The Crisis of Public Health Care T Much has been heard about the so-called health crisis in the h e in the Eastern Cape Eastern Cape over the past few years, both from politicians and C r i s The post-apartheid challenges of oversight and accountability the media. Since 2000 there has been a steady increase in the i s number of reports of health care related problems in the Eastern o f Cape, including overcrowded hospital wards, dilapidation of P u b infrastructure, food shortages, broken-down ambulances and l i c neglected state mortuaries. H e a l t The questions that this report sets out to address are: What are h C the various dimensions of the crisis in the provision of health care a r services in the Eastern Cape between 2000 and 2004? Is this e i n crisis largely the result of the province's apartheid legacy, as t h politicians have often claimed, or the consequence of e E mismanaged health care resources? And, importantly, how can a s t this crisis be overcome? These are serious questions that are e r addressed through an evaluation of the performance of the n C Eastern Cape Department of Health against the Constitutional a p e and Legislative requirements established to govern public service delivery since 1994. This report assesses whether public health care resources have been effectively and accountably utilised since the transition to democracy in South Africa. PUBLIC PSA SERVICE Accountability Monitor Monitoring Transparency and Accountability in the Public Sector Colm Allan, Neil Overy, Zama Somhlaba, Vuyo Tetyana & Lucas Zepe Open Society Foundation for South Africa The Crisis of Public Health Care in the Eastern Cape The post-apartheid challenges of oversight and accountability Colm Allan, Neil Overy, Zama Somhlaba, Vuyo Tetyana & Lucas Zepe © 2004 The Public Service Accountability Monitor (PSAM) PSAM P.O. Box 94 Rhodes University Grahamstown 6139 www. psam.org.za All rights reserved. No part of this publication may be reproduced or transmitted in any form or by electronic or mechanical means, including any information storage and retrieval sys- tem, without prior permission in writing from the publishers. ISBN 1-919833-994 Produced by comPress and distributed by Oneworldbooks www.compress.co.za Cover photograph Daily Dispatch. About the Authors Colm Allan is the Director of the Public Service Accountability Monitor (PSAM). Dr. Neil Overy is the Head of the Case Monitoring Project within the PSAM. Vuyo Tetyana is the Head of the Performance Monitoring Project within the PSAM. Zama Somhlaba and Lucas Zepe are both researchers within the PSAM’s Performance Monitoring Project. ii The Crisis of Public Health Care in the Eastern Cape Contents Glossary _________________________________________________________ v Preface ________________________________________________________ vii Key Findings and Recommendations _____________________________________ xi Introduction ________________________________________________________ 1 1. Public Health Care Provision and South Africa’s New Constitution ________ 2 Health Services in South Africa and the Apartheid Legacy __________________ 2 Post-Apartheid South Africa and the Constitutional Commitment to Health Rights 9 The Reporting Process ____________________________________________ 16 2. The Public Health Care Crisis in the Eastern Cape: 2000 to 2004 _________ 19 3. The Leadership Crisis ____________________________________________ 32 Goqwana and Stamper ____________________________________________ 32 Misconduct _____________________________________________________ 36 4. The Staffing Crisis _______________________________________________ 43 Vacancy Rates ___________________________________________________ 43 The Department’s Response ________________________________________ 47 The Use of Consultants ____________________________________________ 49 5. The Crisis of Financial Management ________________________________ 51 Under-Budgeting for Health Care in the Eastern Cape ____________________ 51 General Spending ________________________________________________ 51 Spending by Programme ___________________________________________ 52 Under-Spending of Conditional Grants ________________________________ 59 Inept Strategic Planning ___________________________________________ 61 Mismanagement of the Staff Payroll __________________________________ 65 The Crisis of Public Health Care in the Eastern Cape iii 6. The Crisis of Oversight and Accountability ___________________________ 69 Auditor-General’s Oversight ________________________________________ 69 Accountability to Legislature Oversight Committees ______________________ 75 7. The Department’s Reaction to the Crisis _____________________________ 79 The Ghosts of Apartheid and Racism _________________________________ 79 Privatisation _____________________________________________________ 81 National Reaction to the Crisis: The Interim Management Team _____________ 83 8. Case Studies ___________________________________________________ 89 The SANTA Hospital Crisis _________________________________________ 89 The School Feeding Scheme Crisis __________________________________ 90 The Emergency Medical Services Fiasco ______________________________ 99 9. The HIV/AIDS Treatment Crisis ____________________________________ 104 Introduction ____________________________________________________ 104 Elements of the Crisis ____________________________________________ 105 HIV/AIDS Programme Planning between 2000 and 2004 _________________ 115 Budgeting and Spending on Eastern Cape HIV/AIDS Programmes _________ 123 Budgeting and Spending on HIV/AIDS Training ________________________ 133 10. Conclusion ____________________________________________________ 137 Appendices ______________________________________________________ 139 iv The Crisis of Public Health Care in the Eastern Cape Glossary AG Auditor-General ARVs anti-retroviral drugs BAS Basic Accounting System CBOs community-based organisation CEO Chief Executive Officer CHC community health centre DG Director-General DORA Division of Revenue Act DORB Division of Revenue Bill DPSA Department of Public Service and Administration FFC Finance and Fiscal Commission FMS Financial Management System EMS Emergency Medical Services FMS Financial Management System HBC home-based care HEPTAR Health, Training and Research Grant HODs Head of Department IMT Interim Management Team JBC Joint Budget Committee LSA local service area MEC Member of the Executive Council MINMEC Meeting of national Minister with nine provincial MECs MPL Member of the Provincial Legislature MTBPS Medium-Term Budget Policy Statement MTEF Medium-Term Expenditure Framework NCOP National Council of Provinces NEHAWU National Education, Health and Allied Workers’ Union (NEHAWU) NGOs non-governmental organisation NP National Party NHS National Health Service PEP Post-Exposure Prophylaxis PERSAL Personnel Administration System PFMA Public Finance Management Act PHC Primary Health Care PMTCT Prevention of Mother to Child Transmission PFMA Public Finanance Management Act PHC primary health care The Crisis of Public Health Care in the Eastern Cape v PMTCT prevention of mother-to-child transmission PPP public-private partnership PSA Public Service Act PSAM Public Service Accountability Monitor PSNP Primary School Nutrition Programme SAHRC South African Human Rights Commission SALGA South African Local Government Association SANTA South African National Tuberculosis Association SCOPA Standing Committee on Public Accounts SLA service-level agreement STDs sexually-transmitted disease STI sexually-transmitted infection TAC Treatment Action Campaign TB tuberculosis UNITRA University of the Transkei VCT voluntary counselling and testing vi The Crisis of Public Health Care in the Eastern Cape Preface This report arose out of the PSAM’s quest to find ways to develop a more comprehensive approach to the monitoring of democratic governance, and the practical implementation of accountability provisions, in post-apartheid South Africa. Between 1994 and 2003 the Eastern Cape provincial government earned itself a repu- tation for sustained service delivery failure and the weak management of public resources. The national and provincial media reported widely on instances of maladministration and corruption involving the provincial administration during this period. This begged the ques- tion of how much of what was being reported was accurate and what action was being taken by the newly elected democratic government to ensure the transformation of the apartheid era public service. In this context, the PSAM was established as an independent research project at Rhodes University in 1999 with a relatively narrow focus on tracking corrective action taken in re- sponse to reported corruption in the provincial administration. It developed a database and public access website to keep the public informed of the steps being taken to resolve these cases. Its emerging monitoring methodology consisted of undertaking a comparison be- tween corrective steps taken and the regulatory provisions governing the discipline, ethics and accountability of public servants in post-apartheid South Africa. This methodology was informed by a simple principle enshrined within South Africa’s new democratic Constitution – viz that those in public office are accountable to the citizens whose interests they were appointed to serve.1 A literal interpretation of this principle was adopted as the basis for PSAM’s engagement with government officials, which asserts that accountability is