The Covid-19 pandemic has brought into sharp focus the long-standing failure of the Eastern Cape Department of Health to deliver proper healthcare to the people of the province.

The health system in the province has been on the brink of collapse for more than a decade, and authorities have failed to heed numerous warnings from activists and healthcare workers.

As far back as 2013, activists marched to the offices of the department in Bisho, demanding they urgently address the issues that had been ignored for so many years. These issues, outlined at the time in a publication called Death and Dying in the Eastern Cape, were identified through ongoing monitoring of the provincial health system by nearly 20 organisations in the Eastern Cape Health Crisis Action Coalition (ECHCAC). This report contained a litany of health rights violations that frequently resulted in patients dying.

Among the myriad issues, ECHCAC in 2013 asked the health authorities to take urgent steps to fix crumbling infrastructure and address matters around the availability of medication, supplies and supply chain management, human resources, the management of hospitals, emergency medical services, and patient transport.

These are the very issues that have again emerged during the Covid-19 crisis as needing the most urgent attention.

Seven years ago, ECHCAC found that there was no proper management in the province’s department of health. As a result, areas like contract management for food and laundry were neglected; the department failed to appoint or pay clinical staff timeously, causing chronic understaffing; facilities fell into disrepair; equipment went unrepaired and new equipment could not be obtained; and staff were left without leadership.

A 2015 South African Human Rights Commission report on the state of emergency services and planned patient transport in the province found that these services were absent in many places and insufficient in others. 

In some places, patients were forced to wait for up to six hours for an ambulance. In others, the ambulance did not arrive at all. Instead of buying ambulances and staffing them, the province’s health department has now entered into a questionable contract to procure scooters, which, by the admission of Minister of Health Dr Zweli Mkhize, are not fit to transport patients.

In 2018, an assessment of the health system in the Eastern Cape, conducted by the Treatment Action Campaign (TAC), found that nothing had improved in the five years since the ECHCAC’s report. 

The TAC report found that the shortage of human resources continued to be a major issue in the province. It argued that ensuring access to quality healthcare services, and ensuring that everyone had access to treatment and care, depended largely on having enough qualified and committed staff – doctors, nurses, pharmacists, pharmacy assistants, community healthcare workers, lay counsellors, peer educators, security guards, porters and cleaners.

Which brings us to 2020

The current crisis at Livingstone Hospital in Port Elizabeth strongly suggests that these issues have not been addressed. 

The top three management positions at the hospital have been vacant for some time. There is a severe lack of doctors and nurses. Staff who do work at the hospital are overstretched and at high risk of burnout. Shortages of general assistants, cleaners and porters at the hospital mean that doctors and nurses have often had to act as porters and cleaners themselves, taking them away from their clinical duties and compromising patient care.

It is almost impossible to provide safe patient care in the casualty unit due to the unhygienic environment. This situation has resulted in patients and healthcare workers being exposed to health risks that could have been avoided.

In addition, there is a lack of supply of personal protective equipment and other necessities at the hospital. This includes the insufficient provision of gowns, gloves, overshoes (boot covers), masks, aprons, sanitisers and body bags.

Unfortunately, the situation at Livingstone does not seem to be unique.

Supply chain management issues and lack of planning at facilities across the province have, for example, resulted in shortages of critical oxygen supplies. There have been several reports of oxygen shortages in Gauteng and the Eastern Cape, and the lack of coordination of national to provincial supplies and storage facilities has further exacerbated the issue in the Eastern Cape.

Doctors are now scrambling to meet the healthcare needs of hundreds of patients. They circulate oxygen between facilities to ensure there is enough for everyone, but the situation is unsustainable.

Urgent intervention is desperately needed

These issues were outlined in a letter to Mkhize and the Eastern Cape’s MEC for Health, Sindiswa Gomba, on 30 June 2020 and again on 16 July 2020 on behalf of the TAC and the Igazi Foundation. The department did not respond in writing, but instead invited the two organisations to a meeting on 20 July.

While SECTION27 was not at that meeting, from what we hear, the responses did not adequately address the concerns raised – certainly nothing said in public has convinced us that the department is willing or able to get its ducks in a row.

In a media statement on 17 July, Eastern Cape Premier Oscar Mabuyane announced that he had taken steps “to address service delivery, administrative, infrastructure facility and clinical problems in some hospitals and in the provincial Department of Health in order to improve the health intervention of our response to Covid-19”.

These steps included requesting that Mkhize appoint a team of experts to assist the province. The team, led by ministerial adviser Dr Sibongile Zungu, assessed and assisted the provincial health department and produced a report that was handed over to the premier.

Not surprisingly, the report reflects the same issues activists, healthcare workers and patients have brought to the attention of the Eastern Cape health department on numerous occasions over the last decade. Seven years after the Death and Dying report, a new report is coming up with the same findings.

History repeats itself 

In July 2014, a group of recently dismissed community health workers was arrested during a peaceful protest at Bophelo House, the offices of the Free State health department in Bloemfontein. After initially being found guilty, the so-called Bophelo House 94 were cleared on appeal following a lengthy ordeal in the courts.

Last week, on the night of 16 July, police fired rubber bullets to disperse 50 community health workers, including elderly women, who had gathered to protest peacefully at the health department’s office in Bisho. Whether someone in the department asked the police to intervene is not clear. What is clear, however, is that the department should have done all in its power to ensure that something like this did not happen. In a pandemic, especially, we should help community health workers – not shoot at them.

In response to the community health workers’ demand for integration into the department, superintendent-general, Dr Thobile Mbengashe, simply said the province could not offer the workers permanent employment outside the ongoing national bargaining council processes. 

That we are still struggling for decent employment for community health workers in 2020 is mind-boggling.

Mbengashe’s intractable stance shows the health department’s dismissive attitude towards cooperation with stakeholders in the province.

In addition to this, the department seems to be suffering from a case of denial. In an interview with the BBC, Mbengashe said the situation in the province was not as dire as the media had painted it.

Of course, he does not acknowledge that healthcare workers in the province have been raising the alarm since the beginning of the Covid-19 pandemic and for many years before. He does not acknowledge the long trail of false dawns since the publication of the Death and Dying report.

If there is to be any hope for the Eastern Cape, this habit of indifferently glossing over matters of life and death must end.

This is the time to work together

Now must be the time for openly and seriously collaborating with all those who have an interest in saving lives. Such collaboration must include activists, health workers, and the community.

Mabuyane has said that the Covid-19 response would be taken to community level. On 7 July, he said that committees would be set up in the province’s Covid-19 hotspots to slow the high infection rate. This is potentially a step in the right direction, but the premier must make available the plans for this community-level response, engage with civil society organisations and be open to adjusting the plans. It’s also critical to ensure that these committees are truly representative and do not become politicised.

Just as community-based actions helped to educate people about HIV in the early 2000s, education and community ownership of the Covid-19 response can help to stem the tide of infections. It simply can’t all be done from the top down.

The same goes for the healthcare system itself. While healthcare workers need far more support, they also need to be given greater authority. They must be given decision-making powers at the facility level to ensure that clinical and administrative decisions can be implemented at speed. This requires information sharing, not only at an individual facility level, but also across facilities in each district.

Doctors have lamented the lack of access to information about the number of beds or levels of oxygen available in their districts. An integrated system for sharing information across public and private sector facilities would help to inform clinical decisions. 

What we need here is not an expensive new tender, but simply some cooperation and a willingness to learn from other provinces that have better functioning systems.

The SA National Defence Force has deployed 75 military personnel to help out, but this is only a temporary measure in a province that has had too many temporary measures and temporary solutions… a province where little has changed in the last seven years.

What is needed to fix the Eastern Cape health system in the longer term is essentially two things: better planning and strong leaders who are accountable to the people in the province. 

For a start, this means serious planning and proper budgeting to solve the ambulance crisis – not some nonsense about scooters. Strong, accountable leaders listen to the desperation of the people, and then put service to the people ahead of their own narrow personal or political interests.

In the meantime, more transparent communication, more collaboration and better coordination of efforts are urgently needed to save lives as Covid-19 continues to ravage the poorest province in South Africa. DM/MC

Nontsikelelo Mpulo is head of communications at SECTION27.

This article was produced for Spotlight – health journalism in the public interest. Sign up for our newsletter.