Access to basic healthcare is a fundamental right guaranteed by the Constitution. But for residents of Xhora Mouth in the Eastern Cape, that constitutional right remains a mirage in some ways.

Almost four years ago, in her May 2020 budget speech, the then MEC for health, Sindiswa Gomba, promised the community a clinic.

The Xhora community consists of villages such as Nqileni, Tshezi, Folokwe and Mgojweni, about 100km from Mthatha. Villagers have to walk long distances, including crossing the Xhora River and navigating through thick bushes to get to the nearest clinic in Nkanya village, about 15km away.

When Spotlight reported on their plight in 2019, they had been campaigning for a clinic of their own for more than a decade.

That there would not, after all, be a new clinic in Xhora Mouth became clear when Nomakhosazana Meth took over from Gomba as health MEC in March 2021.

Eastern Cape MEC for health Nomakhosazana Meth. (Photo: Gallo Images/Die Burger/Lulama Zenzile)

Meth made it clear in her first budget speech that the department would focus on maintaining infrastructure instead of undertaking new construction. The community of Xhora Mouth will have to wait even longer.

Spotlight looks at what else has, or has not, changed in the province’s healthcare system since the last elections in 2019, focusing on leadership, infrastructure, medicolegal claims and emergency medical services. Covid-19 was obviously a big part of the story of the past five years, but we don’t focus on it here — much has been written elsewhere about the severe shortcomings in the province’s pandemic response.

Leadership instability

Meth’s appointment is emblematic of the leadership instability that has plagued Eastern Cape health over the past five years. To what extent this instability has contributed to the province’s health problems is unclear, but it cannot have helped.

Meth replaced Gomba after Premier Oscar Mabuyane fired the latter in February 2021. Gomba’s dismissal followed her being charged, along with several others, in a case of alleged fraud related to the funeral of former president Nelson Mandela.

Meth herself seems likely to vacate the position in June, since she is high on the ANC’s national candidate list and is probably off to serve in Parliament.

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The province’s health department is on its fourth departmental head since the last national and provincial elections. Dr Thobile Mbengashe started the term as head of department but resigned in the wake of a controversial scooter-ambulance tender that was eventually set aside by the corruption-busting Special Tribunal (Gomba was also implicated in the affair).

Mbengashe now serves as an adviser in the premier’s office.

Dr Thobile Mbengashe. (Photo: Luvuyo Mehlwana/Spotlight)

After his departure, Dr Sibongile Zungu, former head of the KwaZulu-Natal health department, was roped in to serve as the acting head of the Eastern Cape department. Before that, Zungu had been called on to assist with the province’s response to Covid-19, which was widely reported to have been severely dysfunctional.

Zungu was followed by Dr Rolene Wagner, who was appointed as permanent head of the department in August 2021. There was initial optimism about Wagner’s appointment, given her experience in both the public and private health sectors.

But just over two years after her appointment, Wagner was controversially moved out of the position by Mabuyane. She was replaced by Sindisiwe Gege.

Dr Sibongile Zungu and Dr Rolene Wagner. (Photo: Luvuyo Mehlwana/Spotlight)

EFF member of the provincial legislature and health portfolio committee member Simthembile Ma­­di­­ki­­ze­­la says this leadership instability is linked to what he sees as the department’s poor performance.

“In addition to the previous MECs not doing justice to the department, the current MEC too has issues with Wagner, who happened to be transferred to the premier’s office. That alone created another instability in the department.

“The current acting head of department [Gege] does not appear confident or capable of resolving the department’s challenges,” says Madikizela.

And, as the Xhora Mouth example reminds us, infrastructure and staffing at health facilities is one of those challenges.

Hospital and clinic problems

In the past five years, health facilities in the province have been the subject of several investigations and damning reports. A report by the Public Protector in June 2021 found that the province’s administration of health at several facilities does not accord with the obligations imposed by the Constitution and the law. The Public Protector also pinpointed several instances of improper conduct and maladministration.

A broader Public Protector report on service delivery in the province, published in 2023, concluded: “The delivery of healthcare services by the Eastern Cape Department of Health is prone to being ineffective and/or unreliable as a result of various challenges caused by poor contract management, which contributes to delays in finalising infrastructure projects, a backlog in upgrading health facilities and defective infrastructure.”

It also found that “the shortage of staff at most health facilities hampers the effective provision of services”. Oversight visits and reports by the provincial legislature’s portfolio committee on health have also flagged serious infrastructure problems.

Clinics built of mud remain a reality in the province. As MEC, Gomba vowed three years ago that clinics with elements of mud construction would be made a thing of the past.

However, of the 13 healthcare facilities in the province identified as having buildings made of mud, only five were included in the R492-million allocated for refurbishment in 2023/24. This indicates that at least some mud clinics will remain in use for the foreseeable future.

Yet, despite the bleak state of infrastructure, the ratio between healthcare workers and patients in the province appears to be improving. According to the latest figures from the District Health Barometer, the number of doctors per 100,000 people in the province increased from 33.5 in 2019 to 39.9 in 2023. Pharmacists increased from 14.1 per 100,000 to 16.4 and professional nurses from 186 per 100,000 to 197.

Critics, however, complain about management at health facilities.

Madikizela says: “The lack of management in our hospitals is another problem because everyone does their own thing since there is no clear direction. Hospital boards are not functioning, and those that are functioning are not receiving their stipends. Almost all hospitals are run by acting CEOs…

“It is not necessary for the hospitals to perform any magic, but a visionary in the form of an MEC is essential.”

Money and medicolegal claims

The Eastern Cape has also been in the headlines in recent years for the high number of medicolegal claims against the province’s health department. Partly because of such claims, the department has slipped into a pattern in which it starts every financial year with a substantial amount of debt accrued from previous years.

There also appears to be a pattern of salary costs and increases being prioritised over other health costs. These financial troubles have at times contributed to the late payment or nonpayment of service providers, which has disrupted service delivery.

Though the Eastern Cape often ranks at or near the top when it comes to the number and value of medicolegal claims against health departments, the high number of such claims is a national problem.

As the Auditor-General has pointed out in Parliament, the government has failed to meet its target of reducing contingent liability from medicolegal claims by 80% from the 2018 baseline of R70-billion. In March 2023 it stood at R77-billion, a 10% increase. Contingent liability refers to the amounts that are claimed; the amounts paid out are much lower.

In one of the most important recent legal developments in this area, the Eastern Cape Department of Health won a significant victory in February 2023.

Judge Robert Griffiths, of the Bhisho High Court, ruled that the department no longer had to make upfront lump-sum payments in certain medical negligence claims and could provide the necessary medical care instead of paying for future medical costs.

A reduction in the amount of lump-sum payments could provide a significant boost to the province’s health budget.

Spotlight asked the department for the latest data on medicolegal claims in the province, but did not receive a substantive response. Thus, we don’t know whether the ruling has had any beneficial impact on the department’s finances so far.

It probably hasn’t, given that, as recently reported by Daily Maverick, the department started the current financial year with a massive R4.8-billion in unpaid bills.

Jane Cowley, DA MPL and spokesperson for health in the province, says the department is in deep trouble.

“All these years we have been calling for an urgent review of the Eastern Cape Department of Health’s budget, which has been pushed through with no consideration of its disastrous implications for residents in desperate need of healthcare services,” she says.

“Every single financial department starts with billions of accruals. The department [and] the office of the premier have not been able to halt the tsunami of medicolegal claims against the department, which continue to decimate their finances.

“It is outrageous that patients must suffer because of years of historical financial mismanagement by the department.”

Ambulance shortage

A lack of quick and reliable emergency medical services (EMS) is also a long-standing problem in the province, especially in rural areas. The situation triggered the South African Human Rights Commission in 2015 to investigate and produce a report with detailed recommendations. Meth, in her 2022/23 budget speech, acknowledged that the department had not yet addressed the shortcomings identified by the commission.

Although the ambulance fleet increased from 306 ambulances in 2018 to 439 in 2023, about 190 of them are grounded for repairs and servicing. The department spokesperson, Sizwe Kupelo, confirmed in November 2023 that the province was not meeting the national target of at least one operational ambulance per 10,000 people — or about 650 ambulances.

Wheelbarrows are an important mode of transport for the sick in Xhora Mouth, Transkei. (Photo: Black Star / Spotlight)

The situation was further complicated when EMS workers from Amathole and King William’s Town went on strike from April to November 2022, alleging that their equipment was inadequate. There has been no resolution to the situation, as the department is now seeking to fire 224 workers who took part in what it described as an unprotected strike.

Spotlight made multiple attempts to get responses from the provincial health department, but had received no comment by the time of publication. DM

This article was first published by Spotlight – health journalism in the public interest.

This story first appeared in our weekly Daily Maverick 168 newspaper, which is available countrywide for R35.