address?
20. Has there been a circular to staff informing them of the name change of Kimberley Hospital to Robert Sobukwe Hospital? Please can you share it?
21. Have HIV Counsellors in facilities been trained in the last 12 months? Please share details?
22. How many EMS personnel are employed that are higher than BLS? Please give breakdown between ILS and ALS?
23. Please comment on reports that most facilities face regular stockouts of basic drugs, medical supplies, food and stationary?
24. How many psychiatrists are employed full-time by the NCape health department?

Hospitals

1. Please comment on reports that Dr Harry Surtie Hospital in Upington is suffering from severe staff shortages? Please share relevant details.
2. Please comment on reports that Dr Harry Surtie Hospital has high death rates and that many patients are fearful of being referred to this hospital as many people die?
3. Can you confirm that Calvinia hospital has only two Community Service doctors who work unsupervised? If this is not correct, please explain what the arrangement is?
4. Please can you supply an update on the Psychiatric Hospital in Kimberley? When will it open, what the reason for the delay is, etc?
5. Please can you supply details on what the old De Aar hospital buildings and land will be used for?
6. Were the old De Aar hospital buildings gutted with the approval of the health department? If yes, who was the contract given to and how much was paid to the department?
7. How much is being paid to station security guards at the gate at the old De Aar Hospital?
8. Is there a plan to clean up the medical waste still on the grounds at the old De Aar hospital?
9. Please confirm how many doctors, specialists and nurses are employed at the new De Aar hospital?
10. How much money is paid for security at this hospital?
11. Please give a breakdown of the specialists employed at De Aar and whether they are full-time?
12. Please confirm that the casualty ward is run by nurses?
13. How many beds does the new De Aar Hospital have and how many of these beds are open and being used?
14. How many wards are not being used at the new De Aar hospital?
15. Please confirm that the TB Ward at the new De Aar hospital remains closed?
16. Is there a shortage of staff at De Aar Hospital?
17. Please confirm that the doctor stationed at Sutherland has resigned and that this means Sutherland and Fraserburg clinics will be without a doctor? Please also indicate what steps were taken to keep this doctor?
18. Please confirm that Sutherland clinic often operates without professional nurses who have to be on standby?
19. Do Sutherland or Fraserburg have any persistent stockouts of drugs of medical supplies?
20. When was Keimoes Hospital changed to a CHC? Why did this happen?
21. Please confirm that Keimoes still has 30 beds?
22. Please confirm that the casualty ward at Keimoes is run by nurses? Are these professional nurses?
23. Keimoes does not have a mortuary. What does the hospital do with deceased patients?
24. What does Keimoes Hospital do with aborted foetuses or stillbirths and what are the timelines related to these processes?
25. Please confirm that there is often only one ambulance operating from Keimoes?
26. Please confirm that the vast majority of ambulances are often not operational and in for repairs?
27. Please confirm that the ambulances are often used as patient transport vehicles transporting more than one patient to Upington?
28. Please supply a breakdown of ALS, BLS and ILS paramedics working from Keimoes.
29. We understand that the province has put out a new tender for an air ambulance service. What will this service do?
30. Have you received any complaints regarding the Kakamas Hospital CEO?
31. Does Kakamas Hospital have any full-time doctors?
32. Who fulfils the HR function at Kakamas Hospital? Is it the hospital administrator? Have her qualifications to be in this post been confirmed?
33. Are you aware that multiple members of the same family are employed at Kakamas hospital and other health facilities in Kakamas?
34. Can you confirm that the Kakamas hospital cleaners only work in the mornings and not over weekends?
35. Please supply a list of drug and medical supply stockouts at Kakamas and Keimoes hospitals?
36. Does Kakamas have supplies to administer IV drips?
37. Are you aware of any irregularities regarding the constitution of the Kakamas hospital board?
38. Are any members of the Kakamas hospital board involved in companies that are in business with the Department of Health in the province.
39. Please supply the operating hours of Augrabies, Alheit, Marchand and Lutzburg Clinics? What time do nurses start consulting patients?
40. Does each clinic have a dedicated nurse?
41. Do these clinics have stockouts of medical supplies and drugs?
42. Is the province satisfied that patients enjoy privacy while being consulted by a nurse?
43. Do TB patients received their treatment at the backdoors of some clinics?