From rural doctor to MP?
Dr Karl le Roux, former chair of the Rural Doctors’ Association of South Africa, says the time has come for him to take his knowledge and experience to the national political arena. He is now hoping for a seat in parliament on the DA’S ticket. Sue Segar c
During the course of 16 exhausting but rewarding years working in a remote rural hospital in the Eastern Cape, Dr Karl le Roux says he came to realise just how dysfunctional the province’s department of health is – and the extent to which a lack of accountability can really harm the poorest of the poor.
Le Roux left Zithulele Hospital 18 months ago and has now turned his hand to politics.
After the 29 May elections, he is hopeful he can start making a difference serving on parliament’s portfolio committee for health.
The odds that he will become a member of parliament are good, given that he is second on the DA’S Western Cape regionto-national list.
“I’ll be brand new in Parliament in June and have plenty to learn,” he says.
Speaking to Spotlight at his home in Rondebosch, Le Roux says: “In Parliament I hope to insist on two things: Firstly, when we bring in new [health] policies or laws, to carefully consider ‘does this make things better for healthcare workers and patients on the ground’ or are we just burying people in more paper and admin?
“Secondly, to consult more carefully with healthcare workers who are actually delivering care on the ground about health policies and the impact they have.”
While he believes in universal healthcare, he said he does not believe the government’s mooted National Health Insurance (NHI) plan is the solution.
“In South Africa,” he says, “there are four things we should do well in health: HIV and TB and the infectious diseases; we need to make inroads into violence prevention, particularly around alcohol; the epidemic of maternal child morbidity and mortality, and the emerging aspect of non-communicable diseases.”
He says the country has an excellent HIV treatment programme which has made a major impact, but we need to ramp up our TB response.
“It needs a more comprehensive approach, which includes prevention.”
From Zithulele to the DA
Le Roux says he decided on the DA because of its record of tackling corruption.
“A lack of accountability is the slow poison that destroys government and public services,” he says. “We saw that playing out clearly at Zithulele.”
And indeed, what happened at Zithulele Hospital near Mqanduli in the Eastern Cape sits smack bang in the centre of Le Roux’s story.
Le Roux and his doctor wife Sally joined their friends, Ben Gaunt, who was clinical manager, and his doctor wife, Taryn, at Zithulele Hospital about 80 kilometres south of Mthatha, in 2006.
Together they attracted a team of committed healthcare workers and built it from a struggling facility into one of South Africa’s best rural hospitals.
“When we started at Zithulele, we were young and idealistic. We wanted to build a rural hospital of excellence and to serve as a model for other areas.
“But the idea of excellence can be a double-edged sword and can come at the cost of relationships,” he says.
“If you focus too much on outcomes rather than processes, you can end up losing the nurses and healthcare workers you’re working with.
“We realised we should rather be realistic in our work context.”
Zithulele, as depicted in
Gaunt’s memoir, Hope, A Goat and A Hospital, was the kind of place where doctors would encounter, for example, a 16-yearold girl, with no income, looking after eight orphans in her family, including an 11-year-old on antiretrovirals, where a woman who – unable to afford public transport – would walk a 40 kilometre round trip to the hospital once a month to fetch medication, without ever complaining, and where doctors would treat an Hiv-positive woman who presented after a traditional healer had bitten a breast mass from her body.
“We learnt how to make things work, under challenging circumstances, practically and philosophically,” Le Roux tells Spotlight.
According to him, the team had built up a “real sense of synergy … focusing on patients, rather than ticking every box and every policy that was foisted on us from above”.
Gaunt, together with the clinical team, had developed a system aimed at ensuring that all patients who’d made the effort (often considerable in rural areas) to get to the hospital were treated, and not turned away.
While acknowledging the rationale for a good referral system between clinics and hospitals, the argument was that this can only work if the primary healthcare system is functional.
Gaunt and his team had taken what they saw as the practical approach of putting patients first and not adhering strictly to the administrative dictates of the health department.
As Estelle Ellis wrote in Daily Maverick as part of a series of articles on Zithulele, things changed when new hospital CEO Nolubabalo Fatyela arrived in September 2021 “wielding the Eastern Cape Department of Health rulebook”.
Ellis added: “Her management style and decisions caused a considerable amount of conflict as she made it clear that she intended to run the hospital according to the letter of the law.”
Conflict over ARV programme
Conflict arose between the CEO and Gaunt over a range of issues, including a decision to start decentralising the care of complex patients living with HIV to primary care clinics.
While the Zithulele team saw the rationale for moving some patients who were stable on antiretroviral therapy to the clinics, they felt there was a need at the hospital for a specialist clinic for high-risk, complicated patients.
“It was particularly for children who are very difficult to manage and patients who were defaulting and on second or third line regimens.
“It was a very well-run clinic, and we had records of patients, who had been with us for 10 or 15 years,” Le Roux explains.
The Zithulele doctors, he says, agreed to down-refer the uncomplicated patients, but said they would keep the complicated patients with their clinic.
The doctors asked for a meeting to discuss the changes, but according to Le Roux, the conflict took a turn for the worse when an outside NGO was called in to start down-referring patients to the clinics behind the back of the hospital doctors.
“They were sending the files we’d put together over many years to the clinics and phoning people and saying, ‘from next month you are going to the clinic’.
“Most of these folders have been lost. And the patients were saying, ‘I can’t as I can’t get those ARVS at the clinic’, says Le Roux.
“If patients have second- or third-line treatment, they are only available through the hospital pharmacy.
“The clinics only have the stock standard.
“It wouldn’t be in the ambit of a clinic nurse to order complex versions of ARVS, and they wouldn’t know what to order or how to manage such complex cases.”
An investigation
At the height of the conflict, Le Roux asked for a meeting with the district manager and a few of the senior members of the hospital.
He submitted a report to the department.
According to Le Roux, the authorities promised to hold an investigation and, two months later, at a report-back meeting which included the MEC of health, he says it turned out there was an investigation not into the CEO, but into Gaunt.
“My understanding the whole way through was that the primary aim of the investigation would be to investigate the CEO and the breakdown in the relationship between the CEO and the clinical team.
“I did find it strange that the investigator never contacted me,” he says.
“On the day of the reportback meeting, I remember feeling very hopeful … so I went into the meeting, on 28 or 29 July, thinking that maybe things would change and they would take her on or at least rap her over the knuckles for her behaviour … and it was basically a completely one-sided attack on Ben.
“It was an awful meeting. I stood up and expressed my astonishment, saying I had understood there would be an investigation into the CEO and it seemed like a new investigation had been launched into Ben without even informing him about it.”
Le Roux says the Eastern Cape department of Health appears not to have the capacity or appetite to manage complicated disputes or misconduct within hospitals or in the health system as a whole.
He says there is a tendency to be reactive, lurching from crisis to crisis rather than proactively planning ahead and implementing policies that will help the poor and the sick.
The escalating dispute eventually led to Gaunt’s departure in mid-2022.
He moved to Port Alfred and took up a position as clinical medico-legal adviser to the Eastern Cape health department. Fatyela also left the hospital, but returned in mid2023.
Mkhululi Ndamase, spokesperson for the Eastern Cape MEC for Health, confirmed that Gaunt had requested to be transferred to the department’s medico-legal section at the head office and that this was approved.
“We can confirm that the CEO was never transferred or suspended but she was temporarily moved because of safety reasons,” says Ndamase.
“Fatyela has been discharging her duties as the duly appointed Zithulele Hospital CEO offsite because of safety reasons”.
Fatyela declined to engage with questions from Spotlight and referred Spotlight to the Eastern Cape health department.
Standing by the CEO
For their part, the department is standing by Fatyela.
Asked to comment on claims by doctors previously working at Zithulele that the focus on strictly keeping to the rules resulted in poorer quality of care for some patients, Ndamase said: “The CEO’S leadership management is within the department prescripts to align the hospital with relevant clinical governance and good institution governance, as a result the institution has been awarded the compliance certificate by OHSC [Office of Health Standards Compliance].”
Asked whether the department concedes that patients with complicated HIV could not be properly treated at clinics and whether there was thus a case for keeping the unit at the hospital specifically for complicated patients, Ndamase responded: “Clinical guidelines are very clear who should be treated at PHC [primary healthcare] and in hospital which is the case at Zithulele Hospital.
“Patients treated in hospital should be integrated to other chronic diseases to prevent patient discrimination.
“Moreover, the hospital doctors are conducting outreach programmes to clinics.
“Where hospital doctors cannot reach, the sub-district has placed doctors.
“Therefore, patients that are eligible to be seen by a doctor at clinics are seen by a doctor.”
It is also worth noting, says Ndamase, that in the Eastern Cape Department of Health, the programme is implemented at primary healthcare level and as such, services are brought to the level of households.
“If there are complications, those patients are referred to hospital or doctors review them at clinic level during their outreaches to clinics.
“The caring government of the day is trying by all means to bring quality services closer to communities without affecting the patient financial status.
“This is why we also have mobile clinics that visit areas without fixed primary healthcare facilities.
“Just in March, the MEC handed over 75 mobile clinics and dental vans to districts as part of strengthening primary healthcare services.”
Propaganda for rural medicine
Meanwhile, the Le Rouxs, who had already been considering returning to Cape Town, mainly related to the education of their three children, left Zithulele six months after Gaunt.
Since returning to Cape Town, Le Roux has been teaching medical students at the University of Cape Town (UCT) where he graduated as a doctor in 1999.
He lectures in the department of Obstetrics and Gynaecology, and together with Gaunt is an honorary lecturer in the university’s primary healthcare department, running a rural medicine seminar for medical students.
“I say to them quite openly that I’m there to do a bit of propaganda for rural medicine … that doing rural medicine, even for a year or two will give [them] perspective, make [them] a much better doctor and will help [them] understand South Africa better”.
As chairperson of the Rural Doctors’ Association of Southern Africa (RUDASA) from 2008 to 2012, Le Roux has directly encountered many of the chronic issues plaguing rural health.
“It’s understaffing, historical underfunding, poor procurement systems, shortages of medication, fragile health teams, a large burden of disease, poor referral systems, a dysfunctional ambulance service and dysfunctional secondary and tertiary referral hospitals,” he says.
“But they have been exacerbated by the current budget cuts, chronic underperformance at management level, lack of planning and an almost criminal lack of capacity in nearly every single provincial department of health, apart from the Western Cape.”
There have been some achievements too, Le Roux says.
“There are still a few clinical teams doing excellent work in rural areas, like at Madwaleni and Isimilela hospitals, but mostly because they are quietly getting things done at their rural outposts without interference by the department.”
Le Roux’s Swedish-born mother, Dr Ingrid le Roux, is well known in public health circles for her work at Philani Maternal, Child Health and Nutrition Trust in Khayelitsha.
He says his mother’s years at Philani, and her work with the Swedish Mission influenced him deeply as a boy.
“I went with her to a Swedish mission conference in Zimbabwe and we visited some old rural missionary hospitals run by the Lutheran Church in southern Zimbabwe. I watched how those generalist doctors did everything.
“That’s where the rural medicine bug bit me!”