The healthcare system in South Africa has been unnecessarily ravaged by a preventable and deadly epidemic. The devastating impact of corruption and corrupt resourcing practices has undoubtedly cost many lives, stretching from long before to long after the COVID-19 crisis. When Vusi fell ill in September this year, for the first time in his life, he and Lizbeth came face-to-face with the impenetrable public healthcare system that is the only option for the majority South Africans.
Corruption, Incompetence & Healthcare
Corruption in the healthcare system has many faces, not unlike corruption in other national, provincial, and municipal service delivery systems in South Africa. It usually boils down to the use of entrusted power and misappropriation of resources for private gain. Suppliers, service providers and funders use political connections to further their business or other interests. With the help of insiders, they frustrate or circumvent the required procurement processes, resulting in increased costs, decreased efficiencies, and under-resourcing and non-delivery of services. Some examples of corruption in the South African healthcare system include:
- Procurement from suppliers, service providers and funders who have no track record and are incapable of delivery.
- Price gouging by suppliers, service providers and funders, exploiting the dismal state of healthcare infrastructure and services.
- Ineffective employment practices and inappropriate staff appointments serving political and financial agendas, rather than healthcare needs.
Corruption has a negative effect on patient care and the morale of healthcare workers. It hampers health access and affordability, efficiency and equity, health policy and spending priorities. Corruption can be deadly. (Policy Brief: Exploring corruption in the SA health sector, January 2016, Centre for Health Policy, University of the Witwatersrand)
Corruption leads directly to the use of ineffective and counterfeit medicine, materials and equipment; a shortage of medicine, materials and equipment; incompetent and poor quality healthcare; mismanagement of resources; and a lack of standardised and accessible protocols and oversight mechanisms, amongst other things. The latter also fuel corruption, creating a vicious cycle. It is not surprising that patient care and the morale of honest and hardworking healthcare professionals and officials in the healthcare system suffer.
The more visible, fiscal markers of corruption include irregular, fruitless or wasteful expenditure. Irregular expenditure refers to the process that led to expenditure when the applicable legislation was not adhered to somewhere along the process. Fruitless or wasteful expenditure refers to expenditure incurred in vain, that could have been avoided if reasonable care had been exercised. This type of expenditure is especially depraved in the context of healthcare and a country with limited resources.
Since 2005, only one of the nine provincial health departments has consistently received an unqualified audit, with no or negligible irregular, fruitless or wasteful expenditure. Between 2009 and 2013, R24-billion of all the provincial health departments’ expenditure was classified as irregular. For 2012/2013, this was 6.3% of the overall provincial health expenditure, according to the Centre for Health Policy at the University of the Witwatersrand.
In addition to irregular, fruitless or wasteful expenditure, some budgeted funds are not spent at all. In 2019, for example, the provincial health department in Gauteng had a budget of R46.8 billion but underspent by R631 million (1.4%). Spending on hospitals and administration exceeded the budget by 2.3% and 26.3% respectively, to pay for medical negligence claims (i.e. medico-legal claim pay-outs), unpaid bills from the previous year (e.g. for medical supplies and the acquisition of goods and services), and performance bonuses that form part of the salary bill.
The nett effect of over- and under-spending can be misleading. For example, the district health services budget was underspent by 5.4%, including R504 million (i.e. 37.5% of R1.34 billion in the budget) that was earmarked for machinery and equipment, reportedly because of delays in acquiring products from overseas. Emergency services did not spend about 10% of a R1.48 billion allocation because they could not fill vacant posts and did not release fleet services payments.
The impact of corruption in its various forms in the healthcare system is profound. In a country with extreme inequities, it means quality healthcare is inaccessible and/or unaffordable to the majority of South Africans. Ineffective and inefficient health policies and spending impact directly on the people who can least afford it and who are already facing the almost insurmountable health challenges associated with poverty. The leading causes of death in South Africa are not only mostly preventable through lifestyle changes, but are also very treatable, given the right, adequate resources, and political will: tuberculosis, diabetes, cerebrovascular and heart disease, and HIV/AIDS.
The Public Service Commission (PSC) earlier this year reported their findings after evaluating five hospitals in Gauteng, namely, Rahima Moosa Mother and Child hospital, Bheki Mlangeni, Dr George Mukhari, Tembisa and Mamelodi hospitals. They found “a shortage of both clinical and non-clinical staff; over-crowding in casualty; high staff turnover and the slow rate of staff replacement due to a lack of funds; too few hospital beds resulting in overcrowding and long waiting times; surgical backlogs and the ill treatment of patients…“abysmal” support from Gauteng’s Infrastructure Development Department in dealing with crumbling infrastructure and lack of maintenance”.
Corruption is also reflected in 20‚417 Serious Adverse Events due to negligence‚ incompetence‚ human error‚ secondment of patients, and system failures, in Gauteng hospitals, between 2016 and June 2018. These events happen when patients are harmed unintentionally‚ either by an act of commission or an act of omission, and not because of their underlying illness or condition. There were 6‚192 such events in 2016‚ increasing to 9‚767 in 2017 and 4‚458 in the first five months of 2018. Amongst the Academic (Training) hospitals in Gauteng, Chris Hani Baragwanath Hospital recorded 4‚320 such events in the specified period; Steve Biko Hospital recorded 1‚789 events‚ George Mukhari Hospital recorded 1‚574 events; Charlotte Maxeke Johannesburg Hospital recorded 1‚262 events.
What happens then, when an ordinary South African has to engage with the corruption-fraught healthcare system?
Vusi and Lizbeth*
Vusi is a convenience store supervisor who is close to sixty. He woke up one morning in September with a stiff neck and back. Lizbeth, his wife, who is a domestic worker in her late fifties, was worried. She was used to not feeling well sometimes, being pre-diabetic and hypertensive herself, but Vusi had never been ill before. That morning he said what he always says when facing difficulties:
What can you do, hey? That’s life for you.
He went to work anyway, as he has done for more than 25 years. Money had been tight since they bought their first home the year before. They used all their savings, and personal and pension-backed housing loans which they were paying back every month. They were looking forward to retirement in their home province, Gauteng, in a couple of years, especially since their only son himself became a father two years before.
The First Diagnosis
Less than a week later Vusi could hardly move, and by 21 September, the pain had immobilised him completely. They visited a clinic near their home, where a general clinical exam was done. They were referred to an Academic Hospital thirty-two kilometres away. They went to the hospital a couple of days later, when Lizbeth could take time off work. There was no working x-ray machine, so they were referred to a Provincial Hospital that was forty-two kilometres from where they live.
The first time they went to the Provincial Hospital, they waited the entire day, only to be told to return the next day as there was nobody available on the day to take x-rays. They went back the next day. Vusi was diagnosed with arthritis of the spine and neck and given medication to treat it, but no pain medication. Their cousin obtained a combination analgesic which contained paracetamol, codeine, and ibuprofen for him, at a retail pharmacy.
Another week went by during which time his condition deteriorated significantly. He was hardly sleeping, he lost his appetite, the pain was escalating, especially in his lower back, and he was too weak to move unassisted. Vusi and Lizbeth went back to the Provincial Hospital, where they were referred to the urology department at another Academic Hospital, twenty-three kilometres from home.
The Second Diagnosis
Vusi went to the second Academic Hospital on the morning of 1 October, accompanied by his sister as Lizbeth had to work. By the time he had been seen by a health professional and a scan had been done, it was 03h00 on 2 October. He was sent home with four days’ worth of pain killers and told to return a week later as there were no hospital beds available, so they couldn’t admit him for the kidney cancer they had diagnosed following the scan.
When I saw him the day before his next hospital visit, he was emaciated and jaundiced, and his face was puffy. He complained of chest pain, which was a new addition to the back and neck pain. He mentioned that they had also told him he had kidney stones.
During his next hospital visit, a treatment plan was discussed, namely, to try and resolve his condition with medication first, and if he did not improve, they would be considering surgery. He was sent home with medication as they did not have enough staff to care for him at the hospital. His next appointment was set for twenty days later.
To be clear: this man with kidney cancer and kidney stones, probably close to, if not in, renal failure, who had been in unbearable pain for close to a month, was sent home with some paracetamol and opioid tablets after he was given an injection that knocked him out for a day. The brand name of the paracetamol tablets was similar to that of another drug, the only difference being one letter. The drug he was not given is used to control, balance, and maintain blood sugar levels in patients with non-insulin dependent diabetes (i.e. Type II).
Did someone make a mistake when they read the script, or was he sent home with nothing but painkillers, under the false pretence of it being treatment for his cancer?
No Ambulance, No Bed
Lizbeth took Vusi back to the local clinic less than a week later, with all the information they had gleaned during their hospital visits. She feared Vusi wasn’t going to last until the end of October, so they went to get help. His was put on a drip, and he felt a bit better and stronger. They were told to come back in a week or two for another drip.
Two days later, at two o’clock in the morning, Lizbeth phoned for an ambulance because Vusi was in and out of consciousness, confused, unable to speak or walk, and bleeding from his nose and mouth. She was sure that he was going to die if he didn’t get help right away.
The hospital that diagnosed Vusi’s cancer said that they were dispatching an ambulance. They lied. After an eternity, she phoned again, to ask where the ambulance was. There was no ambulance to dispatch.
Lizbeth’s cousin eventually took them to the local clinic, in the hope that they would be able to summon an ambulance for the now critically ill patient. Instead, Vusi was put on another drip, and sent home, where their son came to fetch them to go back to the hospital.
There were no beds available at the hospital to admit Vusi, so they waited, sleeping on the Emergency and Admissions Department floor and benches, with the rest of the patients and their families, waiting for someone to see to them. They stayed without food and water for fear of losing their place in the queue. there was no space for social distancing, no sanitising station, and very few masks.
They waited for more than twenty-four hours, until eleven o’clock the next morning, when a bed became available in the general ward. There was nobody to talk to about his condition, or what was going to happen next – just an admission form to complete, and two minutes later Lizbeth and her son were chased out of the ward.
That day I cried for Vusi who had been in excruciating, unmanaged pain for longer than most people would be able to bear, without treatment of the debilitating illness that was eating him alive. I also cried for Lizbeth, because she had not slept or eaten for two days, and there was a strong possibility that she would not be able to see him again, because of COVID-19 protocols at hospitals. And I cried for a miracle.
Vusi waited in the general ward for an appointment with the Urology Department. Four days after he was admitted, Lizbeth got a call from the hospital. She was told to collect Vusi by the next morning, as there was nothing more that they could do for him, and they could not take care of him at the hospital. It turns out they did not take care of him while he was hospitalised, anyway: he had not been given food or water for most of his stay.
When he got home, he was still unable to talk or walk but gained a bit of strength in his arms after gulping down some pap and drinking two litres of water. He had been given much stronger medication and so the pain, at least, was bearable.
Vusi died ten days later.
Where is the Health, the Care, the Service?
The night he was back home from hospital, I lit a candle for mercy and in solidarity with everyone in South Africa who is ill and does not receive the medical care they need; who goes from one under-resourced hospital to the next searching for a diagnosis but who gets it too late; who queues for a hospital bed only to be left without treatment, food and water for days; those who die a slow painful death as a result of an ineffective, corrupt healthcare system; who are sent home from hospital to be cared for by loved ones, and to die. May their loved ones find the strength to endure the injustice, indignity, and pain. May they find peace at the end. May those who steal from the healthcare system face consequences in equal measure to the frustration, anger, sadness, and death that their corrupt actions cause.
Why refer to “healthcare services” when the current health system in South Africa is discriminatory, unequal, cruel, inhumane, and unhealthy for patients, their families and those health professionals who care?
*Not their real names. Their names have been changed to respect Vusi and Lizbeth’s privacy. The information about their healtcare journey is presented as conveyed to me by them. I do not make any guarentees of the accuracy of the information, although I have no reason do doubt their account.
Copyright © Leonie Vorster 2020