Six years after Life Esidimeni: Deinstitutionalisation at risk as NGOs are paid late
Six years after the Life Esidimeni tragedy unfolded in Gauteng, an inquest into the circumstances under which more than a thousand psychiatric patients were moved into the care of NGOs and about 144 died, is set to start in the North Gauteng High Court in July. Meanwhile, some mental health NGOs and activists maintain that the Gauteng Department of Health is still short-changing mental health services and that systemic challenges remain.
One such challenge surfaced earlier this year with late payments to over 100 non-governmental organisations (NGOs) housing and providing care for mental health patients.
DA MPL Jack Bloom sounded the alarm over these late payments by the Gauteng Department of Health. “Towards the end of the financial year which ends on 31 March, there is always a ‘dry season’ because the [Gauteng] Department of Health is short of funds and it carries over to the new year,” says Bloom.
He says another problem is the delay in signing new Service Level Agreements with the NGOs. “It boils down to inefficiency and insensitivity to NGOs who constantly struggle with cash flow problems. Unreasonable demands are made in the SLAs, including unnecessary and expensive technical issues,” he says. “It is disappointing that the Life Esidimeni tragedy has not led to a constructive relationship with mental health NGOs.”
‘Like lending government money’
Manager of Ebenezer Psychiatric Home in Roodepoort Lee-Ann Scholtz told Spotlight that these late payments by the government affect the way NGOs render services to the users.
“The biggest problem,” she says, “is that we almost [lending] government money before they pay us so that we can take care of the patients in the homes. But that is very difficult to do when you don’t have money. We [have] to provide workshops, we have to provide food, we have to provide medicine,” she says.
According to Scholtz, the government sets many stipulations that NGOs have to follow. “It’s very easy to do all these [things] when you have money. But when you don’t have money, it becomes very difficult because you have to look after patient’s well-being [by] making sure they have a home, they have a bed, and they have food on the table,” she says.
“So, when the government doesn’t pay you, the food obviously is a big thing. You need to provide three meals a day for every single user that you have,” Scholz says, adding that the users have to eat according to a menu provided by a dietician. “If you don’t have money from the government, then how do you provide those types of food to the patients?” she asks. Scholtz says the late payments result in staff members having to buy necessities from their own pockets.
She says the main issue between NGOs and the department is how they are paid. She says they are often paid six to eight weeks after they submitted their claims. Many are unhappy with this because it means that in this period while waiting for the payments, they go into debt to provide services. “That means eight weeks of spending money that we also don’t have. Where must we get it from? There is rent, rates, and taxes, operational costs, we have staff that needs to be paid, ” Scholz says.
“We look after people that have disabilities, that require certain medicines. The government gives us a set subsidy. We have to feed them, look after them, house them. You need to pay your rent, your telephone [bill]. Actually, the subsidy doesn’t cover everything,” she says. “We are always fundraising to get a little extra income so that we continue to operate. But when it gets to us not being paid on a monthly basis, it becomes very difficult.”
According to Scholz their operational cost for a month is more than what the government is giving them, however, she says, it does help towards looking after the patients.
Spotlight spoke to managers at other NGOs who expressed similar concerns to those raised by Scholtz, but who did not want to be directly quoted in the media.
Bloom says most of these NGOs get subsidies amounting to about R4000 per patient per month, whereas the patients that Life Healthcare currently looks after get more than R16 000 per patient. “They need to look at a fair subsidy for all mental health patients,” he says.
According to the National Executive Director of the South African Federation for Mental Health Bharti Patel, late payment of subsidies to NGOs is an old problem. She says that people have given up on the government and feel demoralised.
“While organisations try to do their best to provide shelter and daily care for residents, mental health care users are left feeling isolated and forgotten which negatively affects their wellbeing,” Patel says.
When Life Esidimeni happened, the Human Rights Commission as well as the Health Ombud found that the health officials illegally issued licenses to NGOs that were not equipped to care for mental health patients.
“The current established NGOs that have been providing residential care to persons with mental health conditions for decades, have used up all their reserves and donations to provide care for which government is responsible. Government is failing its most marginalised citizens once again,” Patel says.
Legislation and policies that are in place in South Africa state that it is the government’s responsibility to provide basic care and services to its most marginalised citizens. Patel says that this means government officials are duty bearers and responsible for making resources available. “Government does not have the infrastructure and human resources to provide residential services to mental healthcare users in the community. NGOs have been licensed by the Departments of Health and Social Development to provide such services. Service level agreements are signed and government is duty-bound to honour these agreements,” she says.
According to Patel, the NGO Funding Policy developed by the National Department of Social Development has taken over five years to be finalised. Each provincial department may develop its own NGO funding policy which does not seem to take into consideration the needs of the communities they serve, she says.
“It is unclear what system exists for the funding of the care of mental healthcare users in provinces. The Western Cape is the only province that ensures proper and adequate funding to NGOs who are therefore able to provide dignified care to mental healthcare users,” she says.
Gauteng Health responds
The Gauteng Department of Health says that it is important to note that under normal circumstances, NGOs are paid their subsidies on time. However, with the start of a new financial year, there are delays due to budget approvals and other supply chain issues.
“The challenge in 2021 was compounded by the renewal of the expired contracts at the end of March 2021, hence the extension of three months was considered in the meantime while the department was finalising the Service Level Agreement (SLA) and Funding agreement,” Gauteng health department spokesperson Kwara Kekana tells Spotlight.
Kekana says there were also other changes that had to be implemented with the licensing of the NGOs to align the processes with the recommendations in the Health Ombud’s report on the Life Esidimeni tragedy.
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— Spotlight (@SpotlightNSP) June 17, 2021
According to Kekana, the department discharges mental healthcare users from specialised mental health hospitals and general hospitals with psychiatric wards “when the doctors have ascertained that they have been stabilised and have no side-effects of medication that require close observation by professionals; have had rehabilitation initiated for continuation at district health services level [and when] their residual symptoms no longer require professional care for a longer period”.
“Mental healthcare users are commonly discharged back to their families, but those without families or whose families are not in a position to care for them are then referred to NGOs or contracted care,” she says.
Presently there are 145 NGOs in Gauteng licensed to provide services for mental healthcare users with a severe psychiatric disability or severe and, or profound intellectual disability, she says. These NGOs are monitored on a quarterly basis and assessed based on compliance with legislative processes, the quality of services rendered, and how the organisations are managing their finances.
When asked how the department ensures that the mistakes of the Life Esidimeni tragedy are not repeated, she says the provincial health department is implementing the recommendations as per the Ombud’s report. The mental health NGOs are licensed, and the department is currently “scaling up the implementation and supervision of the recommended national norms and standards for Mental Health Care Services for Residential and Day Care facilities as stated in the National Mental Health Policy Framework and Strategic Plan 2013 – 2020.”
But according to Patel the process of deinstitutionalisation has not worked.
“The recommendations made by the Health Ombud and the Human Rights Commission have not been implemented as the government drags its heels. Ongoing delays and failures by health officials to ensure that the system of funding works and ensuring that resources follow the mental healthcare user are yet to be implemented,” she says.
Gauteng Health spokesperson Philani Mhlungu could not immediately provide an update on the department’s progress in implementing the recommendations.