The Life Esidimeni tragedy … a lesson that must be learned

The Life Esidimeni tragedy happened in the early months of 2016 when a long-standing contract with the Life Healthcare Group was terminated by the Gauteng Department of Health. Thereafter despite warnings that this was unwise around 1500 vulnerable mentally retarded patients were transferred from Life Esidimeni facilities in Gauteng to Non Governmental Organisations (NGO’s) in what was known as the Marathon Project. Many of the NGO’s did not have the capacity or resources to manage patients of this nature and as a result at least 144 patients died of neglect and many more suffered inhuman and degrading conditions.

This occurred less than a year after I had retired as Head of the Western Cape Department of Health and so I had met some of the role-players in this drama prior to my retirement. Subsequently I was engaged by the then Minister of Health Dr Aaron Motsoaledi in 2017 as a member of a task team set up to address the challenges faced by the Gauteng Department of Health, which was in disarray. Although the MEC for Health, Head of Department and Director for Mental Health Services deemed by a subsequent Arbitration Hearing chaired by a retired judge and most recently a judicial inquest to have been responsible for the deaths and suffering were no longer in the department, I interacted with people in the department who had experienced at first hand what had transpired.

The morale in the department was at a low ebb and there was little apparent appetite by the management, with an acting Head of Department, to grapple with the significant challenges facing the department not the least of which was a crippling budgetary shortfall. Many suppliers at that time refused to provide services to the department as a result of unpaid accounts. I do not intend to dwell on the details of what were identified by the task team as the challenges and what was recommended by the Gauteng task team since to my knowledge not a great deal came from the 2017 intervention. Rather I will rather focus on the role of the political head of a department (MEC or Minister) set against that of the head of department (Accounting Officer) and senior management related to what happened in the Gauteng Department of Health prior to and subsequent to the events of the Life Esidimeni tragedy.

In my experience there was particularly in the early years after the democratic transition a generally healthy interaction, largely on an equal footing, between the political head and the managerial head of department. This was because there was mutual respect and in many instances we had known one another in various contexts outside government prior to 1994. However, as time passed the divide between politician and senior management widened with the departure of many of the initial tranche of politicians and senior bureaucrats. The result was that politicians, many of whom no longer were health professionals, often felt threatened by senior management many of whom still had a  health background. I remained a provincial head of department from 1995 initially in the Free State and thereafter in the Western Cape until 2015 as the longest serving official in that position across provincial health departments. My experience was that the politicians (MEC’s) heading departments became increasingly less willing to seek or receive advice from their senior managers.

In the case of Gauteng Health and the Marathon Project the then Head of Department at the 2017-2018 Arbitration Hearing advanced his fear of the MEC as a mitigating factor explaining that this was why he had followed an instruction from the MEC to terminate the contract with the Life Esidimeni Group. He did this despite concerns raised from the senior management of the department as to the consequences of this decision. Not wishing in any manner to minimise his culpability in the dire consequences that resulted, having experienced the manner in which this MEC interacted with those she deemed subordinate at national meetings it was clear that she did not easily tolerate dissent from her views on a particular matter.

During my time in the Gauteng Department of Health, the managers who remained described an environment of fear that existed prior to and during the time during which the Marathon Project occurred. This behaviour was replicated by a number of people in similar positions in other health departments of provinces to which I had been exposed as a consultant. This resulted in situations where senior managers chose to remain silent rather than having the freedom to give advice and express their views. While fortunately not resulting in dire situations, of which I am aware, such as the Life Esidimeni Marathon Project there were issues that certainly would have benefited from a greater degree of openness in the relationships between the politician and the senior management of these departments. Even in Gauteng after the Life Esidimeni tragedy I experienced a reluctance by the then political head to accept and act on the advice and recommendations of the task team to deal with the parlous position in which the department then found itself.

Political loyalty must and can never trump what is right. No manager should ever be expected to sacrifice their integrity and ethics on that altar. There are many lessons to be learned from what happened when vulnerable individuals in Gauteng were transferred to NGO’s with a flagrant disregard for their safety and humanity. However, a critical lesson from what happened must be that no-one should ever be afraid to speak their mind and that any individual who refuses to act on an unlawful instruction such as that which caused the Life Esidimeni Marathon Project cannot be sanctioned for doing so. This is similar to the position of whistle blowers reporting an illegal action who must be protected when they do so.

In my own case, I was fortunate to have the ability to resign if faced by a similar situation since with my academic background I would have been assured of employment elsewhere. Thus I could without hesitation object to my political principal if in my opinion what was requested was inappropriate or inadvisable. This was not the case with younger less established individuals who has a lot to lose if they were dismissed on the grounds of insubordination. I am aware of a particular incident in a provincial health department when exactly this occured.

I was fortunate to work with Health MEC’s who were willing to seriously consider my recommendations. In the very few instances when my recommendation was rejected, I was able to indicate that an instruction falling outside of the prescripts could only be carried out after a written instruction from the MEC had been given to do so. I also indicated that the written instruction would be put on record to the Premier of the Province and where necessary reported to the National Treasury and the Auditor-General. Almost without exception, my response resulted in a reconsideration of the instruction and its consensual amendment. If this had occurred prior to the precipitous cancellation of the Life Esidimeni contract, one of the worst incidents in South Africa healthcare and gross human rights violations may have been avoided and many lives saved.

I welcome the court ruling, even after a prolonged period, that individuals responsible for what happened in Gauteng in 2016 will be held accountable for their actions. However, I would hope that there will be a serious focus on the environment that contributed to what occurred. This is a lesson that must be learned to prevent a recurrence of  a similar situation in the future.