SA’s new AIDS plan falls short on community health workers

By Sasha Stevenson

South Africa’s new National Strategic Plan (NSP) on HIV, TB and STIs will be launched on March 24. It presents a unique opportunity to start correcting the rudderless management of community health workers (CHWS) in the South African public healthcare system in recent years. (For in-depth background on CHWs, see Spotlight’s recent special investigation.)

The draft of the new NSP states: “HIV, TB and STI prevention, treatment and care is labour intensive and requires diverse cadres of human resources from multiple sectors.” And, “Community health workers need to be formalized as a cadre, appropriately trained and supported, and fully integrated into the health system.”

These are promising statements on human resources for health in general, and community health workers in particular, being key enablers for NSP 2017-2022. The question, however, is how far the new NSP goes in advancing the discussion around and demand for the development and integration of community health workers as a vital cadre of health care worker for the implementation of the NSP and strengthening of the health care system. The answer, unfortunately, is not far enough.

Focus on prevention

The new NSP puts prevention at its centre. In doing so it supports the new ‘test and treat’ policy which is aimed at reducing HIV-related morbidity and mortality and significantly reducing TB incidence and TB mortality. It envisages a comprehensive multi-sectoral prevention programme focused on high incidence hot spots in the hope of changing individual risky sexual behaviour. It sets ambitious targets and lays out detailed indicators.

Disease prevention, health promotion, and linkage to care are at the core of CHW programmes the world over. Health behaviour and social welfare promotion, preventive health care service and commodity distribution, diagnosing and management of common illnesses, assistance during birth, and community organising are all traditional CHW functions.

Despite the broad statements made, and despite what would appear to be the natural alliance between the needs of the new NSP and the need of the health system more broadly for the employment and integration of CHWs, the NSP is low on detail and does not get into any hard numbers in relation to CHWs.

Important targets missing

The NSP 2017-2022 should set targets for the number of CHWs employed or WBPHCOTs developed. It should set targets on CHW capacitation for TB case detection and for preventing loss to follow up for HIV and TB patients. It does none of this.

Goal 2 of the NSP expressed the need for guidelines on the role of, and tools for the use of, CHWs in HIV testing and counselling, linkage to care, and initiation on ART. The implementation and expansion of “community and peer-led programming” is aimed for under Goal 3, without acknowledgement of the direct role of CHWs in such programming. Clinics will open for longer hours – undoubtedly positive – but it is not clear that CHWs will be appropriately supported in the ongoing provision of home based care.

At a time when CHW policy has stalled; when posts for other health care workers are being frozen; but when there is a renewed focus on HIV and TB and the need to treat 5.5 million people, the incorporation of a properly trained, managed and integrated CHW cadre into the HIV and TB programme is vital. Unfortunately, it looks as if the drafters of the latest NSP are missing this opportunity.

Community health workers: A Spotlight in-depth feature

The role of community health workers in the South African public healthcare system has been

A community health care worker cleans an elderly woman during her visits around the community of Sweet Waters in KwaZulu-Natal. She resorts to using bread bags in the absence of gloves.
A community health care worker cleans an elderly woman during her visits around the community of Sweet Waters in KwaZulu-Natal. She resorts to using bread bags in the absence of gloves.

unclear and controversial. How many do we need? What exactly should their role be? Who should employ them? What should they be paid? Is there good evidence to inform policy? Sasha Stevenson of SECTION27 lead Spotlight’s in-depth investigation into these pressing questions.

The structure of our health system and the nature of our healthcare workforce are unsuited to the goals that we have set ourselves: universal health coverage; an ‘end to AIDS’; and the reduction in non-communicable diseases through preventative and health promotion services. These goals can’t be reached in a hospital-centric health system with unsupervised, NGO-employed and underpaid community health workers (CHWs) serving as the only community-based services in the absence of capacitated and reliable clinic and hospital outreach programmes.

For some time, the national and provincial departments of health have been discussing and partly implementing a CHW programme. There have been multiple policy documents and there has been some action from provincial departments but we remain a long way from establishing a standardised CHW programme, let alone one that is capable of meeting the objectives of the health system, the National Strategic Plan (NSP), and the population.

2: Why do we need CHWs?
3: History of CHWs in South Africa
4: What should CHWs do?
5: How many CHWs do we need?
6: How should CHWs be employed?
7: How much will the CHW programme cost?

 

Fighting for the right to care

By Ntsiki Mpulo

Motsoaledi on the role of community healthcare workers:

Community health workers (CHWs), who are predominantly women have struggled to be formally integrated into the health service delivery system, and they are disgruntled. Thousands of workers have taken to the streets in various provinces for their right to employment and equal treatment under the law and in the interim poor people face being without one of the most direct lines of healthcare.

Community health workers (CHWs), who are predominantly women have struggled to be formally integrated into the health service delivery system, and they are disgruntled
Community health workers (CHWs), who are predominantly women have struggled to be formally integrated into the health service delivery system, and they are disgruntled

Gauteng based workers staged a night vigil outside the Department of Health in May 2016, demanding that the Minister address their grievances. In the Free State, 94 CHWs were found guilty of contravening the Gatherings Act. They had gathered to hold a peaceful night vigil outside the MEC for Health’s office in 2014 after he had summarily dismissed 3800 of them without warning.

In an interview with Spotlight, South African Health Minister Dr Aaron Motsoaledi acknowledged the need for CHWs but said that there was an oversupply of workers who may not have the skills needed to serve the needs of the communities.

“In the NHI whitepaper we said the heartbeat of the health care system is going to be the primary healthcare system,” he said “Nurses are the backbone and community health workers are game changers.”

The calculations on which the minister has based the requirement for South Africa are those proposed in the National Health Insurance plan which states that each ward in the country should have an average of 10 community health workers to administer primary healthcare effectively. As there are 4000 wards in the country this equates to 40 000 CHWs. In South Africa, there are currently an estimated 70 000. “Unfortunately, we have a complex unplanned situation. It is part of our unfortunate past,” says Motsoaledi. “Many people believe the AIDS denialism era is gone but we are still experiencing its consequences.”

The minister explains that many community health workers began volunteering during the height of the HIV/AIDS epidemic. “Most of them came in as home based workers because people were dying and people had to act,” he says. “They were employed by churches, NGOs, philanthropic organisations and the Department of Social Development and even the Department of Health but it was unplanned and chaotic.”

In the much lauded Brazilian primary healthcare programme community health workers (CHWs), recruited from the local community, are each responsible for up to 750 people (approximately 100-150 households) in each micro area.  Current estimates put the number of CHWs in Brazil at just over 250 000. If each of the 40 000 envisaged CHWs in South Africa is responsible for 750 people (as is the case in Brazil), 30 million people will be covered. 70,000 CHWs will cover 52.5 million people.

The Minister insists that CHWs’ require sufficient training in order to discharge their duty to the communities they serve.  “The work of primary healthcare is not just about volunteering, it’s also about selection. We don’t want a primary healthcare worker who will walk into a house and talk about HIV but can’t offer other services or advice,” says Motsoaledi. “When asked about diabetes or high blood pressure they can’t help. We need our community health workers to be able to help on all levels of primary healthcare.”

He says that his department has already trained some 10 000 CHWs and cited SukhumaSakhe, a service delivery model piloted by the KwaZulu-Natal premier’s office through which CHWs were employed, as a model which may be replicated across other provinces. He suggests that the programme has already borne significant benefits for the province. “When the programme was introduced in 2011, KwaZulu-Natal had the highest prevalence of mother to child transmission, now the province has the lowest.”

The SukhumaSakhe programme was conceptualised to comprise representatives from various departments in the municipalities which would gather information about the state of service delivery in the province through meeting with community representatives on a regular basis. A “war room” to which CHWs and other community representatives could report issues was set up – this was to include health issues like drug stock-outs,   A Spotlight team interviewed CHWs in the province, who reported that this model is not as successful as purported.  Some CHWs have complained that when cases are reported to the authorities, they are not investigated and that municipal representatives on the task team do not attend feedback meetings.

The minister acknowledges that nurses and community health workers are often at loggerheads. “Nurses don’t see CHWs as part of the system because of the sporadic nature of their interactions. They see them as nuisances.”

However the Minister expects that a solution to the issue is imminent.  He says that he has asked the directors general and heads of departments in each of the provinces to map out a permanent solution.

“The solution will not be a blanket one, which is what they are asking for. If we want to destroy the primary healthcare system, we’ll just close our eyes and put people into it because they are there rather than assessing the needs of the community and applying the appropriate skills,” says Motsoaledi

The barefoot soldiers of a public health care system that doesn’t seem to care

By Nomatter Ndebele

For the past 17 years, 55-year old Doris Ntuli has worked as a community caregiver (CCG) in the community of Sweetwaters, in Pietermaritzburg, Durban. In that time Ntuli has only received a pay increase of R300 (US$20). Her total monthly income is R1500 (US$95).

Tireless: Doris Ntuli
Tireless: Doris Ntuli

That one increase was all she’s ever been given. Other than that she and her colleagues work without support or resources in a hostile environment and one which provides little help to the people of the communities they serve.

In 2001, the KwaZulu-Natal province launched Operation Sukuma Sakhe, a social health care model that offers an integrated approach to both social and health-care services. The model puts one community caregiver (or community health worker, as it is generally known in South Africa) in charge of 60 households in order to oversee their health as well as their socio-economic wellbeing.

Care givers report to a “war room” with representatives from various social development departments including Home Affairs, Agriculture, Human Settlements, Health and Social Development. Here they are expected to report any issues affecting their allocated households to the relevant departments, who are then required to intervene, either by going back to the specific household or sending whatever is needed back with CCG.

What should be a strict and formal process however, hardly ever happens. On some days, department representatives don’t show up, and care givers say that not once have they received responses to cases written up in the report books in their absence.

This is one of the reasons CCGs, who are a vital part of the primary health care system, have lost credibility in the community. They never seem to deliver on their promises.

Seven years ago, for instance, on one of her rounds, Doris came across a quadriplegic blind man, who was living in an outside room and fending for himself. Although his family lived with him, they did very little to take care of the man. Doris told the family that she would report the matter and ensure that a wheel chair was delivered to the man.

“For seven years, I went back and forth to that war room to report the matter, but I received no help. I eventually stopped going back to the house because I was so ashamed,” says Doris.

The man died before any assistance came.

For two years now, Doris has left reports at the war room, detailing a case of an improperly sealed sewerage access point.

“It’s not safe. It’s just a big dark hole and if a child falls into that pit, they will be gone.”

To this day, the sewage access point remains open and no one from the war room has responded in any way. Doris admits that she is close to giving up on the matter. Clearly, nobody cares.

Although CCGs are employed as an extra hand for the departments of health and social services, they are met with much resistance. Nurses in the local clinics look down on them, viewing them as uneducated and providing very little support for the work they do.

Over the past six years, civil society has pushed for the government to recognise community health workers as legitimate aides of the public health care system, and calling for them to be formally employed and given the support they need to do their jobs.

Simanga Sithebe, a representative from Sinani, an organisation that works closely with CCGs in eThekwini, says that one of the biggest issues CCGs face is a lack of resources. They have no travel allowance and are not compensated for any expenses.

“They often pay out of pocket to provide patients with money for trips to the hospital or clinic,” said Sithebe.

CCGs are also forced to work with few or no materials. Often, Doris will get a bag of nappies and nothing else – no gloves, no TB masks – but she is expected to do her rounds regardless.

“The nurses tell me that they only have enough stock for themselves, and that we haven’t been budgeted for,” said Doris.

“Even people who clean the streets have a uniform. They have boots, but I walk up and down this community everyday in my sandals until they break,” she adds.

Sithebe explained that dysfunctional administrative processes have an impact on the work of these community health workers. The renewal of contracts is not a well-managed process and CCGs can wait for up to two months to find out whether their contracts will be renewed.

Despite the fact that CCGs are contracted by the KwaZulu-Natal Department of Health on one- or two-year contracts, they receive no benefits at all.

“If I die tomorrow, these children you see here won’t even have 20c to their name” says Ntuli.

For years, the CCGs in Durban have been promised better opportunities, but very few have materialised. When Doris started, she was told that she could be eligible for nursing training. This hasn’t happened, and in the 17 years that she has worked, only two other CCGs she knows have received training.

Doris, and many other CCGs in Durban have tried to have their grievances heard. Their peaceful marches and heartfelt pleas have gone unnoticed.

“I am supposedly working for the department, but not once have I seen a representative come and address our issues. For years they have ignored us,” said Doris.

At the beginning of May this year CCGs in Sweetwaters decided to take drastic action.

Doris joined a group of CCGs who staged a shut down at the local clinic. The group arrived early in the morning and locked the gates of the clinic, denying patients and staff access. It was only after this act of civil disobedience, that the CCGs were promised a response.

Their drastic action was a means to an end, but she and others knew that it will quite likely further strain relations between themselves and staff at the facility.

“We have never had a good working relationship with the sister at the clinic, and after this, I know things will be even worse. But what could we do?”

In spite of all these problems, Operation Sukuma Sakhe is hailed as one of the best primary care health care approaches and is supposed to act as the model on which all other provinces will base their systems.

There is a lot of work to be done in terms of supporting the people who drive the operation. For many people in far-flung rural areas, CCGs are their only line of connection to the public health care system and to social services.

It is not enough to theoretically empower CCGs without providing necessary resources for them to carry out their work.

The long wait

By Ufrieda Ho

Nurses are giving Cecilia Mokole dirty looks. Mokole meets their stares. She doesn’t care anymore what they think, or what they may do to her for speaking out.

She’s been edging her way to front of the queue at the Dr JS Moroka hospital one spot at a time in Thaba’Nchu in the Free State since 10am. Now, at nearly 5pm, she’s still in the hospital queue waiting for someone to attend to her leg.

It’s a Tuesday morning. At the weekend she fell and her leg swelled. When the pain became unbearable she knew she had to get to her local clinic – the Mokwena Clinic.

Cecilia Mokole waits for hours in the JS Moraka Hospital for someone to attend to her leg. She had to make three trips before she got the medical help and X-Rays that she needed
Cecilia Mokole waits for hours in the JS Moraka Hospital for someone to attend to her leg. She had to make three trips before she got the medical help and X-Rays that she needed

“They gave me a referral letter to come to the hospital because the pain has been so bad that I haven’t been able to sleep at night. So I came here today. I’ve waited the whole day but I don’t know if I’ll even get medicines because the dispensary closed at 4pm already,” she says.

“I really am fed up with this hospital. It’s not like a hospital; it’s like a clinic. They must hire more people. Now I must sit and wait till the doctor on night duty comes,” says Mokole, her leg resting on the bench.

In the queue of benches is a child on a drip, lying on his mother’s lap. Another eight patients are just sitting quietly as sun dips towards the horizon. No one complains, except for Mokole. Even this makes her mad. She’s tired that people have to put up with bad service and that everyone is forced to keep silent because of the threat of being treated poorly.

She has her grandchild on her lap, babysitting him so her daughter can get some food for them because Mokole thinks it will be a long night. Even at 5pm she doesn’t believe her wait is over.

And she is right. At 8.15pm she sends an SMS. She’s finally been attended to and been given a pain injection, but she has to return the next day for an X-ray to determine whether she has broken her leg.

Each trip to and from the hospital costs her R40.

Still, the next morning she’s back at the hospital. She has no choice: she has to get the X-ray. She has to get pain tablets.

She takes up her seat on the waiting benches.

The waiting begins all over again.

Ufrieda Ho is a Journalist

 

MEC* Malakoane: What the Treatment Action Campaign is charging him with

The charge

The offense of “corrupt activities” in terms of section 4 of the Prevention and Combating of Corrupt Activities Act 12 of 2004 (“the Act”).

An article titled “How a dying woman’s bed was taken by an ANC official” appeared in the Mail & Guardian on 4 July 2014.

073 benny screenshot

The article states that MEC Malakoane, with the assistance of his Head of Department David Motau and Deputy Director-General Teboho Moji, ordered that a patient be admitted to the Intensive Care Unit (“ICU”) at Dihlabeng Regional Hospital despite that the patient did not qualify for admission to the ICU and patients who did qualify for admission had been turned away the same night because the ICU was at capacity. The article indicates that the officials ordered the patient to be admitted to the ICU due to the patient’s political position and connections. The patient was admitted and several other patients who qualified for admission were turned away while he was occupying a bed. A patient who was removed from the ICU to make room for the undeserving patient died in an ordinary ward of the hospital.

The evidence

On the night of 27 June 2014, MEC Malakoane and HoD Motau entered Pekholong District Hospital in Bethlehem and instructed health officials, who were subordinate to the MEC and the HoD, to refer a patient (“Patient X”) to Dihlabeng Regional Hospital to be admitted to the Intensive Care Unit. Pekholong District Hospital does not have an ICU whereas Dihlabeng Regional Hospital does.

A doctor who informed the Mail & Guardian of this information requested anonymity for fear of being fired. Moreover, the real name of Patient X is known to the Mail & Guardian.

It is alleged that Patient X was politically connected and an office bearer of the African National Congress.

When Patient X arrived at Dihlabeng Regional Hospital, the ICU consultant on duty assessed him and found that he did not qualify for admission to the ICU because he was in the last stages of a chronic condition and was unlikely to recover. A senior doctor at Dihlabeng hospital explained “no other ICU in the country would admit a patient like that, especially over other patients we could more likely save.” The ICU was at capacity and two critical patients had been turned away that night due to space constraints. Even though a patient with a prognosis like that of Patient X is usually cared for at a primary level, Patient X was admitted to a secondary level medical ward.

The following morning, on Saturday 28 June 2014, MEC Malakoane issued an instruction to the Clinical Manager on duty at Dihlabeng hospital to admit Patient X to the ICU. Deputy Director-General for the FSDoH Mr Teboho Moji delivered this instruction on behalf of MEC Malakoane. The Clinical Manager on duty at the ICU said that it was explained to him “the MEC had promised family members the patient would go to ICU.”

Another doctor at Dihlabeng hospital explained that “the medical professionals on duty were in trouble for not sending [Patient X] straight to ICU” even though Patient X had already been admitted to a higher level of care than he should have been.

On 2 July 2014, Patient X remained in the ICU with no improvements to his condition. It is alleged that during the previous days, several critical patients deserving of admission to the ICU were turned away due to the lack of capacity. It is particularly alleged that a patient who qualified for admission to the ICU but was turned away died in an ordinary ward of the hospital on Monday 30 June 2014.

In addition to the information reported in the Mail & Guardian, the TAC has reason to believe that Patient X was a relative or associate of another senior political leader in the Free State.

The TAC also have reason to believe that members of the staff at Dihlabeng Regional Hospital and Pekholong District Hospital can confirm the facts reported in the Mail & Guardian.

The mec’s defence (two conflicting reports)

Version 1

In an interview with eNCA aired at 12h00 on 11 July 2014, MEC Malakoane’s spokesperson, Mr Mondli Mvambi, asserted that MEC Malakoane went to Pekholong Hospital, saw Patient X and assessed his file. Mr Mvambi explained “the MEC is a doctor in his own right. He saw this patient, he saw the file, he called the clinical specialist in the hospital, assessed the file and jointly agreed with the specialist that this was a deserving case for the ICU.”

Version 2

An article appearing on page 15 of the Mail & Guardian on 22 August quotes MEC Malakoane as providing a very different account: “I didn’t even know the patient’s identity or that he had been transferred to ICU … All I did was to ask [medical personnel] to isolate the patient, who appeared to be in a coma, to prevent psychological trauma to the ones next door.” (“They call me a killer when I know I’m a saviour, says Malakoane”, Mail & Guardian, 22 August 2014).

What the prevention and combating of corrupt activities act says

Section 4 of the Act reads as follows:

  1. Offences in respect of corrupt activities relating to public officers

(1) Any –

(a)  public officer who, directly or indirectly, accepts or agrees or offers to accept any gratification from any other person, whether for the benefit of himself or herself or for the benefit of another person; or

(b) person who, directly or indirectly, gives or agrees or offers to give any gratification to a public officer, whether for the benefit of that public officer or for the benefit of another person, in order to act, personally or by influencing another person so to act, in a manner-

(i) that amounts to the-

(aa) illegal, dishonest, unauthorised, incomplete, or biased; or

(bb) misuse or selling of information or material acquired in the course of the, exercise, carrying out or performance of any powers, duties or functions arising out of a constitutional, statutory, contractual or any other legal obligation;

(ii) that amounts to-

(aa) the abuse of a position of authority;

(bb)  a breach of trust; or

(cc) the violation of a legal duty or a set of rules;

(iii) designed to achieve an unjustified result; or

(iv) that amounts to any other unauthorised or improper inducement to do or not to do anything, is guilty of the offence of corrupt activities relating to public officers.

(2) Without derogating from the generality of section 2(4), “to act” in subsection (1), includes-

(a) voting at any meeting of a public body;

(b) performing or not adequately performing any official functions;

(c) expediting, delaying, hindering or preventing the performance of an official act;

(d) aiding, assisting or favouring any particular person in the transaction of any business with a public body;

(e) aiding or assisting in procuring or preventing the passing of any vote or the granting of any contract or advantage in favour of any person in relation to the transaction of any business with a public body;

(f) showing any favour or disfavour to any person in performing a function as a public officer;

(g) diverting, for purposes unrelated to those for which they were intended, any property belonging to the state which such officer received by virtue of his or her position for purposes of administration, custody or for any other reason, to another person; or

(h) exerting any improper influence over the decision making of any person performing functions in a public body.

The TAC believes that the officials may have agreed to accept “gratification” for the benefit of Patient X in the form of a bed in the ICU and the financial and other resources that accompany the bed.

In addition, the TAC believes that:

MEC Malakoane may have agreed to accept “gratification” in the form of goodwill and political favour from Patient X and/or his political connections, including another senior political leader in the Free State;

HoD Motau may have agreed to accept the same “gratification” from these sources as well as from MEC Malakoane; and

DDG Moji may have agreed to accept the same “gratification” from these sources as well as from MEC Malakoane and HoD Motau.

The relationships between these individuals may constitute a “mutually beneficial symbiosis … generating a sense of obligation” on the officials; such relationships have been determined to be a form of “gratification” for the purposes of a charge of corruption under section 4 of the Act. [S v Shaik 2007 (1) SA 240 at 33].

By ordering Patient X to be admitted to the ICU, the TAC believes that the officials may have:

abused their position of authority;

violated a legal duty and a set of rules; and

acted in a manner designed to achieve an unjustified result.

The TAC believes that the officials’ act of ordering Patient X’s admission may have included:

a failure to adequately perform his official functions;

showing favour to Patient X and disfavour to other patients in performing a function as a public officer;

diverting property belonging to the state to Patient X for purposes unrelated to those for which it was intended; and

exerting improper influence over the decision making of people performing functions in a public body.

What the Constitution says

THE MEC may have acted in contravention of section 136(2)(b-c) of the Constitution as well as the Executive Ethics Code made in terms of the Executive Members Ethics Act 82 of 1998. These laws specifically prohibit MECs from:

using their position to enrich themselves;

improperly benefiting another person;

acting in a way inconsistent with their office; and

exposing themselves to a situation involving the risk of a conflict between their official responsibilities and private interests.

In addition, the TAC also believes that the officials involved may have violated their obligations created in terms of section 195(1)(a-b) of the Constitution, which requires public administration to be governed by the democratic values and principles enshrined in the Constitution, including the following principles:

a high standard of professional ethics;

efficient, economic and effective use of resources must be promoted;

services must be provided impartially, fairly, equitably and without bias; and

public administration must be accountable.

The TAC also believes the MEC may have acted in contravention of section 136(2)(b-c) of the Constitution as well as the Executive Ethics Code made in terms of the Executive Members Ethics Act 82 of 1998. These laws specifically prohibit MECs from:

using their position to enrich themselves;

improperly benefiting another person;

acting in a way inconsistent with their office; and

exposing themselves to a situation involving the risk of a conflict between their official responsibilities and private interests.

What the Public Finance Management Act says

The Public Finance Management Act 1 of 1999 (“the PFMA”) provides that HoD Motau is the Accounting Officer of the FSDoH.

Section 38 of the PFMA provides that the Accounting Officer:

must ensure that the department has and maintains an appropriate procurement and provisioning system which is fair, equitable, transparent, competitive and cost-effective;

is responsible for the effective, efficient, economical and transparent use of the resources of the department;

must take effective and appropriate steps to prevent unauthorised, irregular and fruitless and wasteful expenditure and losses resulting from criminal conduct;

on discovery of any unauthorised, irregular or fruitless and wasteful expenditure, must immediately report, in writing, particulars of the expenditure to the relevant treasury and in the case of irregular expenditure involving the procurement of goods or services, also to the relevant tender board; and

must take effective and appropriate disciplinary steps against any official in the service of the department, trading entity or constitutional institution who:

commits an act which undermines the financial management and internal control system of the department, trading entity or constitutional institution; or

makes or permits an unauthorised expenditure, irregular expenditure or fruitless and wasteful expenditure.

Section 86 of the PFMA provides that an Accounting Officer of a department is guilty of an offence if he or she “wilfully or in a grossly negligent way” fails to comply with these responsibilities. The TAC believes that HoD Motau may have wilfully or in a grossly negligent way failed to comply with the above provisions of the PFMA. Section 86 provides that he may be fined or imprisoned for up to five years if convicted of this crime.

What the state is charging him with

The National Prosecuting Authority has charged Malakoane with multiple counts of corruption for which he faces a minimum sentence of 15 years imprisonment. He was arrested in regards to these charges on 10 July 2013 following a 2010 Commission of Enquiry that produced incriminating allegations against him. The prosecution alleges that Malakoane used his position as Municipal Manager of the Matjhabeng Local Municipality in 2007 and 2008 to conduct extensive fraud and corruption. 27 August 2014, his prosecution was again postponed for the umpteenth time.

 

Trying to nurse ethically in a broken system

By Ufrieda Ho

“I didn’t go to nursing college to become a politician,” says the matron in her neat office in the facility she heads up.

Nurse X has been working in the Free State health care system since 1988. She’s risen through the ranks over the years and has watched with a heavy heart as the department has slipped into a state of dysfunction – a casualty of gross mismanagement and too much political interference.

She has a long list of what’s gone wrong: the exodus of established nurses from public health care; posts being frozen; nurses not being paid overtime for more than three quarters of last year; budgeting that has compromised the efficient running of institutions; private ambulances arriving to fetch patients without surgical gloves and drip kits, but “start charging you the minute they arrive”; intimidation from politicians who allow politicking to go on in hospitals and clinics, but prohibit senior personnel, like herself, to speak to the media.

She doesn’t want her identity revealed because she says the politicians have become tyrants. At the same time she wants to talk because she says the truth must out and the department’s bloodletting must stop, because it costs patients’ lives.

“I don’t want to keep quiet anymore, because it is the truth. And if the politicians want to deny it, they just have to come and speak to the patients.

“Every night I go home and I tell my husband that I just want to go to work and be proud of the service that we give our patients, but I know that that’s not what we are doing,” says Nurse X.

Her voice shakes and a few tears roll down her face. It hurts for someone who has dedicated her life to public health care. She apologises and composes herself. She clearly still manages a tight ship, even with the constraints. Her facility is spotless and well-kept and there’s a general sense of calm and order.

She also doesn’t shy away from doing the heavy lifting herself when there’s work to be done. She does this too because she says in a medical facility you never know what kind of day you will have – emergencies don’t have a schedule.

“We are often short-staffed and I know that my nurses cannot claim for more than 16 hours a month for overtime. So some days when there’s no one to help, I lock my hospital and go help with the patients – you have to be a jack of all trades to survive,” she says.

Still, the difficulties have been immense and, she admits, at times even life-threatening for the patients. She tells of a period when nurses were not throwing away their surgical gloves in-between patients, resorting instead to disinfecting them and reusing them, such was the shortage of something as basic as surgical gloves.

“It is just common sense that you never do that. It’s an absolute no-no, but there was just nothing we could do,” she says.

She also tells of how the nurses at different hospitals and clinics work on their own system of trade – swapping out medicines with each other so that their supply cupboards and dispensaries can circumvent the central medical depot from whence their orders are returned with “Used Up” or “Stock Out”.

“The medical depots have not paid suppliers, that’s why they often don’t have what we’re asking for. Sometimes it’s as small as some cotton wool, but they won’t have it and we are not allowed to buy directly from a supplier since they took away our budgets by 2004.

“Before, if you were a certain salary code you could sign for certain supplies to be put to a quotation committee. Then they said only CEOs could do it. Then they said, no, it had to be decisions made by the medical depot in Bloemfontein. That is when things went wrong. Now we get quotations for catering from construction companies even – how can that be right?

“But it doesn’t help to get on a phone to complain or to get cross. When we see that the supplies are low we will phone other clinics and see what we can trade,” she says.

She says it’s increasingly tough to make any sensible decision and to stand in her authority as a professional, because intimidation and harassment by MEC Benny Malakoane is a very real.

“Have you ever been in a meeting with him?” She asks. “He will tell you it’s his way, or you can get out. He’ll say: ‘There’s the door and you can pick up your paper from HR as you leave’,” she says.

“I can honestly say that with our HODs, our MEC and even our Premier in this province, we need change. We cannot go on like this.”

Who will help the sick and needy?

By Ufrieda Ho

Back in the mid-90s, Angelina Manale Mookadi had dreams of becoming a nurse. “I thought it was a profession I could afford because the government was going to help me pay for my studies. And I always wanted to help my community,” she says, sitting in the kitchen of her home in Tsephong, outside of Welkom, in the Free State.

She flips through a photo album of her early days working with the community. In the pictures she’s in her 20s and she’s dressed in neat white tops and dark skirts – dressed to visit her patients. She smiles as she looks at photos and talks about former colleagues and “the good ol’ days”.

Community health workers like Angelina Manale Mookadi say health MEC Benny Malakoane must answer to why he’s to cripple a vital limb of the province’s healthcare system
Community health workers like Angelina Manale Mookadi say health MEC Benny Malakoane must answer to why he’s to cripple a vital limb of the province’s healthcare system

Mookadi never went on to become a nurse and became a community health worker (CHW) instead. It has never mattered to Mookadi because being of service was and still is what counts for her.

This year marks 20 years of service that Mookadi has under her belt. They’ve been proud years mostly, but the last two years have signalled a turning point that has disappointed her, hurt her even.

In 2014 the Free State Department of Health dismissed around 3 800 community health workers on the grounds of not having a matric or for being too old to do the job. The following year a peaceful candlelight protest at the Free State Health Department’s Bophelo House led to the arrest of over 120 community health workers. Of those, 94 were charged for being part of a “prohibited gathering”. The case is on-going.

“I’m one of the 94 people who still faces charges. It has been painful to have worked for such a long time and to be treated like this by the MEC. I was one of those got my job back because I have a matric, but there are many other CHWs who are going hungry.

“We are the people who have the experience and we know what our patients need. They need us so they don’t become defaulters so that they can be healthy again – we are the ones who know what they go through.

“Sometimes we bring food and sometimes we even have to help wash them, but that is what we are used to doing and we do it to help them,” she says.

Mookadi says the MEC’s decision to axe the CHWs has already had negative repercussions. It has increased the patient load for the current pool of working CHWs, so that they seldom get to see all the patients on their list in a typical day.

Neither do they get paid more for their extra workload – they still receive a stipend of only R1 700

It’s made the job tougher for CHWs who still only receive a R1 700 a month stipend.

Mookadi is committed to adding more years to her service record in spite of these challenges and the court case that is playing itself out slowly. She feels compelled to speak out against the health department’s decision.

She says: “Benny Malakoane (Free State Health MEC) is in the court himself. He ate the taxpayers’ money, and he must still answer. But we want to work, we don’t want our patients to suffer. He should want the same.”