free state in chains - tac.org.za

FREE STATE IN CHAINSReport back from the People’s Commission of Inquiry into the Free State Healthcare System – 7-8 July 2015

CONTENTSSUMMARY 3

1. Introduction 5

2. Legislation and Background 13

3. The People’s Commission of Inquiry 16

4. A Sample of Testimonies 19

5. Findings & Recommendations 27

Cover: Betty Mabuza testifies in front of the commission about the maltreatment and inadequate care she received while pregnant. Her child was stillborn a month after he had died in utero.

SUMMARY The two-day long People’s Commission of Inquiry into the Free State Health System was held in Bloemfontein, Free State on July 7th and 8th 2015. The inquiry was organised and hosted by the Treatment Action Campaign (TAC) but was set up as a public forum to enable people in the province to give testimony in front of an independent commission of inquiry.

The three commissioners Thembeka Gwagwa, Bishop Paul Verryn and Thokozile Madonko received verbal and written testimony from more than 60 people representing 15 communities in the province. In addition, civil society, activists and healthcare professionals spoke or made submissions to the commissioners. The Free State Department of Health was also invited to testify and to make submissions.

The key findings that emerged from the testimonies were that: 1. The South African government, in particular the provincial Free State government, are

failing to assume their responsibility to protect access to healthcare services, especially for the poor in the Free State.

2. Shortages and stockouts of medication and medical supplies are chronic, endanger the lives and health of vulnerable people across the Free State and discourage people from accessing healthcare and trusting in the healthcare system;

3. The provincial emergency medical services and patient transport systems are characterised by long waiting times, unreliability and indignity—all experienced in the most vulnerable and frightening moments of life for people who depend on these services; and many of the oral testimonies spoke of people having to pay out-of-pocket payments for transport to health facilities;

4. Healthcare facilities in the Free State are often in disrepair and equipment is often broken or unavailable;

5. Insufficient human resources and poor management of human resources prevent the fulfilment of the right of access to healthcare services;

6. Whistleblowing and indeed even candid engagement with the provincial Department on the part of healthcare personnel and/or the public is discouraged and at times met with severe intimidation;

7. There is ineffective, unresponsive and unaccountable leadership, particularly from senior officials in the provincial Department.

8. The provincial Health Department has a history of poor planning, budgeting, expenditure and oversight.

This report acknowledges the dire situation in the province with regard to healthcare. It discusses each of the above findings and offers key recommendations for reform to ensure users of the public healthcare system can access quality services. The commission is committed to working together with communities, healthcare professionals, the provincial government and all other interested parties in order to drastically improve conditions.

FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015 32

1. INTRODUCTION1.1. WHY FREE STATEAccording to the Free State Department of Health, healthcare is one of the key government priorities in the province as well as an essential service, which should be accessible to all living and working in South Africa. The Free State Department of Health delivers healthcare services through four district offices and one metropolitan health area namely Lejweleputswa, Fezile Dabi Thabo Mofutsanyana and Xhariep Districts and the Mangaung Metro to ensure that the district healthcare system is functional. The district offices ensure that the Primary Health Care (PHC) for health services through 210 fixed clinics, 10 community health centres and 75 mobile clinics. Hospital services are provided through 24 district hospitals, 4 regional hospitals, 1 specialised psychiatric hospital, 1 tertiary hospital and 1 central hospital, which are spread throughout the Province.1 The hospitals provide inpatient and outpatient services to the people of the province and the neighbouring areas. According to the Department, in order to ensure a smooth PHC approach, the referral system is implemented through the Emergency Medical Services, which operate an average of 139 rostered ambulances and 70 planned patient transport vehicles. According to the Department’s Annual Report 2013/14, 18 of the ambulances were dedicated to inter-hospital transfers of maternity patients.

1. Annual Performance Plan 2015/2016, Department of Health Free State province. Available here: http://www.fshealth.gov.za/portal/page/portal/fshp/Copy%20of%20FSHP%20Intranet/resource_documents/corporate/business_strategic_plans/resource_centre/Annual%20Performance%20Plan%202015-2016.pdf


According to the Free State Department of Health, the majority of visits to healthcare facilities takes place in rural districts and, as a result, “is one of the major challenges facing the Free State province”.2 The Department in its 2015/16 Annual Performance plan indicated that the “province has had significant challenges in the provision of Emergency Medical Services (EMS) with the low number of rostered ambulances.” In 2013/14 financial year, the province had just 147 ambulances, substantially below the national norm for EMS operation ambulance coverage of 1 ambulance per 10 000 population, which equates to 270 ambulances for the Free State given its population. The Free State has continued year-on-year to have less than half of the required number of ambulances to deliver quality emergency medical care.

The Free State Department of Health reported that in 2013/14 it had an overall vacancy rate of 17.3%. When looking at vacancy rates in permanent posts in district health services; in emergency medical services and in health facilities management, the vacancy rates were 20.1%; 17.6% and 55.6% respectively. The province had 255 pharmacists out of a required and approved number of 460. In 2013/14, 1 108 staff left the employ of the Department with 298 personnel resigning and 378 employees leaving due to expiry of contracts.3

Of concern is that the severe challenges facing the public healthcare system in the province have been previously reported in both the 2007 report of the South African Human Rights Commission4 and in the

2. Ibid.

3. ibid.

4. “Public Inquiry: Access to Heath Care Services”, South African Human Rights Commission, 2007. Available here: http://www.sahrc.org.za/home/21/files/Health%20Report.pdf

2009 Integrated Support Team report5 commissioned by former Minister of Health Barbara Hogan. However, on the face of it, by 2015 little appears to have improved. In addition a number of media articles have also exposed ongoing problems6. The debt of the Free State Department of Health had by 2014 ballooned to over R700 million. As a result, the national Government was forced to put the financial management of the provincial Department under provincial Treasury administration7.

The Free State is home to just under 3 million people and 82% of them rely on public healthcare8. The province has an official unemployment rate of 32.6%, but it’s believed to be closer to 40%9. It falls below national indicators in terms of healthcare and the right of access to healthcare services. It has the lowest life expectancy at birth of out of the 9

5. Free State Department of Health, Report of the Integrated Support Team, April 2009. Available here: http://www.tac.org.za/community/files/bemf/FreeStateIST.pdf

6. See Ground Up, 2015. Available here: http://groundup.org.za/features/freestatehealth/freestatehealth.html and; Mail & Guardian, 2014. Available here: http://mg.co.za/article/2014-07-03-how-a-dying-womans-bed-was-taken-by-anc-official and; Mail & Guardian, 2015. Available here: http://mg.co.za/article/2015-03-19-its-the-free-state-hospital-that-killed-my-husband-frik/ and; Mail & Guardian, 2015. Available here: http://mg.co.za/article/2015-06-12-crisis-what-crisis-africa-check-tests-free-state-health-claims

7. As reported in the Mail & Guardian, 2014. Available here: http://mg.co.za/article/2014-07-11-free-state-health-under-treasury-care

8. Statistics South Africa General Household Survey 2014. Available at: http://www.statssa.gov.za/publications/P0318/P03182014.pdf

9. R75 312 per annum. Statistics South Africa Census 2011 at page 42. Available at http://www.statssa.gov.za/publications/P03014/P030142011.pdf

provinces10 and the third highest HIV prevalence rate at 14%11. In a recent survey the province had the third highest ranking in the country of people who reported that they were “very dissatisfied” with the quality of their public healthcare facilities12.

These indicators speak volumes but they are only one element of what appears to be a growing crisis in the province. Another worrying concern that has emerged over the past few years has been a muzzling of public healthcare practitioners and growing antagonism directed at media from the provincial Department of health. Whilst working on this report the South African Health Review reported that the number of public sector doctors in the Free State had fallen by 24% from 2014 to 201513 – a statistic that whilst shocking, is unsurprising given the testimony we received from doctors at the commission of inquiry.

Civil society has highlighted that the Free State MEC for Health Dr Benny Malakoane continues to face multiple charges of fraud and corruption dating back to 2007 when he was Municipal Manager of the Matjhabeng Municipality14. Whilst we stress that MEC Malakoane has not been found guilty on any of these charges, this clearly has had an impact on the

10. Ibid.

11. Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al. (2014) South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Cape Town, HSRC Press at page 37.

12. A rate of 7.1% following North West and the Western Cape with 10.9% and 10.1% respectively. Statistics South Africa General Household Survey 2014.

13. As reported in Health-E, 2015. Available here: http://www.health-e.org.za/2015/10/21/exodus-of-free-state-doctors/

14. See Treatment Action Campaign, (2014). Available at: http://www.tac.org.za/news/tac-charges-mec-benny-malakoane-corruption-1

trust that civil society and the general public have in his department. It is therefore mentioned here as important context.

Despite a lack of engagement from officials within the Department the media has maintained its focus on the Free State and other entities such as the Democratic Alliance (DA) and the South African Medical Association (SAMA) have also raised concerns around the state of healthcare services in the province15. Civil society and public pressure has also been mounting in the province where the vast majority of people are reliant on the public healthcare system.

Even so, it appears that government has taken very little firm action to engage directly with people, to put in place an action-plan and to remedy problems that range from administrative glitches around stockouts, planned patient transport and the dispatching of emergency services, to low levels of professionalism and lack of caring, to crumbling infrastructure and clinics that are promised but never built.

It is in this highly charged political context that we as the three commissioners were asked to conduct the People’s Commission of Inquiry. The commission was established to provide an open and neutral platform where users of the public healthcare system and other interested parties could testify as to the state of healthcare delivery in the province. Hearings were open to all and broadcast live via an internet stream. As commissioners we aimed to ensure a balanced and accurate report that reflects the lived experiences of the courageous people who came forward to testify. We thank them for their frankness and bravery.

15. See Democratic Alliance press release, 2015. Available at: https://www.facebook.com/DAFreeState/posts/1074583762626886?fref=nf and; South African Medical Association, 2014. Available at: http://www.ofm.co.za/article/Local-News/147937/FS-health-services-sufferring--SAMA


1.3 THE COMMISSIONERS COMMISSIONER THEMBEKA GWAGWA

Thembeka Gwagwa is a professional nurse with 36 years of experience in clinical, education and policy influence/formulation. Her areas of experience include management, lobbying, report writing and negotiations. She led the unification and transformation of nurses and the nursing profession respectively post the apartheid era; a process that led to the formation of the Democratic Nursing Organisation of South Africa (DENOSA). She acted as the founding General Secretary of DENOSA a position she occupied for a solid 17 years.

Gwagwa successfully initiated a process that took South Africa’s nurses back into the fold of internationalism after satisfying the criteria laid in the principles and values of co-operation for the good of all nations. She initiated a structure of nurses in the Southern African Development Community (SADC), SANNAM which is aimed at improving regional health services through strengthening National Nurses Organisations.

She has been appointed by the Minister of Health to serve in different structures that include the Pharmacy Council, Medical Aid Council, the Office of the Health Standard Compliance, Ministerial Task Team to develop a Strategic Plan for Nurse Education, Training and Practice and African Health Profession Regulatory Collaborative for Nurses and Midwives.

Gwagwa was a finalist in 2013 Topco Media Top Women Awards in the individual awards category; awarded by Sigma Theta Tau International Honor Society of Nurses a 2013 Mary Tolle Wright Award for Excellence in Leadership.

COMMISSIONER BISHOP PAUL VERRYN

Paul Verryn is a Minister in the Methodist Church of Southern Africa. He has served in a number of Circuits in the Eastern Cape and Gauteng.

From 1996-2009 he was the Bishop of the Central District of the Methodist Church of Southern Africa.

From 1997 until 2014 he was the Superintendent Minister of the Central Methodist Mission in central Johannesburg. During this time he opened the Church to provide refuge to those who were vulnerable and displaced in Johannesburg. The Church had a significant number of projects and activities under Paul’s leadership including the Albert Street School for Refugee children; a pre-school for children whose parents stayed in the building; a xenophobia monitoring progress; a job bank which saw thousands of skilled people connect with employers across South Africa looking for their specific skills; a wide range of sport and recreation activities, to name a few.

Since 1996 Paul has also been the Superintendent Minister at the Tsietsi Mashinini Community Centre in Jabavu, Soweto. This Centre currently provides a home to over 60 unaccompanied children. The children attend school and are cared for by three child care workers. Approximately a further 100 vulnerable people (single people and families with children) also stay at the Centre.

Paul is also extensively engaged with a large number of communities across South Africa whose members are vulnerable because of poverty; unemployment; lack of accommodation; xenophobic violence; poor service delivery; gender based violence, to name a few. He works with human rights, legal, health, faith based and other organisations to find practical ways of ensuring that needs are met, and that the dignity of those with whom he works is respected.In 2015 Paul has worked with a process initiated through the Church Unity Commission to open

1.2. TERMS OF REFERENCE FOR PEOPLE’S COMMISSION

The TAC initiated this inquiry to investigate and assess the state of healthcare in the province. The Constitution of the Republic of South Africa, 1996 and the National Health Act 61 of 2003 provide for the right of everyone to access to healthcare services. However, evidence both in the public domain and reported directly to the TAC in the province, suggested that in the Free State this right is not being fulfilled and the associated obligations placed on the state are not being met. The problems in the healthcare system had been documented publicly, including in the following:1.2.1. The Mail & Guardian published a feature exposing the health system collapse in the province and makes

allegations implicating the MEC in an “ICU bed for pal” scandal16.

1.2.2. The Stop Stockouts Project (SSP) published a report that indicated there is no improvement in the availability of essential medication in the Free State17.

1.2.3. The TAC had opened a case related to possible corruption by Free State MEC for Health Benny Malakoane, Head of Free State Health Department Dr David Motau, Free State Deputy Director General for Health Teboho Moji and other senior officials in the provincial Department18. The investigation into this matter is ongoing but they are advised it is nearing completion.

It was to determine whether this is the case and, if so, the plans of the Free State Department of Health to stop the rights violations and to meet its obligations, that the People’s Commission of Inquiry into the Free State Healthcare System was held. An independent commission was established to preside over the hearings of the People’s Commission and be responsible for drafting a report outlining key findings and recommendations for relevant stakeholders. The TAC was responsible for convening the hearings and attending to all logistical arrangements. The full “Terms of Reference” for the commissioners is available online19.

16. Mail & Guardian, (2014). Available at: http://mg.co.za/article/2014-07-03-how-a-dying-womans-bed-was-taken-by-anc-official

17. Stop Stock Outs Report, 2014. Available at: http://www.stockouts.org/uploads/3/3/1/1/3311088/stockouts_2014_final_online.pdf

18. Treatment Action Campaign, 2014. Available at: http://www.tac.org.za/news/tac-charges-mec-benny-malakoane-corruption-1

19. Commissioners Terms of Reference, People’s Commission of Inquiry into the Free State Healthcare System, July 2015. See: http://www.tac.org.za/sites/default/files/Terms%20of%20Reference%20-%20Commission.pdf


1.4. METHODOLOGY AND PROCESS ‘Commissions of inquiry’ have long-acted as platforms for individuals to challenge and mobilise against systemic oppression and marginalisation across the world. They are considered independent bodies with the mandate to examine cases of human rights violation upon requests from individuals or civil society organisations. The value of the ‘commission of inquiry’ is the integrity and respect generated from the process and participants. Often successful as a result of their ability to dissect and disseminate findings whilst providing a platform to educate the public. There is an increasingly strong network of such commissions around the world where people gather to make their voices heard, to call for their rights to be realised and their dignity to be restored.20 The issues may be varied but they have a common thread of social justice and of finding solidarity and common ground. The commissions also serve as a platform to form coalitions to share information and to coordinate strategies.

20. For an example the Permanent People’s Tribunal (PPT), which is an international opinion, tribunal founded in 1979, in Italy based on a “Universal Deceleration of the Rights of Peoples”. It looks into complaints of human rights abuses submitted by the communities facing the abuses.

hearings to deal with unresolved issues from the TRC, people who did not get an opportunity to go to the TRC but would like to speak about the past, people traumatised by xenophobia, service delivery protest, poverty, labour and land dispute, women and children who have been violated and abused and other issues that have emerged since 1994.

The specific cooperation of all faith-based organisations is sought in the process of establishing chapters in each Province in South Africa as well as all countries in the SADC region, other than Congo.

COMMISSIONER THOKOZILE MADONKO

Thokozile Madonko is currently the Co-Director of the Alternative Information and Development Centre (AIDC). She was the coordinator of the Budget Expenditure Monitoring Forum (BEMF) and provided technical support to the TAC, SECTION27 and the HIV/AIDS National Strategic Plan Review. Making use of her Master’s in Political Theory, she has worked in the areas of public finance with a focus on health financing and gender responsive budgeting, social justice, national, subnational and parliamentary governance, transparency and accountability. She served as organizer for the People’s Health

Movement South Africa (PHM-SA). She spent four years at the International Budget Partnership (IBP) as a Programme officer for the IBP’s Zambia partnership initiative and was a Trainer/Technical Assistance Provider in the IBP’s training programme. Her love for activism deepened during the four years she worked at the Public Service Accountability Monitor (PSAM) based at Rhodes University, Grahamstown, South Africa, where she worked as a researcher monitoring the performance of the Eastern Cape Provincial Health Department. She holds a Master’s Degree in Political Studies from Rhodes University.

The People’s Commission of Inquiry into the Free State Health System aimed to provide a platform to hear the voices of those accessing public healthcare services in the province. It aimed to make an independent assessment of the realities of healthcare delivery in the Free State from the ground, across a broad cross section of those accessing or working within the public health sector in the province. Through a structured, transparent and inclusive process it aimed to shine a light on people’s lived experiences and show – in their own words– how they are experiencing the Free State public healthcare system.

The process began in May 2015 with a month of community dialogues in the province organised by the TAC. The TAC reached 600 people, in 15

communities, across three of the five districts in the Free State. They collected people’s experiences of using the healthcare system, organised them as testimonies, and then invited people to testify at a public commission of inquiry that would be overseen by three independent commissioners. It was apparent from the outcome of the community dialogues that a full inquiry into the state of health services in the province was necessary.

Many of those reached by the TAC arrived to give their testimonies at this public platform. Many more submitted written testimonies to be analysed by the commissioners. The inquiry was live streamed to enable those who were not able to attend to follow the process and listen to the testimonies.


2. LEGISLATION AND BACKGROUND

2.1. CONSTITUTIONAL AND KEY LEGISLATION

Access to quality healthcare for everyone living and working in South Africa is a constitutional right and the South African government has an obligation to provide it. There are a number of governing acts, regulations and policies that influence the nature and form such delivery should take place at and of what quality. Quality in the healthcare system can be defined as getting the best possible results with the available resources.

The report of the commission has been written within the framework mandated by the Constitution, in addition to the various acts and regulations outlined below.

2.1.1. Constitution of the Republic of South Africa, Act No. 108 of 1996Underpinning the entire healthcare system are the constitutional imperatives enshrined in the Bill of Rights. The South African Constitution Act, 108 of 1996, specifically recognises the right of access to health care in section 27: health care, food, water and social security

i. “Everyone has the right to have access to –a. health care services, including reproductive

health care; b. sufficient food and water; and c. social security, including, if they are

unable to support themselves and their dependents, appropriate social assistance.

ii. The state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights.

iii. No one may be refused emergency medical treatment.”

The Constitutional imperatives set out in the Bill of

Rights cannot be achieved without the collective efforts of all spheres of government. Hence, section 41 of the Constitution requires all three spheres of government to work cooperatively to secure the wellbeing of the people of the Republic, and to preserve the peace, national unity and indivisibility of the Republic. This principle of cooperative government is particularly important in healthcare services, which are a functional area of concurrent competence across national and provincial governments as defined in Schedule 4 of the Constitution.

National government is responsible for developing and monitoring policies, legislation and norms and standards for the health sector. Provincial government can discharge their obligations by passing provincial legislation in the area of health services, but remain responsible for the implementation of national policy and legislation, while local government is responsible for municipal and environmental health functions.


2.1.6. National Core Standards for Health Establishment in South AfricaThe National Core Standards for Health Establishments in South Africa have gone through phases of dev 4elopment based on input from the numerous stakeholders. The document was finally approved by the policy-making body (the National Health Council) and issued by the Minister of Health in February 2011. The purpose of the National Core Standards are to: • Develop a common definition of quality

care which should be found in all health establishments;

• Establish a benchmark against which health establishments can be assessed, gaps identified and strengths appraised;

• Provide for the national certification of compliance of health establishments with mandatory standards.

A subset of these standards, focusing on six critical areas of most concern to patients, has been prioritised throughout the public health system. These areas are: • Values and attitudes; • Waiting times; • Cleanliness; • Patient and staff safety and security; • Infection prevention and control; • Availability of medicines and supplies.

2.2. REGIONAL AND INTERNATIONAL HUMAN RIGHTS INSTRUMENTS

Regionally and internationally South Africa has also committed to frameworks that aim to protect the right of access to quality healthcare. International human rights law recognises two sets of norms relating to healthcare: one relating to the protection of public healthcare and the other, which creates entitlements for individuals and imposes obligations on state. The “entitlements for individuals” norm, which imposes obligations on states forms part of the South African Constitution.21

The Sustainable Development Goals (SDGs)22, to which South Africa has also committed to, are expected to shape the global agenda on economic, social and environmental development for the next 15 years. They will replace the Millennium Development Goals (MDGs), which reach their deadline at the end of 2015. Of particular note are SDG 3 that aims to “ensure healthy lives and promote well-being for all at all ages”, and SDG 16 that aims to “promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels”.

21. For more detailed description of the regional and international legal framework refer to section 2.2 of South African Human Rights Commission report. Available at: http://www.sahrc.org.za/home/21/files/Health%20Report.pdf

22. See more at https://sustainabledevelopment.un.org

2.1.2 The National Health Act, No. 61 of 2003The National Health Act re-affirms the Constitutional rights of users to access healthcare services and just administrative action. As a result Section 18 allows any user of healthcare services to lay a complaint about the manner in which he or she was treated at the healthcare establishment. The Act further obliges MEC’s to establish procedures for dealing with complaints within their areas of jurisdiction.

Complaints provide useful feedback on the areas within healthcare establishments that do not comply with the prescribed standards or pose a threat to the lives of users and staff alike.

The Act highlights the rights and responsibilities of healthcare providers and healthcare users and ensures broader community participation to healthcare delivery from a healthcare facility level up to national level.

2.1.3. Information Act Promotion of Access to Information Act No. 2 of 2000 (PAIA)

Section 32 (1) a of the Constitution of the Republic of South Africa Act 108 of 1996 provides that everyone has a right of access to any information held by the state and any individual held by another person that is required for the exercise or protection of any right. PAIA gives people in South Africa the right to have access to records held by the state, government institution and private bodies.

The following are the objectives which PAIA seeks to achieve: • To ensure that the state takes part in promoting a

human rights culture and social justice; • To encourage openness and establish voluntary

and mandatory mechanisms or procedures which give effect to the right of access to information in a speedy, inexpensive and effortless manner as reasonable as possible;

• To promote transparency, accountability and effective governance of all public and private bodies, by empowering and educating everyone to understand their rights in terms of this Act;

• To understand the functions and operations of public bodies;

• To effectively scrutinise and participate in decision making by public bodies that affect their rights.

2.1.4. National Policy on Quality in Healthcare (2007)A National Policy on Quality in Healthcare was initially developed for South Africa in 2001 and revised in 2007. The policy identifies mechanisms for improving the quality of healthcare in both public and private sectors. It highlights the need to focus capacity-building efforts and quality initiatives on health professionals, communities, patients and the broader healthcare delivery system. The objectives of the National Policy on Quality were to:

• Improve access to quality healthcare; • Increase patients’ participation and the dignity

afforded to them; • Reduce underlying causes of illness, injury and

disability; • Expand research on treatments specific to South

African needs and on evidence of effectiveness; • Ensure appropriate use of services; • Reduce errors in healthcare.

2.1.5. Batho Pele and the Patient’s Rights CharterIn addition to health-specific policies and regulations, Batho Pele principles govern all public services including healthcare delivery. This was an initiative to get public servants to be service-oriented, to strive for excellence in service delivery and to commit to continuous service delivery of public services. These include obligations on public agencies to: • Regularly consult with customers; • Set service standards; • Increase access to services; • Ensure higher levels of courtesy; • Provide more and better information about

services;

• Increase openness and transparency about services;

• Remedy failures and mistakes; • Give the best possible value for money.

The specific commitment of the health sector to this basic policy of government was the development and extensive promulgation of the Patient’s Rights Charter. This specifies that the most critical rights of patients are to be respected and upheld. It also specifies that patients should be empowered to make suitably informed decisions about their health, and to complain if they have not received decent care.


3. THE PEOPLE’S COMMISSION OF INQUIRY

The national anthem, “Senzenina” and a minute’s silence made for solemn salutes to those who have fallen waiting for better healthcare. It also made a fitting kick-off of the People’s Commission of Inquiry.

The mood at the start of the People’s Commission was appropriately subdued, but full of determination and intent from those who arrived – totalling about 200 on each day – to make their voices heard. Community members, some elderly and some clearly unwell, made the effort to be present and engaged over the two days as we heard the testimony of more than 45 people. Those who testified included community members who attended the community dialogues, people who had arrived on the day to tell their stories, as well as healthcare professionals and members of civil society.

The testimonies ranged from patients who had been ill-treated and continue to suffer with their ailments, people who have lost friends and family at the hands of nurses and doctors at provincial public healthcare facilities, community healthcare workers who have watched patients suffer following their dismissal and representatives from community-based organisations who have seen first-hand the impact of dysfunctional systems on the communities they work in. These were emotion-filled pleas and narratives, not simply a catalogue of complaints and gripes.

Also present at the People’s Commission were representatives from the media, political parties, the South African Human Rights Commission, civil society, unions, and members of the Free State Department of Health.

From the outset it was clear that the People’s Commission would be about a brutal honesty, revealing the depths and lingering effects that a failing healthcare system has on people who rely on it. For those who testified, recounting their stories was re-living the trauma of loss and injury, the humiliation of being ill-treated, the indignity of not being afforded any answers, the injustice of no recourse and the hardship of having to make it through another day regardless.

Personal testimony made real the effect of

ambulances that don’t arrive. It’s not simply bungling, it means people’s right to dignity are being violated when they are told to get a wheelbarrow to come to hospital or made to sleep at a pick up spot like a police station almost a day before their scheduled appointments. Worse still when an ambulance fails to arrive it leaves family members to cradle their dying loved ones for hours without medical assistance until the end almost mercifully arrives.

These were the stories of stockouts not as an empty clinic cupboard or a blank entry on a ledger. This was people resorting to taking only a portion of their medicines or having to spend pensions, grants and borrowed money to buy life-sustaining medicines in the hope that at their next appointment there would be medicines for them.

It was the testimony of misery for community healthcare workers stripped of their jobs, losing their R1400 stipend they relied on to survive. Worse still, their axing has meant the patients they served and assisted for years have slipped up on their prescribed medical regimes, have been left weakening or even died.

These were the stories of elders desperately ill but reluctant to return to clinics and hospitals because of how they’ve been disrespected and ridiculed by nurses and doctors. In one hospital a man reflected on how ashamed he felt when he saw women who could be his mother, grandmother or sisters being asked to lift their skirts in hospital corridors to be examined by a doctor.

Unfortunately, although representatives of the Free State Department of Health were initially present at the hearings, following a disruption early on the first day the officials chose to leave. To our knowledge, there was no-one from the provincial Department of Health to hear the testimonies.

Despite the regrettable absence of the provincial Department of Health, the testimonies nevertheless

continued. Commissioner Thokozile Madonko said addressing the audience: “It takes many trees to create a forest and every testimony we have heard is a seed”, it summed up one of the most important aspects of the Commission: recognition for people’s stories and for possibilities in the process to set in motion momentum for change. As commissioners we acknowledge and recognise the desperate situation that exists in the province and the country. We have taken to heart people’s deep hurt.

As a result of a collapsing healthcare system many people had lost loved ones and people who they called members of their families and communities. They recognise that the failings are not isolated to the Health Department but span many sectors of the government and public service.

The inquiry represents an opportunity to collectively turnaround a healthcare system that has slipped to its lowest point and needs to be rescued. Commissioner Bishop Paul Verryn spoke of the need for collective healing and to afford people counselling. Importantly he stated that the People’s Commission should be a call to mobilise and organise. He said in this way communities will be able to stand firmer and stand united to bring their plight to the authorities. “With due respect, I don’t believe the government will be able to fix this quickly, or to fix this on its own. We

must be able to use our collective networks in faith-based organisations, in business and in NGOs to start bringing back dignity in the healthcare service,” he said. He said people who testified at the Commission already understood the power of standing together. Verryn said: “We have heard the people and we have heard from people who came to the Commission to take responsibility for others – it’s not a case of ‘my story’ but of a story that is all of ours.”

The time for denial of the extent of the problem is over and so is the time for finger-pointing. Having said this though we stress that people still need answers to many questions and discrepancies of how the Free State Department of Health is run.

Commissioner Thembeka Gwagwa said: “We are all South Africans and we have freedom of speech and freedom of association. We should remember that people, even those who left the Commission on the first day [the officials from the Department of Health], must come forward and speak and they should be reminded that we are keen to listen, we want to hear everyone’s voice.” She stressed though that it was disappointing that the authorities and the MEC were not present at the inquiry. “It’s a pity, because if they were serious about taking part they would have come to us as the panel of commissioners and indicated to us that they wanted to speak and make a submission.


4. A SAMPLE OF TESTIMONIES

Below are the stories of some of the people who arrived to give testimony to the People’s Commission of Inquiry. Many more were heard and the complete transcript of oral testimonies (as well as the audio recordings), written testimonies, and organisational submissions will be available online. No one story is more serious than the other. They stand as separate experience but reflect the burden of healthcare failure that people of the province carry collectively. They are indicative of a healthcare system in peril that needs urgent and serious intervention in order to protect the right of people to access quality healthcare.


4.2. INDIVIDUAL TESTIMONY VELI RGADEBE, HARRISMITH

Veli Rgadebe is a doting grandfather; he loves two-year-old Melokuhle. But much as he wishes all that’s wonderful in the world for her, he knows she will never have one of the most precious things: she’ll never know her mother Thandeka.

Thandeka died when Melokuhle was just three months old. Veli Rgadebe will never forget the days leading up to his 22-year-old daughter’s death. It’s what’s brought him to the People’s Commission of Inquiry.

The Harrismith local’s testimony is of the callous attitude of nurses, ‘too busy to give his child oxygen’, ambulances that never arrive, bureaucracy, bullying and no one with answers or willing to take responsibility.

It started after his daughter had a Caesarean section. Thandeka started coughing badly and Rgadebe ended up taking his daughter to the Thebe Hospital near their home. But doctors there only see patients between about 8am and 1pm, says Rgadebe. This is the case despite the fact that people arrive hours before to be in the queue and despite the fact that there are still people in the queue after lunch hour.

“The nurses just told me ‘you can write your complaints in the book’ when I complained,’ says Rgadebe.

He took his daughter to a private doctor, someone he identified as “Dr Lucky”. Her symptoms were no longer just coughing. His child was weak, unable to walk or to lift herself up from a prone position.

“Dr Lucky told us to take her to the hospital and said we should call an ambulance, but the ambulance never came. In the end Dr Lucky took us there himself because he knew that she might die,” says Rgadebe.

He adds: “When we arrived at the hospital I asked for a wheelchair and some help to carry my daughter from the car. The nurses pointed to the wheelchair and told me I had to abide by her rules or leave the hospital.

“When I asked her for something to help my daughter breathe, she said she was busy and I would have to wait – she was too busy to give oxygen for my child to breathe.”

Finally a doctor appeared. Rgadebe complained to him and all he did was to give him a number for the hospital where he could lay a complaint. While the doctor saw to Thandeka, Rgadebe tried to lay a complaint, the supervising nurse who was had bullied Rgadebe simply disappeared.

Moments later though the doctor reappeared. “He said who is the father of this child and when

I said it’s me, he told me he wanted to talk privately with me. My daughter had passed on. That is how it ended.”

4.1. INDIVIDUAL TESTIMONY BETTY MABUZA, WELKOM

Talking about the child she lost isn’t easy for Betty Mabuza. The 31-year-old says some days she manages to talk about the baby boy, who would have been her second child, without a tear falling. Most days though she crumbles in a heap of heartache and despair. “Sometimes I am at the PEP Stores and I see all the baby clothes they have and I can’t help thinking about him,” says Mabuza, breaking down. It’s only five months since the ordeal of losing her child.

Mabuza gave testimony even though she knew it would stir up raw emotions. But she wanted to be heard. She says she knows she should have been given better care and she knows that had nurses and doctors done better, her boy would have been given a fighting chance.

Mabuza arrived at the Commission as part of the Welkom delegation giving testimony on day one. She’s a resident in Tshepong, near Odendaalsrus.

Speaking through an interpreter, she said: “I fell pregnant last year and by February this year I had done my whole nine months. I was last at the Tshepong Clinic in February with pains but the sister told me she couldn’t transfer me to Bongani Hospital because my tummy was inconsistent – sometimes big and sometimes small. They just gave me medication and told me to go home.”

Days later though she felt pains she couldn’t understand so she returned to the clinic. At the clinic she was made to wait and nurses told her her appointment dates were wrong and simply told her to walk to hospital if she wanted help.

“I started to walk home. On the way I did a call-back to my mother and when she phoned I said to her ‘Mama I think I’m about to give birth, but I’m still walking’. I just had to walk and pray. I begged God,” she says.

Tears roll down Mabuza’s cheeks. She made it home and got to the Bongani Hospital that morning. But it was here that she would undergo more humiliation and maltreatment, she told the commission.

“When I got to the hospital the sisters told me to sit and wait and I waited for hours in pain. It was after 3pm in the afternoon when they took me to a bed and they told me to sit upright. I was checked by more than 10 nurses and they all said they could feel nothing and said there weren’t any problems and I should wait for the doctor,” she says.

When the doctor arrived though, he had the most devastating news for her. “He looked at me and told me to just rest and sleep on the bed. Then he examined me and he looked me in the eyes and said angrily ‘What does it mean if the baby’s heart is not beating?’. I just kept quiet,” she remembers.

Then the doctor said to her ‘This child you are carrying has been dead since January’. Repeating these words leaves Mabuza sobbing.

It wasn’t the end. She was left in the room alone, even as labour had started. She says: “A nurse came in and just said ‘are you able to give birth on your own?’. I knew I couldn’t and only later when I looked down and the head of the baby was already coming out, did the nurses come to help me.

“I pushed so hard I thought I was going to die. They showed me my baby, it was terrible, my child was rotten,” says Mabuza, choking back tears.

Worse still, straight after the trauma of the process, nurses made her wait in the corridors, without counselling, a kind word and or bathing her. It was only when the nightshift nurses arrived on duty that she was bathed.

The day in hospital was months ago, but the sadness hasn’t left her. Her pain and trauma remains. She says: “I don’t eat a lot, I think about him a lot. I think that if my child could be dead inside of me for so long then I should die too.”

“When I asked her for something to help my daughter breathe, she said she was busy and I would have to wait – she was too busy to give oxygen for my child to breathe.”

“They showed me my baby, it was terrible, my child was rotten.”


4.3. INDIVIDUAL TESTIMONY MELANIE*

Melanie arrives at the People’s Commission of Inquiry with a request for her identity to be protected. She’s a rape survivor but her attackers are still walking free, it makes her anxious, even two years after the crime took place.But fear or no fear, Melanie wants to share her story because she feels she was failed by the healthcare system in her province and the police who were supposed to help her through one of the darkest experiences in her life.

She tells the Commission: “Things went bad from the start. After I was raped the police found me but no ambulance took me to hospital. It made me really mad because I could have been badly injured. There was an EMS guy there but he said he wouldn’t take me to hospital because he could lose his job because I was ‘walking evidence’. So I just stood there waiting.”

Melanie says eventually an investigating office arrived on the scene. His instruction then was for her to go to the rape centre and he would go fetch the rape kit.

“When I got to the centre I couldn’t walk and there were no wheelchairs, eventually one of my friends carried me in. That is where everything went wrong – from the beginning.

“While I waited, I needed to go to the toilet. The nurses didn’t tell me what to do. They didn’t give me anything to wipe with to keep the evidence. They tested me for HIV then sent me to a room to wait for the rape kit. I sat in dirty clothes, covered in blood. No one assisted me because they said there was nothing they could do till the rape kit got there.”

Three hours later the investigating officer arrived with the rape kit. The nurse who attended to Melanie admitted she wasn’t qualified to do the necessary sampling for the rape kit but said she had to do it because there was no one else on duty.

“That is when I experienced secondary trauma. The nurse did more damage to me internally because of how she handled the swabs. To tell you how badly she did her job – three days after the rape I was walking with another rape survivor and needed to go to the toilet. When I went to the toilet a piece of the nurse’s glove came out of me.”

She would have to endure more from policemen who were not conscientious, tardy and just didn’t follow basic protocol. Melanie says she received the same kind of treatment from the nurses at the rape centre.

“I had to tell a man my story in a small room and that was uncomfortable for me. Nobody took my clothes even though I knew there was probably semen on my jeans. I put my clothes in a brown paper bag and sealed it. I also had to fight for them to take samples from under my nails and from the blood on my face, because I knew some of it was probably not mine,” Melanie says.

Melanie’s family did complain and told their story to media. But when the authorities said they’d investigate they said that her case was “dealt with according to the books”.

“I know that this is not acceptable; the system failed me. I feel that if they did everything right at the rape centre and if the investigating officer did things the way he was supposed to that my rapists would be behind bars now.”

*Name has been changed to maintain anonymity

4.4. INDIVIDUAL TESTIMONY QUEEN NTSIENG, THABA NCHU

It’s been a tough year for Queen Ntsieng. The Thaba Nchu resident has watched loved ones get ill and die and all along she’s received no help from the healthcare professionals who were supposed to come to her aid.

Her testimony at the Commission was sadly a mirror to the multiple tragedies that so many families have to endure. She started by telling a story involving her brother who was injured on a Sunday night in March last year in a car crash.

“He was on his way to work. I got a phone call from Pelonomi Hospital in Bloemfontein that day. They said that only family members must come to the hospital. I took my brother’s child and went to Pelonomi that day.

“My brother was in ICU. I heard that there were six people in the accident, four people died and only the driver and my brother survived,” says Ntsieng.

Her brother was in a lot of pain and had injuries to his head and neck. But nurses told Ntsieng there were no beds and that her brother could not stay.

“They told us to go home and come back the following day,” she says.

They made their way back home having to catch a taxi and then a bus to make the hour-long drive home, back to Thaba Nchu. The next morning she took her brother to the local Moroka Hospital in Thaba Nchu. She was scolded by nurses who said her brother should never have been discharged and they said his injuries were so bad he had to be treated at the bigger Pelonomi hospital.

Ntsieng tried to use the planned public transport to get to Pelonomi but that failed.

“The driver said he couldn’t take us because I didn’t have a letter from my clinic. I told him that we had come in very late and the clinic was closed and he said it wasn’t his problem and he wouldn’t take us without a letter,” she said.

She took her brother home and went to her local

clinic to try to arrange a letter to get to the hospital in the province’s capital city. Between being shouted at again, she didn’t get a letter and returned home to care for her brother herself.

“Now my brother just sits at home. He complains about his neck all the time.”

But it wasn’t the end of the sadness for Ntsieng. In April last year, just a month after what happened

to her brother, her mother took ill. “I wanted to take my mother to the clinic but she

didn’t want to go there. She said the nurses were rude to her. She asked me to take care of her instead. She was okay, but by June she got sick again and I realised she was very sick,” she said.

On 2 July Ntsieng’s mother’s condition had worsened and she knew she had to get her mother to a hospital. She called an ambulance at 4pm and kept calling back for the next five hours because no ambulance arrived. Every time she called they just said please hold on. Then when she had waited till 11pm and no ambulance arrived she tried again and was told that there were no ambulance at that time of night for Thaba Nchu.

Her mother could not move and desperate Ntsieng raised a neighbour who had a car. “The neighbour came but didn’t want to transport my mother because he was scared her mother would die in his car. He just told me to hold on till the morning and to try to call the ambulance again in the morning.”

Ntsieng sobbed quietly managing only to find her voice to say that at 2am the next morning her mother died in her arms.

“When I went to the toilet a piece of the nurse’s glove came out of me.”

Every time she called they just said please hold on.


4.6. CIVIL SOCIETY TESTIMONY DR PRINITHA PILLAY, RURAL HEALTH ADVOCACY PROJECT (RHAP)

Dr Prinitha Pillay knows that constraints and challenges in the healthcare system costs lives. Speaking at the Commission she started her testimony affirming the realities of the patients reliant on a failing healthcare system.

She called the current situation that disadvantages the most vulnerable in society as a kind of medical apartheid – where if you’re poor, black and especially if you live in a rural area you will not have access to quality, free or affordable healthcare.

“We as the RHAP are informed by patients, communities and healthcare workers. We have heard about the impact for rural people of things like a shortage of medicines, no equipment, long waiting times, ambulances that fail to arrive. People have lost confidence in our healthcare system,” she said.

Pillay said the dwindling resources for healthcare have also added to the problem. She said healthcare budgets are being squeezed and that the allocation of funds to healthcare in the Free State does not match the growing demand. She also said that money has not been spent properly in the province and that clear under-spending has also been noted by the RHAP.

“The Free State Department of Health is getting less money from national. It means that less is being spent on things like laboratory testing for viral loads and drug-resistant TB.

“The budget is going down, but the need for healthcare in the province is going up – there’s a clear disconnection,” she said.

Pillay had also quoted doctors and nurses that RHAP had spoken to and she also delivered these to the Commissioners.

From one doctor: “Stockouts are a major problem. I have to prescribe medicines that patients have to buy from a private pharmacy, but some of the patients can’t afford it.”

Another doctor said: “Healthcare workers

have simply lost their work ethics because of the challenges they are facing.”

Pillay also quoted another doctor who said: “Most of my colleagues feel intimidated, we don’t speak out, we don’t voice our concerns.”

And another who said: “I’m expected to save lives but at the moment I feel powerless – I have handed in my resignation.“

Morale and job satisfaction already are at obvious low points and Pillay said added to this is human resource capacity with the Department of Health keeps on dropping.

“It’s difficult to fill these positions in rural areas and to attract doctors and nurses to rural areas – there’s no accommodation, no schools, no roads,” she said.

But having said this Pillay also stood up for those nurses and doctors who are doing their best under really difficult conditions. She said: “There are some really good nurses and doctors, but they don’t have what they need to do their jobs. Everyone is frustrated.”

Pillay said the answer lies in patients and healthcare workers communicating more and working together. Even though the fear of victimisation and threats to people’s job security are a reality she said the situation need more people to speak out about a system that is doing more harm than good.

“Imagine if we didn’t say anything about the fact that there were no ARVs in 2004, we wouldn’t be here today where people are able to access medicine.

“But the situation now is bad. We must speak out,” she said.

4.5. HEALTH WORKER TESTIMONY PATRICK MOTLAUNG, PETSANA

Patrick Motlaung from Petsana is a pharmacist and he calls himself one of MEC Benny Malakoane’s victims. He told the Commission he was retrenched and there were promises that he would have a job.

The job that he has now though is writing prescriptions at a clinic and he’s paid R5 for every prescription that he writes. He said: “I’m a breadwinner so you imagine for yourself what you can buy for R5.”

Motlaung who works with other healthcare workers said the reality is that bad attitudes and rudeness from nurses does often come from the fact that they work under extreme pressure.

“For me, you can’t prescribe medicine that isn’t available and you know that you’re not supposed to tell the patients that the medicines are not available. It is difficult when we can’t answer patients,” says Motlaung.

Motlaung said he felt part of the problem is as a

result of Malakoane’s failure to truly understand the situation on the ground.

“The clinic committees are taken for granted and the people are never consulted and we are not supported,” he said.

He added that this problem has been compounded by the axing of community healthcare workers and lay councillors.

“Malakoane should re-employ these people because lay counsellors and CHWs are the people who can help this thing run smoother. People in rural areas are dying. Poor black people are dying in this country and it’s now a case of survival of the fittest,” he said.

“People in rural areas are dying. Poor black people are dying in this country and it’s now a case of survival of the fittest.”

“I’m expected to save lives but at the moment I feel powerless”


5. FINDINGS & RECOMMENDATIONSThe findings of this report are based upon the following evidence presented to the Commission:

5.1 Verbal testimony of individuals, healthcare professionals, civil society and other interested parties presented at the People’s Commission of Inquiry23;

5.2 Written testimony of individuals, healthcare professionals, civil society and other interested parties presented ahead of and during the People’s Commission of Inquiry24;

5.3 The 2007 report of the South African Human Rights Commission titled “Public Inquiry: Access to Health Care Services”25;

5.4 The 2009 report of the Integrated Support Team26 that undertook a rapid review of the Free State Department of Health in March 2009;

5.5 The 2015 report of the Stop Stockouts Project (SSP) that indicated there is no improvement in the availability of essential medication in the Free State27;

5.6 Various recent media articles outlining problems in the provincial health system including an open letter by doctors in the Free State as documented on the Ground Up website and coverage by the Mail & Guardian pertaining to the healthcare system in the province.

The evidence presented to the commission reflects serious shortcomings within the Free State public healthcare system that must be urgently addressed. The healthcare system is not functioning in a way that is ordinarily understood as operational. Instead it is failing those people who rely on it. The challenges found in the Free State are persistent. Little visible change has been made since the investigations made by both the South African Human Rights Commission and the Integrated Support Team. In fact, it is plausible, and even likely, that the situation has gotten worse since the publication of those two reports.

23. Available at: http://www.tac.org.za/news/evidence-submitted-peoples-commission-inquiry

24. Ibid.

25. “Public Inquiry: Access to Health Care Services”, 2007, South African Human Rights Commission. Available at: http://www.sahrc.org.za/home/21/files/Health%20Report.pdf

26. Free State Department of Health, Report of the Integrated Support Team, 2009. Available at: http://www.tac.org.za/community/files/bemf/FreeStateIST.pdf

27. Stop Stock Outs Report, 2014. Available at: http://www.stockouts.org/uploads/3/3/1/1/3311088/stockouts_2014_final_online.pdf


Finding 2 Shortages and stockouts of medication and medical supplies are chronic, endanger the lives and health of vulnerable people across the Free State and discourage people from accessing healthcare and trusting in the healthcare system.28

* As indicated in Oral Testimony 2, 3, 4, 7, 10, 18, 22, 26, 29, 31, 32, 35, 45; and Written Testimony 1, 7, 11, 12, 14, 16, 17, 20, 21, 22, 24, 26, 27, 28, 29, 34, 38, 39, 43, 47, 48, 53, 56, 58, 59, 61

RECOMMENDATIONS 2.1. That the provincial Department of Health implement the recommendations made in the 2014 Stock Outs Survey

in South African Second Annual Report.29 Namely:

2.1.1. The Provincial Department of Health follow example set by the National Department of Health and the Limpopo, Gauteng, Northern Cape, North West and Western Cape provincial Departments of Health and engage with civil society on causes of stock outs and potential solutions to improve the supply chain.

2.1.2. That the Department take urgent action to address those facilities in Fezile Dab Lejweleputswa District reporting ARV and TB stockouts where close to 42% (13/31) facilities have reported ARV/TB stockouts.

2.1.3. That the provincial Department develop and implement a provincial action plan to resolve and prevent stockouts in the province, with clear timelines and evaluation of these action plans and provision for emergencies, and focus on the worst hit districts.

2.1.4. That the National Department of Health in collaboration with the provincial Department of Health establish and implement national minimum standards for supply chain management and resolution of stockouts.

2.2. The provincial Department of Health in collaboration with the Provincial Treasury adequately cost the provision of pharmaceuticals in the province. According to the provincial Department of Health the unavailability of medicines in the provinces is due to “declining provincial allocation and increasing price of medication, including the increasing patient numbers”.30

2.3. That the Department as a matter of urgency address the current shortage of pharmacists in the province and ensure that it has the required funding to fill these positions in the province. 31

Finding 3 The provincial emergency medical services and patient transport systems are characterised by long waiting times, unreliability and indignity—all experienced in the most vulnerable and frightening moments of life for people who depend on these services; and many of the oral testimonies spoke of people having to pay out-of-pocket payments for transport to health facilities.32

*As indicated in Oral Testimony 2, 5, 7, 8, 10, 12, 13, 14, 15, 19, 26, 27, 29, 35, 37, 39, 43, 45; and in Written Testimony 5, 7, 8, 11, 14, 15, 22, 23, 25, 30, 32, 33, 44, 45, 47, 52, 55, 59.

RECOMMENDATIONS 3.1. That the Free State Department of Health, as a matter of urgency, address the current shortage in ambulances

in the province in order to meet the national norm of 1 ambulance per 10 000 population; 3.2. That the Department with the support of Provincial Treasury undertake a full costing of the provincial EMS

programme;3.3. That the Department must review its Planned Patient Transport programme to ensure that patients have access

to transport to and from health facilities to prevent unnecessary out-of-pocket payments. This will also help to strengthen service at the district level and ensure the referral system between facilities is accessible to patients thereby effectively operationalising the primary health care approach;

3.4. That the Department must take the necessary steps to address the shortage in emergency medical personnel by filling all vacant posts. 33

3.5. The provincial Department of Health must cut red tape and bureaucracy – people are being shunted between one facility and the next unnecessarily because of processes that do not work. These include a muddled patient referral process, poor planning for patient transport and mismanagement of the deployment system for ambulances.

The delivery of healthcare in Free State, as with the rest of the country, requires strong leadership and political will. However instead we found an abdication of responsibility of the provincial Department of Health. The fact that provincial health officials were absent for a process that seeks to address challenges facing their own department indicates that the political will to repair the system is lacking. This lack of political will cannot be judged in any other way other than being irresponsible of political leadership. If this is the cause of substantial numbers of deaths in the province, then we are concerned about potential crimes against humanity.

We as the panel of commissioners call on government to respond decisively to the issues that need urgently addressing, as highlighted in this report. Responding decisively is firstly to acknowledge people’s hurt and injury and the continued suffering they must bear being dependent on the healthcare system in the Free State. Secondly it is the acknowledgement that the situation as it is must be turned around with a firm, time-bound action plan that provincial government must and will take the lead on.

At the same time, we reassure government that you will be supported and assisted. The time for pointing fingers or laying blame is over. The people, opposition parties and civil society as a collective want to and will support action to rebuild and turnaround the provincial healthcare system for those who need it most.

As Commissioners we recognise that this report could potentially be regarded as too critical and alienating. However, we would plead that above all we try and keep open the doors of dialogue for the sake of the most vulnerable. We want to ensure officialdom of our commitment to cooperating rigorously with them, again for the sake of the most vulnerable.

Ultimately this report of the People’s Commission of Inquiry is a public document. It is public testimony, which the authorities must take seriously if it is serious about putting people first, about turning around a failing system and committing to unshackling this province to make it one that truly serves its citizens.

Based on our findings, we as the commissioners of the People’s Commission of Inquiry recommend the following:

Finding 1 The South African government, in particular the provincial Free State government, are failing to assume their responsibility to protect access to health care services, especially for the poor in the Free State. *As indicated by all the evidence presented to the Commission.

RECOMMENDATIONS: 1.1. That a national task team should be established by the National Department of Health to investigate the

findings of this report in the context of the 2007 Human Rights Commission report and the 2009 IST reports; 1.2. That the parliamentary Portfolio Committee on Health must hold the national and provincial executives to

account based on our findings and recommendations and demand that the national task team completes its work swiftly and thoroughly and without political interference;

1.3. That the South African Human Rights Commission should, as a matter of urgency, return to the Free State and investigate how the situation has changed since their 2007 report;

1.4. That the Free State Department of Health establish a provincial task team to deal with the challenges outlined in our findings and openly involve community and civil society in this process. The Department must commit to fixed timeframes for this process. The Department must respond comprehensively to the issues outlined in this document within a fixed period. It must show its commitment to move forward by setting transparent targets and deadlines to meet its goals.


Finding 6 Whistleblowing and indeed even candid engagement with the provincial Department on the part of healthcare personnel and/or the public is discouraged and at times met with severe intimidation38. *As indicated in Oral Testimony 10, 22, 26, 32, 45; and in Written Testimony 59

RECOMMENDATIONS6.1. The National Department of Health must ensure that there are safe mechanisms for staff within the provincial

Department of Health to provide the necessary information to ensure that staff and patients are able to communicate their experiences of the health care system in the Free State;

6.2. That the provincial government must listen to the people and create a system of communication that takes management teams out of their offices and back into the community to communicate with the people and to see first-hand and to listen to their needs and concerns on a regular basis.

Finding 7 There is ineffective, unresponsive and unaccountable leadership, particularly from senior officials in the provincial Department.39

*As indicated in Oral Testimony 5, 7, 12, 25, 26, 28, 30, 36; and in Written Testimony 11, 58, 59

RECOMMENDATIONS 7.1. That the MEC for Health and other responsible individuals including the Head of Department be held

accountable for the failings in the healthcare system in Free State. It is essential that those in positions of power set higher standards of professionalism and respect for patients.

Finding 8 The provincial Health Department has a history of poor planning, budgeting, expenditure and oversight.*As indicated in Oral Testimony 5, 6, 10, 11, 28, 36, 39, 40; and in Written Testimony 16, 18, 31, 41, 48, 50, 58, 59, 60, 61

RECOMMENDATIONS 8.1. That the Free State Department of Health must take action to show people what the annual budget is per clinic

and facility. These notices should be displayed clearly at all facilities to be monitored by those who use it;8.2. The Department must ensure that the role of clinic committees and other structures includes monitoring of

resources meant to ensure the proper running of health facilities, and that these structures be re-enforced by the provincial Department.

Finding 4 Healthcare facilities in the Free State are often in disrepair and equipment is often broken or unavailable34

*As indicated in Oral Testimony 8, 7, 22, 26, 28, 31; and in Written Testimony 3, 34, 46, 48, 49, 53, 58, 59

RECOMMENDATIONS4.1. In line with the recommendations made by the SAHRC in 2007, the Department must ensure that there is

adequate funding and personnel to ensure that health facilities are maintained, fitted with the appropriate technology (medical equipment, ICT equipment, access to internet etc.) in order to address the compromised ability of facilities to provide both an adequate environment to staff and to health care users.

4.2. The Department in conjunction with the Department of Public Works strengthen the Infrastructure Unit (engineers, maintenance crew, quantity surveyors, quality control) to address backlog maintenance, routine maintenance and the building of new health facilities and to prevent any unnecessary under expenditure of the Health Infrastructure Grant.

Finding 5 Insufficient human resources and poor management of human resources prevent the fulfilment of the right of access to healthcare services35

*As indicated in Oral Testimony 2, 3, 4, 5, 7, 9, 10, 11, 13, 14, 15, 16, 17, 19, 20, 21, 23, 24, 26, 27, 28, 29, 33, 34, 37, 38, 40, 43, 44; and in Written Testimony 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 17, 19, 23, 31, 35, 36, 40, 42, 46, 48, 49, 51, 52, 53, 55, 57, 58, 59, 60

The findings of the 2012 National Health Care Facilities Baseline Audit (the “Audit”)36 corroborate the communities’ portrait of human resources shortages in the Free State. The Audit notes the lack of national human resources norms as a major impediment to proper staffing and thereby the fulfilment of the right of access to healthcare service. The lack of national norms persists today.

At the provincial level, the Audit measured compliance with six “Priority Areas on Vital Measures.” Free State healthcare facilities were on average only 44% compliant with the priority area measuring whether staff demonstrate a “positive and caring attitude” and only 57% compliant with requirements related to “waiting times.”37

RECOMMENDATIONS5.1. That the Free State Department of Health as a matter of urgency must address the numerous human resource

issues, problems and challenges, including those related to staff shortages and the impact thereof on the provision of quality health services;

5.2. The Department must address the Report of the Auditor General year ended 31st of March 2013 and ensure that there is a human resource plan in place, that vacant posts are filled within 12 months and that an organisational structure be in place based on the Department’s strategic plan;

5. 3. That the provincial Department of Health carry out investigations into each allegation made in the verbal and written testimonies with regard to health personnel failures – including neglect and bad attitudes – and that following this investigation disciplinary action be taken where appropriate and compensation be paid out to victims of neglect or ill-treatment;

5.4. That leaders at the provincial Department of Health must better listen to staff – working conditions for nurses, doctors, paramedics and ambulance drivers are far from ideal. Senior officials must communicate better with them to understand the failings in the system and to rectify this with better planning, on-going training, support and adequate facilities and supplies in the clinic and hospitals where they work;

5.5. That better staff support systems should be put in place by the provincial Department of Health. Staff are aware of the constant projection of failure on the health system and are sensitive to the fact that ultimately healthcare workers themselves become victims to the system and are alienated from what they know to be proper professional conduct. These people do not go into this job by mistake – they go in because they care about individuals. However they are constantly promoted into failure because they do not have the time, tools, or medicines in order to do their job properly. Therefore support systems must urgently be put in place that deal with the systemic psychological and social malfunction of the entire system of healthcare in Free State. Often staff do not treat people properly due to stress, exhaustion, and burn out as a result of the malfunction in health system. Therefore wellness sessions and psychological evaluation relating to suitability should be set in place;

5.6. That the National Department of Health must rapidly finalise and clarify its national community healthcare worker policy, and a transparent plan to re-employ the Free State community healthcare workers under dignified and formalised working conditions must be set in place by the provincial Department of Health.


“plan, manage and develop human resources for the rendering of health services

» Section 25(3) places an obligation on the HoD to “prepare strategic medium term health and human resources plans annually” and “submit such plans to the Director-General”.

» Section 27(1) places an obligation on the provincial health counsel to advise the MEC as to “human resources planning, production, management and development.” It is unknown if such advice was provided and, if so, whether the MEC considered the advice,

• A lack of commitment to implementation of the Department of Health’s Human Resources for Health Strategy for the Health Sector 2012/13 – 2016/17, particularly as it pertains to task shifting and primary healthcare.

• Rights in terms of the Labour Relations Act 66 of 1995, including the right to not be unfairly dismissed or subjected to an unfair labour practice in terms of section 185 (see also, in regard to Community Healthcare Workers, the presumption as to who is an “employee” in terms of section 200(a))

• Obligations and rights in terms of the Basic Conditions of Employment Act 75 of 1997, including

» Obligations related to timeous payment of renumeration (section 32)

36. Available at: http://www.hst.org.za/publications/national-health-care-facilities-baseline-audit-national-summary-report

» Rights of employees and the protection of these rights (section 78 and 79)

37. Compliance is gauged according to a tool and methodology described in detail in the Audit.

38. THE CIRCUMSTANCES IN FINDING 6 INDICATE:• Breaches of:

» Constitutional rights to freedom of expression; to assembly, demonstration, picket and present petitions; and to campaign for a cause in terms of sections 16, 17 and 19 respectively.

» Constitutional values of “accountability, responsiveness and openness” in terms of section 1.

» The requirement that “people’s needs must be responded to, and the public must be encouraged to participate in policy making” in terms of section 195(1)(e).

» The requirement that “transparency must be fostered by providing the public with timely, accessible and accurate information” in terms of section 195(1)(g).

» The requirement in terms of section 195(1)(a) that “a high standard of professional ethics must be promoted and maintained”.

• Breaches of section 18 of the NHA, providing that “any person may lay a complaint about the manner in which he or she was treated in a health establishment and have the complaint investigated” and that the MEC must establish a procedure for the laying of such complaints.

• A failure to implement the National Complaints Management Protocol.

• Undermining of the Protection of Disclosures Act 26 of 2000 and violations of the duty to not subject whistleblowers to occupational detriment.

• Violation of obligations in the Intimidation Act 72 of 1982 to not compel a person to do or refrain from

doing something through assault, injury or the threat of assault, injury, death or damage to persons or property.

• Undermining of the duties of health workers as provided in

∙ the professional ethical codes of health workers; ∙ the Protection of Disclosures Act; and ∙ the Practical Guidelines for Employees in Terms of

section 10(4)(a) of the Protected Disclosures Act, which provide, inter alia, that “By remaining silent about corruption, offences or other malpractices taking place in the workplace, an employee contributes to, and becomes part of, a culture fostering such improprieties which will undermine his or her own career as well as be detrimental to the legitimate interests of South African society in general.”

39. THIS CRISIS IN LEADERSHIP AS OUTLINED IN FINDING 7 INDICATES:

• A failure to uphold Constitutional values of “accountability, responsiveness and openness” in terms of section 1.

• A violation of the requirement that “people’s needs must be responded to, and the public must be encouraged to participate in policy making” in terms of section 195(1)(e) of the Constitution.

• A violation of the requirement that “transparency must be fostered by providing the public with timely, accessible and accurate information” in terms of section 195(1)(g) of the Constitution.

• A failure by the HoD to comply with obligations in terms of section 25(2)(t) of the NHA to promote community participation in the planning, provision and evaluation of health services.

• A failure to implement the Human Resources for Health Strategy for the Health Sector 2012/13 – 2016/17, particularly as it pertains to improved leadership and management

FOOTNOTES TO RECOMMENDATIONS28. THE CONDITIONS IN FINDING 2 INDICATE:

• Violations of the right of access to health care services in terms of section 27 of the Constitution.

• A failure to comply with obligations in terms of the National Health Act 61 of 2003 (“NHA”) to provide health care services, specifically:

» Section 25(1) places an obligation on the MEC to “ensure the implementation of national health policy, norms and standards in his province.”

» The Superintendent-General is under a number of obligations. including duties to: ∙ “plan, co-ordinate and monitor health services and

evaluate the rendering of health services” (s 25(2)(f));

∙ “plan the development of public and private hospitals, other health establishments and health agencies” (s 25(2)(j));

∙ “control and manage the cost and financing of public health establishments and public health agencies” (s 25(2)(k));

∙ “control the quality of all health services and facilities” (s 25(2)(n)); and

∙ “provide and maintain equipment, vehicles and health care facilities in the public sector” (s 25(2)(p)).

• A failure to comply with obligations in terms of the Public Finance Management Act 1 of 1999 (“PFMA”) to ensure the proper and efficient use of public funds and to prevent fruitless and wasteful expenditure, specifically:

» The PFMA places a number of obligations on the accounting officer of a department. In terms of section 36 of the PFMA, the Superintendent General is the accounting officer of the FSDoH. As accounting officer, the Superintendent General is responsible for: ∙ ensuring that the Department has “an appropriate

procurement and provisioning system which is fair, equitable, transparent, competitive and cost-effective” (section 38(a)(iii));

∙ the “effective, efficient, economical and transparent use of the resources of the department” (section 38(b));

» The PFMA Treasury Regulations, enacted in terms of section 76 of the PFMA, explicitly deal with an accounting officer’s obligations with regard to maintaining adequate stock levels. Regulation 10.1.1 requires the accounting officer to “ensure that proper control systems exist for assets and that – (a) preventative mechanisms are in place to eliminate theft, losses, wastage and misuse; and (b) stock levels are at an optimum and economical level.” The accounting officer is also obliged to ensure that processes (whether manual or electronic) and procedures are in place for the “effective, efficient, economical and transparent use of the institution’s assets” (regulation 10.1.2).

• A failure to comply with obligations in terms of the Pharmacy Act 53 of 1974 to ensure the safe and effective storage of medicine.

29. Stock Outs in South Africa Annual Report – 2014 Stock Outs Survey

30. National and Provincial Department of Health Briefings: Challenges in Eastern Cape, Free State, Limpopo in the presence of Minister of Health – National Council of Provinces (NCOP) Social Services. Available at: https://pmg.org.za/committee-meeting/20946/

31. According to the provincial Department of Health in its briefing to the NCOP Social Services the province had 275

pharmacists (pharmacist patient ratio 1: 8 199) and in order to meet the WHO norm of of 1: 2300 pharmacist to patient ratio would require an additional 705 pharmacists the cost implication would be estimated at R236 million.

32. The circumstances in findings 3 indicate:

• Violations of: » the right of access to health care services in terms of

section 27 of the constitution; and » the right not to be denied emergency medical

treatment in terms of section 27(3);

• Failures to comply with obligations in terms of the NHA » on the MEC to “ensure the implementation of national

health policy, norms and standards in his province” (Section 25(1)).

» On the HoD medical services to “provide and maintain equipment, vehicles and health care facilities” (section 25(2)(P)).

• Failure to comply with the Emergency Medical Services Regulations including as related to the equipment required, the need for each vehicle to be staffed by two people and other provisions.

33. According to the Department’s Annual Report the Emergency Medical Services has an approved establishment number of permanent post of 2 170 but currently has on 1 788 of the posts filled with a resulting vacancy rate of 17.6%.

34. The conditions in finding 4 indicate: » Violations: » of the right of access to health care services in terms of

section 27 of the Constitution » a failure to adhere to principles of cooperative

government, as set out in chapter three of the Constitution

• Failures to implement measures to minimize disease transmission and injury or damage to the person or property of healthcare personnel working at health establishments as required by section 20(3) of the NHA

• Failures by the HoD to » “plan, co-ordinate and monitor health services and

evaluate the rendering of health services” (s 25(2)(f)); » “plan the development of public and private hospitals,

other health establishments and health agencies” (s 25(2)(j));

» “control and manage the cost and financing of public health establishments and public health agencies” (s 25(2)(k));

» “control the quality of all health services and facilities” (s 25(2)(n)); and

» “provide and maintain equipment, vehicles and health care facilities in the public sector” (s 25(2)(p)).

• A failure to comply with the Norms and Standards Regulations Applicable to Certain Categories of Health Establishments

• A failure to comply with the Categories of Hospitals Regulations

35. The state of human resources in the province as outlined in finding 5 indicates:

• Violations of the: » right of access to healthcare services in terms of section

27 of the constitution; and » the right to fair labour practices in terms of section 23 of

the Constitution

• Obligations in terms of the NHA, including: » Section 25(2)(i) places an obligation on the HoD to


Note: There have been little or no reparation and compensation for those who have suffered trauma when turning for help to the public healthcare system in the Free State. There has been a disturbing lack of redress for trauma and loss. Too often people are left to come to terms with highly traumatising experiences without any help. Before commencement of day two of the hearings Commissioner Bishop Paul Verryn led a trauma counselling session with some of the people who testified. We recognise that this was a drop in the ocean. We urge that more be done for people who have suffered trauma because of the dysfunction in the province’s healthcare system.

NOTES


NOTES

FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 201536

free state in chains - tac.org.za

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