BHEKISISA OP-ED

Here’s what was – and is – needed to clean up the North West health department

By Jeanette Hunter 21 October 2020

In 2018, protests over alleged corruption in the North West health department literally set the province on fire. (Photo: Oupa Nkosi, Bhekisisa)

In 2018, protests over alleged corruption in the North West health department literally set the province on fire. The Cabinet eventually put six departments under administration. Here’s an inside look from the woman tasked with cleaning house at the provincial health department.

In April 2018, protests broke out in North West province. The media carried images of burning tyres and barricaded hospital entrances. Health facility staff were prevented from getting to clinics and hospitals. Patients were turned away from clinics, many of which were running short of essential medicines. 

The province had reached a boiling point.

Government workers, including healthcare workers, through the National Education, Health and Allied Workers’ Union (Nehawu), had delivered a list of demands to the provincial government. Most, but not all, related to the running of the provincial health department. The letter included calls for better human resource and supply chain management and the suspension of the then head of department, Thabo Lekalakala. But management and the unions did not come to an agreement. 

Some workers embarked on strike action, with community members joining them in barricading streets and health facility entrances. The striking workers harassed and obstructed those workers who chose to continue to work.

When I arrived in Mahikeng in May 2018, the fires were still smouldering. The health department building was filthy, and key financial transactions required to keep health services functional had to be processed in another building because workers in the provincial health department offices were being harassed by striking workers. A small number of workers was trying to foment anarchy, and they abused the situation to advance their agenda of disorder. Senior and middle managers seemed unable to manage those from this group reporting to them.

The Cabinet had placed the health department under administration during the last week of April, and other departments, including education, public works, community safety and transport, social development, finance and the office of the premier, followed suit about two weeks later.

So, more than a decade after I’d left the North West health department I had returned as the woman tasked with administering the provincial health department.

As I entered the building’s auditorium to address employees on Day One, I noticed a placard amid the faces. It was hard not to. On it, someone had scrawled in big, bold letters:

“Hunter, fix this mess or voetsek.”

‘The unions, in that March 2018 letter of demand, had been right’

South Africa’s Constitution divides government into three spheres: national, provincial and municipal. All three, the document says, “are distinct but interdependent and interrelated”. But under Section 100(1) of the Constitution, the national government may intervene in a province – or put it under administration  – if it does not fulfil its “executive obligation in terms of the Constitution or legislation”.

It’s not a decision taken lightly.

Behind the scenes, the then Health Minister, Aaron Motsoaledi, and his director-general, Malebona Precious Matsoso, had been trying to work with North West province since February to solve problems and avoid placing the provincial health department under administration.

It was a good two months before the minister went to Cabinet on the last Wednesday in April 2018 and essentially said, “I’ve tried everything else.”

The unions, in that March 2018 letter of demand, had been right. The North West health department was essentially very, very poorly run: It hadn’t made any appointments for more than four years, as an example. Those who had been hired didn’t always have the skills required for the post. Meanwhile, labour relations in the department between many employees and managers had broken down.

Healthcare runs on people. If you don’t have the right people in place, who is motivating for needed equipment? Who checks whether there is medicine available at facilities? Who supports the few left behind from burning out?

I was also humbled by the courageous work of many in the department, especially our frontline workers. As stone barricades had sprung up on some of Mahikeng’s main roads during the protests, I heard stories of people who arrived at work at 4am for their 7am shifts – hoping to get into hospitals and clinics before protesters barred entrances. When workers at one hospital couldn’t get in to see patients, support staff organised a helicopter to airlift staff on to the roof until it too became blocked by the protesters making towers using office furniture.

Human resources was the big ticket

My team and I believed that the only way to get sustainable change in the province was to work with managers right from the start. So, once I arrived, we got everyone into one room – team members from the national Department of Health, colleagues from the Department of Monitoring and Evaluation in the Presidency, North West district managers, provincial programme managers – and assessed the problems. In the end, we settled on 111 priority activities.

Medicine availability in the province was a long-standing issue we knew needed to be fixed. It’s a battle we continue to wage. Human resources, we realised, would be another big ticket and here, we did manage to make some serious gains. We installed new community liaison positions in our districts to respond to staff and community grievances and problems on the ground. We processed more than 15,000 posts over the past two years and promoted hardworking, competent employees into management. We tackled backlogs in supplier payments and employee performance reviews that went back years.

But, as I’ll explain later, fixing the province’s human resource problem came at a high cost.

One of the key labour relations issues that took up much of my time over most of 2018 and 2019 was the one relating to the former head of health, Lekalakala. One of the union’s central demands in 2018 had been his dismissal. In mid-April 2018, he was suspended for allegedly awarding a fraudulent contract to Gupta-linked company Mediosa following a preliminary investigation by the province.

But Lekalakala’s suspension was far from the end of the story.

A recent raid on the medical depot uncovered unpaid invoices worth millions

Drug stock-outs emerged as a significant problem in 2018. To try to improve medicine availability, we took several steps, including appointing eight qualified pharmacists to assist in the provincial medicine depot. I personally went to the medicines depot several times and met with the managers of medicine supply twice a month to arrive at a root cause analysis and a medicine availability improvement plan. I tasked the team to call suppliers to track down payments and invoices. Initially, we were able to increase the percentage of essential medicines in stock at hospitals from 65% to 82% – a trajectory I had hoped would continue.

It did not and medicine availability fell at the beginning of 2020 when unpaid suppliers began withholding stock. At the beginning of the new financial year, (in April 2020), money became available for the medicine and the depot received technical support. Through the technical expert, we discovered we couldn’t trace many of the invoices suppliers claimed they had sent.

Without finding those invoices, we couldn’t pay. So in mid-August, I and a team went to the Mmabatho Medical Depot and uncovered unpaid invoices worth millions some dating back to 2014.

Rectifying an unpaid invoice isn’t as simple as paying it because you have to ascertain with certainty that the stock – as far back as 2014 – was indeed received and distributed and that you are not going to pay a second time for stock that was already paid for before. In a department with a track record of poor record-keeping, such as the North West Department of Health, you have to work with suppliers to find paper trails that can stretch back years to ensure that suppliers delivered the goods stated on those invoices. This is something we have had to do since I arrived in 2018 in North West, and not just with pharmaceutical companies.

Four managers, including two from the depot, were placed on precautionary suspension, following alleged mismanagement involving expired medication. We also put in place a plan to improve delivery timelines and turnaround, which includes suppliers delivering directly to hospitals. The depot will continue to supply clinics.

Getting eyes and ears on the ground – and keeping them there

From May 2018, when I arrived in Mahikeng, to December 2018, I spent a lot of time on the road, running from facility to facility. Protests may have stopped on the streets but tensions were still running high in clinics, hospitals and nursing colleges. Because labour relations had broken down and staff were understandably frustrated, protests would erupt within facilities. Staff would refuse to work until the administrator, ie, me, came personally. And then, when I arrived, workers would decline to even sit in the same room with managers. Management members, in turn, were unhappy with what they felt was undue power afforded to unions within facilities.

The more time I spent on the road and at facilities listening to unhappy staff, the less time I had to start making strategic, systemic changes. Thankfully when the health department’s new MEC, Madoda Sambatha, arrived, the focus shifted from me as “Miss Fix It” to him as “Mr Fix It”.

Still, the MEC’s governance role spans across many structures and levels and he too could not spend all his time visiting facilities to listen to disgruntled employees. I proposed to the MEC that we assign individuals as liaison officers to be first responders to complaints from staff and community members. He supported this proposal.

But, to successfully win back the trust of staff and community members who have been made cynical through repeated disappointments, we required individuals who would be responsive and energetic, who are respected by both management and staff and with the skill to help mediate disputes in facilities and communicate the department’s viewpoint on specific matters clearly and timeously to staff and community members. Fortunately, we found two such individuals, who currently have been assigned to two districts each and their contribution has had the desired effect.

Another problem was the fact that the provincial department had a single, overstretched deputy director-general for managing health programmes, primary healthcare services and hospital services.

From the outset it was clear that hospital services were severely neglected in North West province. Two of its five larger hospitals had no CEO, again resulting in the administrator, me, having to get involved in the operational matters at these hospitals. The administration, supported by MEC Sambatha, utilised a vacant deputy director-general (DDG) post that was essentially assigned a technical advisory role, converting this to a DDG post for hospital and clinical support services.

Now, this previously vast portfolio has been divided into two more realistic positions – one that focuses on health programmes and primary healthcare and the other hospital services. This has allowed the provincial department to finally begin dealing with a backlog in hospital performance management.

We also started the process of buying much-needed equipment for hospitals, procuring CT scans for Job Shimankana Tabane Hospital in Rustenburg  – although purchases had to be staggered to stay within budget – three more hospitals are slated to receive a machine. Furthermore, we bought four mobile X-ray machines and nine anaesthetic machines.

Human resources for health: The North West hadn’t filled posts widely in four years

Once community liaisons were on the road, I could get back to the office. People had complained about being overworked because of the huge vacancy rate. In response, we processed 7,000 appointments in my first year as administrator and 8,968 in my second year. We recognised workers who had upskilled and performed well, promoting them into vacant managerial positions where we could.

We filled key clinical general and specialist posts. Consequently, I overspent the cost of the employment budget by 3% at the end of the last financial year. However, this was necessary to ensure that we afforded young South Africans the opportunity to do their internship and complete their community service years which they need to register as professionals.

The filling of additional posts also resulted in the appointment of much-needed specialists, an increase in health professionals, and more persons receiving renal dialysis, hip and knee replacements and MRI scans. To support key clinical processes and to ensure that our facilities live up to infection prevention and control principles, additional administrative staff and cleaning staff were also appointed.

Despite thousands of new positions, we were able to shrink the vacancy rate by only 2% on paper because our decision to extend the working hours of facilities meant we added more positions to the department. And, of course, people retire, resign or move on to other positions.

We began to see what I believe was a new vibrancy in the department. 

We also created the department’s first organogram in 16 years. Why does that matter? Departments and even health facilities use organograms to help advocate for posts and funding – it’s impossible to do this if your staffing needs haven’t been revised in almost two decades.

We also cleared the 2017/18 backlog in payments due to healthcare workers by conducting almost three years’ worth of backlogged performance reviews with staff in line with proper human resource practices but also so that employees could access salary adjustments.

When organisations allow disciplinary cases to stall, people tend to think they can get away with dereliction and fraud.

We re-established the Provincial Bargaining Chamber to facilitate the appropriate mediation of human resources issues and started dealing with the huge backlog in staff grievances and disciplinary cases. What was once a weak labour relations unit within the health department now is better staffed and is headed by a director with a legal background.

Each of the province’s four districts has a specially assigned staff member to assist with grievances and disciplinary matters – something I believed was important as my time in North West grew shorter and shorter. Why?

Because when organisations allow disciplinary cases to stall, some staff tend to get the impression that they can commit transgressions as they please. This is also why the team and I doggedly pursued the previous head of department’s disciplinary case to a conclusion that secured his dismissal in January 2020. Consequence management must be effected fairly to all who are suspected of transgressions, and disciplinary cases continue, involving a number of NWDoH staff at all post levels. We also worked vigorously and continue to do so to resolve staff grievances.

Everything has a price

Yes, we’ve made gains in the North West during the 28 months of the Section 100 (1) (b) administration, in both health service and support areas. But because of the many weaknesses in the departmental systems, the progress is slow.

At least three times a day, the thought crosses my mind: If I could come to work and not have to deal with cases of suspected dereliction and fraud, progress would have been so much greater.

Although most of the staff of the North West Department of Health are honest, hard-working men and women, who fervently want to make a positive difference to the quality of health services in the province, a few seem to be hellbent on continuing on the path of abusing government resources for their own purposes. These misguided individuals are found at all levels of the organisation and through consequence management they must be assisted to change direction where possible or be managed out of the organisation. This is crucial if the provincial health department is to ever regain a reputation for clean governance.

I believe the overwhelming majority of frontline workers – on whichever side of the 2018 protests they were on – supported an intervention. I also believe that arguably six out of 10 managers in the province want to see positive change.

I now believe that we have a pool of managers in that department who feel confident in their ability to lead and that the department is on a different course than it was in April 2018. When I arrived at the department then, and yes even now, I wanted to ensure good governance and proper accounting and commitment to public finance management principles, but I also wanted to help build a department that would provide services to the people of North West.

I cannot say to people who need health services now, “Please wait, we still need to fix the supply chain processes in the department.” I cannot say to the relative of a young man who has been admitted to a ward with a fractured femur, “Please wait until next year to see if we will have enough budget to appoint the required orthopaedic surgeons.”

No, I could not, and I cannot.

For this reason, the NorthWest health department under administration, with me as administrator, continues to make decisions in the interest of patient care. We need to continue to provide services while fixing the system.

It’s been two years and we may not have accomplished everything we wanted to, but we have made some crucial gains. And I have been inspired each day by the tenacity of our public healthcare workers who, despite sometimes difficult circumstances, continue to remain committed to our patients. DM/MC

Jeanette Hunter is the deputy director-general for primary healthcare at the national Department of Health and current administrator of the North West Department of Health.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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  • Ms Hunter, This article is a genuine attempt at laying out the issues found and processes to be followed to build sustainable improvements. Everyone needs to understand the basic principles for good management, and better management takes time. Listening to unhappy staff and letting them know their concerns have been heard, and acted upon is even more important. That you have found staff who can take the lead going forward is crucial. Please do not burn out before you have finished this mammoth task. Good leadership starts at the top, and you are proving this.

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