Health Minister should be given greater powers

By Dr Ndiviwe Mphothulo

We need to amend the National Health Act (No. 61 of 2003) so as to give the Minister of Health greater powers to intervene in provinces and avert disasters in provinces. If we do not, the Minister’s hands will remain tied when it comes to the next Life Esidimeni, the ongoing oncology crisis, and the non-placement of medical interns, argues Dr Ndiviwe Mphothulo.

In 1994 a democratic government was finally elected in South Africa. Soon after, section 27 of the Bill of Rights in the Constitution of South Africa placed an obligation on the this democratically elected government to develop legislation and implement measures to ensure that the rights (including the right to access healthcare services) enshrined in the constitution are realised.

The first task of this democratic government was to do away with the historical injustices of the past. The fragmented, apartheid South African healthcare system that had 14 health departments serving four different races was abolished by the new government in 1994.

The South African public healthcare system has made a number of major advances since 1994. These include, but are not limited to;

  • free primary health care,
  • greater parity in district expenditure,
  • the essential drugs programme,
  • choice on termination of pregnancy,
  • the hospital revitalisation programme,
  • anti‐tobacco legislation,
  • an improved immunisation programme,
  • community service for graduating healthcare professionals,
  • training of Clinical associates,
  • improved malaria control, and
  • the biggest ARV treatment program in the world.

With all these commendable gains, our health system still faces major challenges. These include:

  1. the quadruple disease burden of explosive HIV and TB epidemics, a high burden of chronic illness, injury and violence, and the epidemic of maternal, neonatal and child mortality,
  2. Severe shortages of doctors and other healthcare professionals in the public sector, and in rural areas,
  3. the current funding model which sees South Africa having a two-tier healthcare system: the private sector providing for 16% of the population but utilising a greater proportion of health GDP compared to the public sector that provides for 84% of the population.
  4. Poor leadership and governance in provinces.

According to the World Health Organisation (WHO) the functions and objectives of a healthcare system are to impact positively on the health status of its community. To achieve the objectives of responsiveness, fair contribution and distribution, new financing mechanisms will be required to provide the much-needed funds to health systems across the world – but critically, it will also require leadership and stewardship.

The crisis in the North West Province, where the department of health was facing near collapse (due to poor procurement procedures), interns and community service doctors and pharmacists not getting placed due to lack of budget for their posts in different provinces, the near collapse of oncology services in KwaZulu Natal, the Life Esidimeni saga in Gauteng, doctors not receiving salaries in other provinces, all point to poor leadership, collapsed governance and lack of stewardship in provinces.

Some parts of the National Health Act (No. 61 of 2003) make it impossible for the National Department of Health (NDoH) to intervene in provinces. According to the act, one of the responsibilities of the health minister is to “endeavour to protect, promote, improve and maintain the health of the population (within the limits of available resources).

But the people who drafted this act never envisaged the potential negative consequences of giving powers to provinces. As pointed out by Minister of Health Dr Aaron Motsoaledi on various occasions, the Minister of health is unable to deal with the following issues:

  • The Human resource system,
  • financial management and budgeting,
  • procurement procedures, and
  • maintenance of infrastructure.

This means that legally speaking the Minister can do little more than watch as tragedies like Life Esidimeni unfold, as Interns are not placed at various hospitals, as oncology services in provinces collapse, and as crises in provincial health systems deepen. The Minister has no legal powers to intervene except for asking cabinet to place provincial departments under administration or holding provinces to account through the office of the health ombudsman. This situation is clearly untenable.

We urgently need to amend the National Health Act (No. 61 of 2003) so as to give the minister more powers to intervene in provinces and avert disasters in provinces.

Note: Mphothulo is writing in his personal capacity. He is the North West Representative of the Rural Doctors Association of South Africa, a board Member of the Southern African HIV Clinicians Society, and South Africa’s 2015 rural doctor of the year.

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 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 www.ButheleziEMS.co.za 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.

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

Over 70 North West doctors have released an open letter expressing their concern over the impact the ongoing labour action is having on the delivery of health services. Although they support the grievances of the protestors, the doctors said that as “care givers, we have been silent for too long. We have taken an oath to “do no harm” and in our silence, we have contributed to harm. This cannot go on as we are concerned about methods used which include closure of health care facilities that affect the health of our society.”

Read the full letter here: Letter of Concern Health Crisis NWP (iii).

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.

 

Health4Sale Part 3: Mpumalanga department of health broke rules for controversial ambulance company

By Marcus Low and Anso Thom

The Mpumalanga Department of Health has defied guidance from its provincial treasury and acted in contravention of the Public Finance Management Act in awarding a three-year contract to Buthelezi HEMS, a joint venture between a controversial private ambulance company called Buthelezi EMS and HALO Aviation. This has emerged from court documents obtained by Spotlight.

Spotlight has previously reported on complaints about the quality of service

Contracts between Buthelezi EMS and the North West Department of Health is being investigated by the Hawks

provided by Buthelezi EMS’s ground ambulances. Presently, contracts between Buthelezi EMS and the North West Department of Health is being investigated by the Hawks and as part of a “forensic investigation” launched by North West Premier Supra Mahumapelo.

The background

Up until June 2016 aeromedical services in Mpumalanga were provided by the South African Red Cross Air Mercy Service (AMS), a non-profit. The service was provided in terms of a national treasury-administered tender called RT-79 2015. In June 2016 RT-79 2015 was cancelled by treasury due to a technicality regarding a utilisation factor that was not declared in the tender specifications.

Rather than continuing with the existing service provider, AMS, both Mpumalanga and Limpopo opted to switch to Buthelezi HEMS within days of the cancelling of RT-79 2015. This is despite the fact that Buthelezi HEMS did not have an aeromedical presence in either province.

According to Farhaad Haffajee of AMS this was strange because AMS was already delivering a service in these provinces and “there was no question from the Provinces (or anyone else) of the quality of service provided by the AMS or any other problems at all with the AMS service during the time that the AMS operated in these Provinces. In addition, there was a break in the service being provided from the time the AMS was told to stop providing the service to when a non-existent replacement service (Buthelezi) could actually start the service again in these Provinces.”

Haffajee also alleges that AMS was not approached to quote for the continuation of the service “despite having the aircraft, staff and infrastructure already in place.”

The paper trail

A protracted court process followed the cancelation of RT-79 2015, first in the North Gauteng High Court and culminating more than a year later with the Supreme Court of Appeal ruling in November 2017 that RT-79 should be reinstated and AMS should return to provide the service in the relevant provinces, Mpumalanga and Limpopo. It is during these court proceedings that it emerged that the Mpumalanga Department of Health ignored a warning from their provincial treasury that granting Buthelezi HEMS a three-year contract is not allowed in terms of the PFMA.

On 29 June 2016 Dr Savera Mohangi, Head of the Mpumalanga Department of Health, wrote to the province’s treasury indicating that the department wished to piggy-back on a contract between the Free State Department of Health and Buthelezi HEMS rather than going through a tender process. Such piggy-backing on tenders in other provinces is allowed by the PFMA in certain specific cases.

In her motivation for proceeding with the contract for aeromedical services Mohangi claims that there are critical patients that cannot be transported by road “due to their conditions which would result in loss of life due to prolonged transportation times as well as the non-suitability of the road transport”. She added that sourcing other service providers will take longer “as the services are required at such short notice”.

She does not explain in her letter why the department opts against continuing with the existing AMS service on a month-to-month basis until the issues around RT-79 can be sorted out.

Mohangi  also does not wait for treasury to give the green light before setting things in motion. On the same day as writing to treasury Mohangi also writes to Dr David Motau, Head of the Free State Department of Health requesting to participate in their tender for aeromedical services. Then a week later on 4 July 2016 Motau writes a one paragraph letter to HALO Aviation and Buthelezi HEMS asking if they “are willing and in a position to render the same aero medical service in the Mpumalanga Province at the same terms and conditions as per current contract for the remaining period ending 30/09/2018”. HALO Director Ryan Horsman responds to Motau in a one paragraph letter expressing their “willingness, capability and acceptance to render same service to Mpumalanga Department of Health”.

However, Nombedeso Nkamba, Head of the Mpumalanga Treasury, wrote back to Mohangi on 6 July 2016 clearly stating that the PFMA only allowed for month-to-month contracts in such cases up to a maximum of six months. Her letter leaves no doubt that the proposed three year contract is not in line with the PFMA.

This advice was ignored and Mohangi went ahead with the awarding of a three-year contract to Buthelezi HEMS. In her letter to Thapelo Buthelezi, Director of Buthelezi EMS and HEMS, she states “It is with pleasure to inform you that HALO Aviation (Pty) Ltd & Buthelezi HEMS/Trading at Buthelezi EMS is the successful bidder to supply and deliver the undermentioned item(s) to the Department.” She requests that they assume their services on 11th July 2016. (While Mohangi refers to the “successful bidder”, it should be noted that there was no bid process for the Mpumalanga contract.)

Spotlight asked the Mpumalanga Department of Health why a three year contract was awarded despite the province’s treasury pointing out that such a contract would not be in line with the PFMA. To this the department simply responded as follows: “The department requested to participate on the Free State EMS HALO/Buthelezi JV (Joint Venture) tender hence the contract was for a period of 3 years, which participation was allowed by the Free State Department of Health.”

Treasury and SCA instruction ignored

It has also since emerged that despite the appeal court judgment in November 2017 and an instruction from National Treasury in December 2017, both ordering that RT-79 should be reinstated – meaning AMS should be reinstated as the provider –  the Mpumalanga Department of Health has not yet done so. In response to questions from Spotlight the department said:  “The department has not yet cancelled the contract with the service provider as there were technicalities that the department is addressing with National Treasury. As soon as these are addressed, the department will look into the matter.”

By contrast, the Limpopo Department of Health gave Buthelezi EMS notice in February that they are cancelling their contract with the company. Unlike Mpumalanga, Limpopo did not provide Buthelezi EMS with a three-year contract, but with a month-to-month contract as prescribed in the PFMA. It is understood that AMS will resume providing an aeromedical service in Limpopo on the 1st of May.

Buthelezi HEMS was also given a contract in the NorthWest – although the NorthWest was not part of the RT-79 tender and its cancelation. NorthWest also opted to piggy-back on the Free State tender. Buthelezi HEMS continues to provide an aeromedical service in North West.

The Free State never opted to be part of the national RT-79 tender and ran its own tender for aeromedical services which was awarded in October 2015. It is this tender awarded to Buthelezi HEMS on which Mpumalanga, Limpopo and NorthWest piggy-backed.

Spotlight did send a series of questions to Mr Buthelezi relating to the above and other issues. Mr Buthelezi failed to answer any of the specific questions, but did send Spotlight an e-mail which has been published in full with a previous article in this series.

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: Motsoaledi asks treasury to investigate Buthelezi EMS

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

 

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 2: NorthWest pays double for dubious private ambulance service

By Anso Thom and Marcus Low, Spotlight

BREAKING NEWS UPDATE: North West Premier Supra Mahumapelo this afternoon (19  April 2018) confirmed to the SABC that he has now suspended Health Deapartment HOD Dr Thabo Lekalakala. Spotlight revealed that Lekalakala had not been suspended but placed on special leave.

North West’s health services have been in the spotlight for alleged corrupt practices involving healthcare delivery since February when details were revealed of a R30-million pre-payment to Gupta-linked healthcare company Mediosa with another R150-m to follow. The “contract” involved the delivery of primary healthcare services that the province had the capacity to deliver internally.

Health minister Dr Aaron Motsoaledi visited the province in early March where he described the contract between the North West health department and Mediosa as nothing but “an ATM card for the Guptas to withdraw money from the department”.

However, documents in possession of Spotlight reveal that Mediosa may not be the only company using the North West health department as an ATM.

Private ambulance company Buthelezi EMS, which operates under variations of this name including more recently B EMS, have held a contract with the North West Department since March 2016. Buthelezi is being paid between R600 000 and R1-m a day to mostly deliver inter-facility hospital transfers in the province. Inter-facility hospital transfers are the transport of patients by road ambulance from one health facility to another, either for specialist consultations or because they need a more specialized level of healthcare. It also works in the reverse with some patients sent to a lower level hospital once they respond to specialist treatment. This service is provided by the provincial health departments in most provinces.

Popo Maja, spokesperson for the national health minister was adamant that the current public emergency medical service has the capacity to undertake inter-facility transfers.

“In the rare situation, where there is an urgent inter-facility transfer and all ambulances are engaged in EMS responses, there is provision for the EMS manager to engage the services of a private EMS provider. This option should only be in exceptional circumstances,” said Maja.

The North West health department has over 60 ambulances on the road, but an official told Spotlight that the HOD and his supporters had “created a hole for Buthelezi to fill”.

Not a single ambulance post has been filled in at least three years and money earmarked for the purchase of new government ambulances was redirected to other areas.

Buthelezi EMS invoices on average well over R20-million per month, amounting to in the region of R3 000 per patient allegedly transported.

Figures seen by Spotlight reveal that Buthelezi EMS submits hugely inflated invoices for almost every patient they transport, overcharging on average a staggering half a million Rand per hospital per month. However, efforts by some health officials to put a stop to this looting has not had an effect with the head of the provincial department of health Dr Thabo Lekalakala sending out an instruction that all Buthelezi’s invoices be submitted to and paid via his office. This meant that no invoices could be checked or corroborated by Treasury or Department of Health officials in line with good governance practices and the law.

There are also damning allegations that Buthelezi was awarded the contract after the initial tender specifications were illegally adjusted when the tender was awarded to expand Buthelezi’s scope from only supplying P1 services to the more lucrative and higher volume lower level P2 and P3 services which require intermediate and basic life support services.

P1 is very serious, potentially life threatening; P2 means the patient needs to go to hospital, can become life threatening if not treated and P3 is minor injuries. P4 refers to a deceased patient.

Discrepancies also include allegations that although the tender specifications indicated that the tender would cover only transfer between hospitals, this was expanded to include clinics and Community Healthcare Centres when the tender was awarded. The province was already providing a service to clinics and community healthcare centres  – shifting this work to Buthelezi EMS allowed the company to increase their volumes significantly.

Another discrepancy is that the tender required that the successful bidder have a presence (ambulance, response car, advance life support paramedic) in each sub-district. It is a known fact among healthcare workers and departmental staff that the Buthelezi company does not have such a presence in all districts they service and for example patients requiring trauma care in Wolmaransstad have to wait for an ambulance or paramedic to arrive from Klerksdorp 80km away.

There are reports from various healthcare workers that the service provided by Buthelezi is not good.

A private health care provider who works at trauma scenes in North West said they never saw Buthelezi paramedics on emergency scenes. “I have never seen them on a scene around Potchefstroom or Klerksdorp, in fact it is often private providers who do not have contracts with the Department who will be the ones treating indigent patients on the scene, stabilizing them and taking them to hospitals,” the person said.

A paramedic alleged Buthelezi was often not interested in sticking around when there were dead patients as they “not keen on doing the paperwork”.

A visibly angry Motsoaledi demanded during his visit in early March that Lekalakala be removed from his post with immediate effect.

“I want him [Thabo Lekalakala] to face charges. I don’t think he is fit to work anywhere in the public service, least of all as an HOD. Mr Lekalakala is hired by the premier of the North West. The premier must start taking steps to remove him,” Motsoaledi told journalists.

Spotlight understands that Lekalakala has not been suspended by the Premier Supra Mahumapelo, who appointed him, but the Health MEC Dr Magome Masike has placed him on special leave. Various entities have called for Lekalakala to be suspended including trade union Nehawu, who have embarked on protracted labour action to force the HODs removal. This action is now leading to drug stockouts and patients arriving at health facilities with no nurses on duty.

Lekalala was a controversial appointment from the start with reports that the Economic Freedom Fighters and the Young Communist League criticized his appointment claiming that Premier Supra Mahumapelo has simply brought him in to rubber stamp tenders. They also claimed his appointment was irregular and that he did not have the required experience as stated in the job advert. Many were surprised when Lekalakala was appointed HOD from the National Department of Health where he occupied a low-level Director position.

Spotlight sent a number of questions to Buthelezi’s CEO Thapelo Buthelezi. He failed to provide a response to any of the questions, but sent a letter instead in which he among others accused Spotlight of “probably doing this to me because I’m a black businessman and you are indirectly promoting a white monopoly capital and unhappy with a black successful business”.

Buthelezi added: “Please assist NPA and the Hawks by giving them every single evidence on (sic) your possession so that they can quickly finalize the investigations, I can’t wait to have my day in court! NB: Buthelezi EMS is contracted to Department of Health and therefore, I’m only answerable to them.”

Questions directed at the North West health department were also not answered, despite several attempts. Spokesperson Tebogo Lekgethwane said “the management of the Department has looked into all the questions posed. The Department has also considered the fact that Buthelezi EMS and a number of other contracts are a subject of investigation by the Hawks as well as a forensic (sic) initiated by the Premier’s Office. In the light of these development, the Department feels that the investigations should carry on and a response will then be issued afterwards.”

Spokesperson for the Hawks in the North West Captain Tlangelani Rikhotso confirmed that they were investigating the contract between Buthelezi EMS and the North West health department, but “we cannot divulge any more information in relation to the case”.

Read  more in this investigation:
Health4Sale: North West blows HIV money on controversial 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

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

By Marcus Low and Anso Thom, Spotlight

The North West Department of Health blew over R100-million expressly earmarked for HIV health services on two controversial private ambulance companies, it has emerged from correspondence in Spotlight’s possession. Serious red flags are also raised by some of the invoices submitted by one of these companies.

A letter sent by KA Dibodu in May 2016 from the Head of the North West Department of Health’s office to District Chief Directors states that R36-million from the province’s Comprehensive HIV and AIDS Conditional Grant, were to be channelled to two private ambulance companies, Buthelezi EMS and High Care EMS. While the R36-million referred to in the letter relates to the 2016/2017 financial year, the National Department of Health told Spotlight that R93-million in HIV conditional grant funds was transferred to the North West in the 2017/2018 financial year for the line item in question “inter-facility transport”. This brings the total for the two years to a staggering R129-million.

By law the HIV conditional grant can only be spent on HIV-related expenses. Various experts Spotlight spoke to confirmed that inter-facility transfers fall outside the scope of the HIV conditional grant and the spending would thus be unlawful.

“The Division of Revenue Act and grant framework does not allow that a conditional grant should be used for a purpose that is not intended,” says Popo Maja, spokesperson for the National Department of Health. According to Maja the Department has requested that National Treasury investigate the matter. Maja also indicated that steps had been taken by the National Department of Health to ensure that the North West cannot use HIV conditional grant funds for inter-facility transfers in the current (2018/2019) financial year.

Almost half-a-million people (Around 482 000) in the North West are living with HIV (12.5% of the province’s population). The HIV conditional grant is meant to help the roughly 244 000 people in the province already on HIV treatment to stay healthy and on treatment and to get the 238 000 people who still need treatment onto treatment.

Invoices raise red flags

Spotlight has also seen a number of invoices submitted to the North West Department of Health by Buthelezi EMS. Most of these invoices are from Buthelezi EMS CC. But, the Companies and Intellectual Property Commission (CIPC) registration number on these invoices (2013/06/5417/07) is not that of Buthelezi EMS CC, but that of another company called Buthelezi EMS (PTY) LTD. There is a Buthelezi EMS CC registered on the CIPC database, but its registration number is completely different from that on the invoices.

Spotlight has also seen one invoice where the branding on the invoice is not Buthelezi EMS, but B EMS. There is a company called B EMS CC listed on the CIPC database, but its registration number also does not match that on any of the invoices In Spotlight’s possession. The bank account number on the B EMS invoice also differs by one digit from that on other invoices. Some ambulances in North West have been rebranded as B EMS.

The three Buthelezi companies mentioned above are only three of seven Spotlight found with names that are in some way variations of Buthelezi EMS. Mr Thapelo Samuel Buthelezi, the man behind all these companies, failed to answer a question from Spotlight on why he has registered so many companies with similar names.

One clue might be that Buthelezi EMS (PTY) LTD, the company’s whose registration number appears on the service level agreement with the North West Department of Health and the invoices, seems to have had some trouble filing its annual tax returns. According to CIPC records a process of deregistration was started in April 2017 because the company had not filed tax returns since April 2014. With only a few extraordinary exceptions, companies cannot lawfully be awarded tenders or be paid by government without tax clearance certificates. The service level agreement in question was signed in March 2016 when, according to CIPC records, the company could not have had a valid tax clearance certificate. CIPC records show that a week after deregistration was set in motion in April 2017 the company was suddenly taken out of deregistration and reinstated – we do not know whether this is because valid tax returns were finally filed or because of another reason – either way, it would not impact the lawfulness of the initial award of the tender.

CIPC records also reveal an interesting link between Buthelezi EMS and High Care EMS (PTY) LTD – the two companies who between them were awarded the entire North West inter-facility transfer tender with High Care getting Ganyesa District and Buthelezi the rest of the province. Mr Buthelezi, director of the various Buthelezi EMS companies, and Mogale Clifford Mahlo, director of High Care EMS, are listed as co-directors of companies called Vosloorus Ambulance Services CC and VAS Emergency Medical Services (both companies that have been deregistered because of annual return non-compliance).

Two investigations

In February 2018 City Press reported that North West Premier Supra Mahumapelo had authorised a forensic investigation into procurement at the provincial Department of Health.  In addition to the Gupta-linked Mediosa, Mahumapelo’s spokesperson stated that Buthelezi EMS will also form part of the investigation. City Press also reported on alleged overcharging by Buthelezi EMS, something which Mr Buthelezi denies. Additional questions that Spotlight sent to Mr Buthelezi were not answered.

Meanwhile, Buthelezi EMS continues to be paid by the North West Department of Health. Invoices seen by Spotlight show figures in excess of R20 million a month. (The second article in this Health4Sale series will reveal how Buthelezi EMS appears to be overcharging the North West Department of Health and how their service allegedly falls short.)

In addition to the forensic investigation initiated by Mahumapelo, Buthelezi EMS is also being investigated by the Hawks. Spokesperson for the Hawks in the North West Captain Tlangelani Rikhotso confirmed that they were investigating the contract between Buthelezi EMS and the North West health department, but said, “we cannot divulge any more information in relation to the case”.

The North West Department of Health declined to answer any of a long list of questions sent by Spotlight stating only that: “The management of the Department has looked into all the questions posed. The Department has also considered the fact that Buthelezi EMS and a number of other contracts are a subject of investigation by the Hawks as well as a forensic (sic) initiated by the Premier’s Office.  In the light of these developments, the Department feels that the investigations should carry on and a response will then be issued afterwards.” Spotlight allowed the Department additional time to reconsider this position but did not receive comment by the extended deadline.

More in this series:
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

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.