#Vote4Health | Only one of five political parties responds with their plans for KZN Health

#Vote4Health | Only one of five political parties responds with their plans for KZN HealthEstimated life expectancy at birth in KwaZulu-Natal was 63.7 in 2023, compared to 65.9 nationally. (Photo: Denvor de Wee/Spotlight)
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24th May 2024 | Ufrieda Ho

KwaZulu-Natal is a high-stakes province that seems set for substantial political shake-ups come 29 May. Whichever way the pie gets divvied up though, healthcare is a matter of life-and-death. Ufrieda Ho asked five political parties about their plans for health in the province. Only one responded.

Health challenges differ substantially between South Africa’s provinces and the day to day running of the public healthcare system relies on strong and efficient provincial health departments. Spotlight asked key political parties in KwaZulu-Natal to set out their specific strategies to improve the health systems in the province beyond what is set out in broader national-level manifestos.

We previously published similar articles on what parties are putting on the table for health in Gauteng and the Eastern Cape.

In KwaZulu-Natal, the five parties we contacted were the ruling party, the African National Congress (ANC), the official opposition, the Inkatha Freedom Party (IFP), the Democratic Alliance (DA), the Economic Freedom Fighters (EFF), and newcomers Umkhonto weSizwe (MK). Polls suggest that MK will get a substantial share of the votes in the province.

Of the five parties contacted, only the DA responded. Multiple attempts were made to get responses from the other four parties.

The fact that only one political party out of five that were approached in KwaZulu-Natal responded to Spotlight’s questions adds to the disconnection between politicians and the people, says Professor Zamasomi Luvuno, deputy director at the Centre for Rural Health at the University of KwaZulu-Natal (UKZN). “Politicians serve at the pleasure of people who have nominated them and they should know that the way that you communicate with the people who nominated you is also through speaking to the media,” she says.

“South Africa is at a tipping point in healthcare and service delivery, and while the NHI affirmed the government’s position on universal health coverage, it also amplified many challenges around current inefficiencies in service delivery and access to care that cannot be ignored. It requires of government to engage with various stakeholders to address difficult questions that remain unanswered,” says Professor Eliza Govender who is academic leader of the Centre for Communication, Media and Society at UKZN.

The context

KwaZulu-Natal, according to the last census, has a population of 12.4 million people, making it the second most populous province in the country. It’s also the province that has the highest HIV and TB burden. According to Thembisa, the leading mathematical model of HIV in South Africa, over 1.9 million people in the province are living with HIV. This works out to HIV prevalence of over 16% – the national number is under 13%. Around three out of every 10 women and girls in the province aged 15 to 49 are living with HIV. Estimated life expectancy at birth in the province was 63.7 in 2023, compared to 65.9 nationally.

Around 90% of people in the province rely on the public health service, according to the KwaZulu-Natal Department of Health. At the same time, the department’s annual reports state year on year drops in its staff numbers. Currently around 12% of posts are unfilled.

According to the latest KwaZulu-Natal report from Ritshidze, a community-led clinic monitoring and data collection project, in 98 facilities monitored in the three districts of King Cetshwayo, eThekwini and uMgungundlovu, there were 199 vacancies for professional nurses and 47 vacancies for enrolled nurses. Of the 126 facility managers they surveyed, only 35 answered yes when asked if they have enough staff.

Dissatisfaction over unfilled posts and doctors stuck without jobs, turned into protest in April this year. Dozens of unemployed doctors – who had completed their community service but could not secure job appointments – protested and staged a sit-in at the provincial health department’s head offices in Pietermaritzburg.

The province’s health department however, says it isn’t able to resolve the vacancy crisis, stating repeatedly in its most recent annual health report that “inadequate funding allocation received” is the reason it can’t employ more people.

The health budget for the province for the period 2024/2025 comes in at R53.8bn, about R3bn more than the previous year. Beyond the amount it receives from Treasury, the province has struggled with other management and governance issues that put pressure on its budget. Looming over the department is R17 billion in medico-legal claims, with annual pay-outs that eat into its budget. In the 2021/2022 financial year, R353 million in claims were paid out.

Alongside the medico-legal claims, the department has an outstanding debt owed to the National Health Laboratory Services (NHLS). The NHLS notes in its annual report that a payment arrangement had not been reached, adding that at the end of its fiscal year 2023 its “trade debtors amounted to R6.3 billion, most of the debt is owed by KwaZulu-Natal (historical disputed debt) and Gauteng”.

More bad news for the province has been the likes of the high-profile case of alleged fraud and corruption involving the extension of a R32 million contract. This relates to four mobile clinics signed off in 2013 to a company called Mzansi Lifecare when the country’s Deputy Minister of Health Dr Sibongiseni Dhlomo was the province’s health MEC.

Deputy Health Minister Dr Sibongiseni Dhlomo trying to get rid of advertisements for illegal abortions during a march against unsafe abortions in Rustenberg. PHOTO: DOH Twitter
Deputy Health Minister Dr Sibongiseni Dhlomo trying to get rid of advertisements for illegal abortions during a march against unsafe abortions in Rustenberg. (Photo: National Department of Health/Twitter)

It took ten years for high ranking KZN Department of Health officials, implicated in the case, including former head of department Dr Sibongile Zungu, to appear in the Durban specialised commercial crimes court in May 2023. They face charges of fraud and contravention of the Public Finance Management Act. The case is not yet finalised.

A view on what is needed

For Luvuno, a top priority for the provincial health department should be to create and implement patient-centred approaches to healthcare. This includes being awake to shifting health priorities in KZN, using science and research better, and being deliberate about including communities in decision making and policies about their healthcare needs and services, she explains.

“We see for example that with more people doing very well on ARVs, they are living longer and are starting to be affected by a range of non-communicable diseases (NCDs) like hypertension and diabetes,” Luvuno says. While HIV and TB rates are slowly coming down in South Africa, rates of several NCDs are on the increase.

Luvuno says we need an approach that understands that we are treating someone who is unwell, with multiple morbidities. “They need to be treated as a whole person, not as conditions. Our health priorities are shifting but we keep on using old models of care that are not serving us well,” she says.

New models, Luvuno says, could mean flexible or extended opening hours at clinics and doing better logistical planning on a local level, like better patient transport planning, to improve accessibility of services for more people.

Politicians’ relationships with donors and funders, she says, also need to change so that funders are also on board to ensure they are not just “handing over envelopes” but recognise for instance, that non-communicable diseases are not the “a step-child” of the changing healthcare needs in KZN.

Political interference in the day to day running of healthcare also needs to come to an end, she says, adding: “There are positions that should not be politically aligned. We need people allocated to posts who have the health skills, knowledge and framework to understand new information, or new best practices and to quickly translate this information into guidelines and policies.”

‘Relatively simpler’

Andy Gray, a senior lecturer in the division of pharmacology at UKZN, who has worked for 30 years in the province, says the KwaZulu-Natal Department of Health has been through repeated change of MECs and heads of department but has not been in the media with as many problems as other provinces.

“So it doesn’t have the sort of feeling of complete collapse of the Eastern Cape, nor does it have the high profile dramas of Gauteng. This is partly because it’s relatively simpler with one memorandum of agreement between one medical school that covers the training of students and joint appointments of doctors and specialists and one central tertiary hospital, Inkosi Albert Luthuli Central Hospital,” says  Gray.

He points out there have been some successes for the province, including that some districts have achieved the 90-90-90 targets to end HIV. According to estimates from the Thembisa model, in 2023, 96% of people living with HIV in KwaZulu-Natal were diagnosed, 89% of diagnosed people were on treatment, and 94% of those on treatment were virally suppressed. These numbers are substantially better than those for the country as a whole – 95%, 79%, and 91%.

Malaria has also been successfully kept under control. KwaZulu-Natal has consistently reported declining case numbers and of the three endemic provinces, KZN is set to be the one most likely to reach elimination.

Gray however, says the problems for the province are significant. He says much of this stems from under-funding of the province from Treasury, coupled with the need for better management of the budget.

He says, unlike provinces like North West, Mpumalanga and the Eastern Cape, KwaZulu-Natal does not get additional resources per population from Treasury as it’s not considered to be an under-resourced province. Rural areas, for instance, are considered to have higher poverty rates and Treasury transfers are adjusted for this, which boosts provincial budgets.  Gray says the province loses out when the provincial equitable share (PES) formula is used. The PES is a weighted average calculation that Treasury uses to transfer revenue to each of the nine provinces.

Bolstering services in rural areas is essential, Gray says, and must take central focus for any new ruling party. He says this ensures that services are located where people can access them in a province that has vast distances between health facilities and also protects services in the urban centres from being further congested or undermined.

“I am also not convinced that KwaZulu-Natal has managed to equitably staff hospitals in what was formerly the homelands and what was formerly Natal, to ensure that rural hospitals have the same level of service as the more urban hospitals. So the bias towards Durban and Pietermaritzburg is still there,” he says.

Another issue he raises is that of staff shortages, in particular of specialists. As an example, he says clinics are highly dependent on nurses to carry out pharmacy duties, instead of having pharmacy assistants and pharmacists. Roving specialist teams are also unable to get to all the facilities on their lists.

“Just looking at pharmacists per 100 000 uninsured person in the province, we are at a quarter of what we need in KwaZulu-Natal; every single district in the province falls below the national average. By contrast, not a single district in the Western Cape falls below the national average. That is quite revealing because it speaks to persistent under-funding of the province,” he says.

For Gray, the province is “stuck with very much the same system that was in place in 1994” and is in desperate need of modernising. Health systems have not advanced significantly in the past 30 years, he says. It means that the province still does not have an electronic information system for patient files and medical histories to be held digitally and be accessed electronically regardless of which facility they use in the province.

Gray says post 29 May, the key issue to watch will be the impact of National Health Insurance (NHI), following it’s signing into law by President Cyril Ramaphosa. He says what comes next remains a  “big unknown” because of dramatic changes to the role of provincial administration.

“Losing the province’s central hospital to national control I think would be quite dramatic. Also, having the district’s health management offices become national structures, is fundamentally overturning of the role of provinces and their relationship to district. Even though the implementation of NHI might  take a long time to come about, it has the potential to be quite disruptive,” Gray says.

What the DA is promising

Edwin Baptie oversees the DA’s health portfolio in the province. He identifies key problems for the province as the high number of staff vacancies, the state of the emergency and ambulance services, and the “very poor management of the budget” that amounts to “serious negligence” in some cases. It was the DA that laid criminal charges in the beginning of 2020 that led to the investigation into the case of fraud and corruption relating to the extension of the mobile clinic scandal that is working its way through the court system.

Baptie says emergency vehicles and ambulance services are at “near collapse”. He says vehicles are not being properly equipped or maintained and there is a shortage of paramedics.  Private ambulance service providers have in the meanwhile mushroomed in the province, with Baptie describing it as “a situation that demonstrate that a private/public partnership between these services is more likely to meet growing healthcare demands than the ANC’s centralised risk-riddled approach NHI proposal”.

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Baptie also highlights a seeming discrepancy between budget numbers and the high staff vacancy numbers. “We know that two thirds of the budget goes to paying the cost of employees. But if that is the case, one wonders why we have a shortage of professionals, medical professionals, doctors and nurses in the department.

“It’s not a small budget that KZN Health has, but it’s difficult to say where the money goes because reporting to the portfolio committees is inadequate or incomplete. Questions I put in the legislature also go unanswered. Other times you will find a lot of information, but not information that you need to have a full understanding of where the money has gone,” he says.

The DA and the IFP are key parties in the multi-party charter that is contesting the elections as a coalition pact.

Baptie says that the elections presents the chance for the DA and the IFP, which is the official opposition party in the province, to unseat the ANC. In such an instance, the DA would want control of the health portfolio, says Baptie. “If we are in a majority, we will want to be in control of some of the key portfolios such as finance, education and health,” he says.

Baptie says the DA has a five-year plan. For health, the priorities will include changing the oversight model in the legislature to ensure better reporting to portfolio committees. This includes access to and clearer organisation of information.

The party also wants more decentralised powers to clinics and hospitals to improve operations at facilities. “We need to conduct oversight in a way that holds people to account. At a hospital level, we need to ensure that people can’t pass the buck. We also aim to cut patient waiting times by half and to ensure that when people arrive at facilities they are treated with dignity, not met with unfriendly nurses,” he says.

Baptie also says better vetting will be in place to have the most competent candidates employed, retained and part of building human resource capacity in the province. “We also want to put people in positions who can do the job – not people who are beholden or loyal to a party,” he says.

Lifestyle audits would also be on the cards and there would be a finer spotlight on procurement, which is seen as a key area to be targeted to reduce fraud and corruption.

“We need to stop this issue of the department having to pay contractors and consultants to do infrastructure work or to compile reports but the work gets done so badly and has to be redone by another round of contractors and consultants,” Baptie says.

The other four political parties Spotlight approached responded as follows:

The IFP – The IFP is the official opposition party in the province. Ncamisile Nkwanyana is the party’s spokesperson for health and a member of the legislature. Nkwanyana was contacted by email with questions. She was also contacted by telephone call. She took one call and set a time for an interview but at the scheduled time she did not pick up and subsequent attempts to get her to take a call have failed.

The ANC – The KZN ANC office referred questions to its communications officer Hlengiwe Hadebe. Hadebe was contacted via telephone call. Questions and interview outlines were provided to her via Whatsapp. Hadebe took follow-up phone calls and said she would arrange for the questions to be answered by “the person responsible for your task”. No one responded.

The EFF – The EFF was contacted via email and sent reminders for a request for an interview or to answer questions that were provided. No response was forthcoming.

MK – MK was contacted via email and sent reminders for a request for an interview or to answer questions that were provided. No response was forthcoming.

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