Gauteng’s healthcare afflicted by chronic ills
• Province’s hospitals have been hobbled by constant changes in political and administrative leadership
Amalia Slabbert is 67, blind, diabetic, and has been waiting nearly five months for Steve Biko Academic Hospital to fix her heart.
All she needs is a stent to open up a narrowed artery. But her doctor can’t perform an angiogram to pinpoint where the blockage lies, because the company that supplies the dye used to trace her blood vessels hasn’t been paid.
“She can do nothing. She can’t stand for even 15 minutes without severe pain,” says her husband, Pieter, who is also blind and faces an increasingly heavy burden as her carer.
The irony of Slabbert’s tragedy is that Steve Biko Academic Hospital was rated as one of the best in SA by the Office of Health Standards Compliance and was described last week by President Jacob Zuma as “the pride of the nation”.
The unfolding scandal of the Life Esidimeni tragedy, in which at least 118 state mental patients died after they were transferred to unlicensed NGOs, cast the spotlight on the quality of healthcare in Gauteng.
Little data on the health outcomes achieved by Gauteng’s hospitals are publicly available, aside from their collective institutional maternal mortality rate (iMMR), an established gauge of the strength of a health system.
Gauteng fares badly on this score, with an iMMR of 150 per 100,000 live births in 2014 — more than double the Western Cape’s 66.5 per 100,000. The iMMR in Italy was four per 100,000 live births in 2015.
The large number of medical negligence claims against the Gauteng health department also signals serious problems.
There were 396 cases in 2014-15, 330 in 2015-16 and 521 in 2016-17, which led to payouts of more than R1.1bn over the three-year period. No disciplinary action was taken against any of the staff involved.
Questions posed in the Gauteng legislature by the DA’s Jack Bloom exposed a host of further worrying signs: the backlog of patients for operations at Chris Hani-Baragwanath Hospital — which has had an acting CEO since last January — has more than doubled since 2015, rising from 4,846 in 2015 to 11,736 in September 2017.
And one in eight autopsy reports compiled by the Gauteng health department is outstanding; the department no longer keeps records of hospitalacquired infections, which means it cannot track how facilities perform over time.
“Our hospitals are all under added stress because of a massive increase in patient numbers due to natural population increase, migration from many other provinces, and many foreigners — up to 30% in some hospitals,” says Bloom. “I think there is deep rot in this department, with people in key positions who are grossly inadequate. There are a number of vacancies, and no permanent [head], because Barney Selebano has still not been disciplined over Esidimeni.”
Selebano was suspended following the health ombudsman’s report into the Life Esidimeni outrage.
The Gauteng health department had R7bn in accruals at the end of March — almost a fifth of its R39.9bn budget for 2017-18; it hasn’t resolved a long-running billing dispute with the National Health Laboratory Service that entails at least R1.6bn; and its compensation budget is crowding out spending on other programmes as it soared from 52% of total expenditure in 2008-09, to 62.2% in 2016-17.
Many public servants, also in the health sector, have enjoyed an automatic rise up the ranks over the past decade, commanding better salaries without necessarily improving their performance, the Treasury noted in the medium-term budget policy statement in October. A tradeoff has been made between headcount and salaries.
This is clearly evident in the Gauteng health department where the budget allocation for provincial hospital staff costs rocketed 19% between 2015-16 and 2018-19, from R4.76bn to R5.68bn — yet the number of personnel increased by only 0.6% over the same period, from 19,735 to 19,861.
Worse still, the proportion of the provincial hospital budget allocation spent on personnel increased from 71.4% to 72.7% over the same period.
There appears to be little financial discipline within the Gauteng health department, as its accruals have been steadily accumulating for years, leaving suppliers and patients in the lurch as it drags out payments. Gauteng already had accruals of R700m in 2008-09, according to a report commissioned by then national health minister Barbara Hogan.
“If money is tight, you have to have systems to stay in budget. You can’t spend what you don’t have,” says retired former Western Cape head of health Craig Househam, who introduced tight financial controls when he took the helm in 2001.
“It made me unpopular at times, but people eventually realised it gave the department stability,” he said.
Househam co-chaired a task team recently established by Health Minister Aaron Motsoaledi to assess the state of public hospitals. The team visited 25 hospitals in six provinces and realised they had seen enough to draw conclusions about the state of the whole system, including Gauteng (which they had not assessed because the Esidimeni crisis was unfolding at the time).
“Across the country, the main problem is management and administration: what makes a big organisation run is not what the politician pronounces from the top but what capacity is there to run a complex service,” says Househam.
The Gauteng health department has been hobbled by the constantly changing face of its political leadership and senior administrators.
It has had three health MECs and three heads of department in the past five years.
MEC Gwen Ramokgopa replaced Qedani Mahlangu after she resigned in the wake of the Esidimeni scandal in February; Mahlangu was appointed in mid-2014, and took over from Hope Papo, who had been in the job for barely two years.
Steve Biko Academic Hospital CEO Ernest Kenoshi is acting head of department as a result of Selebano’s suspension; he stepped into the spot vacated by Hugh Gosnell in 2015, who left without official explanation. Gosnell’s predecessor Nomonde Xundu resigned in 2012.
This phenomenon is seen across the country, except in the Western Cape, which has enjoyed a stable health administration regardless of which political parties held power at provincial level.
The ministerial task team found that poor human resources management led to people being appointed to jobs for which they lack the skills, and deep-seated logistical and supply chain problems that leave frontline healthcare staff unable to provide the care that they have been trained to deliver.
“It’s like sending an army into battle and they run out of ammunition,” says Househam.
There are similarities across all the provinces, says Treatment Action Campaign general secretary Anele Yawa.
“Most facilities don’t have enough equipment, there is a shortage of medicines, the infrastructure is falling apart, and there are massive human resources problems,” he says.
Managerial stability is clearly crucial, but it won’t be enough to fix the budget crisis facing provincial health departments such as Gauteng. Househam argues they should get a one-off bail-out to stabilise their budgets, but only if they can show they have the capacity to contain their future spending.
Neither Kenoshi nor Ramokgopa had responded to requests for comment at the time of publication.