South Africa: Analysis
For years, the Eastern Cape Department of Health has made the headlines, often for the wrong reasons. From rat-infested hospitals and newborn babies dying in overcrowded and understaffed wards to scooter ambulances that later proved to be unsafe and procured irregularly to a more recent public outcry over the lack of surgical consumables at Livingstone Hospital. Such challenges seem to have been on rinse and repeat for decades.
As far back as 2004, the Rhodes University-based Public Service Accountability Monitor (PSAM) in a research report outlined the various elements underpinning the health crisis in the province. In the report, the then-MEC for Finance in the Eastern Cape, Enoch Godongwana – now South Africa’s finance minister – is quoted as having said in October 2000, that problems being experienced in the provincial health department had very little to do with money, but “everything to do with bad management”. To this, the then-head of the provincial health department, Dr Siphiwo Stamper, retorted that he, and other managers, had “performed as well as possible under the circumstances”, and blamed under-funding as the real problem.
A ‘bad case of déjà vu’
Twenty years later, the province is still plagued by much the same issues and the extent to which budget shortfalls and mismanagement are to blame for the province’s health woes remains debated.
In the intervening two decades, a long list of MECs and heads of department (HoDs) have come and gone. Some of these leaders, maybe most notably Dr Siva Pillay, sparked hopes for a turnaround in the public healthcare system in the province, but despite some successes here and there, the picture generally remains grim. The province seems to provide ample evidence that while strong leadership is needed at the level of MECs and HoDs, it is not in itself sufficient to bring about the badly needed improvement in health services.
The latest person to have taken on the role of HoD of the Eastern Cape health department (also called superintendent-general) is Dr Rolene Wagner.
When she was appointed in August 2021, expectations in some quarters were high. Eastern Cape Health MEC Nomakhosazana Meth said in a statement at the time that given Wagner’s wealth of experience in both the private and public sectors, she is just what the department needs.
Wagner’s background is interesting. While she previously worked as Deputy Director General of Hospitals and Clinical Support Management Services in the Eastern Cape Department of Health, she also has significant private sector experience having worked as Medical Director of Netcare’s Primary Care Division. To our knowledge, it is rare for experienced private-sector health managers to be appointed to such senior public-sector positions.
Twenty-one months later, has Meth’s optimism about Wagner been vindicated?
In attempting to answer this question, Spotlight interviewed a wide variety of people in the Eastern Cape, although Wagner herself, unfortunately, declined several interview requests. To get a sense of current issues in the province’s public healthcare system we also interrogated an oversight report following a visit by MPs to some health facilities at the end of last year. Of course, several years of our own reporting, and especially that of Daily Maverick, on health in the Eastern Cape has also shaped our analysis.
One challenge in assessing an HoD’s performance is that it is hard to untangle the HoD’s performance from that of the department as a whole. From the outside, it is also hard to have a full picture of the political and organisational context in which an HoD has to work.
However, as a committee, we are not at all satisfied with the department’s performance, and even the department is not satisfied with its performance. – Nozibele Nyalambisa, EC Legislature
When approached for his views, the chairperson of the standing committee on health in the Eastern Cape Legislature, Nozibele Nyalambisa said, “As chairperson, the performance of the Head of Department does not fall upon us. The Premier, the MEC, and the Director General are responsible for evaluating the HOD’s performance. Our responsibility is to oversee the department and ensure that it performs its duties. So, we are more about the department’s performance than just the performance of the HOD as the individual,” he said.
“However, as a committee, we are not at all satisfied with the department’s performance, and even the department is not satisfied with its performance. One of the biggest challenges for the department is the budget cut of about R1 billion. As a result, the department cannot fill vacant positions. There is also the problem of medico-legal demands that exceed the department’s budget,” said Nyalambisa.
Others are more critical and go as far as arguing for the department to be put under administration. Nkosinathi Ndlodaka, United Democratic Movement member of the provincial legislature, said there seems to have been little improvement in health services since Wagner took over.
“In spite of having budgeted posts, hospitals are still understaffed and not adequately equipped. In our view, we cannot say a person who has been there for about two years is working but the situation remains the same, if not worse,” said Ndlodaka. “The HOD is promising changes along with MEC Nomakhosazana Meth, but nothing appears to be changing. Because of its failure to serve the people of this province, the department was supposed to be under administration long ago.”
“Wagner took over a failing department,” DA Member of the Eastern Cape Legislature Jane Cowley, told Spotlight. “But she hasn’t been able to fulfil some promises that she made. In spite of the revised organogram, most clinics and hospitals continue to use the 2007 organogram, which does not reflect current facilities’ needs.”
According to Cowley, another pressing issue since 2018 is the worsening mental health services at facilities – something the Public Service Commission, Office of the Public Protector, and more recently a parliamentary oversight report had flagged. “The late administrator, Professor Dan Mkhize, assessed the state of mental health care and provided clear directions. Only a few of those directions have been implemented. Despite employing the Director of mental health, mental health continues to be a crisis in this province,” said Cowley.
The HOD is promising changes along with MEC Nomakhosazana Meth, but nothing appears to be changing. – Nkosinathi Ndlodaka, UDM-MPL
Challenges won’t be solved overnight
Others have been more positive. One senior public sector doctor told Spotlight, “Ever since she (Wagner) took office, we have seen some improvements in the department because she is transparent. There is a lot of visibility happening and she always encourages us to send photos and report on what we are doing, whether it is a training or an outreach activity,” the doctor said. The doctor asked not to be named. Public sector doctors have in the past faced repercussions for speaking to the media without permission from the department.
“As a result of her strong focus on service delivery, she has hired CEOs of hospitals with acting people. She has a strong spirit of doing the basics right and making sure hospitals and clinics are repaired and trees are cut down. With her team, she’s driving the department in the right direction but the department’s problems won’t be solved overnight. Mental health has been backlogged for 20 years, but the department is proactive in improving it.”
Ever since she (Wagner) took office, we have seen some improvements in the department because she is transparent. – public sector doctor
According to the secretary of the Democratic Nursing Organisation of South Africa (DENOSA) in the province, Veli Sinqana, “addressing the issues of the public health sector is a process, not an event”.
“It’s not that we’re defending her or attacking her,” he said, “but she came to the department at a time when there wasn’t a good relationship between the union and the department. Communication and consultation were lacking and unions were not involved in critical issues by her predecessor. She at least showed an interest in including unions in departmental programmes, which was at its lowest level,” said Sinqana.
However, according to Nehawu’s provincial secretary, Mlungiseleli Ncapayi, Wagner and her predecessor inherited a health system that was non-existent because the former homelands of Ciskei and Transkei were not as well equipped as the former apartheid South Africa.
“When she took over a paralysed department during COVID-19, we had hoped she would understand the challenges faced by the department. Because it is not possible for her to turn around a paralysed system on her own, she needs the full support of all the people of the province. The impression I get is that she does not understand how important stakeholders are to the success of the department. The health facilities are understaffed and the working conditions and the facilities’ infrastructure are unacceptable, so it’s difficult to determine whether she’s winning or making progress,” he said.
A tough start
That Wagner came into the job at a particularly tough time is something most sources agree on. The COVID-19 pandemic took a particularly heavy toll in the Eastern Cape, and despite a few remarkable success stories, the province had some of the country’s worst death rates and often made headlines for the wrong reasons.
But, as is clear from Godongwana’s comments more than 20 years ago, and a litany of reports in the subsequent years (see for example the Integrated Support Team report of 2009, the Death and Dying report in 2013, and a Human Rights Commission report in 2015), much of the province’s challenges predated COVID-19. The Integrated Support Team report, for example, bemoaned “the lack of clear roles and responsibilities between different levels of management within the Eastern Cape Department of Health and between the political and administrative role-players” – issues that still plague many of our provincial health departments today.
Wagner replaced Dr Sibongile Zungu who was acting in the position after Dr Thobile Mbengashe resigned in 2020 – the second year of his second five-year contract. As HOD Mbengashe oversaw the controversial scooter ambulance contract. The Special Tribunal in 2021 declared the contract unlawful and set it aside. Mbengashe resigned and moved to the Premier’s office where he now serves as an advisor.
This was despite a series of controversies during his tenure as head of health. In 2019, for example, after a Spotlight investigation into the conditions at the mental health unit at Cecilia Makiwane Hospital, the Public Service Commission visited the facility which left the commissioner in shock over what she called the total neglect of the unit. Other statutory and constitutional bodies, including the Public Protector, the Human Rights Commission, and the Health Ombud after various visits to facilities following community complaints, have made similarly damning findings relating to conditions at health facilities that compromised quality patient care and thwarted the constitutional right to healthcare.
Mbengashe had replaced Mahlubandile Qwase who served as interim HOD after Dr Sivapragas (Siva) Pillay’s contract expired in April 2013. Pillay was known for his tough stance on fraud and corruption and during his tenure, investigations he initiated led to the uncovering of fraud involving hundreds of departmental staff members, who, among others were implicated in moonlighting and doing business with government. The loss to the department at the time was estimated to be R1.4 billion.
“go see for yourself”
Though there are obviously limits to what can be achieved in 21 months, the ultimate measure of how well HoDs and MECs are performing is the quality of healthcare services that people in the Eastern Cape are receiving.
Here, a recent report following an oversight visit by MPs in Parliament’s Portfolio Committee on Health in November last year paints a grim picture of health services at Eastern Cape hospitals, including Livingstone, Dora Nginza, and Uitenhage hospitals. The committee’s oversight visit followed an appeal from the health ombud for MPs to go “see for [them]selves” the conditions at these hospitals.
At Uitenhage Hospital’s casualty unit, MPs found the unit overcrowded and bemoaned the poor ventilation, medicines that were not stored properly, and the lack of patient privacy.
In 2021 Health MEC Meth amid reports of “infant deaths skyrocketing” acknowledged that the situation in Dora Nginza’s (hospital) neonatal ward was dire as some babies are dying because they could not be admitted by either the intensive care or high care units. These deaths, Meth said, also followed infection outbreaks due to overcrowding. In November MPs observed many of the same issues, especially as it relates to staffing and lack of beds. According to their oversight report, the beds in the neonatal ICU at Dora Nginza were inadequate and nursing staff were not trained in neonatal care. There were also bed and staff shortages in the paediatric ICU and “children who need to be in the ICU are sent to the general ward”. According to the oversight report, Dora Nginza’s Mental Health Unit was built in 2015 but is “on the brink of collapse as there are cracks in the walls”.
Whenever a problem is highlighted in the media about Livingstone Hospital, an entourage from the government will visit and guess what? Things will be normal for a week, then the situation will return to its old ways. – Maria Witbooi, healthcare user
At Livingstone Hospital, the report reads, “The hospital is unhygienic and an infection control risk. Medical waste has not been collected and was not properly stored.” MPs were so appalled at the conditions at the hospital, they “told the acting Chief Executive Officer (CEO) of the Livingstone Hospital that the hospital is in a bad state and it doesn’t deserve to be called a hospital”.
This followed an earlier public outcry over unhygienic conditions at Livingstone that prompted a visit by then-health minister Dr Zweli Mkhize back in 2020. Spotlight reported on this visit at the time.
Also in 2020, the Office of the Public Protector investigated conditions at some Eastern Cape hospitals, including Livingstone. The deputy public protector Advocate Kholeka Gcaleka in a report released in 2021, flagged leadership instability and “a shortage of nursing and non-clinical staff, such as cleaners and porters that result in unhygienic conditions” at the hospital, as key concerns. At the time Livingstone was still without a permanent CEO. Among the PP’s findings, for example, were problems with the drainage area at the hospital worsening a rat infestation.
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According to the report, Wagner in her presentation to MPs during the oversight visit said several hospitals, including Livingstone, Dora Nginza, and Uitenhage hospitals are earmarked for “infrastructure improvements”. These projects, which included a planned R36 million upgrade of Dora Nginza and a R14 million upgrade of Livingstone Hospital were still at the initiation stage, she said.
She also undertook that the “department would create conducive health facilities’ spaces which accommodates all staff and clients in all clinical and support services areas to ensure the rendering of quality services in the short, medium, and long term in terms of the Service Delivery Model of the Health Department,” the oversight report reads.
Spotlight made several attempts over the last three months to get comment from the department on these issues and the department’s plans, but we have not received any comment by the time of publication.
Spotlight went back to these hospitals last month to check with healthcare users if there has been any progress following the health committee’s recommendations. Various people Spotlight spoke to, however, said they have not seen any improvements.
At Dora Nginza Hospital, for example, Funde Lulama (43) from Zwide in Gqeberha says she has not seen any improvements in service delivery over the years. “I visit Dora Nginza Hospital almost every month to get my medication and to receive regular check-ups as a result of my medical condition. It has been three to four years since the hospital has failed to meet even the minimum standards expected of it. My file with all of my medical information and history was lost recently, so I had to go home and bring empty medication boxes for the correct prescription. To turn the situation around, I believe proper intervention is needed,” she said.
At Livingstone Hospital, Maria Witbooi (64) From Bethelsdorp in Gqeberha told Spotlight, “Whenever a problem is highlighted in the media about Livingstone Hospital, an entourage from the government will visit and guess what? Things will be normal for a week, then the situation will return to its old ways. I would appreciate it if staff members would put more effort into helping patients who are in need of their assistance. The cleanness (sic) remains a challenge,” she said, “as there are times when toilets are unusable and pose a serious health risk.”
A victory in court
In what is arguably one of the most important developments since Wagner’s appointment, Wagner and the department had a much-needed win victory when a court recently ruled that the department no longer has to make upfront lump sum payments in certain medical negligence claims and may provide the necessary medical care instead of paying for future medical costs. Depending on further legal developments, this could massively reduce the department’s vulnerability to medico-legal claims – something which has been a severe drain on its finances in recent years.
The senior doctor Spotlight spoke to, also cited this as Wagner’s big achievement. “For her, the court judgment on medical claims was a major accomplishment because it meant the department wouldn’t have to start the financial year on the back foot.”
At the time of the court ruling in February, Daily Maverick quoted Wagner as having said, “I am humbled that the judge recognised that we can do this. I don’t want us to lose sight of this. We will do the best we can for the children. But we also need to do this for everyone who depends on the state health services.”