Eastern Cape Health Crisis Action Coalition on findings and recommendations by National and Provincial Departments on Eastern Cape's Systems Intervention Plan

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Health

05 November 2013
Chairperson: Dr B Goqwana (ANC)
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Meeting Summary

The Chairperson said that the Eastern Cape Department of Health (ECDoH) had been invited to the meeting to respond to the presentation made by the Eastern Cape Health Crisis Action Coalition (Coalition) to the Committee - there were certain aspects of the report which the ECDoH disputed, but it had apologised for not being able to attend due to other commitments in the Eastern Cape. The Committee asked the Coalition to present a summary of its report, as Members were already familiar with its content. The National Department of Health (NDoH)’s proposed strategy in response to the Coalition’s memorandum had promised much, but the question was whether it could bring about change, in any province, while being located in Pretoria.

The Coalition said that it was very grateful to have received a response from the ECDoH, the NDoH and indeed, from the Committee in response to the Coalition’s request in its memorandum for a plan/turnaround strategy for the EC health system.

On 13th September 2013, the Coalition and 2000 supporters marched to the ECDoH in Bisho to submit a memorandum to the ECDoH, and requested a response before the 11 October 2013. The ECDoH responded to the Coalition on 17 October 2013 with a plan to address the situation. To date, the Coalition had not had a meeting with the MEC and thus sought intervention by the Committee. The Coalition requested the ECDoH to come up with a clear plan which addressed emergency issues and implemented immediate measures and that all stakeholders, the Minister, Premier, Provincial Treasury and relevant state officials should come on board.

Having looked at the plans received from the NDoH and the ECDoH, the Coalition had responded. The key problems with the ECDoH’s intervention was that there was a need for clarity on the status of the document, there was no budget, no warm bodies appointed to it, no time frames, no indicators, no opportunity for monitoring or evaluation and it did offer long term solutions. The plan also needed to consider the rights of people, such as ambulance and emergency health care. Of great concern was that there was no prioritising of service delivery, while there was a focus on political implications – ‘the improved reputation of the EC government’.

The NDoH intervention was more positive. It contained timeframes, a budget, and commitment and was partly evidence-based after an investigation into hospitals. There was focus on the OR Tambo district for obvious reasons but the ECDoH seemed to be neglecting the OR Tambo district due to the NHI project in the district. Lack of coherence between the two spheres of government was a huge impediment to achievement of the aims and to their obligation under Chapter 3 of the Constitution to realise the rights of the people.

Members asked if the new Head of Department (HoD) listened to the Coalition and had been given a chance to solve the problems; how the Coalition planned to communicate with the new HoD going forward. They also asked how demoralisation of healthcare workers was being remedied; why the presenter would resign at a time when there was a shortage of doctors and a health care crisis; and how to retain doctors and nurses despite unhygienic conditions, no drinking water, electricity, or telephones. A Member requested that the Chairperson should contact the Minister and Director-General to find out whether the equipment promised in the report had been procured and delivered.

The Committee would make certain recommendations to the NDoH and ECDoH as part of its oversight work and would liase with the leadership - the new EC HoD and possibly also the MEC and the NDoH - to communicate the issues. When the Committee was on oversight in the EC, it would call on the Coalition to ensure that the ECDoH was listening to the Coalition.
 

Meeting report

Opening Statement
The Chairperson said that having received the report from the ECHAC, the Committee had called the National Department of Health (NDoH) to respond to the challenges in the EC health system, which it did. The NDoH’s proposed strategy for the EC had promised much, but the question was whether it could bring about change, in any province, while being located in Pretoria. The ECDoH had been invited to the current meeting to respond to the Coalition’s presentation to the Committee, but had apologised for not being able to attend due to other commitments in the Eastern Cape.

Since 1994, healthcare had transformed, but it would take more than 20 years to overcome challenges. There were certain areas where there was no plan, no diagnosis of a problem, denial, inaccurate reports and confusion. The good thing about the National Development Plan (NDP) was that it had a timeframe within which implementation had to take place.

Ms P Kopane (ANC) said that it was unfortunate that the Coalition would be presenting about the ECDoH in its absence, as it was evident in the previous week’s meeting with the NDoH that the ECDoH had to come to Parliament to account for the problems.

The Chairperson urged the Committee to allow the Coalition to present a summary of its report, even though the Committee was already familiar with its content, as the Coalition expected a response from the Committee. There were certain aspects of the report that the ECDoH was disputing, but unfortunately they could not attend the meeting.

Eastern Cape Health Crisis Action Coalition Presentation
Mr Anele Yawa, National Chairperson: Treatment Action Campaign, listed the Members of the Coalition and its origin. After a drug stock-out at Mthatha depot in December 2012, the TAC, Section 27, Medecins Sans Frontieres, Rural Advocacy, and others, intervened. The Superintendent-General at the time, Dr Siva Pillay, came on board and together they deployed volunteers to assist at the depot from December 2012 until the end of February 2013. Subsequently, after the Office of the MEC did not responded to the TAC’s request to intervene on the lack of health services in Lusikisiki in the OR Tambo district, the TAC took the ECDoH to court. The Minister intervened to settle the matter out of court and an agreement was reached between the TAC and the EC MEC. Funds were taken from the NHI pilot budget for the OR Tambo District and designated to a new hospital in Lusikisiki.

The legacy of Apartheid had left the EC in a bad state. It was the only province that had been governed by three different administrations - the Transkei, Ciskei and the Republic. The TAC and other organisations realised that health services of all the provinces should be monitored and between April and June 2013, several public hearing meetings were held. The organisations then formed the Coalition.

On 13 September 2013, the Coalition and supporters marched to the ECDoH in Bisho to submit a memorandum to the ECDoH, and requested a response before 11 October. Unfortunately, it was accepted by the Superintendent-General, Dr TD Mbengashe, on behalf of the ECDoH, and not by the MEC. The ECDoH responded to the Coalition on 17 October 2013 with a plan to address the EC situation. Their response had no time frames or specifics. It was basically a shopping list.

To date, the Coalition had not had a meeting with the MEC of the Eastern Cape and thus sought intervention by the Committee. The Coalition requested the ECDoH to come up with a clear plan which addressed emergency issues and implemented immediate measures and that all stakeholders, the Minister, Premier, Provincial Treasury and relevant state officials should come on board.

The Coalition’s response to the ECDoH’s plan can be found in the attached document: Eastern Cape Health Crisis Action Coalition: response to the Eastern Cape Department of Health "Eastern Cape Health Systems Intervention" 5 November 2013.

Some health care workers who had spoken out against the bad conditions were being intimidated. The challenge was that currently gates were closed to the TAC at all health facilities. It had to get permission from the ECDoH to gain access to monitor, support and educate at facilities.

Dr Nombasa Mayeko, Eastern Cape Spokesperson for Rural Doctors Association of South Africa (RUDASA), thanked the Committee on behalf of doctors and other healthcare workers for allowing the presentation by the Coalition.

The NDoH policies, such as NHI and Primary Healthcare, required sufficient, competent, equipped, caring and valued human resources for health (HRH). Vacancy rates and frozen posts were well known and resignations in the EC were frequent. It was clear that one of the problems was that reasons for resignations were not considered at all. Staff needed more than punctual payment to be retained. Key HRH issues affecting health care delivery in the EC were lack of infrastructure and management capacity at all levels of the health care system; poor implementation of HRH policies; and ‘acting’ positions leading to the inability to make decisions.
In the rural areas, network capacity and essential computer equipment was urgently required to avoid delays. The poor reputation of ECDoH in terms of payment of salaries and poor management deterred doctors from rural health care. The RUDASA found that at a HR department, the network would be offline for two weeks at a time, which resulted in amongst other problems, salaries not being paid. Despite some improvements in the Human Resources processes, the issues still prevailed. There were still bottlenecks in the administrative processes - multiple signatories were required before approval of a vacant post - and lack of funding for vacant posts added to the HR problem.
A survey on retention of staff, conducted by the Coalition, found that there was a problem with the work culture in the Eastern Cape, lack of learning and development opportunities and leadership and non-financial recognition which led to de-motivation of staff in many rural institutions, improper communication procedures, poor interaction with management and a lack of communication between staff and managers.
Ms Sasha Stevenson, Attorney: Section 27, said that the Coalition was very grateful to have received a response from the ECDoH, the NDoH and indeed, from the Committee in response to the Coalition’s request in its memorandum for a plan – a turnaround strategy - for the EC health system.

Having looked at the plans received from the NDoH and the ECDoH, the Coalition had responded. It was important that the plan was formulated to ensure that its aims were achieved and that it met the constitutional requirements of a plan. The constitution required that a plan to fix the health care system in the province and to fulfil constitutional rights must be reasonable, bearing in mind the ten criteria laid out in the courts as to what constitutes a reasonable plan (page 12 in the attached presentation). The key problem was that there was no coordination between spheres of government and it was a plan without a budget and warm bodies appointed to it. Therefore it would not achieve its aims. The plan should address urgent as well as long-term problems. The plan also needed to consider the rights of people to ambulance and emergency health care.

The plan gave no timeframes, aims were impossible to realise; there were no indicators, and no opportunity for monitoring or evaluation at all - from the government to civil society.

There was also a need for clarity on the status of the document, as it was not clear if the NDOH and ECDoH had consulted, and if there had been any civil society engagement. Of great concern was that there was no prioritising of service delivery, while there was a focus on political implications – ‘the improved reputation of the EC government’. Delivery of services to the people did not appear to be a priority.

The NDoH intervention was more positive. It contained timeframes, a budget and commitment and was partly evidence-based after an investigation into hospitals. There was focus on the OR Tambo district for obvious reasons (NHI) but the ECDoH seemed to be neglecting the OR Tambo district due to the NHI project in the district. There was a need for cooperation between the NDoH and ECDoH. Lack of coherence between the two spheres was a huge impediment to achievement of the aims of health care and to their obligation under Chapter 3 of the Constitution to realise the rights of the people.

The Chairperson said that all the communities depended on people to help them fight for health services. The Committee was elected to do oversight and to receive information from communities, media and coalitions. An article in the Cape Argus about two weeks earlier reported that many doctors, particularly anaesthetists, were becoming drug addicts as they were being overworked and stressed by the conditions and inadequate equipment to help the increasing number of patients. The problem with their not being able to work passionately was unrelated to their salaries.

Discussion
Ms M Segale-Diswai (ANC) said that the NDoH and the new Head of Department (HOD) met with the Committee on 30 October 2013 and the NDoH’s turnaround plan was presented. It would have been helpful if the Coalition could have visited the Committee before the 30th, and could now present a progress report.

Ms Stevenson reminded the Member that the Coalition’s response to the plan was included in the documents handed to Members.

Ms Segale-Diswai continued, saying that the Committee visited the EC many times and was aware of all the problems presented. The issues were in the investigation report and the Committee’s oversight reports. The impression was that the ECDoH did not give the Coalition a hearing. She asked if the new HOD listened to the Coalition and had been given a chance to solve the problems, if the Minister had been given sufficient time to work on a plan, and how the Coalition planned to communicate with the new HOD going forward.

Ms Kopane was also concerned about communication between civil society, the ECDoH and the NDoH. She acknowledged the civil society for their responsibility in democracy, which kept government on its toes. She felt that the way in which the ECDoH had responded to the Coalition was not fair. It showed lack of leadership; no commitment and no solutions were given. The Coalition had explained thoroughly how the ECDoH should have responded and it was clear that civil society, ECDoH, the NDoH and the communities needed to sit down and communicate. Dr Mbengashe needed the support of the ECDoH.

Ms Stevenson replied that Section 27, the Democratic Nursing Association of South Africa (DENOSA), Rural Doctors Association of South Africa (RUDASA), Rural Rehab South Africa (RuReSA), South African Medical Association (SAMA), TAC, People’s Health Movement campaign and more specific organisations such as the Keiskamma Trust based in Keiskamma Hoek, had all been working in the EC for a long time and had drawn issues to the attention of authorities, such as the Mthatha depot and Lusikisiki clinic. This was not a public campaign without attempts on the ground to solve the problems. Over the years there had been an accumulation of problems and the individual groups had become aware of the slow but sure collapse of the system. It became known as a crisis and for that reason the individual groups had come together.

She explained that the Coalition attempted to work together with both the NDoH and ECDoH in a constructive manner. In the past, the Coalition members had worked well with the former ECHoD and Minister. In the run up to publication of the Coalition’s report, it had tried hard to get an appointment with the new ECHoD and MEC. Before the report was published, it was made available to the MEC and Minister so that they could consider it before it was published. The Minister chose to meet with the Committee and the MEC chose not to do so. Over the past few months, meetings with the MEC had been confirmed and postponed repeatedly. The Coalition looked forward to the meeting with the MEC on the 22 November 2013.

The Coalition did not doubt the integrity of the Minister and trusted that he would come through with the commitments in the plan. However, in the light of the constitutional requirements, the plans had to be assessed and there was a need for constant monitoring and evaluation. The hold-ups arose as a result of lack of monitoring, evaluation of implementation. For example, delivery of equipment to the Holy Cross Hospital had taken place but equipment to the other 16 hospitals had not yet taken place. Wheelchairs had not been delivered to the OR Tambo District.

While focus by the Minister on OR Tambo district was important, there were significant problems in the rest of the province. The problems in OR Tambo were acute, but there needed to be commitment and broader focus, both nationally and provincially.

Ms Sigale-Diswai said that naming and shaming was important. When it came to leadership problems, the Committee needed to know who did what, where, and when, and could then report it to the Minister. Generalisations were not immediately helpful to the Committee.

Mr D Kganare (COPE) said that it was a progressive move that the Coalition did not proceed with court action and had let the Minister intervene. He wished to place on record that during Apartheid, there were no stock-outs, and the hospitals and clinics were clean and that the current situation was not inherited by apartheid. It was the current government, which changed the culture of clean hospitals, stock-outs and lack of service at hospitals. Superintendents of hospitals used to manage hospitals and even when there were not enough doctors, people received service. Acknowledgement of what was wrong was the first step to finding solutions.

Mr Kganare also commented that the MEC should long have been fired and possibly the premier should also have been fired for not firing the MEC. The ECDoH had no leadership because the premier was not doing her work. However, the EC HOD, Dr Mbengashe had met with the Committee, together with the Minister and they should be given the opportunity to address the problems. He suggested that the Chairperson should contact the Minister and DG to find out whether the equipment promised in the report had been procured and delivered. Mr Kganare asked the Chairperson if he could report back to the Committee on this issue.
The instance where Dr Shiva Pillay was fired when the Minister intervened was only one example of whistle-blowers being under attack. This issue should also be highlighted in a letter to the DG. Victims in the EC should be able to speak and be protected as in the NHLS whistle-blower case.

Ms Stevenson said that the Coalition certainly encouraged whistle-blowers to come forward, and an unprecedented number of dedicated health care workers and providers had come forward - and had also been targeted - as a result of the Coalition and since publication of the memorandum. It was certainly not a simple process. Traditionally, these workers were told that if they spoke out, they would be fired, they would not be promoted, they were threatened and their families were threatened. The Coalition understood when they were unable to do so.

Ms M Dube (ANC) commended the Coalition for checking on the people and ensuring that they received proper health care. In the same vein, information had been conflicting. Since 2009, the EC had been a priority to the Committee, which acknowledged and accepted that there were problems. However, Rome was not built in one day and South Africa came from an era where some of the things needed then were different to what was needed now and the population was increasing – immigrants were using South Africa’s facilities. The Minister was hands-on and was trying his best to help the EC. The Committee had complained that the money from Treasury for Health in all provinces was not sufficient.

Ms B Ngcobo (ANC) said that the National Health Insurance (NHI) pilot should mirror the whole province. The NHI Act gave instructions on how things had to be done in the hospitals. The Coalition had to continue to report to the ECDoH on how to move forward. The NDoH, with the Minister and DG, seemed to be committed to assisting the EC.

Ms T Kenye (ANC) agreed that the report should have been received before the Committee met with the NDoH. The Committee was aware of the focus of the NHI in OR Tambo, but also needed reports on delivery of Public Health Care in other deep rural areas that did not even have clinics. She asked why Dr Mayeko resigned at a time when there was a shortage of doctors and a health care crisis.

Dr Mayeko replied that her resignation was based on lack of support. Strategies for retention of doctors were lacking. There were locum jobs available and opportunities overseas. Doctors wanted to serve people, but if the environment did not allow them to do that, and caused them to have sleepless nights because of it, they would leave that place of work.

Ms D Robinson (DA) thanked the Coalition for making their information available to the public. She had visited Madwaleni Hospital the previous year and was horrified by the lack of care by the hospital staff. She asked if there were any plans to address the demoralisation of healthcare workers by the system, which she believed stemmed from lack of management and leadership. She also asked how to give doctors and nurses reason to ‘hang-in’, despite unhygienic conditions, no drinking water, electricity, or telephones.

Ms Stevenson replied that there was a need to address leadership both at hospital and provincial level, but lack of leadership alone had not caused the system to collapse. It would be a long path to recovery and long-term solutions were required. The DENOSA union had a Positive Practice Environment Campaign to ensure that healthcare workers did not suffer from demoralisation. It was not just about money and paying health care workers, but also about the conditions in which they worked. Anyone who worked in a hospital without clean water, electricity, etc and on top of that was not being paid, it would be extremely difficult to continue to work there. The campaign targeted the seven pillars, which made a difference to the healthcare workers’ environment and also to the environment in which people received quality health care. It ensured retention of staff too. A promise to pay employees was not enough.

Mr Yawa added that patients continued to be turned away from the OR Tambo pilot site because of lack of available medications, and people were dying at village hospitals because they were not given basic treatment. People did not know their rights. They thought it was legal to be sent away by a healthcare worker because the hospital had no medication. Something had to be done. Yesterday he had received a call from five Bolivian doctors who volunteered their services in the EC but were scared to go to work as they were being chased away because they were told that they were too old. South Africa was the only country with a beautiful Constitution. It had Section 19 of the EC Health Act. People were asked to write affidavits to the Office of the MEC but the MEC did not respond. This is why the Coalition was asking the Committee to intervene.

Ms Noloyiso Ntamehlo, EC Provincial Coordinator, TAC, reiterated the problems of the Mthatha depot, lack of drug stock-out plans, lack of transport and distance to facilities, lack of cleaners at the facilities and lack of services. Communication had to be improved not only between civil society and the ECDoH, but also at district and local level with the clinic committees and hospital boards. Issues affecting the communities could not be solved without engaging the communities.

Ms Robinson commented that judging from the EC intervention she was concerned that the intervention had become a political issue. Health care was a human right and a people issue. The sooner that was corrected the better.

The Chairperson thanked the Coalition for its presentation. Having received its report, the Committee would make certain recommendations to the NDoH and ECDoH as part of its oversight work. If civil society did not bring the issues, the Committee may not know them. Since 1994, the EC had built more clinics and hospitals than most other province, but challenges remained. The Coalition’s complaint that ‘it was not heard’ was an important complaint. The Committee would liase with the leadership - the new EC HOD and possibly also the MEC and the NDoH - to communicate the issues, why their plan would not meet their aims, and what the solutions were. When the Committee was on oversight in the EC, it would call on the Coalition to ensure that the ECDoH was listening to the Coalition. The Committee would always listen to the Coalition. The Committee was hopeful that the future of South Africa’s health care would improve – it could not get worse.

The meeting was adjourned.
 

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