In February 2017 after the release of the damning report by the Health Ombud Professor Makgoba on what happened subsequent to the disastrous transfer of mental health patients from Life Esidemeni to ill-prepared NPO’s, the then Minister of Health Dr. Aaron Motsoaledi and the then Premier of Gauteng David Makhura announced the appointment of a high-level task team to address what were termed “critical inadequacies in the capacities and capabilities and competencies to run the system and the management and incapacities exposed by the Life Esidimeni tragedy.” I was a member of that five-person task team for four months working in Gauteng. Ultimately I resigned in frustration as the team’s work became bogged down in numerous meetings and workshops and a reluctance to directly the address the problems identified. I provided the then Health Minister with a concise report that outlined both the challenges and what needed to be done to address them. My comment to Minister Motsoaledi in our final discussion in his Pretoria office was that, ” Minister the report provides the diagnosis and recommends the treatment but the patient is willing to accept either!”
Five years later in 2023, the same Health Ombud has released a report on the Rahima Moosa Mother and Child Hospital in Gauteng in the presence of the current National Health Minister Dr. Joe Phaahla, which according to media reports “paints a shocking picture of a health facility crippled by dysfunction and failure.” The state of the hospital was summarised by the Ombud in a press conference as “dirty, unsafe and filthy”. Other reports emanating from Gauteng public health facilities in the intervening years, most recently related to the fire at the Charlotte Maxeke Johannesburg Academic Hospital, reflect a similar picture that should have demanded immediate and urgent attention, which apparently has not occurred or been delayed. I am sure that there have been numerous meetings, workshops and planning sessions resulting in strategic, annual performance and action plans which clearly have not resulted in the changes to enable the department to provide a quality healthcare service.
I have been involved in a number of nationally appointed task teams with a mandate to investigate the conditions at hospitals and health facilities in a number of provinces since my retirement in 2015. The findings taking into account local differences have been the similar and I will outline a few.
A knee-jerk reaction to budgetary and management constraints is to centralise all decision making and withdraw delegations for all financial approvals to the head office level. While useful in the very short-term, centralisation leads in the longer term to inertia and failure take action to resolve problems encountered at a local or facility level. Rather than centralisation, it is better to create accountability frameworks within which managers at all levels are able to take necessary decisions but are also held accountable for their decisions. I have encountered situations where the head of a clinic was unable to replace a light bulb or repair a leaking tap without requesting authority for a district office with the result that it was either not done or took an inordinate time to occur. Similarly the recent Health Ombud report highlighted broken toilets and a lack of heating, which should have been resolved locally. Clear delegations of authority in a complex organisation such as a health department are essential to ensure its efficient functioning.
Whilst the funding of public sector healthcare is constrained and Gauteng Health as with some other provincial health departments has accumulated accruals resulting from unpaid accounts year on year, it is simplistic to attribute the situation solely to a lack of funds. Even when faced by funding constraints a rigorous process of prioritisation should ensure that the available funds are utilised in the most efficient and effective manner. The healthcare provided may not meet every expectation but should focus on the fundamentals and there is no excuse for dirty buildings and crumbling infrastructure.
Infrastructure is important but in many cases rather than a requirement to embark on major renovation or new construction, simple preventive maintenance at a local level can ensure that a health facility remains functional. It is also important that new health facilities are both fit for purpose, built in the right place and that once commissioned they are adequately maintained. I have witnessed a new district hospital constructed in a small rural town that was clearly too large and sophisticated for what was required and yet in the same district there were existing facilities that could have become more functional with minimal expenditure. I have also seen a major hospital development in which sophisticated systems were no longer functional due a lack of staff and expertise to maintain them. As with other areas it is imperative that every health rand spent on infrastructure is effectively utilised.
Challenges in the public sector health facilities are often attributed to shortages of staff in particular nursing staff, which is a reality. However, in many instances provincial health departments have staff establishments which consume over 65% of their allocated budgets but are uncertain of whether all those on the staff establishment are gainfully employed. Difficult decisions are required to ensure that the staff employed are those essential to provide a health service. Performance management of staff at every level is key to ensure that funds allocated to the remuneration of staff are effectively utilised. In my experience under performance is often tolerated and in the event of those requiring disciplinary steps this is allowed to drag on for prolonged periods. I have encountered examples where senior staff have been suspended on full pay for months and even years pending the finalisation of disciplinary processes.
The staff establishments of the health departments as reflected on the personnel system of the public service, PERSAL, are often poorly maintained resulting in management being unable to determine whether all those reflected on the system are appropriately appointed. As identified by the whistle blower at the Rahima Moosa Mother and Child Hospital and confirmed in the most recent Health Ombud report a shortage of nursing staff was identified as a cause of challenges related to patient care at the hospital. The logical response would then be to appoint more nurses but the budget shortfall would prevent management from doing so without an ability to redirect funding currently utilised to fund appointments elsewhere. What has been identified in the various task teams on which I have served is that taking the normal attrition rate of staff (resignation, retirement and death) which is between 6 and 8% into account, there is an ability to then decide rather than simply filling a post as it becomes vacant, rather to assess where the priorities lie, such as certain categories of nurses amongst others, and preferentially fill these posts. However, to successfully achieve this there must be an accurate reflection of the staff establishment on the PERSAL and a rigorous process that links the filling of posts to the available budget.
Logistics, as I have discussed before, is often sadly lacking in departments challenged by poor quality of care. To provide quality healthcare, health professionals require the support of effective management, administrative systems and logistics to ensure that for example that pharmaceuticals, medical supplies and equipment are always available as needed. When faced with shortages following the lines of supply, the failures in logistics and procurement become apparent. The Public Finance Management Act (PFMA) clearly outlines procurement processes which if rigorously followed should ensure that all that is needed is readily available. I have found in many instances the lack of for example pharmaceuticals at a health facility is not solely due to a shortfall in funding but also a failure of the logistics necessary to ensure the reliable supply.
Probably most important finding was the lack of an effective management that is outwardly orientated toward service delivery. Failing departments and facilities often reflect an inward looking management that sits comfortably in boardrooms and their offices. I have walked around hospitals observing obvious deficiencies and wondered when management last walked the same route. In a hospital that is “dirty, unsafe and filthy”, to quote the Health Ombud, it is clear that management cannot have done so or if so that must have they have closed their eyes to reality. Notably it was reported by the Health Ombud that the hospital CEO was “often absent”. My experience heading a health department was that is was easy to determine from the state of a health facility the degree to which management had a hands-on approach and was regularly in contact with frontline staff. Accountable management, which should not need task teams or investigations of the Health Ombud or Office of Health Standards Compliance (OHSC) to highlight the deficiencies, is the key to successful health departments and health facilities,.
Finally it was recommended in most of the reports with which I was associated that competent managers and staff should be appointed and supported to effectively manage public health departments and facilities free from political interference. The problems faced by the Gauteng Department of Health are not insoluble and it is time that this is done!
