People: Face to face with Dr Bandile Masuku

By Biénne Huisman

New Gauteng MEC for Health Dr Bandile Masuku has had a long day, but it does not show. His voice is slow and thoughtful; his attire immaculate: shiny shoes and a navy cardigan, buttoned all the way. Behind spectacles his eyes are bright. ‘They’re Tom Ford. Yes, I’ve been colonised,’ he says, laughing.

Masuku’s new job is no laughing matter — of this he is well aware.

On May 28 he was sworn in as Gauteng’s new head of health, inheriting a department described by Premier David Makhura as ‘on its knees.’ This despite receiving the biggest portion — R50-billion — of the provincial budget.

‘It’s a daunting task,’ says Masuku. ‘You know, one of those key moments in your life.’

We’re inside a boardroom at the African Pride Irene Country Lodge in Centurion. Outside, an ANC caucus is underway.

Earlier today Masuku joined Makhura on a surprise visit to Mamelodi Hospital, in the Mamelodi township northeast of Pretoria. A video showing 76-year-old patient Martha Marais handcuffed to a bench at the hospital went viral on social media last month. The hospital has been under scrutiny since, with the South African Human Rights Commission stepping in.

Dr Bandile Masuku. Photo by Thom Pierce

‘People are saying Mamelodi is my fire baptism, and in a sense it is,’ Masuku says. ‘It combines all the problems we face in the department: staff shortages, bad staff attitudes, inadequate infrastructure, no appropriate equipment, cleanliness of hospitals.’ While speaking, he ticks off the challenges on his fingers.

‘I mean restraining in a medical ward, this is not something strange. But you cannot restrain a patient by cuffing her hand to a bench. No, we certainly don’t use handcuffs. Appropriate equipment and medicine is needed. A patient should be restrained on a stretcher or on a bed.’

Masuku says — as a starting point — staff morale will be addressed through a human resources programme to be rolled out at health facilities across Gauteng.

‘You know, bad staff attitudes don’t just happen because people are badly raised. So there would be factors that make them edgy; irritable, angry and fatigued. We have enlisted the help of a team who deal with staff morale, who are designing an intervention program. They call it “employee value proposition”. This will be put in place for all our administrators, for all our clinicians. The thing is we also need them to buy into it, to add onto it, so that it’s not just something that comes from the top. I think uplifting staff morale will change staff attitudes,’ he says.

‘We also have to improve training, you know. People need to be trained in customer care. And beside empathy and care, they must be trained in handling difficult situations; handling angry or violent or hostile patients.’

Filing is another pressing concern. ‘The issue of the filing system came up fairly sharply too. Many patient files have been lost. We really need to go electronic, digital. That will save a lot of time and a lot of space.’

Speaking of the Mamelodi incident, Masuku’s words carry the gravity of someone who has worked at the coalface himself. Indeed, he has practised as a doctor at hospitals around Gauteng: Charlotte Maxeke Academic Hospital, Chris Hani Baragwanath Hospital and Pholosong Hospital. His speciality is obstetrics and gynaecology. Right before his appointment, Masuku headed the obstetrics and gynaecology unit at Thelle Mohoerane Regional Hospital, in Vosloorus.

Masuku was born at Baragwaneth in Soweto 43 years ago. ‘So I ended up working the very maternity ward where I was born. I’ve come full circle,’ he says.

In Soweto, he grew up in a family of health workers. One of three siblings, Masuku was the middle child between two sisters.

‘I’ve always been surrounded by health workers,’ he says. ‘Two of my aunts were nurses and my paternal grandmother, well she was one of the first nurses in Soweto. Actually, she was in a class with Nelson Mandela. So it just came from there; their ability to have empathy, their ability to care and to do things for others, all of that played a great role.’

A bright youngster, Masuku excelled at school. ‘I didn’t even do standard four,’ he says. ‘Yeah, I was promoted. I got almost 100% in standard three, so went straight ahead to standard five.’

At Sekano-Ntoane Secondary School, he cut his political teeth at the Congress of South African Students (Cosas). This saw him detained, disturbing his preparations for matric in 1991. Not wanting to jeopardise his career, he repeated the year, matriculating again in 1992. ‘Because of my political activism, I repeated matric,’ he says. ‘My first matric mark was adequate, but not good enough for university and medical school. The second time went much better; I got an A for English, with my maths and physics marks much improved.’

In 1994, he enrolled for a BSc at Sefako Makgatho Health Sciences University in Pretoria, then known as the Medical University of South Africa (MEDUNSA); and in 1998 for a degree in medicine, completed in 2004. Again he repeated a year — 1999 — the year he served as president of the university’s Student Representative Council (SRC).

‘When I was SRC president,’ he says, ‘I didn’t attend any classes, even though I was expected to do so. While I wanted to be a doctor, I also had to fight for student rights and student grievances.’

Speaking to Masuku, it becomes clear that his ambition to become a doctor and his predilection to lead politically have always existed side-by-side, often clashing.

In 2002 he was elected to the national executive committee of the South African Students Congress (SASCO); and in 2013 he became national spokesperson for the ANC Youth League.

What drew him to obstetrics and gynaecology? Was it because he grew up in a family of women? He laughs. ‘Yes, it was a natural choice,’ he says. ‘My first time in a hospital as a medical student was in a maternity ward, I was in my third year. Then, when I finished my medical degree as an intern, my first block was in obstetrics, at Charlotte Maxeke. I fell in love with it — it felt like something I would love to do for the rest of my life. It combines being a doctor with a little bit of surgery. There is also the big satisfaction of having two patients in one — literally.’

On his own home front, Masuku has three sons. The youngest, born in the week of his inauguration, is but a month old. ‘No I am not getting much sleep,’ he says, smiling.

His wife of four years, Loyiso, is a local ANC councillor. The family lives in Alberton.

On his iPad, Masuku keeps mostly political books. He is a follower of Argentine revolutionary and physician, Che Guavara. ‘Most of my books and collections about Guavara are his thoughts about medicine,’ he says. Then there are the icons: Nelson Mandela, Oliver Tambo, Walter Sisulu and Steve Biko. His favourite book is Let My People Go by Albert Luthuli. ‘This is Albert Luthuli’s biography. Actually I think it’s one of the first books I really understood because I wrote an essay about it in my matric exam. The question was: “Tell us about a book you would advise all young people to read?” It summarises the history of our country, the history of our struggle and the basic principles surrounding it.’

Masuku likes to unwind watching soccer, especially at the stadium; with occasional bouts of rugby, cricket, boxing and Formula One support thrown in. ‘I used to play soccer,’ he says. ‘At varsity I even formed a team, it’s still there. But I’ve stopped, I felt that if I get injured now… My daily life really is a bit hectic, especially now.’

On average, Masuku’s days start early: he first reads on his iPad, then from six o’clock, he starts preparing for work. ‘It all depends on where I am supposed to be that day,’ he says. ‘I don’t go to the office much. I’ve been visiting a lot of facilities, doing unannounced site visits. For example, this morning I went with the premier to Mamelodi Hospital. He decided late last night that he needed to go over there himself.’

On the Life Esidimeni catastrophe, which saw at least 144 Gauteng psychiatric patients die after being transferred to inadequate facilities, Masuku says: ‘This is a very big tragedy for our country. We need to see this tragedy not repeating itself.’

‘Esidimeni gives us lessons,’ he adds. ‘In health, when errors happen, these adverse effects give us an opportunity to do things differently. When you understand the problem, it’s the first step to coming out with the right solution.’

According to Gauteng’s shadow health MEC Jack Bloom, of the DA, fifteen Esidimeni patients were still unaccounted for in May.

These are big challenges. In a show of humility, Masuku admits he will need help in his new role. ‘I don’t think with my own wisdom alone I’ll be able to do it,’ he says. ‘I will need a lot of help. I’m going to rely on people who also have experience in the field, and passion. Take for example the Treatment Action Campaign (TAC). These are people, ordinary people, who have a passion for how quality health care could be. And it’s not like they have all the answers, but they work with the people, they develop solutions with the people. They do not intend to solve everything at once, but they understand that there is a bit they can do. So us in government, we can use the strength of the TAC in terms of mobilising communities.’

Masuku says he has invited Bloom over for tea to discuss the portfolio. He has also approached the EFF and IFP for input.

‘What I’ve decided in my head is that I’ll give this my best shot,’ he says. ‘And I’m hoping that my leadership style, my ability to analyse the problem in a proper way will lead us toward something. I have a long history of board experience too, which also gives you a sense of governance.’

It may well be that Masuku’s new position as health MEC is the ideal culmination of his attributes and experience thus far, both as a medical professional and as a leader.

‘We need to change how we do things, improve how we do things,’ he says. ‘We need to achieve a new normal, you know. A level of efficiency that when you get used to it, it just becomes an everyday thing.’

He reiterates that Mamelodi Hospital will serve as the benchmark of his tenure. In fact, he insists that his progress at Mamelodi be assessed at premier Makhura’s State of the Province Address in February next year.

Fixing the public healthcare system in South Africa’s most populous province might well be one of the toughest jobs in the country. For now, Masuku’s frankness and his seriousness about the task at hand inspires cautious optimism. He might well be just the right person for the job. Time will tell.

Welcome detail in Mpumalanga HIV and TB plan

The National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 is supposed to guide South Africa’s response to HIV and TB. While this national plan sets out broad targets and strategies, the implementation of this plan depends on provinces. To this end, each province had to develop a provincial NSP implementation plan (PIP).

Mpumalanga’s plan is called the Mpumalanga Provincial Implementation Plan for HIV, TB and STIs 2017 – 2022 (the Mpumalanga PIP). (Spotlight previously published analysis of the KwaZulu-Natal PIP.)

Broadly speaking, the Mpumalanga PIP stands out for including a series of well-chosen concrete implementation targets. While most provinces include targets in their plans, targets tend to be broad and to relate to indicators such as new HIV infections, rather than to the specific interventions that will help reduce new HIV infections. Mpumalanga is thus one of the relatively few provinces whose implementation plan goes beyond just broad statements of intent and engages seriously with implementation. Below we analyse the PIP more closely. 

The context

Around 7 100 people died because of HIV in Mpumalanga in 2018. This is much lower than the peak of 31 000 in 2006. Around 19 300 people became HIV positive in the province in 2018. Since more people are becoming infected than are dying, the absolute number of people living with HIV in the province is still rising.

As in other provinces, the dramatic decline in AIDS deaths is driven by the increased availability of antiretroviral therapy. By 2018 there was in the region of 470 000 people on treatment in the province – more than ten times as much as 10 years ago. 

Around 700 000 people in the province are living with HIV – This amounts to 15.4% of the population. This makes Mpumalanga the province with the second highest HIV prevalence in the country behind only KZN.

Regarding the first of the UNAIDS and NSP 90-90-90 targets, Mpumalanga is tied with the national estimate of 90.5% of people living with HIV knowing their status. Regarding the second 90 – percentage of diagnosed people on treatment – Mpumalanga is estimated to be on 73.5%, ahead of the national estimate of 68.4%. On the third 90 – percentage of people on treatment who are virally suppressed – Mpumalanga is on 88.1%, just below the national estimate of 88.4%. (This is using the UNAIDS definition of <1000 RNA copies/ml – <400 RNA copies/ml is also used sometimes).

While the performance on the 90-90-90 targets is decent when compared to other provinces, it should be considered in the context of the province’s extremely high HIV prevalence. In this light it is at least as urgent in Mpumalanga as elsewhere to improve on the second 90 by taking concrete steps to help more people to start treatment and to stay on treatment.

The Mpumalanga PIP

As with most PIPs, the Mpumalanga PIP contains useful information on the state of the HIV and TB response in the province. Various problems in the response are identified, often with specific districts or sub-districts identified as focus areas. Two of the province’s three districts, Gert Sibande and Ehlanzeni, are of the hardest hit by HIV and TB in the country. 

In some instances the PIP’s recognition of the problems in the province is refreshingly frank and honest. In relation to TB it states: “The provincial challenges to address mortality and morbidity were largely linked to inaccessible TB treatment services due to drug stockouts, inadequate care provision and poor adherence models.”

Like most PIPs, the Mpumalanga PIP is good on the broad solutions. For example, in relation to TB screening it states: “Testing for TB will be intensified at facility level to amplify TB case finding in high burden areas such as mines, correctional services, mining communities, etc. A provincial drive to promote household symptom screening and the use of a combination of Xpert MTB/RIF and culture tests will be initiated. Ward-based outreach teams will be used to initiate TB positive clients on IPT (TB preventive therapy) and track and trace TB contacts.”

As a general statement on TB detection and TB prevention this ticks many of the boxes one would want to see ticked in the PIP. 

So far, so good. But implementation plans need to go beyond such broad statements of intent if they are to have any impact on implementation. The KZN PIP, for example, generally does not – fortunately the Mpumalanga PIP often does.

More detail than most

A problem with some PIPs is that it sets targets to reduce new HIV infections but does not contain much planning on how the reduction will be brought about. While the Mpumalanga PIP suffers from this to some extent, it also contains some well-chosen targets that get at the “how” and not just the “what”.

So, for example, the Mpumalanga PIP contains a target to increase the number of facilities providing voluntary medical male circumcision in the province from 64 to 85. This may not seem a particularly ambitious target, but it is achievable and provides a concrete means by which to reduce the rate of new infections in the province. In addition, the Department of Health is identified as being responsible for meeting this target. Ideally, the Provincial AIDS Council will ask the Department of Health to report on their plans and progress in this regard every time the council meets. Since it is such a clear and simple-to-track indicator, the Department of Health can have no excuse for not reporting.

Similarly, the PIP sets a target of increasing the number of youth and adolescent friendly accredited healthcare facilities from two to 36 over the period of the PIP. Again it is a concrete and implementable target that the Department of Health can be held accountable for. As discussed later in this article, the PIP falls short in other respects when it comes to young women and girls, but this target at least proposes another concrete and measurable intervention.

But some short comings

The Mpumalanga PIP nevertheless leaves some crucial areas insufficiently addressed. Despite a professed focus on HIV prevention and a “substantially stronger focus on adolescent girls and young women” there are no specific targets on providing PrEP and the condom distribution targets are roughly in line with current levels and does not include the specific targeting of young people and the provision of condoms at schools. Instead, the PIP’s focus is on incremental improvement of interventions that are already being implemented.

This tendency not to contain much ambitious thinking beyond the status quo is unfortunately very common in provincial planning. One can only speculate, but it seems likely that this relative conservatism is due to the relative weakness of civil society representation in many PIPs – which often means PIPs end up reflecting the trajectory government is already on. Ideally though, forums like AIDS councils and planning documents like PIPs should be places where civil society can pressure government to be more ambitious in its response to HIV and TB.

In addition, while the PIP proposes various useful interventions, it arguably relies too heavily on community dialogues and other forms of meetings. Dialogues are important, but, once you have empowered people with information you need to back it up with concrete interventions such as the provision of PrEP or condoms.

As in other provinces, there are questions to be asked about the implementation of the PIP. Two years into the plan, the PIP has not yet been costed – although we understand that a costing is in progress and should be completed soon. Questions we sent the contact person for the Provincial AIDS Council regarding the finalisation and adoption of an M&E framework for the PIP went unanswered.

Finally, the PIP states: “The province will develop a Provincial Social and Behaviour Change Communication Strategy under the leadership of the department of Social Development in order to assist individuals and communities to implement communication strategies that reduce HIV, TB and STI risk behaviours.”

We asked the Provincial AIDS Council’s contact person whether the communications strategy has been developed but received no answer despite various follow-ups.

The way forward

With a costing expected soon and with a number of useful indicators, Mpumalanga has some of the building blocks in place that can set the stage for real progress against HIV and TB in the province. Whether or not this potential is realised will depend largely on whether or not the political will exists in the province to make implementation of the PIP a reality and to improve the functioning of the public healthcare system.

Mpumalanga faces severe HIV and TB epidemics and, as with a number of other provinces, is struggling with widespread dysfunction in the public healthcare system. The challenge ahead of Premier Refilwe Mtsweni and MEC for Health Sasekani Manzini to build a more capable state in the province is daunting.

Arguably the most critical element of this challenge is to ensure enough appropriately qualified healthcare workers and other staff are employed in the province’s public healthcare system. The PIP has the following, among others, to say about the province’s human resource needs:

  •  “Given the ambitious nature of the PIP’s service targets and the imperative to expand efforts to address social and structural drivers, human resource needs under this PIP undoubtedly will grow and further diversify.”
  • “The PIP requires an increase in the number of primary health care nurses who have the skills to administer antiretroviral therapy, manage drug-resistant TB, and address STIs beyond syndromic management, as well as a sufficient number of doctors to support services.”
  • “Linking with national processes that facilitate the formalization of community health workers as a cadre, appropriately trained and supported, and fully integrated into the various systems would be critical.”
  • “Under this PIP, Mpumalanga will invest more resources and effort in the training and mobilisation of peer educators, lay counsellors and support personnel.”  

Maybe the biggest question facing healthcare in Mpumalanga, and the question upon which implementation of the PIP hinges, is whether the necessary investments of funds and political capital will be made to meet these human resource requirements in a way that is sustainable.

Note: Figures used in this article are taken from the recently published Thembisa 4.2 model outputs. Thembisa is the leading mathematical model of HIV in South Africa.

Limpopo to release health workers despite massive shortages

Whistle blowers have alerted the Rural Health Advocacy Project to a decision by Limpopo’s Health Department (LDoH) to release provincial bursary holders from their contractual obligations. RHAP has in its possession a letter circulated to health professionals inviting them to a meeting to discuss the decision which will affect approximately 540 health professionals who have received funding from LDoH. The affected health professionals include medical doctors, professional nurses, pharmacists and allied health professionals (occupational therapists, physiotherapists, speech therapists and audiologists.)

The decision to release the bursary holders from their Bursary Contractual Service Obligations will have severe implications on health service delivery and does not ensure the protection of the core right to health. It will ensure that the reported ratios of 10 pharmacists per 100,000 people will not improve nor will the 3 physiotherapists and occupational therapists, respectively, per 100,000 people, thus underservicing the population in Limpopo and failing to progressively realise the right of access to health care services.

The LDoH has under half (47% – 33,848 of the 63,460 posts) of the personnel it requires to function effectively. To fix the broken provincial health system, LDoH developed a Recruitment and Development Strategy (“Strategy”) to formalise the bursary scheme and ensure that it can attract and retain health professionals. The Strategy is also intended to address some of the factors that result in the high attrition rate, these include a lack of opportunities for career-pathing, inadequate infrastructure, inadequate and non-functional equipment as well as poor working conditions.

It is therefore counter-productive that the LDoH, which has historically suffered from low healthcare worker figures would opt to let go of 540 health professionals whose services are obviously needed. Typical rhetoric would lay blame on the economic recession and austerity measures taken by state departments. However, we should be wary of austerity being the catch-all net for all decisions that fail to meet the Constitutional standard envisioned in section 27 of the Constitution. The International Covenant on Economic, Social and Cultural Rights (ICESCR) to which South Africa is a signatory is explicit when it comes to austerity. It cites the implementation of austerity measures may only be justified when a) less restrictive measures have been exhausted, b) austerity measures must be temporary and that any other course of action would be more detrimental to the realisation of rights and that c) they cannot be intentionally or unintentionally discriminatory, amongst others.

In late 2018, President Ramaphosa released a Stimulus Package for Health. This constituted a significant boost of 5300 posts (clinical and support staff) into the public health system distributed across all 9 provinces. The LDoH, in particular, received 227 medical officer posts (for post-community service doctors), 68 pharmacist posts, 309 professional nurses’ posts and 57 allied health professional posts. A total complement of 701 new posts were funded, in addition to the number already budgeted for by the LDoH. It is curious that a decision to forego the services of 540 health professionals be implemented with such haste. Surely, the lack of available funding was anticipated earlier in the year. If so, a large portion of the 701 new posts could be used to offset the 540 posts that will be lost. There has been no information on how many of the posts created by the Stimulus Package have been filled.

We are also unsure how the LDoH intends to staff the state-of-the-art central level hospital whilst failing to adequately implement its Strategy and retain 540 skilled and willing health professionals whose studies the LDoH has already funded. The current state of Primary Health Centres (PHC) and district level hospitals also leaves much to be desired and it does not seem that this decision will improve services at these facilities.

Only 25% of Limpopo’s clinics meet ideal clinic status, the second lowest of all provinces, competing for last place with the Eastern Cape; another predominantly rural province. Spending by LDoH shows a strong focus towards district hospitals. Consequently, it would appear that the bulk of health services are provided at this level. Over the 2017/18 period, 51.3% of District Health Services was spent on district hospitals. However, this contrasts starkly with the investment in PHC services with Limpopo being the lowest spender in the country. Over the 2017/18 period, per capita spending on PHC was R352, which is almost R100 less than the national average. And therefore, incongruent decision making and spending is not isolated solely to the 540 health professionals who are soon to lose their jobs but rather is characteristic of Limpopo Department of Health. The investment in the studies of 540 health professionals to improve health services in Limpopo will be lost to other provinces or the private sector.

Due consideration must be given to the inherent challenges that rural provinces, such as Limpopo, face. The government must take into account factors such as low population numbers that are spread across large areas and resultant diseconomies of scale which make providing services to these provinces more expensive, and budget accordingly. The users of the healthcare system will bear the brunt of the loss of personnel most and the figures reported by LDoH will not allow for increased access to health care services.

There is contradicting information on the number of posts in LDoH and the number which has been filled and how many remain vacant. There has been no explanation as to how the LDoH funds bursary holders but fails to ensure that there is funding for their posts in order for them to continue working once after their community service. There are also no reports on the progress in implementing the Strategy.

As a coalition of social justice organisations committed to the protection and advancement of socio-economic rights, we appeal to:

  • the Minister of Health to support the development of costed provincial Human Resources for Health plans that consider the varied implementation contexts in different provinces;
  • the Minister of Finance to consider rural adjustments starting with HRH to be included in Equitable Share Formulas;
  • the Premier of Limpopo to amend the framework that informs how the province distributes its unconditional provincial equitable share allocation in order to increase the portions dedicated to health and education.
  • the MEC for Health and the administrative heads of health to work together to ensure that the decision to release bursary holders is reversed in order to fulfil their Constitutional obligations of ensuring access to health care services so that the wellbeing of the people of Limpopo is placed at the centre of all decisions.

This open letter has been endorsed by the following social justice organisations:

RHAP, SECTION27, the Treatment Action Campaign, People’s Health Movement, Rural Rehab South Africa, Rural Doctors Association of South Africa, Institute for Economic Justice.

KZN’s HIV and TB plan: Good on structure, low on detail

The National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 is supposed to guide South Africa’s response to HIV and TB. While this national plan sets out broad targets and strategies, the implementation of this plan depends on provinces. To this end, each province had to develop a provincial NSP implementation plan (PIP). KwaZulu-Natal’s (KZN) PIP is called the Multi-Sectoral Response Plan for HIV, TB and STIs for KwaZulu- Natal Province 2017-2022 – but in this article we will refer to it just as the KZN PIP.

Broadly speaking, the KZN PIP’s engagement with the governance and consultative structures required to implement a plan like this is refreshingly realistic and shows an awareness of the very real risk that PIPs can become inconsequential processes parallel to existing government planning processes. The plan also does a good job of using data to define the particular problems in the province and flagging, in general terms, the kind of interventions that are required. Unfortunately, the KZN PIP is very low on detail when it comes to implementation – which is deeply disappointing in an implementation plan.

Some context

KZN is at the epicentre of South Africa’s HIV epidemic, if not the world’s. Annual AIDS deaths in the province peaked at 87 000 in 2005 and fell to around 17 000 in 2017. In 2019 there was probably around 15 000 deaths, although there is significant uncertainty regarding the 2019 figures. The decline in AIDS deaths in the province is driven largely by the provision of antiretroviral therapy – in 2005 there were 27 000 people on treatment in the province, today there is around 1.4 million.

One major concern however, is that growth of the HIV treatment programme in the province has slowed significantly in recent years. In 2014 around 230 000 people in the province were newly started on treatment. That number has dropped every year since and is now estimated to be under 100 000.

While AIDS deaths have declined dramatically, the rate of new HIV infections remains stubbornly high in the province. While the estimated 61 500 new infections in 2017 is much better than the 160 000 per year seen around the turn of the century, it is nevertheless high and means that the absolute number of people living with HIV keeps going up. Just over a third of the new infections in 2017 (around 21 000) were in women and girls aged 15 to 24. Around two million people in the province are living with HIV.

The KZN PIP

Probably the most important target in the KZN PIP is to reduce new HIV infections to below 20 000 by 2022 – roughly a third of 2017 levels. Modelling suggests that this very ambitious target will not be met and that by 2022 levels would still be in the high 40 000s. According to the PIP “interventions revolve around expanded and intensified provision of biomedical services, sexual and reproductive health and the provision of pre-exposure prophylaxis to high risk groups.”

While specific mention of PrEP is welcome, the PIP rather confusingly says that PrEP should be provided “as part of a prevention package for the general population and key population groups e.g. sex workers” and elsewhere it refers to providing PrEP to “high risk groups”. Who exactly should be offered PrEP is never made much clearer than this. The plan does not specifically set out to provide PrEP to women and girls aged 15 – 24, as one might expect given the high infection rate in this group. It also doesn’t set any concrete targets or make any meaningful commitments regarding PrEP.

Some might argue about the cost effectiveness of PrEP, but even if the cost-effectiveness case is not as strong as that for say medical male circumcision, one could argue that the state has an obligation to nevertheless provide young women and girls at very high risk of contracting HIV with the means to protect themselves. Either way, if ambitious PrEP targets were rejected based on cost-effectiveness grounds, then the PIP should state that explicitly.

Given the high rate of infection in young women and girls, one would also expect a strong focus on the promotion of safe sex and condom use. As is recognised in the PIP: “While the province achieved its condom distribution targets, these were not adequate when calculated at number of condoms per eligible male.” One would expect such an admission to result in ambitious new condom distribution targets. Maybe more importantly, given the high rates of HIV in young women and girls, one would expect an unequivocal commitment to making condoms available at schools. Yet, while the PIP does not prohibit it, it certainly does not make a strong case for increased condom distribution or making condoms available in schools.

DREAMS and various specific interventions are mentioned, but unfortunately the KZN PIP does not break any new ground in plotting how the province will address HIV infection in young women and girls.

Touches on key issues

Though lacking in detailed planning and concrete commitments, the KZN PIP does nevertheless touch on a lot of the key interventions required at this stage of South Africa’s response to HIV and TB and provides useful district by district breakdowns of some key indicators. It is to be welcomed, for example, that HIV self-testing and same day initiation are both endorsed. With some help and guidance from national or the province, these are issues that districts can run with.

While increased testing is relatively easy to do, many other interventions require the province to play a greater role and for districts to be given more guidance. The KZN PIP could, for example, have set targets for how many adherence clubs would be needed in each of the province’s districts and included an estimate of the additional human and financial resources that would entail. Without such guidance and support from a provincial level, many of the good things mentioned in the KZN PIP might not be implemented, or not be implemented with sufficient ambition. It could be that these issues will happen through other channels, but the PIP should at least contain some thinking on it if it is to meaningfully impact implementation.

The PIP identifies some serious problems in the province’s HIV response. For example, it states that “information indicated that only 55.7% of those on ART had viral loads done”. Identifying and admitting problems like this is positive. It is not clear however from the PIP what will be done to address this problem. Ideally, a serious problem like this would have triggered the commissioning of research to understand why viral load testing rates are so low – and that research would then have been used to inform the PIP.

Reduce TB incidence by 50%

The KZN PIP sets a target of reducing TB incidence by 50% by 2022 when compared to 2017 levels. According to the KZN PIP: “Currently TB incidence is way above the World Health Organisation threshold of 200 per 100 000 population. Earmarked interventions relate to increasing the uptake of TB preventive therapy using various strategies including mass screening.”

The PIPs endorsement of interventions like mass TB screening and intensify contact tracing is to be welcomed. But whereas the intent is good, the lack of actual planning here too is concerning. There is no sign in the KZN PIP of serious engagement with the human resource requirements of expanding screening and contact tracing – and without the people to expand these services the expansion simply won’t happen. We had similar concerns with the NSP at a national level. The explanation then was that this kind of grappling with the nitty gritty of implementation would be addressed in the PIPs.

It is true that the KZN PIP does include a matrix of which departments and sectors or organisations would be responsible for various interventions, but it does not go much further than this. The background is good, the general ideas are good, but in the final analysis there is no real plan to implement.

Serious about structure

Some of the short comings with the KZN PIP outlined above might be explained by the disconnect that often exists between AIDS council and Department of Health planning processes. An AIDS council might set laudable goals, but the Department of Health controls most of the relevant resources. For this reason, the NSP and PIPs should ideally be taken into account in departmental planning processes and budgets. The odd thing is that, unlike most provinces, KZN seems actually to have put some real effort into making these various processes talk to each other. In fact, much of the KZN PIP engages with just this kind of structural problem.

The PIP states: “This plan has to the extent possible incorporated issues relating to HIV, TB and STIs as mentioned in other departmental and sector plans to enhance mainstreaming and multi-sector participation. It further presents a platform for participation in the response by departments and sectors that may not have HIV, TB and STIs activities in their current plan. They should use this plan as a reference document to inform their implementation in line with the departmental mandate. The activities can then be incorporated into departmental strategic plans when the opportunity arises.” And, “The PCA through its secretariat will be required to facilitate the process of ensuring that all departmental plans support the goals and objectives of this plan.”

The above should be in every PIP – with a premier using his or her clout both as premier and head of the PCA to enforce it.

In KZN the Premier has for years been chairing the Provincial AIDS Council and Spotlight sources report that the council meets regularly and is functional. In addition to the PCA, the PIP indicates that the province has 11 District AIDS Councils and 43 Local AIDS Councils. It seems however that leadership at PCA level has not filtered down. The PIP itself states: “While functionality of the PCA was impressive, that of AIDS Councils at the other spheres of government was generally poor especially, at local municipality and ward level. In some cases ward AIDS Committees were non-existent. More broadly all AIDS councils face the challenge of effective stakeholder participation with few stakeholders from different departments, organisations and civil society participating in AIDS councils. This affects governance and mutual accountability of the response.”

The problem of ensuring greater functionality at district or local AIDS council level is certainly not unique to KZN. It is also not something that can be solved in a PIP. For it to be flagged and grappled with in a PIP is welcome.

According to the KZN PIP “6 districts and 21 local municipalities had AIDS coordinators that were exclusively assigned to HIV.” Ideally all districts will have such AIDS coordinators, and all district-level councils will be chaired by mayors.

The plan also shows a good understanding for the fact that health crises of the scale of HIV and TB cannot be stopped by the Department of Health alone. It reads: “Government organisations, non-government organisations, civil society, the private sector, development partners, traditional leadership and the religious sector all have individual and complementary roles in implementing this plan and ensuring delivery.” It is arguably at district and local level that these “individual and complementary roles” are most important. More guidance on how to turn these good intentions into actual shared programmes and shared responsibilities may be useful.

 

No costing and no communications strategy

 

One area that the PIP gives a lot of attention to is communications. It goes as far as to commit that a “comprehensive provincial multi-media HIV, TB and STIs communication strategy will be developed”. This strategy is mentioned time and time again in the PIP in different contexts and in relation to various specific interventions.

The idea of a single communications strategy around HIV and TB in the province is not a bad one. While some HIV communications projects in South Africa have had only limited success, that is not to say that a properly conceived and executed strategy might not be more successful in KZN.

Unfortunately, according to Bonolo Pududu of the HIV and AIDS Directorate in the office of the KZN Premier, by mid-2019 this communications strategy has not yet been developed.

Another concern is that by mid-2019 the KZN PIP, which is a 2017 – 2022 plan, has not been costed. According to Pududu, this is not the province’s responsibility. “The costing of the Provincial Implementation Plans (all provinces) is/was the responsibility of national (i.e. SANAC),” says Pududu. “Initial processes commenced to cost the plans, however, the finalisation of this process is yet to be communicated.”

The PIP refers to a monitoring and evaluation framework document. A draft of this framework was shared with Spotlight. According to Pududu, “final consultations” with “provincial stakeholders” have not yet taken place and the PCA has not yet adopted the framework.

The lack of a costing of the PIP, the fact that the communications strategy has not been developed, and the fact that the M&E framework is only now being adopted are all worrying signs.

Though the KZN PIP is low on detailed plans, there is also some indication that some of the good things in it are not being implemented. Under goal 4 “Social and structural drivers” the PIP sets out to “implement and scale up a package of harm reduction interventions for alcohol and substance use”. Yet, for much of 2018 a needle-exchange programme in Ethekwini was shut down by the authorities, ostensibly because needles were not being disposed of appropriately.

What is to be done

With a new Premier in the province and a new MEC for Health, there is significant potential for change in KZN. The various good things in the PIP can and should be built on.

Ensuring district and local AIDS councils meet and are given sufficient guidance is one urgent priority. Making this happen will require strong political leadership together with clear thinking on what roles district and local AIDS councils can and should play.

A second urgent priority would be to flesh out some of the ideas in the KZN PIP into fully fledged implementation plans. How should new infections in young women and girls be addressed? Should the province embark on a massive scaling up of PrEP for young women and girls? Should there be a new safe sex and condom distribution campaign? Will these campaigns be funded and who will implement them?

Thirdly, whatever revised plan is made must be costed and, if a communications strategy remains central to the plan, then such a plan must be developed. If the PCA and the Premier is serious about the KZN PIP, then they must show that seriousness by executing the plan and integrating it into government planning and service delivery in the province.

Note: The KZN PIP uses estimates from the Thembisa model version 3.2. In this article we use more recent estimates from Thembisa version 4.1.)

 

 

Dear Premier Zamani Saul, the Northern Cape health system is in your hands.

Dear Premier Zamani Saul

You have certainly made a great start to your tenure as the newly minted fifth Premier of the Northern Cape. A country, thirsty for good news and ethical leadership has embraced your messages of activist leadership and people have been sharing posts and article links across social media platforms.

You have among others undertaken to not buy new cars for yourself and your executive, but to rather invest in new ambulances. How can such news not be welcomed!

By accepting your appointment as Premier, you have become the custodian of a rough diamond. It is now in your hands whether it will reach its full potential and become a sparkling gem or remain a dusty stone. For too long your home province has been neglected and discarded, an orphan province that despite its size, beauty, uniqueness and presence was discarded and used as a playground for the corrupt and immoral.

The unique people and the breathtaking nature of this province have for very long suffered under a debilitating drought in big parts and a health system that only exists in name. Your health system is an empty shell of buildings that resemble ghost structures, either with no staff or staff so overworked and overburdened that their hospitals are death traps. Patients have been rejected and failed by a health system that mostly exists in name.

You may rightfully question who we are to make such damning statements. Perhaps a little context with be useful. Last year Spotlight, an editorially independent publication of the Treatment Action Campaign and SECTION27, turned our searchlight on your province. We were keen to understand what the state of your province’s health system was – the good, the bad and the ugly. Our experience in other provinces has been that we often will find deeply disturbing challenges but amidst the collapse or problems, we will find places that buck the trend where health workers are finding innovative ways to deliver health services. In the Northern Cape there is a sense of resignation, pockets of health workers are trying to keep the health system afloat, but far too many who spoke to us had either left, were about to leave or did not know how long they could continue carrying an impossibly heavy burden.

There is no doubt that you have by now been briefed on the state of your province’s healthcare system by all kinds of advisors and officials and you have already indicated that you would be occupying a corner office at Kimberley’s Robert Sobukwe Hospital (did you know the name change has not been officially communicated to staff?) to hear complaints from patients. However, we wish to caution you that there is a very real danger that you will spend your time putting out fires instead of dealing with the deep systemic problems.

Spotlight has for many months, since last year, been researching the health system in the Northern Cape, reading the scant information that is available and trying to speak to as many people as possible. We visited many health facilities in the Northern Cape, in small towns such as Keimoes, Fraserburg and Sutherland and larger epicentres such as Upington and Kimberley.

After five months of trying to engage officials in your health department to afford them an opportunity to respond to our list of questions or simply to understand their challenges, we published a series of articles without them answering one, single question. It is hard to understand if they simply did not have the answers or they have become so arrogant that they do not believe they are accountable to anyone.

During our work we identified many common themes and challenges and as you chart the course of your term in office, we thought it may be useful to humbly share some of our observations and findings:

  • There are critical doctor and nurse shortages in the province and you are even losing the ones that are still employed. Doctors and nurses who have left told us that the health department made no effort to convince them to stay. Once we published our articles we received several heartbreaking letters from doctors and nurses who told us they had been desperate to work in the Northern Cape, but they were messed around so much they had to give up. One of these doctors, was one of your own who had been selected to go and train in Cuba only to return with no prospect of a job.
  • There are often no ambulances to deal with emergencies with the few vehicles that were still in running order mostly used to ferry patients to Upington and Kimberley. However, many of the ambulances that do respond to trauma or life-threatening situations are not equipped to deal with the emergency, in fact they cannot even stabilize or transport a patient. As you add sparkling new ambulances to the fleet, we do hope that this will be coupled with a serious campaign to recruit intermediate and advanced life support paramedics. Premier, you speak passionately about rooting out corruption. You may want to pose 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. It makes complete sense to bring back the excellent outreach services similar to those that the Red Cross Air Mercy Service offered from 1996 to 2012, in such a vast and sparsely populated province with a dire shortage of specialists.
  • The Northern Cape is a province of ghost “hospitals” with many downgraded to Community Health Centres, which is just a fancy term for hospitals with no doctors. Hospitals are functioning with skeleton staff or no staff. Many family members are forced to care for the sick and dying in your facilities. The story of the Kimberley Mental Health Hospital is well-known. A visit to this facility reveals beautiful, uninhabited buildings with weeds already taking over everywhere, some parts in need of maintenance already. It is utterly heartbreaking to see such a monument to corruption and endless spending still not functional in a province that has such massive mental health challenges and almost no services to meet the need. Key hospital such as Dr Harry Surtie in Upington, De Aar hospital and Robert Sobukwe in Kimberley have severe staff shortages with health workers and patients who spoke to Spotlight claiming the hospitals have high death rates. Patients are fearful of being referred to these hospitals saying too many people return home in coffins.
  • The province has a slew of vacancies and political appointments in the healthcare system with very little evidence that there have been serious attempts to attract qualified people. We have 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.
  • There are question marks over the appointment of the Head of Department Dr Steven Jonkers. The province failed to produce the advertisement for the job when asked. At the time of his appointment to the health department Jonkers was reportedly facing charges of corruption. Premier Saul, if you are serious about cleaning up, you need to investigate the appointment of this HOD.
  • Basic medical supplies, drugs, food and stationary are often out of stock in facilities.
  • 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 we went there, waiting for a nurse to arrive, hours after the clinics were supposed to open. It is undignified.

 

Premier, our experience has been that the Northern Cape government couldn’t care less about accountability. We truly hope this will change as you take office.

Our experience over the last six months is that there was very little effort by those in power in the Northern Cape to show any accountability. For several months, our efforts to elicit any comment, explanation or meetings with the then MEC, her advisor, the head of department or any other people in decision making positions came to nothing. We would continuously try to contact those in the communication positions and despite reading our messages no response was forthcoming. 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 .

Premier Saul, you have made some truly impressive and heartening statements and commitments and have  already fulfilled some of your promises. It is wonderful to see that some of these actions involved the healthcare system. However, we will be watching you closely.

Your health system is in the Intensive Care Unit on a ventilator. You cannot afford to waste any more time. Delays lead to the deaths of the poor people in your province. The people who look to you to make their lives better, to save their lives.

You quoted a poem titled Courage in your inaugural address.

One part reads:

To map out a course of action

And follow it to the end

Requires of the same courage

That a soldier needs.

Yes, Premier Saul you are going to need a lot of courage to overhaul your broken health system. We wish you much courage. Going forward, you will need to look into the eyes of the desperate in the Northern Cape who have been holding on or working hard with so much courage despite the impossible odds stacked against them.

Yours in the struggle for better health

The Spotlight Team

 

 

 

 

 

 

Only 2 of 9 Health MECs in job for more than 2 years

Following South Africa’s 2019 national and provincial elections, new members of provincial legislatures have been sworn in and new provincial executives appointed.

Four new MECs (provincial ministers) for health have been newly appointed and five were reappointed. MECs have substantial power in South Africa since most of the day-to-day running of the public healthcare system is devolved to provinces.

The latest set of changes follow a busy 2018 in which five new MECs for Health were appointed – two of those five have now been replaced.

Of the nine current MECs for health, four were appointed in 2019, three in 2018, and two in 2015.

Of the nine MECs seven are women and two are men.

Below is a province-by-province breakdown of the changes. Spotlight will provide more detailed analysis of some of the new appointments at a later stage.

Eastern Cape

Ms Helen Sauls-August is replaced by Ms Sindiswa Gomba. Sauls-August was appointed MEC for Health in 2018 and was only in the position for a year. Gomba was charged in relation to the Mandela Funeral scandal. The case was withdrawn earlier this month, but National director of public prosecutions Shamila Batohi has expressed serious concern over the withdrawal of the case.

Free State

Ms Montseng Tsiu remains MEC for Health. Tsiu was appointed MEC for health in 2018.

Gauteng

Dr Gwen Ramokgopa is replaced by Dr Bandile Masuku. Ramokgopa was Gauteng MEC for health from 1999 to 2006 and again from 2017 to 2019. Masuku is a medical doctor and a board member of the Office of Health Standards Compliance and chair of the Tswane University of Technology council.

KwaZulu-Natal

Dr Sibongiseni Dhlomo is replaced by Ms Nomagugu Simelane-Zulu. Dhlomo was KwaZulu-Natal MEC for Health from 2009 to 2019. Simelane-Zulu was previously the ANC’s spokesperson in the province. Both the DA and IFP have expressed concern over her appointment given her lack of health qualifications and experience.

Limpopo

Dr Phophi Ramathuba remains the MEC for Health. She was first appointed to this position in 2015. She is currently the joint longest serving Health MEC together with Nomafrench Mbombo of the Western Cape.

Mpumalanga

Ms Sasekani Manzini remains MEC for Health. Manzini was appointed as MEC for Health in 2018.

Northern Cape

Ms Fufe Makatong is replaced by Ms Mase Manopole. Makatong was appointed as MEC for Health in 2018. Manopole was previously a member of the National Council of Provinces.

North West

Mr Madoda Sambatha remains MEC for Health. Sambatha was appointed as MEC for Health late in 2018.

Western Cape

Dr Nomafrench Mbombo remains the MEC for Health. Mbombo was appointed MEC for Health in 2015. She is currently the joint longest serving Health MEC together with Phophi Ramathuba of Limpopo.

 

#FootSoldiers: The biggest and happiest family In Limpopo

Matriarch Sally Duigan. Photo by Thom Pierce.

Sally Duigan is never alone, with every move she makes there is a posse of happy, smiling children clinging to her arms, grabbing whatever bit of her clothing is within their reach. Not because they are overly “needy” but because they know she will always give them a little time. Sally leans forward and pauses thoughtfully for each child that joins the train, greeting them by name and asking those who are ill if they feel better, and simply just asking others what they’re up too.

If anyone in this world can remember the names of 70 odd children without missing a beat, it is Australian nun Sister Sally Duigan. Sally left Australia in January 1989, 20 years ago, with the sole purpose to come to South Africa and play an active role in the response to HIV/AIDS. Upon arrival her first stop was at a Catholic-run school outside Tzaneen, Limpopo. Where she spent many years as a teacher and later as principal. Later Sally played an important role during the years of government HIV denialism when she offered care and support to those living with HIV in the northern areas of Limpopo.

In 2001, she found herself at the doors of Holy Family Care Centre (HFC), in Sekororo, Limpopo. Before becoming a fully-fledged home to orphaned children, HFC was a facility where HIV positive mothers and their children were discharged to when the health care system could do nothing else for them. At the time HFC was never supposed to be a long-term solution, but a space where the mother could grow stronger before going home. However, mothers started dying, leaving their orphaned children at HFC. At that moment, it evolved into a long-term solution for orphaned children.

Today HFC is a fully-fledged children’s home. The facility is on a large plot of land near the famous Kruger National Park border, with acres of green grass, tall fruit trees, bright colored jungle gyms, trampolines, a sandpit and even a race track. At the moment this is home to 70 children (Sally sheepishly admits that they never turn a child away, sometimes the facility cares for up to 80 children) eight of whom are babies. There is a large staff contingent who care for the children 24/7, bathing them, feeding them, clothing them, teaching them, helping them with homework, playing with them and showering them with heaps and heaps of love. It is absolutely clear that this is one big family.

During our visit a social worker arrives at the home with the family of one of the toddlers, staying at the home. Two of the care staff are standing anxiously in the nursery, quietly watching the proceedings through a doorway. They are torn understanding that today, may be the day the baby leaves.

“Don’t worry, she isn’t going anywhere, it’s just a visit,” Sally assures them and in an instant a wave of relief washes over the staff as they both let out a nervous giggle.

“It’s so easy to get attached to the children here, we’re not supposed to have favorites, but everybody has their somebody and it’s hard to watch them leave,” Sally admits.

Sally Duigan and members of the happy family. Photo by Sally Duigan.

Each child that comes through the gates of HFC is guaranteed two things, regardless of how they arrive or where they come from, they will be loved and well taken care of.

Over a third (38%) of the children at the center are HIV positive, and many others are battling other illnesses.  One of these children is *Adam Nala. Adam has a heavy seriousness about him. When we meet him, he is sitting alone in the dining room. He had not eaten earlier, but was now feeling hungry. One of the home mothers was preparing a meal for him.

Photographer Thom Pierce walks ahead of me, while I pause to speak to Adam. His tiny forearms are covered in mosquito bites and he is sitting up straight at the table, quietly waiting for a meal. I ask him if he is okay, he nods silently. I try another question to draw him out, eventually I ask him about the R1 coin he is playing with in his hand.

“Is that yours?”, I enquire. He opens his hand to show me “Yes,” he says. I pat Adam on the back and leave the dining hall.

“Sometimes we will give the kids some pocket money, but the trick is that we have to give them each a R5, so everyone has the same thing. Yesterday Adam did not get a coin and he screamed all the way to school, he was quite upset. So, when I saw him this morning I slipped him the R1 coin,” smiles Sally.

Some of the children that find themselves at the care center have been victims of abuse. “It breaks my heart to read some of these files, some of these kids have suffered from a young age and they’ve experienced so much trauma,” says Sally.

It is due to this knowledge that the staff takes extra care when it comes to attending to the children. “Each of these kids have their thing, so when they cry about something, we are very wary to not just look past that, but rather respond in a way that considers the past  experiences of the child,” Sally explains.

Not always keen to speak about herself, Sally speaks passionately and easily when she explains why she chose to be at HFC.  “Since I was a child I’ve always had a desire to help kids who didn’t have the same background as me.” It is this desire that pushes Sally to ensure that every child that comes through the centre has a fair chance, at starting afresh, at being part of a whole, and being loved. “The one thing they really need is love and care, and you can’t buy that,” says Sally.

Despite the challenges that the centre faces when it comes to placing undocumented children, or having to welcome extra children, Sally has high hopes for all these children. “I can’t even begin to talk about them, they are creative, resilient, tough, survivors in spite of everything they’ve been through,” she says.

However, the world may change, the children at the center all have a chance at a normal life. There is routine, there is school, there is homework time, there is TV time and above all, there is companionship for every single child.  Behind the gates of the center these children are loved, they are fussed over and they are made to feel part of a family. There are no days off in this kind of work.

“I hope the children will always remember this place as a kind place,” says Sally.

And just like that, she is off on the rounds again – she stops at a homework class to marvel at the kids in their new winter pajamas. The excited kids are all trying to sit up a little taller to show off their new pajamas to Sally. She takes a good look around the whole classroom, and gives a satisfied nod at the group, before she waves goodbye.

“No tears, everybody got a pair and they all fit, that went quite well,” she says grinning.

*Name changed to protect the identity of the child.

  • Foot soldiers of the health system: It’s election time which means men and women in party regalia take to the streets, podiums, loudhailers and stadiums. Invariably they tell people about all the good and wonderful things they have done or plan to do in the health system. SECTION27’s Nomatter Ndebele and photojournalist Thom Pierce travelled the roads of South Africa in search of the foot soldiers of the health system, the men and women who quietly get on with doing the job and saving lives, often without any acknowledgement.

 

 

 

 

Donor shift threatens adherence clubs in the Free State

Mosamaria’s Connie Motsoeng addressing an adherence club at Pelonomi Hospital in Bloemfontein Photo by Khothatso Mokone

A shift in donor funding for HIV has endangered the continued existence of successful and effective antiretroviral adherence clubs in the Free State.

The Mosamaria project, an NGO-run adherence club project based in Mangaung, has in the last five years reached 25 000 people through 21 health facilities and achieved a 98% patient retention rate. The clubs operated on a R4 million a year budget, which translates into about R161 per patient, per year.

These gains are in danger of being reversed as donor support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) shifts to other programmes.

Right to Care (a large national NGO), which for five years has been a primary recipient of money from the GFATM, has been distributing funds to Mosamaria. The GFATM distributes funds to a series of so-called primary recipients in South Africa, who then distribute it to specific projects.  Right to Care is no longer a principal recipient of GFATM funds and none of the new primary recipients will be stepping in to fund the Mosamaria Project. The key reason for this appears to be that South Africa’s country coordination mechanism (CCM – a committee that submits funding applications on behalf of the country) decided last year that no further application to the GFATM to support community adherence clubs would be undertaken. The CCM is administered by the South African National AIDS Council (SANAC).

Mosamaria’s funding for adherence clubs came to an end on 30 March 2019.

As a result, the Mosamaria project is in the process of being shifted to the Free State health department, a risky move in a province with a poor track record when it comes to health and more especially HIV.

That adherence clubs are part of the solution to South Africa’s HIV epidemic is now widely accepted. The clubs have been a model of successful HIV management since they were first piloted by MSF (Medicins Sans Frontieres) in Khayalitsha in the Western Cape in 2007. By filtering stable HIV positive patients into the clubs it helped patients receive their medicines on a fixed schedule and helped them save time by avoiding regular long hospital or clinic queues. Peer support is also a key part of adherence clubs.

As a result of successful pilot projects, adherence clubs as a model was adopted, along with CCMDD (Centralised Chronic Medicine Dispensing and Distribution) and Fast Lane dispensary services as part of the National Department of Health’s ARV adherence policy.

What clients say

Patients’ adherence club logbooks Photo by Khothatso Mokone

Bloemfontein local Margaret Baratang is one of the Mosamaria patients at Pelonomi Hospital in Bloemfontein. On the morning of her last club meeting with the Mosamaria team, Baratang was angry and deeply anxious.

“These people [Mosamaria facilitators] treat us nicely. I’ve been coming to the club for three years. Every time I’m here 30 minutes then I can go. Now if we must go back to the hospital queue and we will have to wait for two or three hours, I’m telling you,” she says.

She talks as she shuffles up the rows of seats. The queue moves fast. In her hand is her club booklet. It’s covered in decorative wrapping paper. Most of the patients have done the same – they are a support group after all. The foil wraps, the prints of flowers and butterflies represent their care and respect for a club model that’s come to represent service and significance in their lives.

Others in the queue with Baratang include a man who works as a driver. He’s juggling car keys and says he is irritated. His HIV status is his private business and the club model respected this he says, by allowing him to arrive every second month, have a basic medical screening, receive his medicines and still arrive at work on time. Now he will have to explain to his employer and colleagues why he has to take a whole morning off every second month to be at the hospital.

Another patient, Boitumelo Mokeane, launched a petition to the Free State MEC for Health. In representing “concerned people living with HIV”, she said in her petition that patients deserve access to quality healthcare. She raised fears that the Mosamaria facilitators’ expertise would be lost and that CHWs would not be able to cope. Over time Mokeane also said people would default because collecting medicines would become too much of a hassle.

“We don’t want the situation where we have to start from scratch in adjusting with new people and new systems,” she says.

Mosamaria workers host one of their final adherence club meetings. Photo by Khothatso Mokone.

CHWs assigned to take over

With the absorption of the project into the Free State Department of Health, community healthcare workers (CHWs) have been assigned to take over the running of the clubs. Mosamaria facilitators spent the last few weeks while they were still employed, training the CHWs. It was a scramble against time as the Free State’s Chief Director of district health service and health programmes only sent out an internal memo on 6 February. It was a memo to the three affected districts of Fezile Dabi, Mangaung Metro and Xhariep to identify two CHWs per facility to be trained to run adherence clubs. It was also only in February that the Department met with NGOs for a “transitioning meeting”. This was less than two months before Mosamaria was scheduled to wrap up its operations.

Thapelo Mabule, Mosamaria’s outgoing programme manager for the adherence clubs, says often CHWs didn’t show up for training sessions in those weeks.

“CHWs are being paid a stipend by the department of health, not salaries so maybe they don’t care enough to come for training. The clubs as we know them will collapse the minute we hand them over,” he says.

His seems a realistic assessment, because without the structure, that includes salaried facilitators trained in record keeping, monitoring and evaluation and managing patient loads and communicating with the pharmacy for filling pre-packing scripts, the club model has a slim chance of succeeding.

Free State Department of Health spokesperson Mondli Mvambi however, is confident there will be few disruptions. He says: “The transitioning of Mosamaria will not negatively influence the patients as the clubs will continue using the principles outlined in the National Adherence Guideline Standard Operating Procedure. When the project was started the Free State Department of Health was aware that funding was only for a limited period of time, hence the province has worked on a transitioning plan for when funding comes to an end.”

He adds that in addition to the two CHWs assigned to each club, each facility will have a nurse and an operational manager for continued implementation of the clubs and other differentiated care interventions.

“Patients trusted us”

Mosamaria’s Connie Motsoeng Photo by Khothatso Mokone

For Connie Motsoeng, a Mosamaria club facilitator, walking away is tough. She says: “We are losing something that we love. Patients trusted us and now we worry that they will suffer without properly run clubs.”

She’s also worried because she has a baby on the way – her second child. She’s one of 39 facilitators and administrators who are now jobless as their posts were funded through Right to Care funding.

According to Mabule, communication with Right to Care has been minimal. Mosamaria were notified that their funding would be discontinued in mid-October last year and they had a close-out meeting with Right to Care in Johannesburg, but not much else has been communicated.

According to Right to Care discussions with Mosamaria were initiated in October 2018 to indicate that the funding will come to an end in March 2019. “Representation to the CCM were undertaken to indicate that adherence clubs will require continued support.  The Department of Health indicated that transition plans would be made,” Right to Care said in response to questions from Spotlight. Going forward, Right to Care will provide adherence club services in Ehlanzeni and Thabo Mofutsanyane districts in the Free State with support from the United States government.

By the beginning of December Mosamaria fired off hopeful funding proposals to new Global Fund South African principal recipients and also notified the provincial department of health of the situation.

Trudie Harrison, a Mosamaria co-ordinator, says one local principal recipient didn’t respond, another told them to wait till February to submit proposals. A month after that they were told HIV adherence clubs would not be funded.

“Five months is not enough time to close out a project like this. We did assume that one of the other local principal recipients would continue funding the clubs because they have proven to work so well.

“We are a small organisation but instead of being in the field, we end up spending more time writing proposals, stuck in meetings and following up with would-be funders,” says Harrison.

She adds: “International donors do not consult sufficiently, if at all, with the people who are actually implementing programmes in communities. We just get told by principal recipients ‘the Global Fund has decided …’ without any reasons why this has happened.

Government’s responsibility

Lynne Wilkinson, a differentiated service delivery consultant with the International AIDS Society, says closing out plans need to be properly and effectively managed so there is seamless transfer and patients are not put at risk or under any anxiety over the future of their care.

Wilkinson, who was involved with MSF’s first clubs launched in the Western Cape (that now are run by the Western Cape Department of Health), says it remains government’s responsibility to ensure that adherence club models are not compromised, even as outside funders’ priorities shift.

“The national adherence policy guidelines are in place to ensure that stable patients can access their medication as easily as possible throughout the cycle of lifelong treatment,” Wilkinson says.

She adds too that it’s adherence clubs that have over time proven to be the cheapest most effective model of keeping patients on treatment. She says: “The government’s target is to get another two million people on ARV treatment by 2020, it means we need to use every resource we have. So when an organisation like Mosamaria has successfully built up clubs that have proven to be successful and cost effective, they should be supported and funded, not allowed to fall away.”

South African National Aids Council (SANAC) CEO Dr Sandile Buthelezi drives home the point that donor funding is finite. He says: “Principal recipients [like Right to Care] are aware that their funding is for three years. It is therefore imperative that sustainability plans and transition plans are part and parcel of the application, and the Oversight Committee of the Country Co-ordinating Mechanism ensures that these plans are followed and implemented. In addition, the main reason for the Department of Health to always be part of principal recipients is to ensure that this transition takes place.”

He says SANAC, through its Resource Mobilisation Committee, will canvas for more domestic and donor funding to ensure that ARV adherence is implemented and that South Africa continues to wean itself off foreign donor funding.

#Vote4Health: No road to health in the Northern Cape

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

Calvinia, Sutherland, Fraserburg, De Aar, Keimoes, Kakamas. Join Spotlight on a disturbing road-trip through the Northern Cape public healthcare system.

In November 2018 Spotlight travelled through the Northern Cape meeting with doctors, nurses, activists, politicians and community members. After months of follow-up and attempts to get comment from government, we have decided to publish the disturbing information we have. Below are some reflections on six towns we visited – also see our more in-depth feature on the Northern Cape here.

 Calvinia

Road works: Somewhere along the road between Calvinia and Sutherland.

In November last year this town had two Community Service doctors only. It now has three Community Service doctors, a Congolese-qualified doctor and two private GPs doing sessional work in the hospital. One of the Community Service doctors now travel to Sutherland once every two weeks for a few hours, with no supervision.

Sutherland

Desolation: The road out of Sutherland

Sutherland has no doctors after the last state doctor left at the end of November. A professional nurse Marguerite Jordaan who recently retired after 29 years in the service said it has been extremely challenging to deliver a 24 hour service at the 24 bed Community Health Centre which includes an eight bed maternity unit. What does she do when she has a serious case and there is no ambulance or doctor? “You pray a lot,” she smiles. “You do what you can and you hope for the best.” The Community Health Centre relies heavily on the nearby Southern African Large Telescope (SALT) operation to sponsor crucial basic medical supplies such as bandages, syringes, suture material and plasters.

Fraserburg

Health workers often have to travel the 100km plus dirt road between Sutherland and Fraserburg, a road that notoriously destroys vehicles.

About 110km on a corrugated dirt road east of Sutherland, Fraserburg also has no doctor and reports of several nursing staff simply not pitching for work on some days. A nurse told Spotlight that referring patients to hospitals was a massive challenge with ambulances often forced to transport up to eight patients to Calvinia or Upington. She recalls instances where Calvinia could not take on any surgical cases as they had no gauze. The nurse also said there has been times when the depot in Kimberley had no insulin and no drugs for epilepsy.

De Aar

De Aar: Shiny, new and deserted.

Both the outside and inside of The De Aar hospital building looks like a shiny pamphlet. The hedges that line the drive ways are trimmed, the signs on the hospital are gleaming in the afternoon light, the security guards at the gate are many, there isn’t any litter in sight- just paved walkways and seemingly unused red benches.

About a year ago, the old De Aar hospital was suddenly closed and almost overnight, the entire hospital was moved a few kilometres down the road to the new facility.

The old facility is now an empty lot, guarded day and night by two security guards.

Over five or six months, thieves have looted the hospital of what furniture was left. Pieces of the ceiling have been ripped out, corrugated iron roofing and other equipment ripped from the walls. Everything that is possibly worth anything has been removed.

The corridors are littered with patients files, sealed syringes, used syringes, medication packets, floppy computer discs, and other debris. Some say that the old hospital was supposed to be turned into a nurse’s home, but that the delay meant the thieves could take what they wanted.

Now De Aar, famous for being home to one of the country’s most important railway junctions, is home to what appears to be two mostly empty facilities, and a story that just doesn’t add up. 

Keimoes

Keimoes hospital: Not much of a health facility

It does not really matter from which side you approach Keimoes, chances are you would have negotiated some serious dusty desert to reach the heart of the so-called Green Kalahari, an oasis resting lazily on the banks of the Orange River, also known as the Gariep. Fat, thick vines are luminous green with irrigated water glistening in the sun. The surroundings are bone dry, but the Gariep pumps more than enough of the lifegiving fluid to grow the best export sultanas as well as tons of wine grapes, pecan nuts, watermelons, peaches and lucerne. The manicured farm entrances all speak of prosperity, lush Bougainvillea and Cannas showing off several rainbow colours. Everything seems to grow and prosper and shine.

But scratch a little so you can see below the green, and the tranquil, almost fairytale-like picture dissolves. Driving towards Kakamas, the hospital sits on the edge of the town, in a dustier section of Keimoes off the main road. The brick building is tucked away towards the back of a large dusty yard and there is almost no human activity. There is also no security or a manned gate. A walk around the hospital’s exterior presents flung open doors with empty rooms filled with rubbish and waste, rubbish has also been dumped in the veld a few steps from the hospital and the morgue is behind rickety lock and key, no longer in use.

The health services inside the hospital appears to be in a similar state, despite the best efforts by those who bother to pitch up for work. Most parts of the hospital are deserted with some signs of its former heyday… “hospital” is actually not the correct term or even more correctly, Community Health Centre. There is no doctor. There are very few other health workers or staff such as cleaners. Community members speak of constant shortages of medicines and basic supplies such as bandages. Ambulances are glorified taxis between the hospital and Upington about 45km away. Two nurses and their assistants try to keep the 28-bed hospital running. Patients, admitted to the beds (including the six-bed “maternity” ward) are left to fend for themselves. A health worker who spoke to Spotlight admitted openly that they mostly have to ask family members to bath and feed patients. As we walk down a particular passage, the moaning from one of the rooms leads to a man lying on his side, staring into space, groaning in pain with no health worker to attend to him. In another room a young mother watches every breath from her baby in the cot. Further down another passage just past the room where women give birth, a chest freezer reveals buckets with human tissue. Read more in the main article.

In another wing, patients wait in the hospital’s now former theatre (the overhead lights are a giveaway), as the nurses try to get through the waiting queue. This is not a hospital, it is barely a health facility. The people of Keimoes deserve better.

(Spotlight visited an ambulance base in at the hospital which is basically a rundown little office with collapsing ceiling and electrical extensions running across the floor. A manager who spoke to Spotlight admitted that “the ambulances are more broken down than running”.

  • A list of questions were sent to the MEC and the Northern Cape health department with specific questions on the state of Keimoes hospital. None were responded to.

 Kakamas

Alternative view: The outside of Augrabies Clinic near Kakamas.

From the outside Kakamas hospital is picture perfect. The image of the hospital is delicate, so delicate that if one looks a little bit harder. The hospital starts to unravel, from the inside out. There are session doctors in the hospital, but the theatre has been locked for years. There are doctors, but there are no oxygen tanks. Staff tell us there are no IV drips and very little drugs and other medical supplies.

They tell us that nepotism is rife, that friends are appointed into senior positions with no qualifications, that HR functions are a joke. Community activists, hospital staff and NGO workers spoke openly about the dysfunctional state of the hospital. “There is corruption everywhere” says NGO worker Caroline Booysen, “The only people that get help here are relatives or friends,” she said.

We are led down a green passage, with yellow doors alongside it, at the end of the passage are two doors, with the words “Theatre”  painted on a panel above the door. At first glance, all seems well until you notice the big golden padlock dangling on a latch. The theatre is closed. And has been so for months.

 

 

 

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

Helping hand: An elderly man is helped through the streets of Prieska in his wheelchair. All Photos by Thom Pierce

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.

A chest freezer at Keimoes Hospital containing human tissue. In the background an incubator.

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.

Road to somewhere: The R356 that winds through the Northern Cape desert between Sutherland and Fraserburg.

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.

Going home: This man was dropped next to the road by ambulance and left to walk a few kilometres to his home in 30 deg C. He still had a raw wound from major abdominal surgery. 

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
Waiting for healthcare at Augrabies Health Care Clinic outside Kakamas.

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.

  1. There are often no ambulances to deal with emergencies
No Ambulance: Waiting for healthcare at Augrabies Health Care Clinic outside Kakamas.

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

  1. The Northern Cape is a province of ghost hospitals
Deceiving looks: De Aar’s new hospital, but by all accounts not too much happening on the inside.

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.

  1. The province has a problem with vacancies and political appointments in the healthcare system
Keimoes: Nurses are struggling to cope with looking after patients in beds and those waiting in the Outpatients department. There are no doctors.

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

Many questionmarks and questions: Northern Cape Head of Department Stephen Jonkers (file photo)

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

Drug shortages: A medicine trolly in Keimoes Hospital.

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

Northern Cape Hospitals: Road to nowhere?

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

Ward shifting: Some wards are used as officers at Keimoes Hospital.

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

Dirty waiting game: Dirty water and waste next to patients waiting at Augrabies Health Care Clinic.

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

No accountability: Almost none of the clinics Spotlight visited operated in accordance with the stated hours. Most of them were not open yet late morning.

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?