South Africa

A case of sick clinical management at Mpumalanga’s Tintswalo Hospital

By Mandy De Waal 14 March 2013

Situated in the remote heartland of Mpumalanga, Tintswalo Hospital should be a facility that offers public healthcare to the community of Acornhoek, many of whom are marginalised. Instead, the clinical management itself is in a shambles, with good doctors leaving in droves and no new physicians are being hired for a facility that’s imploding. The doctors who remain are either stretched beyond the limit, or are allegedly using the hospital as an income-producing private practice. By MANDY DE WAAL.

From one of the most beautiful parts of South Africa comes one of the most terrible stories of government blindness and neglect. It is the saga of Tintswalo Hospital in Acornhoek, an impoverished rural hamlet nestled next to the Orpen Gate of the Kruger National Park in Mpumalanga.

Tintswalo, a 423-bedded acute hospital, sees some 500 patients a day and serves a catchment area of about 1.5 million people. If you lived in Acornhoek it is highly likely Tintswalo would be your only option for medical care, because the closest similar public health facility is hours away.

For years now, people have been complaining and protesting about the disastrous management at the hospital, yet despite the dysfunction, deaths, injuries, community action, lawsuits running into millions rands, and the steady stream of talented medical staff regularly lost, nothing has been done about the situation. If anything, the problem has only become more pronounced and desperate.

“I am on the verge of resigning. I am a doctor and will be able to get a job very quickly anywhere in the world, but what is going to happen to my patients? Who is going to care for them if I go?” says a medical doctor working at the hospital, speaking to Daily Maverick on condition of anonymity.

There is a massive shortage of doctors in the public health sector in South Africa, a scarcity which is more pronounced in rural areas – yet this medical practitioner says the clinical management at the hospital is so poor that it is driving doctors away.

“The clinical manager deals with the doctors and manages the clinical team, but for the past few years the management is so poor, unsupportive and hostile that it has created a leadership based on fear, division and absence,” the doctor says in an interview from Acornhoek in Mpumalanga.

“Currently we only have about 12 doctors for a big district hospital, and we’re all overwhelmed by work. There is a lack of resources and equipment, which means we need good clinical management which is not here,” he says.

“The work environment is toxic and hostile and the doctors are leaving. In the last two years we have lost six specialists… Six specialists! Do you know how hard it is to get a specialist in this area? I can’t work anymore in such a toxic environment, so even though I dread leaving my patients, I will end up resigning as well. A colleague of mine quit last month; another is planning to go soon if the situation doesn’t change,” he adds.

“The clinical manager should do his job and recruit more managers, but the applications are lost, not followed up, or people hear about the bad reputation of the clinical manager and don’t want to work here. More doctors are resigning here than are being recruited,” the physician says.

Retha Grobbelaar, a spokesperson for Africa Health Placements, which places doctors in rural public health services, writes that the biggest challenge facing public healthcare today is the shortage of healthcare workers. “There is an estimated shortage of approximately 80,000 healthcare professionals in South Africa. Even with this massive shortage, the private sector, which serves 16% of the country’s population, enjoys 70% of the country’s doctors. The remaining 84% of South Africa’s population uses public healthcare and languishes with access to only 30% of the country’s doctors.

“Thousands of our doctors are also working overseas. In fact, there are more South African doctors working abroad than there are working in the public sector in South Africa. The enormous staff shortages in the public sector certainly have an impact on the care offered to patients,” Grobbelaar states on the Public Health Association of SA website.

The doctor speaking to Daily Maverick from Tintswalo says the stress of an overloaded schedule is compounded by absent clinical management. “After hours when you need to refer a patient, or get an ambulance to take a patient somewhere, you can’t reach the clinical management. There aren’t regular clinical meetings and if you voice a problem the clinical manager becomes very aggressive, so the doctors have very low morale here,” he says.

“Because of the lack of organisation and clinical management, activities aren’t organised. The outpatient department is overwhelmed; patients wait for hours and get upset because they cannot access proper care. Because there aren’t enough doctors, patients often must be sent away to come back the next day,” the doctor says.

“The patients’ files and records are lost. Or they just lie on the ground. They are not organised in a proper place. Most of the equipment isn’t maintained and we have equipment that doesn’t function; there’s a shortage of drugs. These issues aren’t about clinical management, but if we don’t have clinical support, it becomes impossible to deal with.”

The doctor adds: “I am an HIV specialist in an area (Mpumalanga) which has amongst the highest number of patients. I was appointed as the clinical head of the unit, and then for no reason was demoted to go and work in the outpatient unit. Currently there isn’t a full-time doctor in the HIV unit, which means that the patients in that unit are suffering. It is such a crisis, but the clinical management remains and nothing is done about the problem.”

The medical facility is currently at the centre of a damages claim brought by a father of three who lost his wife and new born child at Tintswalo. The Mpumalanga health MEC has accepted liability in the case of Erick Zwane, who claims that he lost his wife and child because of the poor health care they received at the hospital. The Pretoria News reports that the damages for the claim have yet to be decided. 

Marije Versteeg of the Rural Health Advocacy Project tells Daily Maverick that Tintswalo Hospital has been on her radar for some time now because of the challenges the hospital faces with the clinical manager, Dr Phillip Mkhanjane Thuketana.

“The complaints we have date back three years. In 2010 already we were informed by health care workers that there were management problems at that hospital that affected service delivery there. It is a matter of poor clinical management, poor decision making and problematic standards of care. For example, the neonatal equipment was broken some time back, and a baby died because of that,” says Versteeg.

“Our reports show that Dr Thuketana doesn’t attend clinical management meetings, and if he is present, doesn’t deal with the problems presented, but rather attacks those who raise problems. He doesn’t take action on broken equipment, or doctors who are on stand-by and switch off their phones,” she says.

Versteeg says the doctors are divided, scared of being victimised and have been threatened by Thuketana, who is allegedly protected by political allies and feared by hospital staff. “As a result, specialists and doctors are resigning in high numbers, which is incredibly problematic because it is difficult to recruit for this area, and this impinges on patient’s rights to quality health care,” she says, adding that the hospital recently lost a paediatrician, which was a massive blow to the community.

The rural health advocacy director says her organisation has made representation to the National Department of Health, and the provincial health department but as of yet there has been no change in the situation. “Already patients have problems with transport to referral hospitals, so it is critical that these scarce skills are retained at Tintswalo Hospital,” she says.

“The new MEC of Health and Social Development, Candith Mashego-Dlamini, did pay a surprise visit a couple of weeks ago, but she didn’t ask for the clinical meeting register or look at the minutes, and she only spoke to two doctors that were provided to her to interview by Dr Thuketana himself,” Versteeg states.

Daily Maverick got further insight on the rot from a source who, like the physician, asked to remain anonymous. This person says that Thuketana is never around, and that he allows doctors to do private work alongside their public sector work. The source reveals that private patients are brought to the hospital and alleges that Dr Thuketana is engaged in corruption with building contractors at the hospital.

“He is powerful and connected to the ANC. The people here are afraid of him, not only because his connection but because he threatens to harm people if you go up against him,” the source says, adding: “The reason why he doesn’t take action against doctors who don’t come to work is because this is what he does himself. He comes and goes as he pleases and turns a blind eye to other doctors doing private work and even bringing private patients to have their pregnancy scans done here.”

Daily Maverick spent most of the day on Wednesday 13 March 2013 trying to get hold of Thuketana, but he phone just rang off the hook with every call. After some persuasion, an insider offered his mobile phone number. At first the clinical manager claimed not to understand the allegations being put to him when he was offered a right of reply. Then Thuketana said:

“I don’t think that I am the right person to respond this. Maybe you can tell the hospital – you can talk to the acting CEO or the MEC of this province. I don’t think I am qualified to respond. I can’t comment,” and put down the phone.

A phone call to Ronnie Masilela, spokesperson for Candith Mashego-Dlamini (the abovementioned Mpumalanga MEC for Health and Social Development) revealed that the provincial government was aware of the problem. “The MEC did visit Tintswalo, and is on a fact finding mission to investigate. I must stress she didn’t go there because of problems; it was an unannounced visit,” he said.

“She needs to go with a clear attitude and investigate the good and the bad. The report will be finalised by the end of the week and only then will we see what we have found. We will take action with any problem that we find but I cannot comment now ahead of the process,” Masilela added.

Bertha Peter-Scheepers of the Health Professions Council of SA, a statutory body that governs the health professions in this country, tells Daily Maverick that a complaint was lodged against Thuketana with the council at the beginning of March this year. “We now need to get an explanation from the practitioner, and this will be served at preliminary enquiry. At that committee it will be decided if there will be a formal investigation of Dr Thuketana,” she says, and adds: “There is an old complaint from 1990, but that has now been closed.”

Indeed. This is not the first time that Thuketana will be investigated. On 08 March 1998, Mzilikazi Wa Africa wrote a story for City Press headlined “Doctor on stolen medicine charges”.  The article states that Thuketana was remanded for “practising as a doctor in direct defiance of the SA Interim Medical and Dental Council, which revoked his licence in 1993 for unspecified misconduct” while he was in court for allegedly dealing in stolen medicine.

The docket presented to court showed that police had raided Thuketana surgery after getting a tip-off from unhappy patients who were being made to pay for medicine that was “stamped as State property”. At the time Wa Africa wrote that Thuketana was further being probed on a second charge related to fraud for allegedly processing irregular medical aid claims to the value of R100, 000.

Daily Maverick is also in possession of a letter from Section27, the public interest law centre, which details further incidents of misconduct by Thuketana. The letter from Section27’s Executive Director, Mark Heywood, addressed to National Health Minister, Aaron Motsoaledi, indicates that between 2010 and 2011, Thuketana was suspended from Tintswalo Hospital for financial impropriety, and then reinstated. It further alleges that in 1998, the clinical manager was reprimanded for continuing to practice as a doctor despite having had his licence revoked in 1993.

Will Health Minister Aaron Motsoaledi and the new provincial health MEC, Mashego-Dlamini, consider the mounting petitions from civil society to have Thuketana investigated? How many good doctors need to quit the Tintswalo Hospital and how many more patients need to die before something is done?  DM

Read more:

  • R1m claim after wife, newborn die at IOL 
  • Patients pay price in ailing health system in Mail & Guardian

Photo: Tintswalo Hospital

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