Little accountability as Health MECs dodge questions

Gauteng Health MEC, Dr Gwen Ramokgopa. Photo: Joyrene Kramer.

By Ufrieda Ho for Spotlight

1 May 2019

Missed deadlines, non-communication and excuses sum up the overwhelming ‘responses’ from the country’s nine health MECs when Spotlight asked them to reflect on their time in office and what people can expect from them beyond the elections.

As part of Spotlight’s #Vote4Health series, nine questions were posed to South Africa’s nine provincial MECs for health. Only two of the nine MECs provided answers. They were MEC Nomafrench Mbombo from the Western Cape and MEC Montsheng Tsiu from the Free State.

The following seven MECs of health failed to provide answers to the nine questions despite a generous deadline of several weeks: Sasekani Manzini (Mpumalanga), Sibongiseni Dhlomo (KZN), Gwen Ramokgopa (Gauteng), Phophi Ramathuba (Limpopo), Fufe Makotong (Northern Cape), Helen Sauls-August (Eastern Cape) and Madoda Sambatha (North West).

Ramokgopa indicated that as she would not be available for re-appointment to the role of MEC after the elections she didn’t want to take part in the series. A revised set of questions was sent to her but these were not answered either.

All nine MECs were contacted through provincial communications and media departments. Popo Maja, national head of communications in the Department of Health, was copied on all emails. The provinces were given over two-and-a-half weeks to respond when they were first contacted in mid-February. (KZN’s deadline was slightly shorter because correspondence was initially sent to an incorrect email address.) Numerous follow-up emails, phone messages, WhatsApp messages and SMSes were sent before the deadline. Maja also responded to the emails, asking his provincial colleagues to assist.

Not a single province met the deadline, two provinces requested extensions and did provide responses, some acknowledged receipt of the emails, forwarded these to colleagues they said would “handle the query”, which never happened, and some communications teams simply ignored the media request.

The nine questions posed to the nine MECs were:

1)      Healthcare is close to the hearts of people – why would you say you are the right person to remain in the job as MEC?

2)      If you are reappointed as MEC for Health in your province, what will be your top priority in your province?

3)      Default rates on HIV/ TB remain a constant and widespread concern, what do you see as the main reasons why people are defaulting on treatments and how are you addressing these problems?

4)      What role do you see civil society playing in ensuring that healthcare is transformed and inclusive?

5)      Corruption and a dire shortage of skilled healthcare workers to fill positions are two of the biggest challenges in healthcare; how would you fix these problems?

6)      In your view, how does the role of the MEC for Health differ from the role of the Head of the province’s health department?

7)      How would you go about implementing policies set by the National Department of Health in your province and how do you see the relationship between province and national?

8)      What is the one thing you’re most proud of having achieved in your time as MEC? 9) What is the one thing you wish you had done better on?

How the nine MECs responded

Below we provide details of our interactions with all nine provinces, ending with the two provinces that provided answers to the nine questions. We have edited the original answers for length, but did not do heavy edits as it was preferable to let the reader access the unedited version.

Gauteng Health MEC, Dr Gwen Ramokgopa. Photo: Joyrene Kramer

Gwen Ramokgopa (Gauteng)

Responsiveness: Ramokgopa’s team acknowledged receipt of the email and initially committed to giving input. Before deadline, they said Ramokgopa had decided not to respond as she is not making herself available for re-appointment in the role. A new set of questions, focused on reflections on her role and what it has meant for the province, were sent to Ramokgopa’s team. There was no response or further communication in this regard.

Sibongiseni Dhlomo (KwaZulu-Natal)

Responsiveness: The department spokesperson acknowledged the media query and copied it to a colleague who was also contacted directly by Spotlight. No response to the nine questions was received despite follow-ups.

Phophi Ramathuba (Limpopo)

Responsiveness: Her department failed to acknowledge receipt of emails, though they received and read SMS messages that were sent as follow-ups. Ramathuba was tweeted directly and sent screen-grabs of the communication between Spotlight and her communications team. She said she would follow-up. No responses were subsequently received.

Sasekani Manzini (Mpumalanga)

Responsiveness: Manzini’s communications department acknowledged receipt of the questions. They wrote to the Spotlight editors to check the credentials of the reporter and even when this was confirmed, Manzini’s communications team, in WhatsApp messages, insisted the reporter was unknown to the Spotlight editors (an obvious error or misrepresentation). Another set of emails were sent re-confirming that the questions were indeed from Spotlight. No response was received.

Fufe Makatong (Northern Cape)

Responsiveness: No response was received.

Helen Sauls-August (Eastern Cape)

Responsiveness: No response was received.

Madoda Sambatha (North West)

Responsiveness: No response was received.

Nomafrench Mbombo (Western Cape)

Responsiveness: Mbombo’s media liaison team asked for an extension and responded six days after the initial deadline.

SPOTLIGHT: Healthcare is close to the hearts of people – why would you say you are the right person to remain in the job as MEC?

Mbombo: I am a community activist by heart and fighting for the right to access quality health services is my number one priority. Health is a human rights obligation, and we ought to take it upon ourselves in leadership to ensure services are delivered where it is most needed. I spent almost two decades teaching healthcare and I was involved in provincial and local government health departments in the Eastern Cape and KZN respectively. I also served in advisory and consultative capacity roles to various ministries of health in Africa and in multinational organisations across the globe.

After having served as the first-ever female MEC appointed to the Western Cape Health Department, I gained enough insight into the executive role, and am well prepared to serve as MEC.

If you are re-appointed as MEC for Health in your province, what will be your top priority in your province?

Mbombo: The provision of quality, person-centred healthcare to all in the Western Cape remains our number one priority. Our focus remains on providing our citizens with dignity and improved quality lives. We are working towards service transformation that will improve health, improve quality and patient experience. We are also working towards improved governance and accountability; improve infrastructure, and strengthening leadership and a positive culture, with improved staff satisfaction.

Default rates on HIV/ TB remain a constant and widespread concern, what do you see as the main reasons why people are defaulting on treatments and how are you addressing these problems?

Mbombo: The main reasons for people defaulting on treatment in my view are:

Heavy pill burden, treatment fatigue,

Limited conversation with clients about their treatment journey and to co-plan,

Treatment as a biomedical intervention rather than supporting clients’ context and conditions,

Clients social economic conditions which include many social determinants e.g. unemployment, poverty, overcrowding, hunger, shelter, etc.

Migration – internal and cross border – the main driver – looking for employment.

Stigma in our communities.

Disclosure to family and friends.

The Western Cape Department of Health, with partners, are putting measures in place to find the TB and HIV missing cases – to link them back to care. Both our HIV and TB case treatment has improved over the years because of research. We are, through NPOs, trying to build relationships with clients to build trust. We are supporting and investing in research to reduce pill burden.

What role do you see civil society playing in ensuring that healthcare is transformed and inclusive?

Mbombo: Civil society interaction is vital to ensure our service users are part of the health system. When I took office as MEC, central to my vision was to improve the patients’ voice. The aim was to ensure that we strengthen the voice of the patient, and that they become active participants in health, and allow them to participate within a system that is designed to serve them as patients. The idea is for them to move away from the notion of being mere recipients of health services, to encourage them to become active participants.

Increasing community representation at all levels, and ensuring community concerns are reflected on each of these structures, is thus of critical importance.

Each level of consultation provides opportunities for incorporating communities and their leaders into the healthcare system – instilling a sense of ownership and responsibility for health services in communities.

Corruption and a dire shortage of skilled healthcare workers to fill positions are two of the biggest challenges in healthcare; how would you fix these problems?

Mbombo: With the shortage of healthcare professionals, in particular nurses, the Western Department of Health has developed a provincial nursing strategy to address this problem. Through this strategy, the following has been put in place:

Rural nursing campuses were established to increase the number of nurses enrolled for nursing training;

The department provides nursing bursaries to qualifying students;

With regard to specialist nurse training ( post basic) the department has implemented a policy on the study by assignment;

We have also recently created relief posts for nurses undergoing speciality training to enable hospitals to release more nurses for post basic/speciality training without compromising service delivery – this has significantly increased our training outputs in respect to these categories of nurses.

We currently do not have shortages in the Western Cape of general nurses, we actually have a surplus of this category, the challenge might be a shortage of funded vacant posts. The shortage is on specialist nurses hence the focused interventions listed above to address this.

In your view, how does the role of the MEC for Health differ from the role of the Head of the province’s health department?

Mbombo: The role of the MEC is in an executive capacity to implement provincial legislation, implementing appropriate national legislation, coordinate the functions of the Provincial Government and its departments, and preparing and initiating provincial legislation. The HoD, on the other hand, is to ensure that the vision of the Department of Health is implemented, and that health services are delivered to the people who most need it, as well as to ensure delivery of a comprehensive package of health services to the people of the province.

How would you go about implementing policies set by the National Department of Health in your province and how do you see the relationship between province and national?

Mbombo: We are actively working with the National Department to ensure we work in alignment to implement policies, programmes and projects that directly impact the delivery of quality person-centred healthcare to all citizens in this province.

What is the one thing you’re most proud of having achieved in your time as MEC?

Mbombo: Despite the challenges we face in the health sector, the Western Cape Department of Health has made impressive strides towards providing access to quality healthcare for all the people of the Western Cape and beyond. We can celebrate the highest life expectancy in the country, lowest inpatient crude deaths, the lowest child and maternal mortality rates nationally, the most successful HIV treatment programme in the country and 13 consecutive years of unqualified audits. We can boast state of the art health facilities delivered in the past financial year, and take heart that we have successfully navigated the drought crisis of 2018.

Another key achievement is access to health services in the Western Cape. 91.5% of the citizens in the Western Cape have access to health services within 30 minutes of their residences. We also ensure rural access to healthcare through the HealthNet patient transport system that operates at around 230 pick-up points across the province. Every year over 150 000 patients are transported to healthcare facilities. This system is unique to the Western Cape.

What is the one thing you wish you had done better on?

Not answered.

Montsheng Tsiu (Free State)

Responsiveness: (Tsiu’s media liaison team asked for an extension and responded one week after the initial deadline.

Healthcare is close to the hearts of people – why would you say you are the right person to remain in the job as MEC?

Tsiu: I am a Health Professional who has served the Department for more than 30 years in various capacities from the grassroots in the most rural periphery to Provincial Director of Nursing. This cumulative experience over the years has exposed me to various challenges and competing needs in the health fraternity with the purpose of saving the lives of our people.

I, therefore, believe based on my background and passion to saving and changing the lives of our people for the better, through the ANC policies that have sharpened my consciousness and commitment to health. This is not a job but as a calling. I am conversant with the needs of the various stakeholders such as the different professional disciplines of health, the allied health workers, the support staff as well as the expressed needs of our communities who are eager to see transformation towards a responsive, efficient and effective healthcare system.

If you are reappointed as MEC for Health in your province, what will be your top priority in your province?

Tsiu: The topmost priority is to transform the workings of the department in the province through partnerships of the various stakeholders towards an increased efficient and effective healthcare provision leading to the implementation of the NHI. We are grappling at the moment with the implementation of the 90-90-90 strategy which espouses the vision of healthcare trends in the world by the World Health Organisation, to be realised by 2020.

Efforts towards achieving this have begun as we are continuously evaluating our achievements every year. Now we are at the stage of Tracing and Finding the Loss to Follow Up Patients who have to be on treatment immediately. However, there is still a challenge of the cross border cases that require higher levels of cooperation between governments of neighbouring countries such as Lesotho, Namibia, Botswana, Zimbabwe and Mozambique, amongst others, of which the Free State is more closer to Lesotho. Already, there are processes initiated towards finding a solution to this challenge with Lesotho.

If I am reappointed to the position of MEC for Health, this would be among my main priorities.

Filling of vacant posts ranging from non-clinical to clinical and Strategic Top Management posts. I have realised that health is not only a subject of Clinical Services but require a fair balance between the core business and support services such as Clerical Services, Cleaning Services, Security, Laundry, Kitchen Services and others to achieve health objectives and realise the vision of the Department.

Default rates on HIV/ TB remain a constant and widespread concern, what do you see as the main reasons why people are defaulting on treatments and how are you addressing these problems?

Tsiu: We need to upscale awareness and educational campaigns on the burden of diseases and for our patients to understand the importance of adherence to Screening, Testing and Treatment. We have observed over a period of time that some of our patients are initiated on treatment but soon get lost to follow up because:

They abandon treatment as soon as they recover from the adverse effects of illness and feel better. They associate taking treatment as a stigmatised phenomenon, especially long duration treatment such as that of TB and HIV.

Migration patterns within the country and neighbouring countries. In South Africa, patients are treated for free while in other countries they are subjected to a stipulated fee determined by each country. Some of these patients are from poor backgrounds and cannot afford medical costs associated with their treatment. These patients end up defaulting on treatment and automatically increase the default rates, hence the constant and widespread concern default rate becomes a factor.

In an attempt to address these challenges on HIV and TB, the Department has initiated a campaign of “Taking Primary Healthcare to the People” since July 2018. Through this campaign, both TB and HIV Units in the Department are pursuing the Screening, Testing, Counselling and Treatment Programmes in various communities in the province. This is a constant because we do this in all the Districts targeting both rural and urban communities alike.

We have initiated a programme of Tracing those patients that are missing and lost to follow up for both TB and HIV. We re-initiate these patients as soon as we find them. Our Community Health Workers and Community Care Givers are playing a significant role in assisting the Department to achieve this objective as well as adhering to the goal of World Health Organisation with respect to the 90-90-90 Strategy.

We are further contributing towards achieving the objectives of the National Development Plan on reducing the rate of infection by 2030.

What role do you see civil society playing in ensuring that healthcare is transformed and inclusive?

Tsiu: Civil Society is a strategic partner in healthcare. We are working towards making our partnerships valuable and significant throughout all our programmes. We are sharing common platforms with organs of civil society and advocacy groups. Our concern is the fragmentation and competition amongst these critical voices. This leads to an undue misunderstanding of each other’s roles and thus leading to a lack of coherence in our engagement. We are committed through campaigns and programmes to involve these organs of civil society as partners in healthcare through the Provincial Council on Aids and their involvement in the various Departmental campaigns.

Corruption and a dire shortage of skilled healthcare workers to fill positions are two of the biggest challenges in healthcare; how would you fix these problems?

Tsiu: On Fraud and Corruption

We have strengthened our Anti-fraud and Corruption Unit through the appointment of skilled, qualified and specialised personnel. We have strengthened the risk Management systems in the Department to minimise and eliminate any form of instances of fraud and corruption. These platforms will increase the ability for personnel to blow the whistle and be empowered to expose acts of fraud and corruption whenever they happen.

On filling of vacant posts

We are continuously filling all vacant posts with relevant, qualified and skilled personnel as and when these posts become vacant or as and when the need for importance and relevance becomes evident.

We have in the past three years made the following appointments:

The department has been allocated 127 posts through HR enhancement grant on HR capacitation. It is an indirect grant of R 13,7-million for the following categories:

Medical Officers 13

Medical Specialists 8

Professional Nurses 43

Enrolled Nurses 12

Staff Nurses 31

Community Services 20

All the above appointments have been finalised. An additional amount of R2.9-million is being processed to employ support staff as follows:

Cleaners 100

General workers 50

Porters 25

Forensic Officers 12

The support staff will be distributed across the province for enhanced service delivery.

In your view, how does the role of the MEC for Health differ from the role of the Head of the province’s health department?

Tsiu: The MEC is the Executive Authority of the Department, this is where the strategic and policy direction is given in terms of what the country wants to achieve through the vision as outlined by the governing party in line with the electoral mandate.

The Head of Department is the Accounting Officer who must ensure that the vision of health is implemented in uniformity. The accounting officer must ensure that there is a fair, adequate and equitable distribution of resources and responsibilities to implement the vision of both the National and the Provincial Department of Health.

How would you go about implementing policies set by the National Department of Health in your province and how do you see the relationship between province and national?

Tsiu: South Africa is a unitary state, with national as the centre and the provinces as the strategic links. The National Department of Health sets the tone with regards to how health should be administered and managed through the set National Core Standards and Objectives, while the Provincial Departments aligns their own systems to the national strategic objectives in a commonly defined and response to the burden of diseases. For example, we are implementing the National Core Standards of Health determined by the National and the Provincial Departments, the National Strategic Plan on HIV and AIDS, 90-90-90 Strategy and the National Development Plan.

In no way, the province may operate or execute any mandates that are contrary to the framework of the National Department of Health.

The Provincial Department reports on its achievements annually to the National department and when required to the Parliament of the Republic on its activities.

What is the one thing you’re most proud of having achieved in your time as MEC?

Tsiu: The launch of “Taking Primary Healthcare to the People”. This is the milestone campaign that brought about the realisation of the long theorised vision of a preventative healthcare system. The healthcare system of South Africa has been mainly curative and hospital centred in approach yet neglecting the preventative element that is community centred and people-driven. Over many years, this approached is theorised and not driven to implementation. I am happy to see an old man receiving their eyesight through a cataract campaign, others getting spectacles, hearing aids, orthostatics; wheelchairs, walking aids and many others provided by the Department.

What is the one thing you wish you had done better on?

Tsiu: If I may, let me sponsor only two. Firstly, I wish that I was able to increase the numbers of women in strategic positions including Top Management of the Department. Secondly, I wish I had more time and resources to implement improvements in Infrastructure with state of the art equipment that conforms to the dictates of the Fourth Industrial Revolution and Artificial Intelligence and thereby expanding access to healthcare for people in the rural areas with dedicated professionals to serve them there. DM

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