People: Face to face with Dr Bandile Masuku

By Biénne Huisman

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

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

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

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

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

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

Dr Bandile Masuku. Photo by Thom Pierce

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dear Premier Zamani Saul

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

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

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

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

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

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

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

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

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

  • There are critical doctor and nurse shortages in the province and you are even losing the ones that are still employed. Doctors and nurses who have left told us that the health department made no effort to convince them to stay. Once we published our articles we received several heartbreaking letters from doctors and nurses who told us they had been desperate to work in the Northern Cape, but they were messed around so much they had to give up. One of these doctors, was one of your own who had been selected to go and train in Cuba only to return with no prospect of a job.
  • There are often no ambulances to deal with emergencies with the few vehicles that were still in running order mostly used to ferry patients to Upington and Kimberley. However, many of the ambulances that do respond to trauma or life-threatening situations are not equipped to deal with the emergency, in fact they cannot even stabilize or transport a patient. As you add sparkling new ambulances to the fleet, we do hope that this will be coupled with a serious campaign to recruit intermediate and advanced life support paramedics. Premier, you speak passionately about rooting out corruption. You may want to pose serious questions around the awarding of the aeromedical ambulance service contract in the Northern Cape which has gone to a company that by all accounts failed to conduct outreach services in the province when it had the previous contract. It makes complete sense to bring back the excellent outreach services similar to those that the Red Cross Air Mercy Service offered from 1996 to 2012, in such a vast and sparsely populated province with a dire shortage of specialists.
  • The Northern Cape is a province of ghost “hospitals” with many downgraded to Community Health Centres, which is just a fancy term for hospitals with no doctors. Hospitals are functioning with skeleton staff or no staff. Many family members are forced to care for the sick and dying in your facilities. The story of the Kimberley Mental Health Hospital is well-known. A visit to this facility reveals beautiful, uninhabited buildings with weeds already taking over everywhere, some parts in need of maintenance already. It is utterly heartbreaking to see such a monument to corruption and endless spending still not functional in a province that has such massive mental health challenges and almost no services to meet the need. Key hospital such as Dr Harry Surtie in Upington, De Aar hospital and Robert Sobukwe in Kimberley have severe staff shortages with health workers and patients who spoke to Spotlight claiming the hospitals have high death rates. Patients are fearful of being referred to these hospitals saying too many people return home in coffins.
  • The province has a slew of vacancies and political appointments in the healthcare system with very little evidence that there have been serious attempts to attract qualified people. We have information of administrative appointments made based on political affiliations and people without the proper qualifications being appointed or administrators being appointed at facilities without there being vacancies or communication with facility managers.
  • There are question marks over the appointment of the Head of Department Dr Steven Jonkers. The province failed to produce the advertisement for the job when asked. At the time of his appointment to the health department Jonkers was reportedly facing charges of corruption. Premier Saul, if you are serious about cleaning up, you need to investigate the appointment of this HOD.
  • Basic medical supplies, drugs, food and stationary are often out of stock in facilities.
  • Many primary Health Care clinics are virtually non-operational. Around Kakamas and Keimoes, several primary healthcare clinics such as Augrabies, Alheit, Marchand and Lutzburg had patients sitting outside when we went there, waiting for a nurse to arrive, hours after the clinics were supposed to open. It is undignified.

 

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

Our experience over the last six months is that there was very little effort by those in power in the Northern Cape to show any accountability. For several months, our efforts to elicit any comment, explanation or meetings with the then MEC, her advisor, the head of department or any other people in decision making positions came to nothing. We would continuously try to contact those in the communication positions and despite reading our messages no response was forthcoming. All questions or requests via the media office or the HOD’s office were simply ignored. Almost 70 questions were sent to the MEC, the HOD and the head of Communications at end of 2018. These questions were resent in early 2019 with several follow-ups. There was no effort to engage or answer the questions .

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

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

You quoted a poem titled Courage in your inaugural address.

One part reads:

To map out a course of action

And follow it to the end

Requires of the same courage

That a soldier needs.

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

Yours in the struggle for better health

The Spotlight Team

 

 

 

 

 

 

Uganda’s Constitutional Court hears a Landmark Maternal Health case

By Paul Wasswa

In what many describe as a landmark case, Uganda’s Constitutional Court will tomorrow morning (Thursday, 13 June) hear a case which challenges the government’s failure to stop the high number of women who die while giving birth.

The case of Center for Health, Human Rights and Development (CEHURD) and others vs. Attorney General (Constitutional Petition 16 of 2011) reveals that more than 16 pregnant women die every day in Uganda with many of these tragic deaths preventable.  Research shows that most of the deaths are due to absence of maternal health kits, no midwives, stock outs of essential medicines and the lack of emergency obstetric care. This state of affairs is attributed to the failure of the state to address the problem of maternal mortality.

Genesis of Uganda’s Maternal Health case

CEHURD’s case is based on the fact that Uganda has an extremely high maternal mortality rate – it increased from 418 maternal deaths per 100,000 live births in 2006 to 438 maternal deaths per 100,000 live births in 2011. This was attributed to the absence of enough midwives and doctors attending to expectant women, frequent stock-outs of essential drugs and other basic supplies such as gloves, an absence of maternal health kits and the lack of Emergency Obstetric Care services at Healthcare facilities and hospitals. The shortage of health workers was compounded by poor pay that greatly contributed to absenteeism and poor attitudes of workers towards pregnant women, according to CEHURD. Rhoda Kukiriza and Inziku Valente also submitted affidavits describing the loss of their relatives at child birth with a belief that it was linked to the poor quality of service in the healthcare system.

When the case was heard in 2012 before the Constitutional Court, CEHURD contended that the poor services coupled with inadequate financial resource allocation to the health sector contributed to the high maternal mortality rate which amounted to the violation of Government’s obligation to provide basic maternal health care services in health facilities.

However, the State argued that the court did not have the power to hear the petition because the government had the power and authority to handle issues connected to maternal health and not the Courts. The court agreed and found that it did not have the power to hear the petition as it raised no questions for constitutional interpretation and summarily dismissed the case.

CEHURD appealed the Constitutional Court Judgement in the Supreme Court (Uganda’s highest court) in 2013. The  Supreme Court found that the Constitutional Court was being called upon to determine whether the Government had taken all practical measures to ensure the provision of basic medical services to the population and in this case maternity services.  It thus held that the Constitutional Court had the power to hear the case on its merits and ordered the Constitutional Court to re-hear the case.

Why this case is important

In a country where the Right to Health is not a constitutionally guaranteed human right, this case seeks to question the progressive realisation of the Right to Health and its rightful place within the ambit of the Ugandan Constitution. Though Uganda is a signatory to several international human rights instruments such as the International Covenant on Economic, Social and Cultural Rights and General Comment No. 14 on the Right to the Highest Attainable Standard of physical and mental health, this case demonstrates the fact that not much has been done by the Ugandan government to address the problem of maternal deaths.

By contrast, South Africa’s constitutional framework, which recognizes the right of access to health care services and the Guidelines on Maternity care in South Africa; which recognize the right to emergency obstetric care, provide the basis on which the public health system has been able to make strides in combating maternal deaths. The maternal death ratio in 2016 in South Africa was 134 per 100 000 live births down from 189 in 2009.

The CEHURD Petition asks the Constitutional Court to take the same progressive approach as South Africa and to breathe the Right to Health into Uganda’s Constitution. It seeks to address the systematic and structural imbalances in society that have led to the death of pregnant women while giving birth in Uganda’s public healthcare facilities. It seeks the recognition that maternal health is a right for all and not a privilege for a few.

Paul Wasswa is a fellow at SECTION27 and Programme Associate at the Center for Health, Human Rights and Development (CEHURD).

 

How does the roles of MECs differ from those of heads of departments?

Last week we saw the appointment of the national cabinet and provincial executive councils following South Africa’s 2019 national and provincial elections. The people serving on these structures are entrusted with providing coherent strategic leadership and coordination in policy formulation and overseeing service delivery planning and implementation in support of national and provincial priorities and plans.

Each of the nine provincial executive councils has an MEC (member of the executive council) for health. Spotlight reported earlier this week that only two of the nine current MECs for health have served in their positions for more than two years. In addition to a MEC for health, each province also has a head of department (HoD) for the province’s health department.

Broadly speaking, the MEC has executive authority (political power) and the provincial HoD plays an administrative role. Unfortunately, through ignorance, over-reach, or in some cases in the service of corruption, these roles often get tangled up.

How are MECs and HoDs appointed?

MEC appointments are often described as political appointees. This is because the appointment is solely at the discretion of the Premier of the province and there is no legal obligation for the appointment to be based on merit or experience. So, for example, new KwaZulu-Natal Premier Sihle Zikalala was fully within his rights to appoint Nomagugu Simelane-Zulu as MEC for health, even though she lacks what many would consider the qualifications and experience required for the position.

Premiers typically appoint MECs from their own political parties and who are willing to associate with the political direction and agenda of the government.

By contrast, the appointment of HoDs must be based on merit as the appointee is required to have educational qualifications to justify their appointment to a specific provincial department. The vacancy of an HoD position must be advertised widely and the recruitment process must be transparent.  The same is not required when appointing an MEC.

Once appointed, HoDs are protected by stringent labour laws and public service regulations that shield from arbitrary dismissal. The same cannot be said for MECs who may be removed at the discretion of the Premier.

Powers and responsibilities

The general powers and responsibilities for MECs, regardless of the department for which they are responsible, are set out in section 125(2) of the Constitution. It states that MECs exercise their executive authority through a wide range of responsibilities that include implementing national and provincial laws; developing and implementing provincial policy, and co-ordinating the functions of provincial administration and its departments. Put simply, the role of the MEC is to the policy objectives and ensure that those objectives are implemented.

During the Life Esidimeni Arbitration, the then Gauteng MEC for health, Qedani Mahlangu, sought to distance herself from the tragedy by stating that she was not responsible for the implementation of the Gauteng Mental Health Marathon Project, a project that was supposedly carried out in pursuance of the National Mental Health Policy Framework and Strategic Plan 2013-2020 (NMHPFS). This defence was rejected by the Arbitrator, as he found that it was in fact her job to ensure the implementation of plans in the delivery of mental health services in Gauteng in line with the NMHPFS. The implementation obligation on the MEC does not mean she must herself take every step to implement; it means she must ensure that all steps are taken.

MECs are responsible for the four I’s of authority: identifying; initiating, integrating and interpreting.[1]

  • Identifying – the MEC must identify the challenges and opportunities within their provinces.
  • Initiating – the MEC for health is expected to take initiative in developing and implementing policies that are necessary for the realisation of the right to access health care.
  • Integrating – At any given time, there are thousands of programmes aimed at addressing different issues in health. An MEC must have the ability to integrate and coordinate those programmes and ensure that they do not work against each other.
  • Interpreting – policy objectives must be clearly interpreted to those who implement.

Specific responsibilities for MECs for health are set out in section 25 of the National Health Act. It provides that the MEC for health must ensure the implementation of national health policy and norms and standards in his or her province. MECs are also obligated to perform any other functions assigned to them in terms of the Constitution or any other Act of Parliament e.g. the Public Finance Management Act (PFMA).  An example of an Act that assigns specific functions to MECs for health is the Choice on Termination of Pregnancy Act which states that the MEC must approve facilities that offer termination of pregnancy services.

Whilst the task of the MEC for health is to ensure that the right policies are implemented to achieve the objectives of the National Health Act, the implementation itself is carried out by the public service – in this context headed by the HoD.

The general roles and functions of HoDs are not set out in the Constitution, but rather in the specific Acts relevant to the function allocated to them.

Section 25(2) of the National Health Act sets out the extensive powers and responsibilities of a provincial department of health HoD.  It is evident from the long list of responsibilities in section 25(2) – including “(I) Plan, manage and develop human resources for the rendering of health services” and “(n) Control the quality of all health services and facilities” – that HoDs bear far-reaching responsibility in the delivery of health care services.

According to the PFMA, as the accounting officer of a department, the HoD implements a department’s policies and delivers the outputs defined in the department’s budget.  They are responsible for the effective, efficient, economical and transparent use of the department’s resources – which would include the hiring and dismissal of staff – to produce policy output. The PFMA also places the awarding of contracts strictly in the purview of the accounting officers who are supposed to ensure that the department has, and maintains, an appropriate procurement and provisioning system which is fair, equitable, transparent, competitive and cost-effective.

This does not mean that MECs do not have financial responsibilities. Firstly, the HoD must report to the MEC on the financial, commercial and socio-economic strategic performance of the department. The PFMA clearly states that it is the responsibility of the executive authority (the MEC) to ensure that departments perform their functions within the limits of the allocated budget and in compliance with the PFMA and other relevant policies. In circumstances where a directive from a MEC has financial implications, this must be done in writing. The failure to do so will result in the HoD being accountable for any resulting unauthorised expenditure.

While MECs can and should raise questions about appointments and procurement processes where there are valid concerns, these areas are the responsibility of HoDs. Maintaining the separation between the executive role of the MEC and the administrative role of the HoD is critical to avoiding political interference in procurement and human resource processes. For example, MECs should not have any say in the outcome of tender processes, nor should MECs appoint or dismiss staff employed by the department, as appears to have happened when Limpopo MEC for health Dr Phophi Ramathuba reportedly removed the entire management team at Tshilidzini Hospital.

So what should we expect from the MECs for health and HoDs?

Although they have differing roles, MECs and HoDs are all bound by the Constitution. In section 195 of the Constitution, the values and principles within which public administration must take place are set out. Amongst others, it demands that public officials perform their duties to a high standard of professional ethics, responding to people’s needs and encouraging the public to participate in policy making.  It also requires that public administration be accountable[2] and transparent by providing the public with timely, accessible and accurate information. Accountability, transparency and responsiveness means that when the media or general citizenry seeks answers from public officials, public officials must take all reasonable steps to respond, and not simply ignore.

Prior to the 2019 national and provincial elections Spotlight sent questions to all nine MECs for health. Despite various attempts at follow up, only two of the nine answered the questions. This reflects a wider trend of non-responsive MECs and provincial departments of health. In a number of instances, Spotlight has been refused basic information on tenders and government spending and asked to request information by lodging an application in terms of the Protection of Access to Information Act (a slow and time-consuming process). This is unacceptable – no matter if you are an MEC or an HoD.

Finally, in the interest of good governance, all MECs and HoDs should serve the public within the bounds of the their legally-defined roles. This is critically important for both the smooth and correct functioning of the state and for the fight against corruption. MECs or HoDs who act outside of their roles or who underperform in other ways should be held accountable. After all, in the exercise of their powers and the discharge of their duties, MECs are individually and collectively accountable to the legislature, and by extension to the public.

[1] Adapted from “the role of local government” https://repository.up.ac.za/bitstream/handle/2263/25724/03chapter3.pdf?sequence=4&isAllowed=y Visisted 27 May 2019.

[2] In the exercise of their powers and the discharge of their duties, MECs are individually and collectively accountable to the legislature. Section 133 of the Constitution.

  • Mafuma is a senior researcher at SECTION27

Assessing the Motsoaledi years

Dr Aaron Motsoaledi became South Africa’s Minister of Health 10 years ago, in

Former SA Minister of Health, Dr Aaron Motsoaledi.
Photo: David Harrison

May 2009. For most of the past decade, Motsoaledi and the Director-General of Health Malebona Precious Matsoso (appointed in 2010) have been tasked with ensuring people in South Africa have access to quality healthcare services. This week the Motsoaledi era came to an end with the appointment of Dr Zweli Mkhize as South Africa’s new Minister of Health. It is not known whether Matsoso will stay on.

The Motsoaledi years can broadly be judged on two fronts: The response to the HIV epidemic and the functioning of the public healthcare system and its related institutions. The verdicts in these two instances are quite different.

Turning the page on Aids denialism

Until September 2008 Thabo Mbeki was President of South Africa and Manto Tshabalala-Msimang Minister of Health. The Mbeki and Tshabalala-Msimang years were years of state-sponsored Aids denialism. The details of those terrible years will not be recounted here, except to say that South Africa needed to make a clean break from it. That clean break started with the appointment of Barbara Hogan as Minister of Health in September 2008.

Building on years of resistance and the hard work of many principled activists, lawyers, healthcare workers, and some politicians, Hogan spoke clearly about HIV and Aids and ended the policy madness of the Mbeki and Manto years. Hogan was in the position for only eight months before she was replaced by Motsoaledi.

Arguably the biggest job facing Motsoaledi when he took office in May 2009 was to accelerate the provision of antiretroviral treatment. Motsoaledi had some credibility owing to his time in the Limpopo provincial government and the fact that he is a medical doctor. He was also energetic, passionate and outspoken. All of this made him a great figurehead for the establishment of the world’s biggest antiretroviral treatment programme.

The numbers are worth looking at carefully. In 1994 an estimated 15,000 people died of Aids in South Africa. Deaths increased rapidly during the worst years of Aids denialism to a peak of around 273,000 in 2005. When Motsoaledi took office in 2009, Aids deaths had already dropped somewhat from the 2005 peak to around 195,000. By 2017 (eight years into Motsoaledi’s time in office) it had dropped much further to around 89,000. (In 2019 it is estimated at around 80,000 — but it is better to emphasise the 2017 figures given that they are more reliable.)

The decrease in Aids deaths over the past decade is particularly impressive given that the absolute number of people living with HIV has been increasing over the same time period. People are still contracting HIV, but antiretroviral treatment has clearly kept hundreds of thousands, or even a few million, people alive who would otherwise be dead by now. When Motsoaledi took office in 2009 about 792,000 people were receiving antiretroviral treatment. Today that number is estimated to be more than 4.7 million.

Important context to the Motsoaledi years is also to be found in changes in life expectancy. In 1994 life expectancy at birth was about 63.1. In 2017 it is estimated to have been about 65.2 (about 66 in 2019). The increase over the 1994 level is thus marginal and does not suggest massive improvements in public healthcare in the post-apartheid era. Between 1994 and now, however, things first got very bad and then better again.

Life expectancy declined to an incredibly low 53.8 in 2004, driven mostly by Aids deaths. As with Aids deaths, the recovery in life expectancy was already underway when Motsoaledi was appointed in 2009 (with life expectancy having risen to around 58.3 by then).

Either way, the increases in life expectancy in the Motsoaledi years are better thought of as a recovery from the specific disaster of Aids denialism than a general improvement in the quality of healthcare services.

Ultimately, the HIV epidemic would probably have been bad no matter what, but government intransigence in the early 2000s undoubtedly made it much, much worse than it would have been otherwise. Similarly, while things had already started to turn by the time Motsoaledi was appointed in 2009, he used what positive momentum there was to accelerate the provision of treatment, saving many, many lives in the process. For this, he deserves immense credit.

But what happened to the healthcare system?

If Motsoaledi took the baton from Hogan regarding HIV, he seems to have dropped the baton when it came to the healthcare system. In her short stint as Health Minister Hogan commissioned a series of reports into the public healthcare system in various problems. These so-called Integrated Support Team reports still stand as some of the best diagnoses of the problems in our public healthcare system. Ten years later, it seems these reports are still gathering dust and most of the problems they identify remain or have become worse.

Generalising about the public healthcare system is not always fair. There is significant variation between provinces, between districts and between individual facilities. There are undoubtedly many qualified and committed people out there putting in the hours for the communities they serve. But there are also persistent reports of under-staffing, long waiting times, patients sleeping on the floor and worse.

While much information is anecdotal, and while the media tends to focus on some of the worst cases, there are objective reasons to be very worried. So, for example, it is hard to argue against the deeply depressing picture painted by the reports of the office of Health Standards Compliance.

It is also hard to look at tragedies such as Life Esidimeni in Gauteng, the oncology crisis in KwaZulu-Natal, and the persistent problems with emergency medical services in multiple provinces without concluding that these are symptoms of deep-seated dysfunction in provincial health departments. The president himself talks of a “crisis”.

There was a sense in the Motsoaledi years that there was always a new crisis, always a new fire to put out, and that there was just never enough capacity in the National Department to deal with it all. Often short-term interventions were found.

After our Death and Dying report exposed serious problems in the Eastern Cape healthcare system in 2014, the Minister moved swiftly to intervene. Emergency plans were made and announced at a press conference. But then the Minister and the media moved on and things slowly reverted to the way they were.

After the PharmaGate scandal of 2014, Motsoaledi made headlines by describing the pharmaceutical industry plot to derail law reform efforts in South Africa as “genocide”, but strident as his public statements were at the time, he never used his powers to issue a compulsory licence on an overpriced medicine, nor did he expend much political capital on reform of South Africa’s outdated patent laws.

Similarly, while Motsoaledi was an outspoken critic of the private healthcare sector in South Africa, the draft report of the Competition Commission’s Health Market Inquiry leaves little doubt that he failed to use the levers he had at his disposal to regulate the private sector.

How to make sense of all this?

One version of the past 10 years would see Motsoaledi as a victim of the politics of State Capture. As good as his intentions may have been, unruly provincial health departments, often beset with corruption, made it impossible for him to implement.

For example, various Free State MECs for Health and the head of the Provincial Health Department were essentially untouchable, given that they were protected by Ace Magashule, Free State Premier for much of the Motsoaledi years. It could be argued that if Motsoaledi stuck his head out too far, Zuma would have fired him, and that he was therefore justified in playing the long game, much like Ramaphosa. There is definitely something to this excuse, but it only takes you so far.

As an aside, while Motsoaledi, like Ramaphosa, could and should arguably have done more to arrest the institutionalisation of corruption in the state, it is important to recognise that he was one of a small number of ministers who stood up against former President Jacob Zuma when the political crunch came in 2017. He was brave and right to do this and, quite apart from what he may or may not have done in healthcare, deserves credit for it.

A second version of the last 10 years would hold Motsoaledi and those close to him at the National Department responsible for much of the systemic failures in the healthcare system. It could be argued that the National Health Act gives the Minister much greater powers to interfere in provinces than Motsoaledi was ever willing to use. It could also be argued that what influence he did have in provinces, was not always used particularly well.

For example, the National Department of Health has relative control over the HIV conditional grant (having to approve business plans submitted by provinces), yet the grant was grossly misused in the North West to pay a private ambulance company. In addition, rather than allowing dysfunction in provinces to be exposed, Motsoaledi’s instinct was often to spin his way out of it — take the specific problem seriously, deny that it is systemic, protect your ANC comrades in the provinces.

While unruly provinces are one thing, there are various national level processes and institutions that Motsoaledi had significant influence over in his decade in office. Today the Special Investigating Unit (SIU) is looking into alleged corruption at the Health Professions Council, the National Health Laboratory Service and the ongoing problem of fraudulent medico-legal claims against the state.

Motsoaledi both supported the appointment of persons now suspected of corruption and failed to intervene effectively when the extent of some of these problems became apparent. That the SIU has now been asked to mop up, does not reflect well on Motsoaledi’s leadership – although the politicised Hawks and National Prosecuting Authority did not make things easy for him.

Some critically important policies were allowed to expire, such as the Human Resources for Health Policy in 2017, which has not yet been replaced. The need for a single electronic health records system for the public healthcare system has been a priority for years, but progress has been painfully slow. National Health Insurance has been on the cards for ages, but when a draft bill was published in 2018 it was half-baked and lacked clarity in various key areas, such as the role of provinces.

State Capture or unruly provinces cannot be blamed for these policy and leadership failings. Something else has clearly gone wrong.

Even so, while the healthcare system and many of the institutions meant to support it have struggled in the Motsoaledi years, these failings are arguably outweighed by the tremendous growth of the HIV treatment programme and the many lives that have been saved through this programme. The numbers do not lie.

In the final analysis then, Motsoaledi is likely to be remembered primarily as the minister who definitively closed the book on Aids denialism and made sure that millions of people living with HIV received life-saving antiretroviral therapy.

Note: Figures quoted in this article are taken from the Thembisa model outputs version 4.1.

 

 

 

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

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

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

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

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

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

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

Eastern Cape

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

Free State

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

Gauteng

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

KwaZulu-Natal

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

Limpopo

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

Mpumalanga

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

Northern Cape

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

North West

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

Western Cape

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

 

Five health policy priorities for the new administration

Under Health Minister Dr Aaron Motsoaledi’s watch government has made generally good HIV policy over the last decade. Treatment guidelines kept up with international best practice, newer medicines with fewer side effects have been introduced, and the malicious compliance of the last years of the Mbeki presidency was replaced with real political will and commitment to ensure people get the treatment they need, at least at national level.

But, while HIV and some aspects of TB policy has been good, there have been important failures in other areas. Below we highlight five important government policies or plans that have been stalled, are out of date, or simply never got off the ground. We recognise that National Health Insurance constitutes a major area of policy uncertainty, but we will not discuss that in this article.

These five health-related policy areas are not only areas that we hope will receive higher priority in the new administration, they are also areas in which we urge government to communicate its plans more clearly and more timeously.

  1. Human Resources for Health Strategy

People, or human resources if you will, are critical to the functioning of the public healthcare system. We need to have enough nurses, doctors, pharmacy assistants, managers and so on where they are needed most. This involves ensuring that enough people are being trained, but also ensuring that there are jobs and careers for these people in which they receive enough support. To make all this happen we need an over-arching plan or strategy.

Government’s key human resources strategy document for healthcare in South Africa is the HRH strategy for the Healthcare Sector 2012/2013-2016/2017 – in other words, it expired around two years ago. When we recently contacted the Department of Health to ask for the HRH plan, this outdated plan is what they sent us. They did point out that work is underway on a new plan, but did not say when it would be finished.

  1. Community Healthcare Worker policy

Community healthcare workers play an important part in the provision of primary healthcare services. Particularly in South Africa, where people with HIV or tuberculosis often only go to clinics or hospitals when they are very sick, CHWs can help get people into care earlier. This benefits both the individuals who are linked to care, but also helps prevent further transmission of HIV or TB.

Over the last decade provinces have gone about the employment of CHWs in very different ways. Salaries or stipends differ widely, required qualifications have differed, many provinces essentially outsourced the employment of CHWs to NGOs, training and job functions were not standardised across provinces, in one instance over 3 000 CHWs were dismissed without warning.

The need for a single, coherent national policy was recognised as far back as 2010 when the Health Minister and MECs went to Brazil and returned with a vision of a wide-reaching CHW cadre integrated into the health care system. Between 2011 and 2018, policy development and implementation moved at a glacial pace until the Policy Framework and Strategy for Ward Based Primary Healthcare Outreach Team 2018/19 – 2023/24 was published.

We now finally have the policy but adaptation to local needs and implementation is up to provinces. It should be made a top priority as new provincial administrations come into power. While having the right policies in place is essential, implementing policies is often another matter altogether.

  1. Policy on Occupational Health for Health Workers in Respect of TB and HIV

Healthcare workers are at a much greater risk of contracting tuberculosis than the general public. It goes without saying that we need to have good policies in place to ensure that as many healthcare workers as possible stay healthy.

By the end of 2016 a policy on “Occupational Health for Health Workers in Respect of TB and HIV” was completed. According to sources involved in the drafting of the policy, the policy was to be released on World TB Day (24 March) 2017. However, more than two years later the policy has still not been published.

  1. The National Drug Master Plan

The National Drug Master Plan is supposed to guide South Africa’s response to addiction and drug use – everything from tik to injecting heroin. A progressive, evidence-based plan is particularly important given that HIV and hepatitis rates are much higher among injecting drug users.

South Africa’s last National Drug Master Plan covered the period from 2013 to 2017 – in other words, it is now out of date by about two years. In April 2019 cabinet approved an evaluation report of this plan.

When a new plan will be published is not known – although we understand that drafts have been around for well over a year.

  1. Guidelines for Sexual and Reproductive Health Rights, Contraceptives, Abortion, PrEP and Cervical Cancer

Everyone has a right to reproductive health care services. Exercising that right is beset by difficulties, however, including health workers who refuse to provide abortions, contraception stock outs, the non-availability of pre-exposure prophylaxis outside of a limited number of donor-funded pilot sites, and oncology crises across the country.

A Guideline on Abortion is in its sixth or seventh draft currently and, we understand, has been approved by the technical sub-committee of the National Health Council. When it will be passed by the National Health Council itself and whether it will be implemented is not known. We are also aware of pending draft guidelines relating to SRHR, Contraceptives, PrEP and Cervical Cancer but are uncertain as to the status of these guidelines.

Setting priorities

Apart from finalising all the above guidelines and policies, making those guidelines and policies that have been finalised easily accessible online should be a priority.

In addition to all of the above, there are areas in which clear national policies are needed, but where we are not aware of any sufficiently far-reaching policy processes that are underway. So, for example, emergency medical services and planned patient transport services in many provinces appear to be in a constant state of crisis. New EMS regulations came into effect late in 2018 and EMS is often mentioned as a key element of NHI, but beyond that there appears to be very little planning, leadership and public consultation on how to fix our chronic EMS and planned patient transport problems. If NHI is to be part of the solution, then maybe the EMS element of NHI should be fast-tracked and prioritised. Either way, we need publicly available and consultative plans and policies to address urgent crises such as those in EMS.

 

#FootSoldiers: The biggest and happiest family In Limpopo

Matriarch Sally Duigan. Photo by Thom Pierce.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*Name changed to protect the identity of the child.

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

 

 

 

 

Donor shift threatens adherence clubs in the Free State

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

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

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

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

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

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

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

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

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

What clients say

Patients’ adherence club logbooks Photo by Khothatso Mokone

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

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

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

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

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

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

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

CHWs assigned to take over

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

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

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

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

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

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

“Patients trusted us”

Mosamaria’s Connie Motsoeng Photo by Khothatso Mokone

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

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

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

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

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

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

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

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

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

Government’s responsibility

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

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

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

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

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

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

#Vote4Health: No road to health in the Northern Cape

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

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

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

 Calvinia

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

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

Sutherland

Desolation: The road out of Sutherland

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

Fraserburg

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

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

De Aar

De Aar: Shiny, new and deserted.

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

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

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

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

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

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

Keimoes

Keimoes hospital: Not much of a health facility

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

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

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

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

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

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

 Kakamas

Alternative view: The outside of Augrabies Clinic near Kakamas.

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

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

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