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: Still no end in sight to orthopaedic disaster in Free State

An overcrowded Pelonomi hospital has forced patients into cramped quarters. Mattresses on floors are the new normal here. Pic by Khothatso Mokone

Orthopaedic surgery backlogs have become old news at Bloemfontein’s Pelonomi Hospital, but it’s still fresh hell for the patients admitted every day and forced to sleep on chairs, on floors and on stretchers pushed up against corridor walls waiting for beds, often for weeks.

Even when orthopaedic patients at the hospital eventually get a “bed” it may be a mattress on the floor and sometimes men, women and children are forced to sleep in the same room. Patients are also being told that they could wait weeks to get to an operating theatre slot if their surgery isn’t considered a priority. This means patients with fractures considered less serious are simply left to wait.

Delays in surgery puts patients at risk of complications in the future. Improperly treated bone fractures can lead to long-term or permanent nerve damage; deformity and disability; damage, rupturing or stress on the muscles and ligaments; blood clots and sores; infection in the bone and marrow or avascular necrosis – there the bone loses its blood supply and dies. If a neck fracture is left untreated it could result in paralysis or death.

On top of this, patients are also told that if they choose to go home to wait for a surgery date they’ll lose their spot in the queue.

Spotlight already reported in December 2017 on the shocking state of affairs in Pelonomi’s orthopaedic ward. It was a story of long waiting lists and undignified hospital waiting areas. At the time Free State Department of Health spokesperson Mondli Mvambi said “We are constantly making plans to intervene and cutting the backlog of services.  We are appointing professionals especially to the periphery and the sustenance of orthopaedic services to Botshabelo.” Referring patients to Botshabelo has been a common refrain from the Department since Spotlight started covering this story.

When Spotlight returned to Pelonomi earlier this month it appeared as if nothing had changed in the 16 months since we last wrote about the hospital – in fact the waiting times seemed longer, the wards more chaotic and the patients more defeated.

Patients are told to limit the time they spend out of their wards, so nurses don’t have to repeat messages to them. For the patients it’s a torment of boredom, anxiety, frustration and discomfort being confined to a bed (if they lucky) waiting for surgery. The ward is noisy and stuffy with visitors coming and going at all hours and staff smoking inside offices behind closed doors.

Patients speak of long queues for bathroom time, very little privacy and no communication or clarity on when they will get their operations.

Lying on the bare floor

The plastic chairs in the foyer area of the fifth floor orthopaedic ward also double as beds and as dining area for the likes of Mpumelelo Mattroos (seated on the chair), who are left for days without being given a bed. Pic by
Khothatso Mokone.

On a Tuesday morning earlier in March Mpumelelo Mattroos is one of the patients sitting on the zig-zag of plastic chairs in the waiting area of the orthopaedic ward. Mattroos arrived at the hospital two days earlier on the Sunday after being in a car accident that left him with a broken arm, cuts and bruises to his left eye and severe whiplash. He’s arm is bandaged and in a sling but he’s been told there’s no bed, and he must wait. His personal items he’s had to store in an emptied out plastic dustbin pushed into a corner. His coat is folded over the dustbin and he takes sips from a two litre bottle of cooldrink on the floor.

Mattroos switches from sitting on the chairs to lying on the bare floor. He grimaces every time he moves. Another patient who is also sleeping on the chairs, translates for him as he tells Spotlight how frustrated, angry and in pain he is.

“I thought at least I could have the operation today and leave by Friday because I must report at work,” says Mattroos, who works on a mine in Rustenburg. His employer doesn’t know his situation and he’s anxious he’s going to lose his job.

As he talks he daubs at his weeping injured eye with his own handkerchief, he’s still in his own clothes, not hospital pyjamas. Later when the food trolley arrives he’s dished up a plate of food that he must balance on his lap and negotiate with his uninjured arm.

Mattroos does get a bed later that night and his surgery is considered enough of an emergency that he’s operated on two days later. But he misses his deadline to get back to work, his future uncertain.

“It’s the same story”

Bereng Ramosebi is at Pelonomi’s orthopaedic ward for a second time in less than two years and is again being told there’s no certainty when he will get his surgery. Pic by
Khothatso Mokone

Still waiting however, are the likes of Bereng Ishmael Ramosebi. He’s furious because it’s the second time in less than two years that he’s been in Pelonomi Hospital for a broken bone and each time he’s been left waiting.

“It’s the same story. This is very painful that nothing has changed,” he says.

Back in 2017 Ramosebi, who works as a security guard, broke his hand. It took nearly three months, he says, to get his surgery. In a ground floor ward this time around he’s been given a bed after two nights but he’s not been given a surgery date. In his ward one man with a broken leg has been waiting for more than six weeks unable to return to work. A student has missed two weeks of class waiting for surgery.

Ramosebi is anxious he too has a long wait ahead of him. “The nurses tell us they aren’t in charge, the doctors tell us that they have lists with 45 other patients on it. I have to work so I can pay rent but I can’t go anywhere.”

Ramosebi was injured running from robbers who attacked him for his cellphone and wallet. He hasn’t been able to communicate with family and friends or his employer since he came to the hospital. Five days into his stay he says he’s seen a doctor only once.

Waiting for three weeks

Also among the orthopaedic patients is Treatment Action Campaign (TAC) Free State provincial manager Enoch Moware. The activist broke his arm and was waiting at Pelonomi for a surgery date. He speaks about his experience, nearly three weeks into the wait.

“I feel very bad. We are told stories like this all the time, but now I’m experiencing it for myself,” he says.

Moware has used his hospital stay to push for action and insists on answers from hospital management. Eventually, he was told “contingency” plans would be put in place and efforts to close backlogs would commence.

“Whatever the politicians say, it’s still a crisis, because we are still getting more patients coming in, so there will still be a backlog. One doctor told me that he alone has 45 patients waiting to be operated on,” he says

On Moware’s doctor’s note it says: “Due to the nature of theatre procedures it is difficult to predetermine the duration of his/her hospital stay”.

Earlier this week, after nearly three weeks when he first arrived at Pelonomi, Moware was woken up at 2.30am, loaded in a van and transported to Botshabelo where the surgery was supposed to take place. At Botshabelo they were left till dawn in a waiting area with no clarity on what was about to happen to them.

A history of failings

In October 2016 Spotlight reported on unlawful stem cell research being conducted at the hospital with the support and approval of the then Free State MEC for Health Dr Benny Malakoane. Experimental stem cell therapy was being used to treat musco-skeletetal diseases in orthopaedic knee patients.

As soon as Spotlight alerted authorities the Medicines Control Council (MCC – now SAHPRA) suspended the unlawful stem cell experimentation at the hospital. At the same time the Free State Department of Health cancelled its contract worth a potential R90-million with the company ReGenesis Biotechnologies, the company that was conducting the unlawful trial. What angered doctors is that the department was prepared to spend this money on an unlawful trial, but did not have money to conduct straightforward orthopaedic surgery. Following coordinated exposes by Spotlight and the television programme Carte Blanche, Malakoane was moved out of the health portfolio in the following week.

Even though the Free State department of Health was involved in an unlawful trial and was set to spend tens of millions of Rands on unproven and potentially dangerous stem cell therapies, neither Malakoane or the ReGenesis doctor Wian Stander have been investigated by authorities or the Health Professions Council.

Spotlight also reported in October 2018 on the on-going problem of inferior hospital equipment supplied by a company called Mediquip Hub SA to Free State hospitals, including equipment needed for orthopaedic surgery at Pelonomi. It is a tale of, among others, nepotism, contracts for political allies, unusable x-ray machines, wonky theatre beds and  theatre lights that are too low.

Flood of patients

Mvambi acknowledges that Pelonomi has been under pressure for years. He ascribes it to the “flood of patients” from surrounding areas and also because of high road accident numbers as major national roads cut through Bloemfontein. He claims they had managed to clear a backlog of about 200 orthopaedic surgery cases in 2018 and early 2019. However, he says storm damage in February to Botshabelo Hospital (about an hour from Pelonomi), that had worked with Pelonomi to alleviate the backlog, resulted in Botshabelo’s operating theatres being temporarily put out of commission.

He said operations at Botshabelo would resume by 20 March. He also said several other measures had been put in place to ease congestion at Pelonomi. Some of these, he says, include clearing unused Intensive Care Unit areas to make bed space, instituting 24-hour surgery lists and operating at Albert Nzula Hospital. This facility is over an hour away from Bloemfontein, making it difficult for family and friends to support patients there.

The department didn’t answer Spotlight’s questions regarding what is considered a reasonable waiting time at Pelonomi , the costs involved with accommodating patients for extended waiting periods, and continued allegations of irregularities in procurement of services and equipment including the use of locum agencies.



Health4Sale: More dodgy equipment supplied to the Free State

The 5 x-ray units at Pelonomi

A company with a track record of supplying inferior medical equipment to the Free State health department recently sent five mobile x-ray units to Pelonomi Hospital, but it had to be returned after a key part of the machines was too short, making it unusable and increasing the risk of radiation exposure for patients.

The latest reports comes five months after Spotlight first wrote about problems with equipment provided to the Free State Department of Health by a company called MediQuip SA Hub – a company with some politically well-connected directors.

Over and above the too-short columns, staff in the radiology department also discovered that the mobile X-ray  machines, procured by the province at over R2,5-million each, had not been registered with the radiation control body and that MediQuip could not supply a compliance certificate.

A radiologist in private practice explained to Spotlight that the x-ray tube which is mounted on the unit column has to be at a safe distance of no less than 120 centimetres from the patient for a supine/flat chest x-ray on an immobile patient.

The patient is x-rayed either flat or sitting up in the bed. If the bed is fixed at a certain height then it is impossible to reach the required minimum distance. This means that if the column is too short, then the x-ray tube, which rotates around the column, will be too close to the patient. After inspecting the photographs supplied by Spotlight, the radiographer said that the column did appear to be too short – as alleged by doctors in the Free State.

This problem leads to the contravention of a number of radiation standards such as over exposure of the patient to radiation and inadequate field of view for the radiologist.

She added that each hospital or province should have a radiation inspection or control board that deals with compliance. This board would have to register the equipment and conduct periodic radiation inspections in each centre where x-rays are provided. “They are quite strict as radiation overexposure is a huge concern,” she explained.

MediQuip SA Hub, a preferred provider of some of the Free State health department’s most expensive and technical equipment, continues to supply apparatus that either breaks or cannot be used at all, including these x-ray units. Free State health department spokesperson Mondli Mvambi confirmed that the province has already paid over R105-million to MediQuip. Mvambi was unable to supply details on the equipment which was broken or too inferior to use as “Our Health Technologist is not available at the moment and we are unable to give details on these.”

The equipment list supplied by Spotlight includes the x-ray units, orthopaedic surgery traction beds that broke within weeks of being installed, too low theatre lights, anaesthesia machines that cannot be used as there are parts missing and mobile clinic buses unable to travel on rural roads.

Spotlight reported earlier this year that surgeons were facing massive challenges with beds and other equipment supplied by MediQuip.

They said that newly purchased theatre beds were breaking in Free State hospitals within months of installation, making it hard to perform critical surgery.

“The department have bought entry-level equipment from China. The mechanism that was supposed to get the tables to move up and down and tilt broke within weeks. The anaesthetists refuse to use the machines,” said a frustrated specialist, who has asked to remain anonymous. We also did not identify the hospital where the specialist is based as health workers are sanctioned if they speak to the media.

At one hospital, a height-adjustable orthopaedic theatre bed got stuck on a too high setting, forcing doctors to stand on benches while operating. In other cases, newly installed theatre lights were too low, resulting in some of the theatre personnel often knocking their heads while performing surgery.

Doctors also reported that a number of new anaesthesia machines, delivered last year, were gathering dust because anaesthetists were not willing to use the machines since they were missing components and various alarms did not work. Anaesthesia machines typically have multiple components and a sophisticated set of alarms to ensure that nothing goes wrong while someone is under general anaesthetic. Spotlight understands that these machines are still not being used despite undertakings from the health department that MediQuip was addressing the challenges.

However, in contrast to what health workers were reporting, Mvambi claimed that “the challenges between the Department and the service provider with regards to compliance to specifications were resolved”.

Mobile clinic buses gathering dust in Bloemfontein

MediQuip is also the supplier of the R12-million each “mobile clinics” also known as “China buses” in the province. Media reports reveal that these six buses are standing gathering dust at various health facilities. A Spotlight photographer found two at the Bloemfontein Psychiatric Complex. Even though the department is not using the mobile clinics it already has, a recent parliamentary oversight report indicates that the department nevertheless purchased an additional 20 mobile clinics. It is unclear is they were all from MediQuip.

The six mobile clinics were going to be operated by the Gupta-linked Mediosa before that link was exposed and stopped earlier this year.

Mvambi confirmed that all this hospital equipment had been supplied by MediQuip. He confirmed that MediQuip had among others supplied 10 anaesthesia machines and 8 mobile x-ray units to various hospitals. He claimed the department was in the process of recruiting full-time drivers for the buses.

MediQuip Hub SA has on its Board of Directors Eskom board member George Sebulela and three representatives from a Chinese company.

The fifth board member, still listed on the Companies and Intellectual Properties Commission records, is Tefetso Phitsane, among others a close ally of African National Congress Secretary General and former Free State Premier Ace Magashule, Chairperson of the beleaguered Bloem Water and husband to Nelisiwe Phitsane the Chief Director Supply Chain Management and Asset Management in the Free State Department of Health.

Phitsane told Spotlight earlier this year that this relationship was disclosed when bids were submitted to the Free State Department of Health. The department confirmed this to Spotlight, but failed to provide proof when requested earlier this year. When again asked this week to provide evidence of this, Mvambi said Spotlight would have to “follow procedures in terms of access to Information Act”. Phitsane promised Spotlight that he would supply the form disclosing their relationship. He also claimed that he has resigned from MediQuip in August last year and that the company was failing to remove him as a director.

Phitsane is also listed as a director of Dinaka Trading 5 CC, a company of which Ace Magashule is a former director and his son Tshepiso Magashule is still listed as a director.

According to information revealed in the #Guptaleaks articles published by Amabhungane Tshepiso Magashule (Phitsane’s co-director of Dinaka Trading 5 CC) has been linked to various deals with the Gupta family for whom he worked.

Phitsane was also on the board of the Free State Development Corporation from July 2012 to October 2014. In the 2014/2015 Annual report of the FDC, MediQuip is listed as one of the FDC’s pipeline projects. The FDC describes MediQuip as a company that will manufacture medical equipment, employ 200 people  and is estimated to have a potential value of R500 million. As it turns out, MediQuip’s main business would not be manufacturing, but importation of medical equipment from China.

In May, Spotlight reported that MediQuip Hub SA, which receive millions of Rands did not have a website. A website since appeared, but was removed again this week after Spotlight sent questions to Sebulela, who failed to respond despite reading the whatsapp message. When the website was live it had no content other than an “About Us” section which states it is a “South African company consisting of foreign investor, Shangai Medical Hub and 100% black owned and managed South African companies”. It however then appears to contradict this by stating that “Shanghai Medical Hub owns 60% and the other 40% is owned by South African companies”.

While they claim their “main target” is “to have local assembly, local
manufacture, create South African brand , south African IP, jobs and skills” – they appear to be little more than an importer of cheap Chinese medical equipment.

The contact details on the website listed an office in Johannesburg and Bloemfontein, but with the same telephone number in Johannesburg. When Spotlight called this number we were told we had reached the “Mtimandze Group”. The telephone receptionist told Spotlight she would have to call us back when we asked for MediQuip.

Mtimandze is a licorice allsorts of a company describing its objective as “based on the provisioning of business solutions & services to the following sectors of the South African economy; Public Sector, National, Provincial and Local government, State Owned Enterprises, Socio-Political Organisations, Private Sector and Mining.” This includes “foreign exchange, mining, project management, coal mining, smart metering and PPP municipality projects”.

Muzi Kunene, the sole director of the Mtimandze Group and Sebulela are directors of InSpur SA, with various Chinese and South African directors, some who used to sit on the MediQuip board.

George Sebulela failed to respond to a list of questions related to MediQuip. He read a Whatsapp message, but did not respond.


Eskom Chairperson, Mr Jabu Mabuza accounced today (19 October 2018) that George Sebulela tendered his resignation as a non-executive director.

Sebulela’s resignation took effect immediately.

The Eskom statement said Sebulela resigned after “considering legal advice on his continued role as an Eskom director after the Board was made aware of certain conflicts of interest.”

“In this regard, Mr Sebulela made the correct decision to resign from the Board and to help ensure that acceptable standards of good corporate governance are maintained,” said Jabuza.








Health4Sale: Government employee represents private company as Free State again prepares to outsource part of ambulance service

By Marcus Low and Anso Thom

On 5 October 2018 the Free State Department of Health advertised a large new three-year private ambulance tender that requires 30 ambulances and around 250 paramedics. This flies in the face of comments  by Health Minister Dr Aaron Motsoaledi that it is not national policy to outsource ambulance services. Earlier this year Motsoaledi said he told then Free State MEC for Health Butana Komphela that “it is wrong for them to privatise ambulance services. They must run them on their own”.

The new tender also comes as a surprise given the controversy surrounding the previous tender, with widespread complaints of poor service from Buthelezi EMS – a company that is currently the subject of both Hawks and National Treasury investigations. National Treasury this week told Spotlight the investigation into the Buthelezi EMS contracts “is still continuing as information is still being gathered, and will be concluded in due course”. In addition, according to Mariette Pittaway, Democratic Alliance (DA) member of the Free State legislature and spokesperson on Health, the DA in July requested the Public Protector to investigate three controversial contracts the Free State Department of Health entered into with Buthelezi EMS, Mediosa and Halo Aviation.

The tender also flies in the face of undertakings given to parliament regarding the in-sourcing of ambulance services in the province. A recent parliamentary report notes the commitment to in-source and lists a long series of complaints regarding the current ambulance service in the province, mostly relating to long waiting times and to calls not being answered at the call centre.

“The Department is not outsourcing but augmenting its capacity because we have been replacing the ambulance fleet and not increasing it,” said Mondli Mvambi, spokesperson for the Free State Department of Health. “What we require is an increased EMS fleet in order to meet the service requirements of 1 ambulance per 10 000 people in a population excluding inter-facility transfers.

Mvambi also said that the new tender was not large in comparison to previous contracts. “The initial contract had 47 ambulances.  The cancelled contract required 40 ambulances in line with the commitment to downscale.  The current advertised contract requires 30 ambulances,” he said. “We are not going against the advice of the Minister but responding to EMS service requirements.”

“Due to the inadequate EMS capacity, especially in rural communities where ambulances often double up as patient transport services, the Department should rather maintain and enlarge its own ambulance fleet,” said Pittaway.

The only other province that has outsourced its road ambulance service is the North West. We understand that unlike the Free State the North West will not be advertising a new private ambulance tender when their current tender runs out in March next year.


R123 million since end of contract

The new contract follows on a previous three-year contract awarded to Buthelezi EMS at the end of 2013. “The contract with Buthelezi EMS expired in August 2017,” says Mariette Pittaway of the Democratic Alliance. “On a question in a Portfolio meeting I directed to the Health HOD, Dr (David) Motau, he informed me it was renewed on a month to month basis.  This is problematic since the department knew exactly when the contract would expire and could have advertised the new invitation to tender long before the termination date.”

The month-to-month extensions of the Buthelezi EMS contract appears to have continued for more than a year until September 2018 – the date on which the Free State Department of Health claims its contract finally ended. The department declined to respond to a suggestion that the contract extensions was in contravention of the Public Finance Management Act (PMFA). The PFMA typically does not allow month-to-month extensions for more than six months.

According to the Free State Department of Health Buthelezi EMS has been paid over R123 million since the contract expired.

In October 2017 a new tender was advertised, but that tender was never awarded – and has essentially been replaced by the tender advertised in October 2018. According to the department the tender advertised in 2017 was never awarded because “the specifications had to be amended in order to allow broader competition”.

While having advertised the new tender the province has also purchased 110 ambulances, 60 of which have now been delivered.

Government employee represents B EMS at tender briefing

A Facebook post of Edwin Lecheko in a BEMS helicopter from August last year.

On 16 October 2018 Spotlight attended a compulsory tender briefing for the new Free State ambulance tender. One of Thapelo Buthelezi’s many companies, B EMS (the current incarnation of Buthelezi EMS) was represented by Mr Edwin Lecheko. Lecheko filled in the attendance register with his own name, Thapelo Buthelezi’s e-mail address, and a phone number that TrueCaller identifies as belonging to Thapelo Buthelezi. It is also the same number which Buthelezi used to respond to questions from Spotlight earlier this year.      .

Lecheko is currently an employee of the Maluti A Phofung municipality. Until at least November 2017 he worked closely with the former Maluti A Phofung mayor Vusi Tshabalala, a known ally of former Free State Premier Ace Magashule. There is online evidence of him being quoted as a spokesperson for the former Mayor at events. Spotlight previously reported on how Magashule cleared the way for a controversial rates increase granted to Buthelezi EMS. Neither Lecheko or Buthelezi responded to questions sent by Spotlight.

The specifications for the new tender are contradictory on whether state employees are allowed to bid. First it says, “Any legal person, including persons employed by the state’, or persons having a kinship with persons employed by the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid”. Then later it says, “All the state employees are not allowed to do a business with the Free State Department of Health.”

When asked about this contradiction, Mvambi did not address the question, but merely referred us to the latter of the two quotations above. The DA’s Pittaway said, “we believe that civil servants should not be allowed to tender for lucrative government contracts and a cooling off period should be adhered to after they have exited the civil service.”


Questions regarding tender specifications

One aspect of the new tender that has at least one rival ambulance company concerned is that it requires a fleet of 30 ambulances and around 250 registered paramedics ready to be deployed. It seems likely that the current service provider, Buthelezi EMS (or B EMS), will have this capacity in place given that they are currently contracted to provide the service. For other companies to invest in this capacity would be risky given that they may well not be awarded the tender.

“The insinuation that the Department is tailor making specifications to favour Buthelezi EMS and its associates is unfair and baseless because if this was the case, they would have been advantaged in the previous round of the cancelled tender,” said Mvambi, when asked about this aspect of the tender. “We cancelled the tender and readvertised it in order to allow broader competition and responsiveness from potential suppliers.”

The new tender also requires that the service provider seconds staff to the provincial call centre. Healthcare workers in the province previously alleged that some of the alleged overcharging in the province is due to corruption at call centre level. We understand that Buthelezi EMS has for some time had staff in the provincial call centre.

In recent parliamentary meeting minutes produced by the Parliamentary Monitoring Group, it was reported that a private company (presumably Buthelezi EMS from the context) had an office inside of a casualty ward inside a public hospital in the Free State. The minutes read as follows:

“At Albert Nzula District Hospital the Committee had to note that it had found an ambulance service provider provided with office space inside the casualty ward whereas; there was an ambulance facility 50 meters away from the casualty. It had also been clear and suggestion had abounded that Buthelezi EMS had a choice in taking the most lucrative trips because of its proximity in the hospital. How and why could a private contractor have an office inside a public hospital casualty ward? The Committee was never answered satisfactorily in that regard.”

When asked why the tender required bidders to second staff to the call centre, Mvambi said “This is so in order to ensure better control of the resources and improve coordination as the EMS Centres are interlinked.  As the Department of Health is the custodian of Patient Records pertaining this contract.”

The National Department of Health did not provide comment by the time of publication.

Note: While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence – independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Not forgotten: The sordid story of how Mosebenzi ‘Gupta’ Zwane’s thugs wreaked havoc in a Free State hospital

Opinion: An article this week by the Daily Maverick’s Ferial Haffajee The sordid story of Mosebenzi ‘Gupta’ Zwane – South Africa’s most captured Cabinet minister reminds us just what a scumbag this former MEC, Minister and still Member of our Parliament is.

However, Haffajee omits one other sordid story from this politicians CV which is worth reminding people about. Not only was he prepared to pull all kinds of strings for his friends the Guptas, he was also prepared to pull all kinds of strings to access an extremely scarce Intensive Care Unit hospital bed in the Free State for his relative and Comrade.

In keeping with the thug nature of Free State politics, one hand washes the other, Zwane reportedly found willing bouncers in the form of a group of medical doctors who happened to be provincial health department government officials. They were then Health MEC Dr Benny Malakoane, the head of the provincial health department Dr David Motau and a Deputy Director General in the department Dr Teboho Moji.

Whistleblowers leaked the repugnant details to SECTION27 Executive Director Mark Heywood, who then made it public via the Treatment Action Campaign (TAC) and the media. While Malakoane, Motau and Moji were the targets of ongoing attempts by the TAC and SECTION27 to get this case prosecuted, it is worth reminding the public about what happened that night in June 2014 and subsequently in Bethlehem in the Free State and the “background” role of Zwane.

Whistle-blower health workers in Bethlehem in the eastern Free State told Mark Heywood that Malakoane and Motau walked unannounced into the Phekholong hospital on the night of 27 June 2014. They instructed doctors to transfer a male patient, who was later revealed to be Zwane’s relative and an ANC member, to Dihlabeng Hospital as Phekholong had no Intensive Care Unit beds. Both hospitals are in Bethlehem.

The transfer went ahead and upon the patient’s arrival at Dihlabeng, the ICU doctor on duty assessed that he did not qualify for admission to the already full unit because he was in the final stages of a chronic condition and was unlikely to recover. According to doctors two more deserving and critical patients had already been turned away from the ICU earlier in the night because there simply were not enough beds.

Zwane’s relative was then admitted to the medical ward and not ICU.

It is worth noting that Malakoane and his department had taken a decision previously to close two of the five ICU beds at Dihlabeng because apparently there was no money. This meant that many patients who met the criteria for ICU admission were turned away.

However, on 28 June, Dr Moji arrived at the hospital and called a doctor to the car park where he allegedly enquired about the patient (Zwane relative) who was supposed to be admitted to ICU, allegedly on instruction of Malakoane (who the doctor claimed had been on the phone to Moji moments before). Moji told the doctor that Malakoane was not happy that his instruction had been ignored and that the then Agriculture MEC Zwane knew this patient and wanted him placed in ICU.

The hospital proceeded to open the fourth ICU bed after much pressure and upon Malakoane’s instruction. This was despite the fact that multiple patients with the same diagnosis and prognosis as Zwane’s relative were not being admitted to ICU and were dying.

On 30 June a fifth bed was also opened for a burns patient. A day later a young burns patient also arrived and needed an ICU bed. Doctors had to make a decision about who to transfer out of ICU…an elderly patient was transferred to the surgical ward where she died.

After having spent several days in ICU, where Zwane’s relative received palliative care he could have easily received in another ward, he was transferred to the medical ward on 6 July and died 12 days later.

Once the media reported on the case, the Free State health department went into denial. Spokesperson Mondli Mvambi told enca at the time that it was not true that Malakoane had intervened to access a bed in the ICU when the patient was much too sick to benefit from it and that other patients were turned away and one of them died as a result.

“No that is absolutely not true, the MEC was acting on the case of an individual whom he saw because you must remember the MEC is a doctor in his own right he saw this patient, he saw the file, he called the clinical specialist in the hospital, assessed the file and jointly agreed with the specialist that this was a deserving case for the ICU and taking that decision which was still left to the prerogative of the clinical head to make a decision to remove the patient from Pekholong to Dihlabeng hospital, the MEC was not aware of the other case that was at Dihlabeng hospital, a patient who was allegedly in ICU previously and had been removed from an ICU to a normal ward because they were recuperating in that ward.”

The TAC, with the legal assistance of SECTION27, tried several avenues to get charges instituted against Malakoane, Motau and Moji. These included pressing charges under a section of the Prevention and Combating of Corrupt Activities Act and the Public Finance Management Act.

A timeline included below reveals a story of lost police dockets, pickets to try and get matters moving, a National and Provincial Prosecuting Authority dragging its heels and finally a decision with flimsy reasons to not prosecute.

Finally, on 2 April 2017, by now Zwane was Minister of Mineral Resources in Jacob Zuma’s Cabinet, the NPA informed the TAC that “after careful consideration of the relevant legal provisions, the available evidence in the docket and the consultations conducted with some of the state witnesses, the Prosecution Team who dealt with this matter has decided to decline to prosecute anyone in connection with this matter.” Advocate E Smith, Deputy Director of Public Prosecutions in the Free State said the reasons not to prosecute were as follows:

  • A doctor at Phekolong said that Malakoane and Motau had “requested” that the Zwane relative be transferred to Dihlabeng ICU. Smith said that in two subsequent statements the doctor said the two men had “told” him to transfer the patient. Smith said this constituted a contradiction which affected the veracity of the witness negatively. The doctor did also not “mention or implicate” Moji.
  • The Dihlabeng doctor who had been instructed in the parking lot by Moji was found to have not had “direct/personal contact with Malakoane regarding the alleged “instruction”” to have the patient admitted to ICU. The NPA said this constituted hearsay. The NPA also revealed that Moji declined to become a witness and depose a statement.
  • It could not be proved that a patient who had been turned away from ICU had died

The NPA’s Smith then makes an interesting statement in his final paragraph. “A letter had been addressed to the Premier of the Free State (then Ace Magashule) recommending that he deal with the conduct of MEC Dr Malakoane, Dr Motau and Dr Moji internally in securing a bed for the patient in ICU when he did not qualify to be admitted to ICU in order to a prevent a reoccurrence thereof.”

The wheels of justice and accountability turn slowly, however in the Free State they often stop turning when political connections are involved and it is clear that then Premier Magashule did not pay much attention to the letter the NPA claimed it had sent.

Dr Benjamin Malakoane is now the MEC for Economic, Small Business Development, Tourism and Environmental Affairs, Zwane’s old job. This is in spite of a slew of corruption allegations during his time in local government and as Health MEC.

Dr David Motau continues to be the Head of the Free State Health Department. This is despite a number of questionable tenders, some with links to the Gupta family, and a severely depleted health system on his watch.

Dr Teboho Moji comes up as the acting Deputy Director General for District Health Services in the KwaZulu-Natal health department.

And Mosebenzi Zwane is now an esteemed Member of Parliament. How does that often referred to old saying by Austrian-British economist Friedrich August von Hayek go? “In Government, scum always rises to the top.”


1 September 2014 – The TAC lays charges against Malakoane, Motau and Moji at Parkway Police Station in Bloemfontein. TAC General Secretary Anele Yawa submits a 12-page affidavit detailing the events.

18 September 2014 – Yawa writes to Brigadier Tosholi in Bloemfontein confirming that he had been informed on 4 September that the case had been transferred to Bethlehem and allocated a new case number. However, an investigating officer had not been assigned due to the absence of the docket which was presumed missing. Also, on 15 September SECTION27 was informed that the case had been now transferred to the provincial head office as “the case is a high profile fraud matter involving senior police office bearers”. A Lieutenant-Colonel at head office informs SECTION27 that the docket is currently missing.

29 September 2014 – SECTION27 writes to Brigadier Tsokolo Posholi on behalf of the TAC, asking how the docket which had earlier been reported missing had been found. They also requested an update on the case.

29 October 2014 – Yawa writes to Posholi stating that the witnesses he wishes to interview fear being victimised. The TAC express serious concern in the lack of response from the Brigadier’s office.

26 May 2015 – Yawa writes to Brigadier Posholi (cc-ing Senior Public Prosecutor H Holtzhuizen) detailing a number of calls and letters to the Brigadier’s office. Several letters and phone calls to the Brigadier remained unanswered. The letter also revealed that Holtzhuizen had told SECTION27 that Posholi had said that the investigation was “nearly completed” and that upon completion he would “personally hand the docket over to the Director of Public Prosecutions for a decision”.

12 October 2015 – The Free State Public Prosecutor subpoenas a number of doctors who were on duty at the two hospitals. The doctors are ordered to appear before a Magistrate or the Prosecutor to answer a range of questions.

12 May 2016 – 500 TAC and Free State Health Coalition members march to the South African Police Service and the Free State Prosecuting Authority demanding that the police urgently conclude its investigation into the matter. A memo was handed over to the police as well as the prosecuting authority.

19 May 2016 – Advocate E Smith, the Deputy Director for Public Prosecutions in the Free State sends a three sentence letter to Yawa stating they addressed a two page list of queries to the SAPS to be investigated. He claims that some of the issues have been investigated, but “the outstanding matters are still under investigation” and once the investigation is complete “this office intends to consult with some of the witnesses before a final decision will be made whether to institute a prosecution or not. Smith fails to address any of the questions in the TAC memo.

20 May 2016 – The TAC writes to NPA Director of Public Prosecutions Shaun Abrahams as well as advocates Ketani and Xolisile Khanyile of the NPA. The letter expresses concern regarding the ongoing delays. The TAC requests that the NPA gets the provincial office to respond properly to the memorandum and act.

4 April 2017 – Advocate E Smith, Deputy Director of Public Prosecutions in the Free State writes to the TAC’s Anele Yawa stating that, “After careful consideration of the relevant legal provisions, the available evidence in the docket and the consultations conducted with some of the state witnesses, the Prosecution Team who dealt with this matter has decided to decline to prosecute anyone in connection with this matter.”

Smith then set out the three flimsy reasons for their decision, none of which could be considered good enough. It is also notable that the one key witness, Dr Teboho Maji, who could have placed Malakoane at the centre of this case, declined to give a statement. The NPA did not explain why they did not opt to subpoena him.

Want to read more about corruption in the Free State health department?

These links go to several articles published in 2018

This article also appeared in the Daily Maverick

Ambulance bases of shame

An ambulance base has to comply with a certain set of minimum requirements contained in among others the National Health Act. At the end of last year, the Department of Health published a new set of regulations which detail exactly what the requirements are for an ambulance base.

The new regulations can be read here

Spotlight recently sent a photojournalist to four Buthelezi EMS bases. Two in the North West, Klerksdorp and Potchefstroom; one in the Free State, Bloemfontein; and what is suspected to be a central base or headquarters in Eikenhof, Johannesburg.

Images from Bloemfontein and Potchefstroom specifically, show filthy yards, bare insides with no evidence that it is an ambulance base and further evidence that safety and hygiene is not a priority. The images are published alongside our series of investigative articles #Health4Sale.

Picture credit: Spotlight

Health4Sale Part 6: Magashule cleared way for controversial private ambulance company to cash in

By Marcus Low and Anso Thom, Spotlight

Buthelezi EMS netted more than R15-million from two suspect back-dated price increases from the Free State Department of Health, apparently without much scrutiny. Documents that Spotlight has had sight of reveal how the increases were signed off during a five-day period, when it seems the Free State Department of Health was temporarily taken out of administration by decree of then Premier Ace Magashule. The Democratic Alliance told Spotlight that they will ask the Public Protector to investigate.

Five days in February

According to a response by the Free State Department of Health to questions posed by Spotlight, the department was under administration by the provincial treasury for almost four years from 17 March 2014 to 15 February 2018. Among others, this means that the accounting officer, the person who ultimately signs off on all health spending, was not the head of the provincial department of health, but the head of the provincial treasury.

Yet, contrary to what the department told Spotlight, this was not the case for

Ace Magashule
Photographer: Khothatso Mokone

five days in February 2017. In a signed memorandum dated 3 February 2017 seen by Spotlight, then Free State Premier Ace Magashule effectively takes the provincial department of health out of administration for five days by appointing the head of the department of health, Dr David Motau, as acting accounting officer from 6 February 2017 to 10 February 2017. In this five -day window, Motau signs off on what procurement experts describe as two highly unusual back-dated 8.5% price increases for Buthelezi EMS.

When asked about the five days that the Free State Department of Health was taken out of administration, Mariette Pittaway, Democratic Alliance (DA) member of the Free State legislature and spokesperson on Health, told Spotlight: “The DA is fully aware of this. We are in possession of a copy of this appointment letter and are compiling a case docket to submit to the office of the public protector for further investigation.”

Red lights over price increases

The first price increase, signed off by Motau on 10 February 2017 grants Buthelezi EMS an 8.5% price increase for their inter-facility transfer service. Critically, the price-increase is back-dated to April 2016.

Where government contracts allow for back-dating of increases, they typically do not allow for backdating beyond the date at which the increase was applied for. It could be that this specific contract has more flexible conditions attached to it, but in that case the question would arise as to why Buthelezi EMS was granted such an unusually favourable contract.

Free State Department of Health spokesperson Mondli Mvambi has previously said that the Department of Health paid Buthelezi EMS a total of R204 million in the 2016/2017 financial year. It is not clear whether or not this includes the 8.5% increase. Either way, the increase would amount to a back-payment of between R15-million and R17-million. (Spotlight previously reported on how the Free State Department of Health overspent its emergency medical services budget by around 100% during the period in question. It is this budget line that paid for the increases.)

The second price increase relates to a contract between the Free State Department of Health and Buthelezi HEMS, a joint venture between Buthelezi EMS and HALO Aviation. Internal departmental documents show that on 10 February 2017 this price increase is both recommended by Motau in his capacity as Head of the Provincial Department of Health and approved by Motau in his temporary capacity as accounting officer.

This increase is also backdated, but to October 2016. According to internal departmental documents that Spotlight has had sight of, this price increase was only applied for on 27 January 2017.

Also raising red flags, is a letter dated 24 January 2017 in which the departmental bid adjudication committee expresses its support for Buthelezi HEMS’s requested increase. As noted above, according to the department’s own documents this increase was only applied for by the service provider Buthelezi HEMS, three days later on the 27th.

Motivation for increases

While the back-dating of increases raises eyebrows, normal price increases are not straight-forward either. Where government contracts allow for increases, they either happen simply as a matter of course since it is priced into the original contract, or they do not happen as a matter of course, in which case the increase requires a detailed motivation with supporting evidence (as in this case).

Spotlight asked the Free State Department of Health for the full documentary justification for the rate increases given to Buthelezi EMS. The department’s response, signed off by Motau, was simply: “Rate increases are based on the annual Price adjustments and price schedules”. A request for clarification of this answer was not responded to.

Internal departmental documents seen by Spotlight show departmental officials making the case for the increase granted to Buthelezi HEMS (the joint venture) only in broad terms. The key motivation also signed by Chief Director Supply Chain and Asset Management Nelisiwe Phitsane, a senior procurement officer in the department and wife of Tafetso Bernard Phitsane – a senior ANC member in the province and known ally of Magashule – motivates the increase by referring in relatively broad terms to import duties, currency fluctuations, inflation and increases in fuel prices.

The internal departmental documents seen by Spotlight make no reference to any more detailed justification for the increase – as is typically required for such increases in government contracts. There is, for example, no records of specific imported items of which the cost may have increased and how those increases impacted the cost of delivering an aeromedical service to the province. Spotlight asked the Free State Department of Health to share any documentation they may have in support of the increase granted to Buthelezi HEMS (the joint venture). No such documentation was shared by the given deadline.

It emerged last week that Minister of Health Dr Aaron Motsoaledi had asked National Treasury to investigate the Free State’s ground ambulance contract with Buthelezi EMS. In previous articles in the Health4Sale series Spotlight described various complaints about the service provided by the company and various irregularities around the Free State tender. Spotlight also previously published a two-part investigation into similar concerns around Buthelezi EMS in the North West.

Spotlight contacted African National Congress Spokesperson Pule Mabe as well as Ace Magashule’s personal assistant in an unsuccessful attempt to get comment from Magashule. Messages were also left on two different numbers we have for Magashule.

Read more here:

Health4Sale: North West blows HIV money on controversial private ambulance service

Health4Sale: NorthWest pays double for dubious private ambulance service

Health4Sale: Mpumalanga department of health broke rules for controversial ambulance company

Health4Sale: Motsoaledi asks treasury to investigate Buthelezi EMS

Health4Sale Part 4: Buthelezi EMS running a taxi service, not an ambulance service – Doctors and nurses

North West doctors release open letter calling for end to closure of health services

Health4Sale part 5: Controversial private ambulance company in line for new Free State tender

Note: While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence – independence that the editors guard jealously. Spotlight is a member of the South African Press Council.



Health4Sale part 5: Controversial private ambulance company in line for new Free State tender

By Marcus Low and Anso Thom, Spotlight

A Gauteng-based ambulance operator, Buthelezi EMS, that is currently the subject of both Hawks and Treasury investigations has scored road and air ambulance contracts in the so-called Premier league provinces amounting to over a Billion Rand since 2013 and they are frontrunners to secure a lucrative new three year tender for Emergency Medical Services in the Free State.

National Health Minister Dr Aaron Motsoaledi last Thursday told Spotlight that he asked Treasury to investigate the Free State and North West’s contracts with Buthelezi EMS. He also made it clear that he did not want the new Free State tender to be awarded at all and that the national department is not in favour of outsourcing ambulance services to private companies. Yet, on Friday afternoon the Free State Department of health told Spotlight that the award of the tender for outsourced ambulance services is going ahead and that the evaluation of bids is at an advanced stage. Free State Health MEC Butana Khompela previously said that he does not want to re-appoint Buthelezi EMS, but he too hasn’t given any indication that the new tender will not be awarded.

The director of a rival ground ambulance company told Spotlight that industry rumours are that another company will front for Buthelezi EMS in the Free State and that such fronting is nothing new in the industry. While Spotlight  could not find any evidence of fronting, Companies and Intellectual Property Commission records paint a complicated web of connections. So, for example, Thapelo Buthelezi of Buthelezi EMS and Clifford Mahlo, director of High Care EMS, are also listed as co-directors of two other companies. Both Buthelezi and Mahlo were previously co-directors of ambulance companies with Thomas Maponya, the director of Maponya 911 Rescue.

Several well-placed sources have told Spotlight that Buthelezi has been receiving special briefings from health department officials in the Free State.

Spotlight has also this week visited a smallholding in Eikenhof, Johannesburg, where at least 20 new ambulances appear to be in the processes of being branded as “B EMS” ambulances. These ambulances have Free State number plates and the emergency telephone number on the side of the ambulances is the same as that on Buthelezi’s ambulances in the Free State – and not the same as those seen on ambulances at the Klerksdorp base in the North West. (see pictures)

Aerial pics and the pics over the wall of ambulances: Buthelezi EMS’ new ambulances on a smallholding in Eikenhof in the south of Johannesburg waiting to be branded.

The Free State Department of Health denies that Buthelezi has been given any advance notice of the outcome of the new tender.

Spotlight has also been told that Buthelezi arrived 15 minutes late for the tender briefing for the new tender in November, but that a senior Free State health official opened the door after he phoned them. Invitations to these meetings explicitly state that the doors will be locked at the starting time and no late-comers will be let in. When Spotlight asked the Department about this, they responded that “No bidder/s was allowed entry after 15 minutes after the meeting has started.”

As it stands, Buthelezi EMS’s previous contract with the Free State Department of Health is being extended on a month-to-month basis until the new tender is awarded or the relevant services is absorbed back into the department.

The controversial rise of Buthelezi EMS

Prior to Buthelezi’s arrival, the Free State was doing remarkably well with their

Orange wall: Buthelezi EMS’ control centre based in a house about 1km from where the new ambulances are being branded.

government-run inter-facility transfer service. In August 2013 Professor Martiens Schoon reported in the South African Medical Journal that maternal mortality in the province decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The improvement was mainly ascribed to the department procuring 48 new vehicles (18 dedicated to maternity care) and the use of these vehicles to transport women with pregnancy complications. For a while, this state-run programme was held up as an example for other provinces.

Then everything changed when late in 2013 the province decided to outsource its inter-facility transfer ambulance service to a private company. Well placed sources in the province say that this move coincided with the scaling down of the province’s own capacity building efforts in relation to emergency medical services.

The Free State Department of Health claims a tender was advertised, but Spotlight can find no record of this tender advertisement anywhere online or in a newspaper. Netcare 911, a company that would have liked to bid, says they never saw the tender advertisement despite subscribing to various systems that would alert them to such tenders. Spotlight twice asked the Free State Department of Health where the tender was advertised. Both times they dodged the question, merely saying that “The requirement to advertise tenders on-line by law only came into effect in 2016.” They did provide Spotlight with a copy of the province’s tender bulletin, but there is no indication where it was published.

According to Mariette Pittaway, Democratic Alliance (DA) member of the Free State legislature and spokesperson on Health, the DA has also struggled to get hold of documents relating to the tender. “I have requested these documents from the HOD and MEC of Health in a portfolio meeting, when this was not forthcoming, I submitted written questions, which remains unanswered,” she told Spotlight. “There is a general disregard by the FS Executive Council, save for MEC Finance, to answer written questions submitted to them within the stipulated 10 working day period as contained in the Standing Rules and Orders. When questions are replied to, they lack detail and substance, and the tone is generally dismissive. When we raise issues in Committee, which is constitutionally mandated to do oversight, and has the power to subpoena, the ANC uses its majority to protect MECs and dismiss DA concerns. So in effect the legislature is dysfunctional in this regard.”

Buthelezi EMS was awarded the contract in December 2013 – with the contract signed on 20 December, around the festive season. What followed was ballooning expenditure and, according to a range of sources, a decline in the quality of services (see the previous article in this series for details). The Free State and North West are the only two provinces to outsource their ground ambulance service – the North West gave Buthelezi a three-year contract in March 2016.

“The DA is of the strong view that the Buthelezi EMS contract is irregular, over-priced, ineffective and could possibly have links to ANC politicians, since the ANC has been on the defensive over this contract from the very beginning,” Pittaway told Spotlight.

How costs ballooned

Spotlight investigations show that although the North West has been a good source of income for Buthelezi’s EMS operations, his stronghold and springboard into the so-called Premier League provinces (Free State, North West and Mpumalanga) has been via the Free State. We wrote previously about how Buthelezi was awarded a Free State air ambulance contract, that North West, Mpumalanga and Limpopo all piggy-backed on.

Spotlight calculates that Buthelezi EMS has received well over R1-billion in revenue from government contracts, mostly in the Free State and North West,  over the last four years – with annual revenue rising sharply over time.

In February Mondli Mvambi, spokesperson for the Free State Department of Health was quoted in the media as stating that the department had paid a total of R613-million to Buthelezi EMS since the 2013/2014 financial year. The breakdown given was as follows:

  • 2013/2014 R4 million
  • 2014/2015 R99 million
  • 2015/2016 R159 million
  • 2016/2017 R204 million
  • 2017/2018 R147 million (Not yet full-year figures)

The year-on-year increases in the above figures raise eyebrows since the service Buthelezi EMS is contracted to provide does not change year-on-year. While some increase from the first to the second year might be explained by teething and scaling-up challenges, the steady increase over multiple years suggest another cause.

Spotlight asked the Free State Department of Health what the budget and what the overspend/underspend on Inter-facility Hospital Transfers was per financial year since 2015. We received the following response signed off by head of department David Motau: “Budget R531 297,000 (Total EMS budget); IFT expenditure R843 132,80 (for both Inter-Facility Hospital and Aeromedical)”

This response is incompatible with the figures previously given by Mvambi. It is also not clear which year it refers to. Spotlight wrote back to the department to request clarification, but the department failed to respond.

Spotlight has however had sight of internal Free State government figures that indicated extreme overspending on the province’s emergency medical services budget:

  • In 2015/2016 the department spent R152 million on EMS, overspending their budget by R88 million.
  • In 2016/2017 the department spent R163 million on EMS, overspending their budget by R86 million.
  • By the time the figures were generated, the EMS expenditure for the 2017/2018 financial year up to that point was R161, already overspending the budget by R117 million.

A pattern of alleged overcharging

The dramatic overspend in the Free State suggests that the province is either being charged more than expected (with invoices inflated as in the case in the North West) or the service is being used much more than anticipated. Almost everyone Spotlight spoke to suggests the former. While Buthelezi EMS’s quoted rates are in line with the industry, it is on the billing side where red lights start going off.

A senior healthcare worker based at a Free State hospital alleges that Buthelezi EMS often transports multiple patients in a single ambulance as part of their inter-facility transfer service. Sometimes as many as five patients will be transported in one ambulance, but Buthelezi would allegedly then bill as if five different ambulances were used and write invoices with five different reference numbers. This pattern was confirmed by more than one healthcare worker we spoke to. (See the previous article in this series for more on the impact this has on patients) At other times, patients who could safely be transported in cars are allegedly transported at great cost in ambulances.

It is also alleged that Buthelezi often charges for distances that are longer than the actual distances travelled. Spotlight was told of a case where a 2km trip was charged for as a 100km transfer. While we have not seen invoices proving such overcharging in the Free State, essentially the same allegations were repeated to us by senior hospital management as well as a well-placed person in the Department of Health in the province. This is also in line with what has been happening in the North West. Part of the problem seems to be that Buthelezi EMS often does not have Advanced Life Support (ALS) capacity in all the districts that they are supposed to – and that as a result ALS vehicles and staff must be sent from other districts – thus increasing both cost and waiting times.

There has also been a shift in the Free State whereby from the 2016/2017 financial year invoices are submitted to the provincial emergency medical services Department in Mangaung, rather than to hospitals as the case was before. According to Motau, the payment of these invoices was at the same time shifted from hospital budgets to the provincial emergency medical services budget. Some senior doctors complain that this shift has made it much harder for hospitals to verify that government is not being overcharged.

Spotlight sent Mr Buthelezi a long list of questions about overcharging and a number of other issues. Mr Buthelezi did not respond to any of the specific questions, but sent Spotlight an e-mail that has been published in full with a previous article in the Health4Sale series which can be read here.

No website, many companies

Despite having had revenues of over a billion Rand in the last four years, Buthelezi EMS does not have a website. The domain has been registered, but the site has remained under construction for the more than two years that the company has been on Spotlight’s radar. Some posts are made on the company’s Facebook page, but the kind of information one expects to find on a company with this level of revenue is nowhere to be found online.

In addition, CIPC records and invoices that the company has submitted in North West (see previous article) indicate that technically Buthelezi EMS is sometimes one company, and sometimes another. In the North West the company name on invoices did not correspond to the company registration number on the same invoices.

Thapelo Buthelezi is, or has been, a director of at least six different companies all named as variations of Buthelezi EMS.

  1. Buthelezi EMS CC
  2. Buthelezi EMS (PTY) LTD
  3. B EMS CC (Currently some ambulances are being rebranded as B EMS)
  4. Buthelezi HEMS CC
  5. Buthelezi Helicopter EMS (PTY) LTD
  6. Buthelezi One Stop Emergency Medical Services CC

A number of these companies have been in deregistration due to the non-filing of annual returns. Failure to file annual returns would result in companies not having a valid tax clearance certificate, and thus not be eligible for government contracts. The Free State contracts we have seen do not contain registration numbers – which makes it hard to verify with which of the various companies the Free State are in fact contracted. In the North West, the name of the company on Buthelezi’s invoices did not correspond with the company registration number on the same invoices.

Apart from the above, he is listed as a director of at least 14 other companies, including amongst others Ndizani Funeral Services, TSB Motors, Thapelo Buthelezi Hospital, TSB Medics, Ikanyezi Trading and Construction and Mt Ararat Apostles (a non-profit).

Read more here:

Health4Sale: North West blows HIV money on controversial private ambulance service

Health4Sale: NorthWest pays double for dubious private ambulance service

Health4Sale: Mpumalanga department of health broke rules for controversial ambulance company

Health4Sale: Motsoaledi asks treasury to investigate Buthelezi EMS

Note: While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence – independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

Health4Sale Part 4: Buthelezi EMS running a taxi service, not an ambulance service – Doctors and nurses

By Anso Thom and Marcus Low, Spotlight

Doctors and nurses in the Free State and North West have accused Buthelezi EMS, the private company contracted to run provincial ambulance services, of operating like a minibus taxi and “drop and go” service. They accuse the company of providing limited medical support and expertise during transport, leaving the desperately sick and injured, including babies, unassisted and putting people’s lives at risk.

Buthelezi EMS has landed lucrative state tenders worth hundreds of millions to run hospital and clinic transfer services in the Free State and North West. Last week Spotlight reported that Minister of Health Dr Aaron Motsoaledi had asked Treasury to investigate the procurement of Buthelezi EMS’s services in the two provinces. This is in addition to a Hawks investigation and a forensic investigation instituted by North West Premier Supra Mahumapelo.

An aerial shot of the Bloemfontein ambulance base, likely to be the busiest and “largest” base Buthelezi EMS runs in the Free State and North West.

Nurses and doctors have revealed a litany of failures, some life threatening, with common complaints extreme waiting times of up to six hours (even when patients, often babies, are critical), overcrowded ambulances, poor staff attitudes, poorly equipped staff on the ambulances and in the call centres, lack of equipment, extremely poor medical skills, no medical care while patients are in transit and a lack of compassion for patients.

A visit by a Spotlight photographer to the company’s Bloemfontein, Klerksdorp and Potchefstroom ambulance bases, also showed that the services are run from tiny, rented houses with the bare minimum and in some instances dirty, messy yards, not resembling what would be expected of a professional ambulance base (see accompanying photographs).

All the doctors and nurses who spoke to Spotlight asked to remain anonymous for fear of losing their government jobs. Names of specific hospitals have also been omitted as it will make it easy to trace the sources.

Patients squashed into ambulances

A senior doctor based at a Free State hospital alleges that Buthelezi EMS often transports multiple patients in a single ambulance. Sometimes as many as five patients will be transported in one ambulance, but Buthelezi will allegedly then bill with five different patient reference numbers as if five different ambulances were used and five different trips undertaken. This pattern was confirmed by all healthcare workers Spotlight spoke to in both provinces.

One Free State doctor said that it had become the norm for Buthelezi ambulances to arrive at their hospital with several patients squashed inside. “But we are not allowed to complain, if we do it simply goes nowhere or we are harassed by Buthelezi staff and our patients suffer,” the doctor said.

Another doctor said even if there were sick patients who needed to be transferred to a hospital Buthelezi ambulances would not transport the patient, but wait for the vehicle to first fill up.

The overloading of ambulances could also at times place patients at risk and infringe on the dignity of patients. Spotlight was for example told of an instance where a woman with birth complications had to share the back of the ambulance with a male patient not known to her. In another instance a patient with a broken leg had to ride in the front of the ambulance because the back was full. At other times, patients who could safely be transported in cars are transported at great cost in ambulances.

Lack of skills and equipment

A North West trauma nurse said she had a case where two severely ill women arrived in the same ambulance. During the handover Buthelezi staff told the nurse that the women both had bleeding complications from their pregnancies. The nurse conducted a pregnancy test on one of the patients after she suspected something else was wrong. The woman was not pregnant and the problem was completely unrelated to what she was told.

The nurse said lack of equipment was a major problem. She said patients almost never arrived with oxygen, drips or connected to any monitoring equipment. “They mostly don’t have equipment, not IV drips, not drip bags, not saturation monitors (used to measure if patients need oxygen), nothing.”

She said the problem was that Buthelezi staff exercised no medical care or procedures on patients while in transit. “They’re a taxi service and they are always impatient to drop and go,” she said.

Long waiting times

The nurse said a clinic sister recently had to wait four hours for an ambulance to collect a severely ill new-born baby.

“They run a taxi service, not an EMS service,” said a Free State doctor.

All healthcare workers Spotlight spoke to said that they waited hours for Buthelezi to arrive.

One North West nurse in a large town said they waited on average three to four hours for a Buthelezi ambulance to arrive, even though the hospital is not far away. “When we contact the call centre, we are not told how long they will take, we are simply made to wait. The staff also mostly have terrible attitudes when they arrive or when we follow-up with the call centre to find out where they are,” said the nurse.

The service level agreement (SLA) between the North West Department of Health and Buthelezi EMS explicitly states that “The Service Provider must ensure that its call centre gives the NWDoH a reference number and estimated time of arrival of the ambulance for each call.”

The SLA also sets out a schedule of required response times for different levels of emergency. The longest response time allowed for (for the least serious calls) is 60 minutes (measured from when the call centre receives the call). The SLA states that response times in excess of those on the schedule will result in financial penalties against the service provider. As with most aspects of this contract, it appears these penalties has not been enforced.

A North West nurse said Buthelezi’s ambulance staff are not interested in the handover process. “They seem to consider themselves to be a taxi service who simply has to transport the patient. I have very rarely had a Buthelezi staff member show any interest in the patient, put up an IV drip, discuss the patient or even take their blood pressure, they don’t even listen when we do the handover,” the nurse said. She said nobody dared ask for proof of qualifications. This is necessary as certain patients require certain levels of care for example Advance Life Support.

Call centre problems

One nurse said they recently had a new-born baby who was in a critical

The Buthelezi EMS ambulance base in Bloemfontein, overcrowded and filthy. The Free State health department said it’s contract does not require for it to inspect the base, despite the fact that the company transports most of the province’s patients.

condition and in respiratory distress. Despite several desperate calls, an ambulance only arrived after three hours.  “When we contact the call centre, they ask us the age of the patient, the gender and what is wrong. I more often than not have to explain to them what the problem is and even then they will tell me they do not understand,” the nurse said.

A doctor said call centre staff often did not understand standard emergency medical terms. When he calls for an ambulance he would as an example not refer to a cranial injury, which is a widely accepted and understood medical term, especially in emergency medicine. “The call centre does not understand that, I have to just say brain injury. I also cannot say Caesarean section, I have to say – we did an operation for a baby – then the call centre agent kind of understands, sometimes,” the doctor said. A nurse had the same experience, saying that even after explaining medical conditions to call centre staff they still failed to understand.

Is the motivation money?

The Free State doctor also said when they called for an ambulance from the provincial government or other private service providers such as ER24 of Netcare 911, it would take 15 minutes to get a reference number as the handover was meticulous, however via Buthelezi the reference number is generated within minutes, adding that the motivation was not patient well-being but money. “We know that 2km trips could be charged at R3 000,” he said, adding that Buthelezi did not have enough ambulances or a presence (with Advanced Life Support paramedics) in sub-districts as required.

The allegation that Buthelezi EMS incorrectly charges thousands of Rands for short trips is confirmed by invoices submitted to the North West Department of Health that Spotlight have had sight of (and previously reported on here).

Sources inside the North West Department of Health confirmed that Buthelezi EMS only has sufficient advanced life support staff based in five of the 19 sub-districts where they are supposed to have such staff according to the service level agreement with the province. Apart from this, resulting in advanced life support often being severely delayed, it is also alleged that Buthelezi charges the province for the extra distance advanced life support vehicles and personnel must travel to sub-districts where there is no advanced life support in place. This state of affairs was confirmed by Free State doctors as well.

Ambulance bases

Spotlight sent a photographer to Buthelezi’s Bloemfontein ambulance base. The base does not have any external signage. The outside of the suburban house in Bloemfontein was in a shocking state with rubbish, mud and a yard full of ambulances, some seemingly no longer in running order. Aerial photographs show a backyard littered with rubbish and no sign of any waste disposal.

Spotlight asked the Free State Department of Health whether they visited and inspected Buthelezi’s ambulance bases. Head of Department David Motau responded “Sites visits was not a requirement as per the tender document”.

The Potchefstroom “base” is a house which is mostly empty inside, with only a

The Buthelezi EMS ambulance base in Bloemfontein, overcrowded and filthy. The Free State health department said it’s contract does not require for it to inspect the base, despite the fact that the company transports most of the province’s patients.

few bare beds used by staff to sleep in. The backyard of the house has rubbish dumped at the back door. None of ambulance bases appear to have dedicated medical waste areas that are marked biohazardous. Access to these waste areas must be controlled. Unsecured oxygen cylinders are seen lying in the corner of a room. Several horrified paramedics confirmed that oxygen cylinders must be safely locked up and secured. There has to be a sign which cautions that it is pressurized oxygen. The front porch has a derelict bed with no indication that this is a Buthelezi ambulance base. The entrance hall to the house has what appears to be a radio transmitter.

At the Klerksdorp “base” the only sign that it is a depot is two branded ambulances and a car parked in the road.

Mariette Pittaway Democratic Alliance member of the Free State legislature and spokesperson on Health, questioned whether the health department conducted regular checks on Buthelezi operations to ensure compliance with the provision under the National Health Act (No 61 of 2003). Some of these provisions deal with whether an operator is licensed and whether staff are being supervised by a Medical Services Manager. In terms of the base, the Act prescribes that the operator have sluice facilities for cleaning contaminated equipment and linen, have access to washing facilities, including medical-waste traps, have all the relevant equipment listed in the regulations. The Potchefstroom base had none of this. The Act also requires for there to be a log stating how many checks were conducted at the base and what were the findings of each.

Responses from Health Departments and Thapelo Buthelezi

Last week Minister Motsoaledi told Spotlight the following in relation to Buthelezi EMS and the Gupta-linked Mediosa: “On my side as health there is

The backyard of the house with rubbish dumped at the back door. None of ambulance bases appear to have dedicated medical waste areas that are marked biohazardous. Access to these waste areas must be controlled.

nothing to investigate in terms of whether it is serving the health needs etc. It is very clear, as clear as daylight, that we do not need this type of service.”

Asked about the complaints from healthcare workers Motau said: “The department is aware of only one formal complaint from Botshabelo and the matter was resolved. The department is not aware of ambulance (sic) being poorly equipped and overloaded.”

The North West health department has declined to comment to Spotlight on any Buthelezi-related matters, saying the matter is being investigated by the Hawks and the Premier’s office.

In addition to a previous round of questions, Spotlight also sent a list of the above allegations and complaints to Thapelo Buthelezi via email.  This was his Whatsapp response:

“There isn’t anything I can assist you with. More especially after you have lied to South Africans that you have published everything I said. I spoke about other provinces utilizing aero medical service without any formal contracts and you did not want to say anything about the matter. You are most probably avoiding to talk about that because it will tell South Africa the truth behind all the allegations. It is clear that you are after Buthelezi EMS, hence you can’t talk about other provinces’ aero medical contracts. You may carry on and publish whatever and continue to protect your buddies. This matter is being dealt with from a different platform. I’m also aware that one of your informers, (Spotlight omitted this name) is busy talking to different provinces, recruiting managers to support him in taking Buthelezi EMS down and give you a falsified information. I wish you could report the real events  and stop talking to the competitors. It is a common knowledge that the competitors will always give a negative info. However, I still maintain what I said earlier, we are working on publishing the truth and not nonsense you have been telling South Africa. Good luck!!!!!!”

Read more in this series:

Health4Sale: North West blows HIV money on controversial private ambulance service

Health4Sale: NorthWest pays double for dubious private ambulance service

Health4Sale: Mpumalanga department of health broke rules for controversial ambulance company

Health4Sale: Motsoaledi asks treasury to investigate Buthelezi EMS

Note: While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence – independence that the editors guard jealously. Spotlight is a member of the South African Press Council.