The deaths of Life Esidimeni’s former patients represent a full-blown symptom of this crisis in care. Its cure does not lie in government’s wholesale appropriation of NGO services, as Yonela Diko argues.
Surveying the wreckage of the Life Esidimeni disaster, eighty per cent of which occurred in five NGOs, Yonela Diko concludes that government must take back services. Life Esidimeni, however, is hardly a wonderful example on which to base an argument for government’s superior care. After all, it was the spectacularly debased duty of care exercised by senior Gauteng Department of Health officials that killed the 94 former Life Esidimeni patients.
Further, the five agencies recording the most deaths had been in existence for barely a month when they were unlawfully issued with a licence to provide mental healthcare. Can it honestly be said that they even qualified to be described as services at all, NGO or otherwise? Still, Yonela Diko does raise important questions around South Africa’s systems of social welfare.
Calling for government to take back services assumes that government did, at some point, actually provide services – and then contracted them out to NGOs. This assumption is incorrect and based on reading far too much about the crumbling welfare states of the global north, and not enough about the particularities of South Africa’s welfare services.
These date back to the colonial era when a range of benevolent societies, temperance unions, religious and self-help associations and the like formed to address the various social ills of the time. (Some of these organisations exist to this day.) When the first Department of Welfare was established in 1937 it did not seek the wholesale replacement of these services with its own. Instead, it provided some additional services while regulating and subsidising the existing services.
Reflecting on this history in 1997, the White Paper for Social Welfare noted that newly democratised South Africa had inherited social welfare programmes which were “not considered to be critical social investment priorities and were under-resourced” and that these were being provided under circumstances where “salaries are extremely low, and working conditions and service conditions are poor for all welfare personnel”.
The racial and urban bias to services entrenched by the apartheid government had also abandoned large swathes of the black population to their own devices, especially in the rural areas. These inequities had also to be addressed.
Nineteen years later, writing in the introduction to the Review of the White Paper released in October 2016, chair of the review committee Professor Vivienne Taylor could still observe “huge gaps” in the provision of social welfare services that “leave the poorest individuals and households in extreme distress”.
One factor significantly contributing to this is the static nature of funding to social welfare services over the last two decades. During this period, welfare services have been allocated just 10% of the Department of Social Development’s budget overall. A second factor is the pay increases consistently higher than inflation that civil servants have enjoyed for the past 10 years. Because these increases have shrunk the budget for the actual provision of services, they have correspondingly diminished funding to the NGO sector. And with most of these services provided by women, underfunding has also effected a particularly feminised form of inequality.
A second outcome of underfunding has been the creation of a two-tier system of care which sees government services considerably better resourced than their starveling NGO counterparts. Life Esidimeni illustrates this graphically. Patients were moved to NGOs because these could be paid R112/day for their care, as opposed to Life Esidimeni’s cost of R320/day. By contrast, the cost per patient in the Gauteng government’s psychiatric hospitals ranges between R1,386 and R1,960/day.
Other examples of underfunding are cited in the 2010 case brought by the National Association of Welfare Organisations and Non-governmental Organisations (Nawongo) against the Free State Department of Social Development. According to the judgment, costing of the Child Justice Act showed R6,000/month to be needed for every child placed in a child and youth care centre. The department in that province was paying R5,000 and R6,750 per child in its facilities but paying NGOs a scant R2,091 per child per month.
The Department of Social Development’s 2016/17 Budget Vote revealed that a budget of R20-million per year over the next three years had been allocated to its Gender-Based Violence Command Centre established in 2013. The document also reported the command centre as having received 3,641 calls in 2014/15. By contrast, the Stop Gender Violence Helpline, in existence since 1999 and managed by the NGO Lifeline is given a subsidy of less than R2-million annually. The help line reports receiving approximately 18,000 calls annually.
Further worsening NGOs’ financial situation is the late payment of their subsidies. This too featured in the Health Ombud’s investigation into the deaths of the former Life Esidimeni patients. He noted that while some NGOs had sufficient financial reserves to tide them over during the two to three months they went unpaid by the Department of Health, a number didn’t. Patients went hungry as a result, which contributed to their deaths.
The 2010 Nawongo matter had already brought the late payment of transfers by the Department of Social Development to the court’s attention. My ongoing research shows late payment of subsidies to remain both pervasive and entrenched. When it occurs, services are disrupted or even closed because staff cannot afford the costs of transport to work – although some staff solve the problem by sleeping at work. Staff go into debt, while others take loans in an effort to keep the organisation running. In one instance the director of an organisation was even threatened with death over the late payment of monies.
Serobe shelter, the only domestic violence shelter in Bloemfontein, closed in 2014 because the organisation was unable to operate under these conditions. The Free State Department of Social Development has not filled this gap, which prompted the Department of Justice’s Tshepong Domestic Violence Centre to launch a campaign in November 2016 to re-establish a shelter. This followed the murder of a woman by her intimate male partner earlier that year, in March, followed in April by an assault on another woman, also by her intimate male partner, that left her disabled. Both women had obtained protection orders earlier in the day of the attacks upon them, and both had been forced to return to their homes in the absence of alternative accommodation.
The deaths of Life Esidimeni’s former patients represent a full-blown symptom of this crisis in care. Its cure does not lie in government’s wholesale appropriation of NGO services, as Yonela Diko argues. Doing away with NGOs will not only result in a significant loss of of skill, knowledge and experience that has little equivalent in much of government, but would also drive the cost of services up, thus further limiting their availability.
What needs to change urgently is the low value attached to those who need care, and the equally low value placed on those who offer care. The report by the National Minimum Wage Panel has already recommended that an expert panel be established to address the pay challenges experienced in the care work sector, including government’s low subsidies. This needs to be implemented as a matter of priority.
Ring-fenced increases to the budgets for NGO welfare services are equally crucial. If these do not start reflecting the true costs of services but continue to treat NGOs as cheap, unskilled labour, then we can only look forward to further variations on Life Esidimeni’s savage themes. DM
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