MEMORANDUM

ABOUT THE CRISIS IN EASTERN CAPE HEALTH

MEC SICELO GQOBANA Over the last few months, following many reports of the deterioration in the quality of health care services in the Eastern Cape, the signatories to this memorandum have been involved in consultations with health care workers and health care users across the Eastern Cape. The consultations have revealed serious problems in the system. Some of these problems are not new and have been the subject of correspondence from the signatories to this memorandum to the Eastern Cape Department of Health over a number of years. In response to the range of problems that we have witnessed, the Eastern Cape Health Crisis Action Coalition was established. It is a coalition of organisations with an interest in the improvement of the health care system in the Eastern Cape. The members of the Coalition are as follows: Treatment Action Campaign (TAC) Rural Health Advocacy Project (RHAP) Democratic Nursing Organisation of South Africa (DENOSA) South African Medical Association (SAMA) Rural Doctors Association of South Africa (RuDASA) Junior Doctors Association of South Africa (JuDASA) Rural Rehabilitation South Africa (RuReSA) Public Service Accountability Monitor (PSAM) Democracy from Below SECTION27 Professional Association of Clinical Associates in South Africa (PACASA) Peoples Health Movement (PHM) Igazi Foundation Budget Expenditure Monitoring Forum (BEMF) World AIDS Campaign

 The primary problems identified occur in the following aspects of the health care system: Facilities The poor quality of many facilities in the Eastern Cape hampers the delivery of health care services. The Treatment Action Campaign recently brought the appalling conditions at Lusikisiki Village Clinic to the attention of the MEC, finally instituting litigation when no steps were taken after several months of correspondence calling for the improvement of the facility. Fortunately, the National Department of Health has now stepped in and completed construction of a temporary structure pending the construction of a permanent and well- equipped facility. Lusikisiki Village Clinic is by no means the only facility the quality of which hinders the delivery of health care services. In conducting investigations throughout the province, we have come across numerous examples of such facilities. For example, facilities often lack electricity and running water. Many facilities are too small for the number of people served. Some facilities are, literally, falling apart. The availability of medication and supplies / supply chain management The catastrophic situation at Mthatha Medical Depot has been allowed to continue despite numerous reports and letters sent to the MEC on this issue. In late 2012 and early 2013, it required an intervention by Mdecins Sans Frontires (MSF) and the TAC to make the Depot functional. Since the withdrawal of MSF and the TAC in March 2013, a steady deterioration has occurred. Facilities are once again receiving long dues out lists and are unable to access essential medicines and medical supplies. Supply chain management throughout the health care system in the Eastern Cape is in a state of chaos. Continuous stock outs (in facilities served both by the Mthatha Depot and the Port Elizabeth Depot), reports of corruption, incorrect ordering and unreliable processing systems lead to shortages for patients as well as wastage. Efavirenz has been out of stock for some time, requiring that patients are switched to other ARVs or face non adherence. Several facilities report receiving insufficient quantities of the new Fixed Dose Combination ARV, which leaves clinics vulnerable. When facilities run low they borrow or give patients only a few tablets at a time, necessitating frequent returns to the clinic. This is not reflected in the reports on stock outs. There has been a recent attempt to take action on stock outs through monitoring availability at depot, sub-depot and facility level, identifying hot spots (starting with the OR Tambo District), and emptying sub-depots. While this action is to be welcomed, it is not a long term solution in that sub-districts remain without sufficient transport for the delivery of medicines, human resources in the medicines supply chain remains a problem and only ARVs and TB medication is monitored. A long term and inclusive plan is required. Human Resources The combination of a high vacancy rate and an out of date Persal system has catastrophic consequences for the delivery of health care services. The Persal system contains a multitude of ghost workers who occupy posts on Persal despite not actually working in the facilities. A Provincial Treasury directive prohibiting the filling of certain posts, such as those vacated before April in the current financial year, perpetuates the high vacancy rate for posts within the ECDoH. Even with respect to posts vacated after April, the bureaucratic process required to fill posts means that it frequently takes at least six months for an appointment to be confirmed, by which time candidates may well have found other jobs.

Human Resources problems plague not only the appointments process but also the management of staff already within the system. We have been informed that it regularly takes three months from the date of commencement for an employee to be paid his or her salary. This discourages health care workers from applying for positions in the province. We have had numerous reports of irregularities in the payments of health care professionals. After three years of SAMA Border engaging with the management of the East London Hospital Complex about correct payment for doctors, a crisis point has been reached. After lengthy bureaucratic processes, Persal was successfully loaded with the correct salary scales for doctors, long overdue OSD and PMDS payments and arrears. The CEO of the complex had budgeted R67 million to finally address this backlog but had to report on 1 August that the Executive Committee of the Eastern Cape had refused to release the money. Only after the threat of a strike has some progress been made. Staff at the complex are demoralized and angry as after 3 years of negotiations, their contractual rights have not been met. This is one example of the human resources department not fulfilling its contractual obligation, leaving staff unhappy and often financially insecure. Complaints of this nature are not limited to just one hospital complex in the province. This has been a huge contributor to health care workers hesitating to take up a career in the public sector in the Eastern Cape, as issues of non, under or late payment are regular occurrences. The Eastern Cape needs to attract high quality doctors and nurses to improve health care delivery to patients and a secure salary is non-negotiable. Management In the absence of proper management, the day-to-day functioning of health facilities goes unattended to. Clinical staff are not appointed or paid timeously and properly, which perpetuates the chronic under-staffing throughout the Eastern Cape; facilities fall into disrepair; equipment goes unrepaired and new equipment cannot be obtained and staff are left without leadership. Poor management has a number of other consequences that should be self- evident. Ultimately, health care users suffer. Many district hospitals in the Eastern Cape have managers with little or no health background who may struggle to grasp the urgency of some managerial decisions. Examples include the timely service and fixing of equipment, for example Cathcart hospital, which has had no x-ray machine for over a year; or ensuring that interruptions to water or electricity supply are addressed as a matter of urgency. St Elizabeth Hospital in Lusikisiki recently went without water for a week, a disaster for infection control. The Eastern Cape needs hands-on hospital CEOs and clinical managers that look after the needs of health care workers and patients as a matter of priority. This will create an environment that attracts health care workers and builds good partnerships with the community. Most importantly there needs to be accountability and managers should both have power to implement urgent action where necessary for patient safety and be held accountable if patient safety suffers. Patient Transport and Emergency Medical Services Patient Transport and Emergency Medical Services are entirely absent in many places and desperately insufficient in others. In Tarkastad, we have heard reports of numerous patients dying before the ambulance arrives due to the four to six hour wait for an ambulance. In Cathcart, if an ambulance is called at 16:00, it will not be dispatched until the change in shift at 19:00. In some areas such as Folokwe, no one has ever seen an ambulance. The right to emergency medical services cannot be said to be fulfilled in the absence of proper ambulance services.

 Equipment We have received many reports of equipment shortages and faulty equipment in facilities. There has been no x-ray machine at the Marjorie Parrish TB Hospital in Port Alfred for four or five years. In Port Alfred Town Clinic, there is only one blood pressure machine in the clinic. These equipment shortages are frequently reported to District Offices without response. Staff accommodation Many facilities suffer from poor quality and insufficient staff accommodation. In some facilities, such as Kotyana Clinic, no electricity or running water is available. In Madwaleni Hospital, the accommodation is filthy and run down, and the sanitation facilities are inadequate. Some facilities simply have no staff accommodation at all. These shortcomings dissuade health care workers from staying in the province and thereby contribute significantly to staff shortages and, in severe instances, violate the rights of health care workers to dignity. Rehabilitation, home based care and preventative services These services are plagued by a number of inadequacies. The Eastern Cape has been without a permanent Rehabilitation Coordinator for a number of years and the acting Provincial Rehab Coordinator has to do her job without the support of Provincial Physiotherapy or Occupational Therapy Coordinators, because none has been appointed. Some facilities have absolutely no budget with which rehabilitation departments can procure supplies, making this vital aspect of preventative and home-based care near impossible. There are no standard budget line items for vital assistive devices such as crutches and walking devices. There is a minimum wait of 12 months for wheelchairs and other equipment in the OR Tambo District as orders are processed through procurement in Bedford Orthopaedic Hospital and patients then need to wait for delivery to Bedford before the equipment is distributed to clinics and other hospitals. This leaves patients immobile and vulnerable. The failure to facilitate these services has several devastating consequences. For example, the lack of outreach and preventative services increases the likelihood that people come into the health system with serious and expensive health problems that early rehabilitation could have prevented, and secondary complications that are entirely avoidable. The lack of rehabilitative services reduces the likelihood that these people will recover and successfully exit the system. The lack of home based care or transport to support community-based rehabilitation services means that people who are unable to access health care facilities, whether through illness, poverty or other life circumstances cannot be reached. Therefore, the most vulnerable are left without any means of accessing health care services. Budgeting and expenditure Underpinning many of the challenges discussed above are the many chronic failures in the effective mobilisation of the health budget in the province. There is little doubt that the provincial public health system is underfunded due to historical and incremental budgeting that has not overcome entrenched structural inequities that are a legacy of apartheid. But there is little hope that the provincial department could motivate for its fair share of revenue if it does not deal with endemic financial mismanagement that continues to contribute to the inefficient, ineffective and unaccountable use of public resources for health. Commissions of inquiry, special investigations, and the Auditor Generals Annual Audit of the provincial department of Healths financial statements have all revealed that tens of millions of Rands are lost annually through fruitless & wasteful expenditure and corruption.

 There are a number of specific areas within the departments budget that must be addressed if progress is going to be made in turning the tide on this crisis. These include: o A review of the provinces budget with a view to determining funding requirements based on need o The introduction of budget processes that ensure greater equity between urban areas and traditionally neglected and underfunded rural districts o A full baseline assessment and costing of the provinces human resource requirements and staffing establishment o A full review of pharmaceutical and laboratory services that identifies mechanisms to ensure the adequate financing of these areas in the budget, improvements in supply chain efficiencies and value for money o Introduction of intergovernmental infrastructure development and maintenance programmes that include the ECDoH, Transport, and Public Works, amongst others o A full review and costing of EMS and patient transport services including fleet management and maintenance o Active promotion of community participation in budget and expenditure processes with the aim of entrenching social accountability as standard practice The problems identified above can be found to varying degrees across the province. The ongoing failure to address these issues leads to people going without health care, poor health outcomes and avoidable deaths. The ARV programme is being undermined by stockouts and shortages, the TB programme is under threat, the neonatal mortality rate in facilities remains the highest in the country, and five of the eight districts in the province record under-5 mortality well above that of the national average with OR Tambo reporting the highest rate in the country. The constitutional rights of health care service users and staff to access to health care services, dignity and life are being violated. The rights of patients under the National Health Act 51 of 2003 are being undermined, and the obligations both in that Act and in numerous policies of the national and provincial departments of health are being breached. Failure by the Eastern Cape Department of Health to attend to these serious problems in the health care system is unlawful and contrary to its constitutional and legislative obligations. The problems identified above require urgent attention. We call on the MEC to develop a plan with clear timeframes that includes components that address the items listed urgently to remedy the crisis in health in the Eastern Cape. We demand a response from the MEC to this memo, including the plan referred to above, by 11 October 2013. SIGNED BY: EASTERN CAPE DEPARTMENT OF HEALTH REPRESENTATIVE:- NAME:.. SIGNATURE:. DATE: EC HEALTH CRISIS ACTION COALITION REPRESENTATIVE:- NAME: SIGNATURE:... DATE:..