A print and online publication monitoring South Africa's response to TB and HIV, the state of our health systems and the people that use it and keep it going.
In episode 2 we catch up with the processes around the Life Esidimeni tragedy. Christine Nxumalo discusses what further action the families are hoping for. Tendai Mafuma provides fascinating insights into the prospects for criminal liability. Mark Heywood gives his views on the politics surrounding the case and what that means for accountability.
Continue reading “Episode 2: Life Esidimeni revisited”
In this first episode of the Spotlight podcast host Nomatter Ndebele speaks to Dr Daphney Conco of Wits about what SRHR is and why it matters. We also hear from Vuyokazi Gonyela of TAC about their SRHR work in provinces. Finally, Nomatter chats to Spotlight guest editor Thuthu Mbatha about some of the highlights in the special Youth edition of Spotlight. Continue reading “Episode 1: Sexual and reproductive health rights”
By Marcus Low
South Africa has been in the grip of a TB crisis for decades. It is a crisis that has mostly dropped below the radar – socially, politically and economically.
When one considers the numbers, it boggles the mind that TB is not dominating the headlines, not a top priority for political parties or trade unions, not one of the key issues in every single State of the Nation address. Almost half-a-million, more than 400 000 people, develop active TB every year in South Africa. By World Health Organisation estimates, over 100 000 people in South Africa die of TB every year. While, say, Ebola and listeriosis are also very serious, the numbers involved in those outbreaks are dwarfed by the scale of the TB epidemic.
We have a deadly disease tearing through our communities, killing at an alarming rate – and yet, politically it is hardly raising a flutter.
A first reason for our apathy about TB is class. If you are middle-class in South Africa, chances are you don’t consider TB to be a threat. That is not to say that some middle-class people do not develop TB – some do – but it is relatively rare and does not capture the middle-class imagination in the way that say cancer does. It is also not something you encounter when you visit private hospitals or your GP’s office.
By contrast, it is almost impossible to avoid contact with TB if you are dependent on the public healthcare system in South Africa. In a just-published survey conducted by the Treatment Action Campaign (TAC) 145 of 207 facilities assessed were found to be in a “RED” state with very poor TB
infection control measures in place. Facilities got a “red” rating if they failed on three or more of seven measures of infection control. In short, this means that people who are visiting these clinics, people who may well be there because they are already ill, are at significant risk of being exposed to TB.
Except for TAC, organisations representing the poor in South Africa have generally failed to make TB a political issue and to hold government accountable for its TB response. This means that there is hardly any pressure on Premiers or MECs for Health to improve the response to TB. The fact that those most effected by TB are not organising themselves politically, means the President can get away with doing little more than paying lip-service to TB. This political failure of civil society, trade unions and political parties is a second key reason for our apathy toward TB.
And yet, partly due to the work of South Africa’s Minister of Health Dr Aaron Motsoaledi, TB is suddenly high on the international agenda. This September the United Nations will hold a so-called High-Level Meeting on TB during its General Assembly in New York. Such High-Level Meetings attended by heads of state are rare – and even more rare for health issues.
It is quite possible that the meeting will produce a declaration that sounds good and aspirational, that heads of state will pat each other on the back, that the positive headlines will echo across the internet – but that at the same time clinics in the Free State, Mpumalanga and KwaZulu-Natal will remain much the same as they were before, that people will still contract TB in trains, taxis and in clinic waiting rooms, and then struggle to be diagnosed and to access treatment.
While Motsoaledi has helped to shift the dial internationally, it has been hard for him to change things within South Africa. On the one hand he deserves credit for making South Africa a leader in introducing new TB tests and medicines for drug-resistant TB – on the other, Motsoaledi has seemed powerless to halt the widespread mismanagement and dysfunction plaguing our provincial healthcare systems.
The sobering reality is that the health departments responsible for the Life Esidemeni tragedy in Gauteng, the oncology crisis in KwaZulu-Natal, the Gupta-linked mobile clinic corruption in the North West and the Free State, are the very same departments at the frontline in the fight against TB. To pretend that the TB response is not also entangled in this web of mismanagement would be naïve – as is clear from TAC’s infection control findings.
Government may intend the right things at a national level and make generally sensible policy decisions, but that is of little use if implementation of those policies is derailed by corruption and mismanagement in provinces.
So what is to be done?
If President Cyril Ramaphosa, and the current administration more broadly, are serious about fighting TB they can start with an aggressive campaign to uproot corruption in the public healthcare system. This will mean getting rid of corrupt provincial officials and unqualified political appointees in provinces. It will mean following up on the many serious allegations of corruption made by whistle-blowers and in the media and asking serious questions about the irregular expenditure identified by the Auditor General. It would mean taking on some still well-connected members of the ANC in their own backyards. Whether Ramaphosa has the stomach for this essential step toward fixing our public healthcare system only time will tell.
A second thing the President can do right away is to launch an emergency plan to ensure appropriate TB infection control measures are in place in all clinics and other public facilities. Over the next few months this could expand to a government wide emergency plan for TB involving all of cabinet and all provinces. We already have a National Strategic Plan for HIV, TB and STIs, but unfortunately that plan simply doesn’t cut it – and the scale and seriousness of the TB crisis is frankly too great for Ramaphosa to shirk the responsibility by delegating to Motsoaledi and the dysfunctional SA National AIDS Council.
And then there are the healthcare workers who must make it all happen. The depressing reality is that years of corruption, cadre deployment and mismanagement has ripped the heart and the ethos of public service out of much, but not all, of our healthcare system. Many committed and passionate healthcare workers have become demoralised. This is not something that will be changed by a UN declaration made in New York, or by a few words said in the National Assembly in Cape Town – It will require serious and sustained commitment and leadership from Ramaphosa and those around him.
The role of community health workers in the South African public healthcare system has been
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?
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.”
By Ufrieda Ho
The “bus stop” and the “slaughterhouse” – these are the nicknames locals give for the Nketoane Hospital in Reitz and the Dihlabeng Regional Hospital Bethlehem.
Both fall into the government’s National Health Insurance (NHI) pilot area of Thabo Mofutsanyane in the Free State, one of 10 pilot districts in the country. Pilot areas are meant to assess the readiness of facilities to rollout the NHI plans and also meant to uplift the needs of the most vulnerable communities in the country first.
Thabo Mofutsanyane is, according to Health Minister Aaron Motsoaladi’s assessments (which looks at socio-economic indicators, health service performance and financial and resource management), among the most needy in the country.
Locals in Reitz and the nearby location of Petsana say the problems began with the downgrade of Nketoane Hospital in 2002 from a 65-bed facility to a 45-bed facilities, to one that now accommodates just ten patients in a step-down facility.
It is, for locals, a travesty. They feel they have been robbed of their hospital.
Even though the hospital still runs a 24-hour maternity and casualty facility, it’s a shadow of its former self; a bus stop really, they say, where ambulances pick up patients to transport them nearly 50 kilometres away to the Dihalabeng Regional hospital in Bethlehem where they are supposed to be able to access a broader spectrum of health care services.
However, they don’t trust Dihlabeng Hospital. It’s a facility that will kill you before it heals you, they say. The slaughterhouse. Reitz locals, including those who live in the surrounding locations and townships, say they are often treated with disdain by nurses at Dihlabeng, with the common snipe of “Why don’t you just stay at your own hospital?”
A Petsana local, Victor Mlangeni, who also heads the United Residents’ Front, says that one of the major problems about being serviced by a hospital nearly 50km away is that people can’t visit their families easily. A taxi ride one-way costs R30.
“They should have left that hospital as it was. Before it had all the services that we needed. Now it has nothing,” says Mlangeni.
Mlangeni says they’re also always given the run-around by the provincial authorities, who keep promising that things will improve.
“In 2010 we were told that the Reitz Hospital would be back to normal within six months and we would have all the services back. But we waited and waited. In 2015 the government came again and said we would have to wait three more months.”
During his visit to the Petsana residents in 2015, Free State Premier Ace Magashule publicly gave his support to the residents over their concerns that there was shortage of doctors at Nketoane Hospital and that the vast distance between Nketoane and Dihlabeng, and even the Phekolong Hospital, were less than optimal. He promised to look into the matter personally. It’s half way into 2016: nothing’s changed and locals are still waiting for services to improve.
The Nketoane Hospital is essentially a storage facility now. There are currently two Cuban doctors at the hospital and eight professional nurses for the still-busy maternity section. It remains well-kept, clean and tidy, but it’s also strangely silent for what should be a busy medical hub.
Inside the hospital, empty beds are stacked on top of one other, filling up rooms. Whole wards stand empty and the operating theatres remain in darkness. A hospital insider, who spoke on condition of anonymity, says everything was operational and in running order in the theatres, even though some of the equipment was old. But gradually it has been stripped, with working equipment shipped off from the hospital.
“What’s working has been taken and so when there’s and emergency we have to send patients to Bethlehem. Even then, we can wait up to two hours for an ambulance to arrive,” he says.
The insider, who has worked at the hospital for years, says the morale among staff is low and he calls the NHI roll-out in Nketoane “a joke”. The hospital, he says, has to submit plans based on the old information that it is a 45-bed hospital. It’s skewed data but no one has bothered to make the necessary adjustments. This means that the planning for the day-to-day running of the hospital is based on inaccurate information.
“When you work it out like that (at 45 beds) the hospital will always look like it is under-performing. It’s bad for the hospital and it’s bad of the morale of staff. The nurses are also not getting all their overtime pay and we aren’t getting any more staff because positions have been frozen.
“We are supposed to be an NHI hospital but we are not compliant with anything. It really is a joke and the Premier, the MEC and the HODs should all be fired.
“This is also our community, we work here, we live here. All we want is to be able to serve this community properly and we can’t,” he says.
By Ufrieda Ho
The Free State’s health care system – in tatters in so many places – also has one recurring nightmare: Buthelezi Emergency Medical Services, to whom public emergency services have been outsourced.
Why did the province’s services needed to be outsourced or supplemented in the first place? Secondly, was Buthelezi the best company to land the tender, and, thirdly, why are the on-going complaints about the company’s service – since it got the contract at the beginning of 2014 – falling on deaf ears?
According to the Democratic Alliance’s questions put to MEC Benny Malakoane in August 2014, there were 106 ambulance and emergency services vehicles in the province, 54 were being serviced in workshops and 28 were about to be added to the fleet.
That year, Buthelezi EMS had been given the tender that comprises 47 ambulances for district and regional hospitals. Its staff was expected to have “basic life support and intermediate life support” training. This tender was also intended for emergency inter-facility transport, not for call-outs. According to a health department response to a DA question, billing is done according to the skill level of the paramedic attending to the patient.
The contract is ongoing and by November of 2014 – the first 11 months of the contract was worth R32 million to Buthelezi.
Mariette Pittaway, DA member of the Free State Provincial Legislature said: “We still cannot understand why we were not servicing our existing fleet properly instead of spending that amount of money on an outsourced service.”
Pittaway says she’s never without fresh complaints about the services rendered by Buthelezi EMS. This is what worries her most.
“We hear about ambulances arriving to pick up sick babies without incubators. We also hear that some clinics and hospitals are left without their blood-pressure machines and other equipment because they’ve had to hand them over to the ambulance staff. We’ve also heard how hospitals wait for up to two hours for an ambulance to arrive and, in one incident, the excuse for a delay in Gastron was that the ambulance had a flat tyre and the driver had to wait for a spare tyre to arrive. This kind of things is just not acceptable,” says Pittaway.
A matron who spoke to Spotlight had her own horror stories that mirror Pittaway’s slew. She said they routinely give surgical gloves and drip kits to the Buthelezi EMS paramedics who are simply not properly equipped to do the job.
“They ask us for these basic things and then we get a bill for anything between R3500 and R4800 per patient,” she says.
In a letter written by a doctor in the Xhariep area more complaints emerge. The letter details how a Buthelezi ambulance, supposedly with an advance life support paramedic in attendance, was ordered for a 1,2kg premature newborn at 4pm. The ambulance arrived at 7pm to transport the baby to Pelonomi Hospital in Bloemfontein.
“The paramedic was handed the baby for transfer, but they had the wrong oxygen cylinder. The ambulance had to drive back to Bloemfontein to fetch the correct oxygen pin index cylinder. Unfortunately the patient deteriorated and passed away at 12.30am. The ambulance arrived after the patient passed away,” the letter read.
It concluded: “We’ve had numerous problems with Buthelezi Ambulance Service in the past few months”.
In Bloemfontein this autumn, Spotlight visited the Buthelezi offices, situated in a house on the industrial outskirts of the city centre. Ambulances appeared to be serviced or repaired in the backyard. This is a clear compromise of safety standards for emergency medical services.
Outside Welkom, Spotlight saw Buthelezi ambulance vehicles and staff parked under trees. Tender stipulations require EMS private companies to have proper facilities where paramedics can take a shower, have a nap and recharge and refresh properly in-between assignments.
Pittaway says it’s clear that Buthelezi EMS is plagued with problems, yet they continue to be defended by the department of health and continue to cost Free State taxpayers millions of rands.
“We will continue to ask the questions because we don’t feel that we’ve been given good enough answers. We haven’t been able to pinpoint that the premier Ace Magashule and Health MEC Benny Malakoane have direct relationships with Buthelezi EMS, but we believe that how the tender was given out is problematic. We will keep up the pressure,” says Pittaway.
Spotlight’s questions to Buthelezi EMS remained unanswered by the time of going to print.
The National Health Assembly, held at the University of the Western Cape from 24 – 26 June brought together organisations and individuals from all provinces in South Africa and beyond.[i]
The NHA participants identified the following issues around health and health care provision in South Africa:
It was acknowledged that while identifying the problems within the health sector is important, identifying solutions and how to bring about the change we seek is vital. There is no more time for talking. Participants committed to specific local, provincial and national campaigns. The broad themes of the campaigns are:
The Assembly committed to the establishment of provincial coalitions on health with clear goals and plans.
We need the voices of health care users in the health system. Strong health committees put real people in the driving seat of health facilities to make decisions that improve access, and the use of resources.
The Assembly committed to engaging Treasury on taxation, financing for the health sector and the social determinants of health, and maximizing resources available for key reforms.
The Assembly resolved to campaign for more community health workers who are integrated into the health work force and health system in the interests of the health of the population; and for the filling of critical health posts throughout the system, from cleaning staff, to community health workers, to specialists.
The Assembly committed to developing a manifesto on health and requiring responses from all political parties contesting the August elections. The manifesto will include challenging public officials and other users of the private health care system to use the public health system. It will also require a commitment by ward councilors to improve health in their wards through strengthening health care facilities services to address the social and environmental determinants of health.
The Assembly resolved to monitor and report on health rights violations and health systems failures and in particular to “adopt” the NHI pilot districts to focus monitoring and health systems improvements in these districts. The International AIDS Conference, to be held from 18 July 2016 in Durban, is an important opportunity to get eyes on the health system in South Africa.
Children have an unqualified constitutional right to basic health care services and yet vaccines are frequently out of stock and children use the same failing public health care system as their parents. The Assembly resolved to campaign for health system reforms targeting children to realise their rights.
Our environment, diets, access to water and other social determinants of health continue to make us sick. The Assembly resolved to campaign to link health system improvement with improvements to the social determinants of health.
Finally, the Assembly noted that South African civil society cannot and should not act alone. Civil society is under attack in many parts of the world. In particular, the Assembly recognised the contribution of the Lawyers Collective in India, condemned the attacks on the organisation and resolved to express our support to Lawyers Collective to continue their work on promoting access to health care services.