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Face to face with North West Health MEC Madoda Sambatha

“Mr Fix It” is how North West Health MEC Madoda Sambatha hopes to become known, but there’s a long way to go before he can claim the moniker and he knows it.

North West Health MEC Madoda Sambatha

Problems in the province have piled up spectacularly in recent years. Just over a year ago the North West was brought to its knees with hospital strikes and violent service delivery riots. The strikes took place against the backdrop of a complex political tug-of-war between trade unions and factions in the ANC – all while various provincial government departments, including health, were under national administration because of severe inefficiencies and failures.

Sambatha (44) says it’s time for new rules of engagement with “a highly unionised sector”. He acknowledges that “a wedge has come between workers and departmental managers”.

“We need to have a different work culture and a different approach where it’s not about meeting every demand the workers want, but we don’t run away from engaging either. We must have peaceful co-existence whether we agree or disagree; we can’t wish each other away.”

But uncertainty remains

Despite strikes in the public healthcare sector in recent years, there is still not a definitive national ruling or guidelines on a minimum service level agreement when strikes happen.

“I don’t think that the two constitutional rights of the right to access to health and the right to strike should be pitted against each other. But we can’t allow people to block patients from getting into hospitals for medical treatment,” he says.

Sambatha was the chair of the portfolio committee on health and social development in the North West before he was axed by the controversial former North West premier Supra Mahumapelo in 2017. This was ostensibly over a questionable sign-off on a land deal – although there is speculation that he was a victim of internal ANC politics in the run-up to the party’s hotly contested December 2017 congress.

He is also the South African Communist Party’s regional secretary in the North West and a former mineworker who rose through the ranks of the National Union of Mineworkers in the mid-1990s.

Longstanding grievances

Sambatha says that various longstanding workers’ grievances in the province’s healthcare sector must be resolved. Key among these, he says, is the issue of outstanding performance assessments and unpaid performance bonus payments for the last three years.

“It has cost us about R5-million to catch up until 2018 and to make these pay-outs, but this is a step forward in compliance from the government’s side. It means we move closer to closing this grievance. It creates stability and responsibility for the employee and the employer.”

The MEC says the department intends in-sourcing security services as per national guidelines. This will be phased in over the next few years because in-sourcing doubles the bill for security.

“We will also be doing evaluations on all out-sourced services to see where we can cut costs. We have some private companies that were providing services to us that our own HR and corporate services should be doing,” he says.

The Mediosa and Buthelezi EMS scandals

Two high-profile scandals in the province’s health department in recent years relate to contracts with the Gupta-linked Mediosa, which was contracted to provide the province with mobile clinics, and Buthelezi EMS, a private ambulance service. Spotlight revealed in April 2017 that the province had misused funds earmarked for HIV to pay Buthelezi EMS and reported on allegations that Buthelezi EMS had dramatically overcharged the department. Contracts with Buthelezi EMS has since become the subject of National Treasury, Hawks, and most recently Special Investigating Unit investigations.

City Press reported in August on the Hawks’ arrest of former North West finance MEC Wendy Nelson on charges of fraud linked to her involvement in appointing head of department of health Thabo Lekalakala, who signed off the contract with Mediosa. Lekalakala was suspended but went to court and successfully contested his suspension. He has, however, subsequently been arrested on charges of fraud.

Sambatha says even though the dubious Mediosa contracts have been terminated, investigations are under way. Mediosa has been liquidated, and Sambatha intends pursuing avenues to recoup monies lost in these deals, so “we are sure we only paid for services rendered”.

The province has a dire shortage of ambulances. It needs 260 ambulances and only has 100. Sambatha has budgeted for 40 ambulances to be purchased every year; he also needs more competitive salaries to retain trained intermediate life support teams and a new dispatch system for provincial-level operations.

“We have to pay paramedics to stay. Every ambulance needs to have working communications systems with the control centre, a panic button and a tracker to stop attacks on paramedics and to stop the element of abuse,” he says.

Suspected corrupt officials suspended

Emerging from the Buthelezi and Mediosa scandals has made Sambatha take a dim view of how tenders and some procurement contracts have become “properly regulated corruption schemes”.

He says it has been a case of having to “make yourself known” to politicians and officials if you want to land a tender or a contract.

Sambatha says he has recently suspended senior officials who have been suspected of nepotism and offering jobs for sexual favours.

He also challenges government’s own inefficiencies that, according to him, have made procedure a red tape nightmare.

“Sometimes there is no logic. When you have to buy something you must source three quotations from preferred providers and you are told to take the cheapest but sometimes if you just go to retail you’ll get it even cheaper. Compliance can be wastage, it’s ticking a box while we are told that the South African economy needs to improve money circulation for enhanced economic participation,” he says.

He feels the same way about transversal tenders. He says some tenders that are prescribed nationally don’t stimulate local growth. As an example, he points to a hospital oxygen supplier who, in its tender, offered to train about 44 people. Sambatha considered this to be a win for skills training, job creation and localised procurement but couldn’t sign off on the tender because of transversal tender agreements.

Other changes he’s implementing include the ordering and delivery system for medical supplies. He says individual hospitals will be ordering supplies directly while clinics will continue to order through the medical depot to better manage stock levels. The MEC also wants revised delivery schedules to stop time and fuel wastage.

According to Sambatha, the moratorium on frozen posts has finally been lifted, allowing the department to advertise 3,000 posts for professional, clinical and support staff. He says they are at the halfway mark of filling these posts.

More public-private partnerships

The province also intends leaning more on public-private partnerships. Sambatha says the imbalance of overcrowded public and under-utilised private hospitals needs to be levelled out.

“I want to change the conditions of licensing of private facilities so that we can offload patients there and they will charge us at government rates to treat these patients.

He says these partnerships offers an alternative to simply building more facilities that will ultimately not have staff to run them properly.

The MEC will also focus on a campaign of health, diet and exercise for the province and believes people should work to stay well.

Maybe more difficult than getting people to exercise and change to healthier diets, however, will be to undo the culture of corruption distrust that seems to have become pervasive in the province.

He’s determined to rebuild that public trust, which is why he’s making surprise appearances at clinics and hospitals throughout the province.

“Every week I take three visits and arrive unannounced. Then I introduce myself and ask to see the facility,” he says.

“I knew the level of rot before I came to this office so I can’t say that things are okay now because I am the MEC,” says Sambatha. “I want to be a Mr Fix-It, I’m not running away.”

 

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Mbombo: From domestic worker to MEC

By Biénne Huisman

Western Cape Health MEC Nomafrench Mbombo’s office is on the 21st floor, with views over Cape Town. Seated at a large desk, her eyes flit over a television screen on the far wall. For a moment her features cloud over.

It’s August 8, the day Health Minister Zweli Mkhize introduced the National Health Insurance (NHI) Bill in Parliament.

“This,” sighs Mbombo, gesturing at NHI headlines floating across the TV screen.

Western Cape MEC for Health Nomafrench
Mbombo. Photo by Joyrene Kramer.

She has been outspoken about opposing the bill. While supporting universal health coverage goals in South Africa, she says nationalisation is not a viable means for achieving that.

“Centralised government decision-making in healthcare has shortcomings. This was already evident in the testing phases of the NHI. Strong provincial health systems are key,” she says.

Mbombo’s beliefs are underpinned by her nursing and academic career spanning the country’s three coastal provinces: the Eastern Cape, KwaZulu-Natal and the Western Cape.

Here in the Western Cape, her unique challenges include crime-related injuries such as gunshot and stab wounds. Gang shootings are on the rise on the Cape Flats, with more than 70 patients treated for gun injuries at Groote Schuur Hospital each month this year.

“Surgeons have done the costing,” says Mbombo. “It costs about R25,000 per person who presents with a gunshot, especially multiple gunshots. And this does not include EMS [emergency medical services] transport and recovery time afterwards. Our health budget is going to crime.”

Surgeons and paramedics are so busy saving the lives of people caught in the crosshairs of crime that the waiting time for other patients with less immediate life-threatening problems has skyrocketed.

“A pregnant mother who might have called an ambulance, or an elderly person who has difficulty breathing are probably categorised as ‘priority two’, but due to priority-one injuries, such as gunshot wounds, they now have to wait,” says Mbombo.

Another problem is paramedics having to wait for police escorts to enter “red zones” – the most dangerous areas. Mbombo has joined paramedics when they need to get to these areas.

“I went with an EMS team to Mitchells Plain, it was 10pm, [and] I observed firsthand the delays the ambulance faced getting to a 5-year-old boy.”

She says most incidents take place on payday weekend at the end of the month.

Mbombo, the first black woman in former premier Helen Zille’s cabinet, is not scared to pack a punch. Perhaps this is due to her formative years in Mdantsane township outside East London, which is famous for its boxing culture. Mdantsane is home to boxing legends Welcome Ncita and the late Nkosana “Happy Boy” Mgxaji. Mbombo keeps a boxing bag and gloves ready at her double-storey home in West Beach, near Blouberg Beach, in Cape Town.

Growing up, her father was unemployed and her mother worked at a fish and chips café. From a young age Mbombo assumed the role of the family’s caretaker.

“We had such a big family. I only realised in about Standard 9 [Grade 7] that I was one of just three siblings. I always assumed that all of my cousins were siblings.

“I mean, my mother would leave home by 4am and come back at 10pm. So you didn’t see your actual parents; you were being cared for by anyone in the council house. Then, when I was older, I ended up having responsibilities to look after the younger ones too.”

Mbombo was also the family “nerd”; the one who read newspapers and listened to the radio. “I used to write letters on behalf of the community,” she recalls. “They would ask: ‘Can you please write me a letter for a grant? Can you write a letter to the school?’”

After matriculating, Mbombo was determined to become a healthcare professional. “Generally, for our generation growing up in the township, the thing you always wanted to be is a nurse, sometimes a doctor.”

She applied to several universities for bursaries – without success.

“It was common that after matric you must find work so you can help take care of the others. When I didn’t get a bursary I became a domestic worker.”

Mbombo was fired three times; the third was spectacular. “With the third job, my employer would go out with her children, leaving me to clean the house. Usually, she would return at around 3pm,” says Mbombo, who stares out the window and starts to chuckle.

“It’s common,” she continues, “when you have not been exposed to things, to start exploring.  I used to explore that whole house. I would wear the madam’s clothes and stilettos, and take tea from her best China cups. On that day – it was a Monday – I was wearing the madam’s best dress and reading their Sunday newspapers on the sofa. Well, imagine my surprise when she arrived home early. She was angry. She scolded me and said: ‘You don’t belong here.’”

These cutting words became deeply significant. “I will always remember those words,” says Mbombo. “I realised that, yes, I don’t belong in that domestic worker job … that God has different plans for me.”

Some months later, while roaming East London’s streets unemployed, Mbombo bumped into a neighbour. A nursing sister, who had good news.

“I was window shopping, looking at a dress and thinking: ‘I will buy this dress one day.’ And then this woman said to me: ‘Nomafrench, did you apply?’ I said, ‘No, what’s happening?’ It turns out they had introduced a nursing degree at [the University of] Fort Hare, where you didn’t have to pay for anything. Actually, they paid you; you got a salary while studying.”

The next day Mbombo applied. Competition was tight as the course had capacity for only 40 students, from all over the country, but her results were good and she was accepted.

“I was 18. It was a four-and-a-half year course. So, yes, that’s how it all started,” says the MEC as she leans back in her chair.

She recounts her first job – as a maternity nurse – at Frere Hospital in East London. “I ended up having lots of these low birth weight babies. In addition, HIV was rearing its head.”

After three years at the hospital, Mbombo went on to complete a master’s degree at the University of KwaZulu-Natal. Her research focused on homecare for children from informal settlements living with HIV/Aids. She was then headhunted by the University of the Western Cape (UWC), where she obtained a PhD. “By the time I was pursuing my PhD, I was combining my professional midwifery experience with aspects related to gender,” she says.

“I had learned that health is about more than just physical illness, it’s about empowerment too.” She was promoted to associate professor in sexual and reproductive health and rights.

After 15 years at the UWC, Mbombo needed a new challenge. She was considering going to Bangladesh to do humanitarian work, when she received an invitation to a Democratic Alliance (DA) meeting of black professionals.

“I must just tell you,” she says, “behind the scenes I was an ANC person. I went to this dinner. There were lots of us: accountants, academics, whatever. We didn’t know each other. What they said was this: ‘We invited you because we know you are disinterested. We want you to dissect our policies – as the DA – and tell us what is wrong so that we can fix it in order to attract people like you.”

The seduction was successful, and Mbombo joined the DA in 2013. “I realised that in order for there to be constitutional democracy in South Africa, you need to have a strong opposition,” she says.

In May 2014, she became a member of the provincial legislature. Soon after, she received a call “out of the blue”. It was Helen Zille, who was then the premier. “I was at a mall when I got the call,” recalls Mbombo. “It was noisy. I heard, ‘Hi, Nomafrench. I’m Helen Zille. How are you?’ I said, ‘Hi, how are you?’ And she said, ‘Would you please be my minister of sports and culture?’ I wasn’t expecting that. In December I got a call from her again and she said, ‘Can you do me a favour, please?’ I said, ‘Yes, prem.’ And she said, ‘On the first day of January I’m announcing a cabinet change…’ I was like, ‘Oh, okay, so you’re firing me?’ And she said, ‘No, silly, can you please be my minister of health?’”

Today, Mbombo is in her second term as the Western Cape MEC of Health. Meanwhile, she is also the federal leader of the DA’s Women’s Network. On Women’s Day, August 9, in Port Elizabeth, she delivered a speech titled Women Shall Rise and Break Their Silence.

“We remain at the top of the unemployment chain. Women who are employed face the painful reality of being manipulated into giving sexual favours in return for keeping their jobs,” she says, adding that in many communities young women are forced to sleep with teachers to get better marks.

Mbombo shares her house with her two daughters. One is a student at the University of Cape Town, the other has a job in public relations. “We are the three musketeers,” she says, explaining that she raised her daughters alone, as she is “happily widowed”. Her husband, originally from Port Elizabeth, passed away in 2003.

“The bottom line,” concludes Mbombo, “is to fix South Africa… in a large part, for the future of my children.”

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A children’s hospice rising like an oasis

Sunflower Children’s Hospice. Photo: Joyrene Kramer

In July Bloemfontein is dry and hued in shades of brown. Against this backdrop, the Sunflower Children’s Hospice rises like an oasis: the house is covered in bright murals and surrounded by trees and budding shrubs. Inside, food smells pour from the kitchen. There are stuffed toys perched on stools: Barney the dinosaur, a giraffe, and a teddy bear.

In 1998, as the Aids epidemic was sweeping through South Africa paediatric palliative pioneer Joan Marston founded the special hospice for children. At the time, it was a first of its kind in the country. Most of the home’s early patients were babies dying of Aids. Situated next to Bloemfontein’s National District Hospital, its patients have access to top medical and surgical care.

Joan Marston, founder of the Sunflower Children’s Hospice with one of the children in her care. Photo Joyrene Kramer

Today, the house is home to fifteen young patients with life-threatening diseases. They sleep in fourteen donated cots in three bedrooms; the eldest, nine-year-old Fransina, has a bed. At any time two carers are on duty to look after them. Even at night, two members of staff stay awake.

Fransina has spina bifida and kidney problems. In the house’s lounge, she is bent over a small table, meticulously shading a picture with coloured pencils. Next to her is two-and-a-half-year-old Thandeka, recently recovered from kidney removal surgery. Thandeka smiles, chirping greetings and waving at us.

‘Thandeka is now absolutely fine,’ says the hospice’s manager, Melinda Muller. ‘But when we got her from Trompsburg she was very sick. We got her and Fransina together — Fransina is from Petrusburg — about a month ago.’

Melinda is sitting behind a large desk, paging through a ledger book where notes on each child is kept. Some of the children were abandoned by their parents. Some require ARVs or were simply too ill to stay at home. Some were abused — horrific details that cannot be divulged as court cases are underway.

Some of the children, like two-year-old Amo, who is blind with cerebral palsy, will probably never leave the house, as she is too sick. Amo is fed through a tube.

The rest hopefully in time will get well enough to return home, or to be released into foster care. Just last year, the hospice released seven children.

‘For example, Thandeka won’t go back to her parents,’ says Melinda. ‘But we will see if there is an appropriate relative, otherwise a foster parent to take her in. If so, we will let her new mommy come over here so they can first get used to each other, to see if it works.’

During the interview, there is a small knock on Melinda’s office door. It opens, and Fransina peeks in. ‘What is it Fransina?’ asks Melinda. Fransina enters, pulling a face. ‘Sister, the salt in the food is burning my tummy. I don’t like my lunch,’ she says. Melinda gazes at the young girl patiently. ‘Now what, dear child?’ she asks.

We see miracles

A professional nurse, Melinda has managed the hospice for ten years now. Before that, she worked at the Bloemfontein Mediclinic’s children’s ward.

‘We see miracles,’ she says. ‘Doctors who say there’s nothing more they can do, but then the children get better here. Like this boy, he was in a coma for a year. He had TB meningitis. Then one day he woke up. He went back home, too.’

She says the last time a child died in the house was two years ago. It was a baby with hydrocephalus, a build-up of fluid in the brain. On the house’s outside wall, the deceased girl is remembered: ‘Bokamoso Kotoyi 12/07/2017 seven months,’ reads a small plaque. Around it, many more plaques recall young lives.

‘Sickness and death; we explain this to the children in their own terms,’ says Melinda. ‘We tell them that their friend has gone to Jesus.’

Despite all the bright toys and care, do the children miss their own homes? ‘Yes,’ says Melinda. ‘Most miss home, they do ask for their mothers.’

The hospice’s true scope lies in its outpatient project, which reaches 400 youngsters aged from one-month-old to 18 around Bloemfontein: in the townships of Batho, Joe Slovo, Rocklands and Heidedal, and in surrounding rural towns.

Nurse Olga Molahloe is in charge of the outpatient operation. In the Sunflower bakkie, driven by Thomas Selibe, she visits countless households each day, delivering food parcels — with eggs, long-life milk, pasta, soap, tinned food and tea — ARVs and other medication.

‘Sometimes, when the patients are very sick, Thomas becomes an ambulance driver too,’ says Olga. ‘Then he must bring the patient back here to the hospital fast.’

Olga has worked at Sunflower for 26 years. ‘The relationships you build with the families are very strong,’ she says. ‘And over the course of time the children make you their confidant, it is a big and loving responsibility.’

Making ends meet

The hospice has struggled with finances in the past. But between Joan’s fundraising drives and generous local donations it makes ends meet.

During Spotlight’s visit, two men with bulging bags arrive at the hospice. They are delivering spinach and pumpkin from a nearby church garden. ‘This will be divided between the hospice kitchen and parcels for the outpatients,’ says Melinda. Woolworths donates food to the hospice too, as does the Môreson egg farm.

 

Inside the bedrooms are curtains with cartoon piggies and butterflies, and soft bedding. These were gifts from the local Cheetahs rugby team, who also raised money to have the house painted and its floors newly laminated. ‘The rugby players and their wives have done so much, we are very grateful to them,’ says Melinda.

Over weekends, Melinda and a friend run a cake and confectionary stand to collect money for the organisation too. ‘I know we’re making a real difference. It feels good,’ says Melinda, smiling shyly. Behind her a big sign reads: ‘Stay focused and never give up.’

 

 

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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.

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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.

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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.

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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.)

 

 

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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

 

 

 

 

 

 

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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.

 

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#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.