“As a doctor, you … try to help and save as many [patients] as possible, but under no circumstances publicly speak out. That will be career suicide.”

These are the words of a dejected health worker recalling their ordeal with a public health system hellbent on covering up its failures. This health worker had written to the media as a student doctor to raise concerns with administrative issues in a public hospital. Their actions landed them in hot water, and they lived to regret that day.

More than 10 years later, that incident remains firmly in the health worker’s memory, a constant reminder of how they can never speak out unless they want to ruin their career.

This is the story of many public health workers. They have learnt to never speak publicly for fear of losing their jobs, intimidation, harassment and potentially getting killed. Yet, the public health sector continues on a downhill trend. Their silence comes at a high price.

We recently woke up to headlines about the Health Ombud’s report from a year-long investigation into allegations of patient neglect, an unsafe environment for both workers and patients and maladministration at the Rahima Moosa Mother & Child Hospital (RMMCH).

The findings of the health ombudsman corroborate new research by the Campaign for Free Expression (CFE), which found that authorities in public hospitals abused the law to cover up their incompetence. They cared more about protecting their image than they did about saving patients’ lives.

As a result, they abused their power to bully workers into silence. Health workers are afraid to speak out to address the challenges that they face in the workplace because authorities use the Public Service Rules and Regulations which restrict public workers from speaking with the media, to disproportionately discipline workers who do so.

The ombud’s report details chilling findings of the hospital management’s failure to run the facility efficiently, and both the provincial and national government’s “lack of care” to address issues that have been highlighted since as far back as 2017.  

“Quite simply, it appears that no one seems to care,” said the report. It adds, “the failure of leadership, management and governance resides at all levels – province, district and RMMCH itself.”

Ironically, this is the same hospital where a dedicated paediatrician, desperate to save the lives of children whose lives were at risk due to the lack of resources necessary for providing them with critical care, was disciplined for going public with his grievances.

Dr Tim De Maayer was suspended in June 2022 after he published an open letter decrying the deteriorating working conditions at Rahima Moosa hospital. According to De Maayer, the conditions made it difficult for him and his co-workers to execute their duties efficiently, contributing to the needless deaths of children.

“How do you manage to come to work every day, fail at your job of ensuring basic healthcare for the people you serve and still sleep at night?” De Maayer asked.

Instead of addressing the issues, the hospital management was more concerned with protecting the reputation of the institution (and theirs of course). They took action against him for bringing the Department of Health into disrepute. However, a public outcry forced them to overturn their decision, and they reinstated De Maayer within a few days.

CFE’s research includes an analysis of the application of the law in De Maayer’s case. It finds that the CEO of Rahima Moosa did not apply ethical reasoning in suspending De Maayer for his open letter. Ethical reasoning is recommended by the Ethical Code of Conduct for Health Professions which requires that when faced with a conflict of ethics in the workplace, one should always consider the effect of their actions on the public’s interest.

De Maayer either had to remain silent and watch children continue to die in breach of his moral obligation to save lives, or make a disclosure in the public’s interest, but in breach of the Public Service Rules and Regulations – which he did and for which he got victimised.

With recent developments around the release of the ombud’s report, CFE has received credible reports that there have been new efforts to silence De Maayer after he made a few comments in the media in response to the ombud’s report, leading him into cancelling a scheduled interview with eNCA.

The new Public Service Rules and Regulations as amended in 2016 encompass a Code of Conduct for public workers which specifies that employees may only communicate with the media with authority from the head of department.

Chapter 2, section 3.3 stipulates that a public service employee should use “appropriate channels” to air grievances or to direct representations. This means they must report the grievance to their immediate supervisor first. The supervisor is expected to escalate the matter if they fail to adequately address it. However, in many cases the challenge is that when such a procedure is followed grievances are not addressed.

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Most public health workers’ grievances are related to the way that public hospitals are run. They implicate senior management and the government. This is why officials seek to stifle public health workers from speaking publicly.

The ombud’s report confirms this when it notes that their findings were consistent with a 2016 report that was compiled by Prof Ashraf Coovadia and Prof H Lombaard titled “An Unsafe Hospital”, which detailed all the current challenges at Rahima Moosa hospital.

It further highlighted that despite the two professors having made relevant recommendations for the challenges to be addressed, the ombud’s investigation could not establish any evidence that the recommendations were ever taken into consideration or implemented.

Although the Public Service Rules and Regulations restrict workers from speaking to the media, the Protected Disclosures/Whistle Blower Act allows public workers room to utilise the media to make a “general disclosure” under certain conditions.

Under this law, a public employee can speak out if the grievance will benefit the public. De Maayer’s open letter and public comments may qualify as protected disclosures. The Protected Disclosures Act states that “every employer and employee has a responsibility to disclose criminal and any other irregular conduct in the workplace … [and] every employer has a responsibility to take all necessary steps to ensure that employees who disclose such information are protected from any reprisals as a result of such disclosure”.

Yet, public health workers are victimised when they use the media to expose wrongdoing in the sector.

The overemphasis on adherence to the Public Service Rules and Regulations borders on abuse of power. This can be attributed to the lack of independence of senior management at public health institutions.

They appear to be under the control of political bigwigs, which means political interests are overriding efficiency and the need to serve the interests of the public. 

A lot of the issues reported in public hospitals result from a lack of good management and accountability, wasteful/unnecessary expenditure, and corruption. This may stem from the way that board members and senior management officials are picked. There is a lack of transparency and accountability when appointments are made, which the ombudsman confirmed.

The ombud’s report states that “the criteria used by the Gauteng Department of Health to select CEOs is far below the required standard for such senior positions”.

It further notes that the Rahima Moosa board was non-functional, something that surveyed and interviewed participants in CFE’s research also found to be the case in other public hospitals.

Public health workers have a moral duty to save lives, as set out in their Hippocratic Oath and the Ethical Code of Conduct for Public Health Professionals. According to these ethics, a practitioner should act in the best interests of the patient.

However, their inability to speak publicly to disclose maladministration by senior public officials means that a lot of wrongdoing is concealed, which may lead to unnecessary loss of lives when predeterminants of health are not provided, as can be evidenced by the findings of the health ombud’s investigation.

Imagine yourself as a patient going into surgery and having a self-made concoction which has not been approved by the medical council used on you as a sterilising scrub. Such is the direness of the situation in most public hospitals as medicine stock-outs have been repeatedly reported.

During a stock-out of Povidone-Iodine and SteriPrep, which are often used for pre-surgical antiseptic management, a senior nurse at Rahima Moosa hospital is reported to have resorted to using a diluted solution of Steriscrub to prepare the skin of patients who were getting operated on. Steriscrub is meant for use to scrub hands in theatre before sterile gloves can be worn. As a result, several patients who were operated on during this period had to be relooked at after developing sepsis.

The Department of Health should be held accountable for its failure to run public hospitals effectively. Expecting public health workers to raise their grievances internally when most reports of tender fraud and corruption in the public sector implicate senior management and government officials, is like reporting a crime to the perpetrator and expecting to see justice served.

The silencing of public health workers has no place in a democratic society. The Department of Health’s silencing tactics have devastating effects, not only on the workers but on the public’s ability to enjoy basic human rights. We need individuals who can expose misconduct. Silence from public health workers is a silent killer.

This month, on 21 March, South Africa commemorates Human Rights Day. Can South Africans celebrate Human Rights Day when the public health system is on its knees?

Download the full report from www.freeexpression.org.za – as well as an invite to next week’s webinar on this topic. DM

Hanifa Manda is a Project Manager at Campaign for Free Expression. She is a human rights, democracy and governance enthusiast who has researched and contributed to the design and delivery of projects to enhance Freedom of Expression and Access to Information in Africa, including through the provision of technical support to the office of the Special Rapporteur on Freedom of Expression and Access to Information at the African Commission on Human and People’s Rights. [email protected]