A bridge too far: Patients travel to Standerton from as far away as 30km away to visit the government clinic there. (Troy Enekvist)

Mpumalanga's health is failing - but it won't take its medicine

Ina Skosana
Poor management and leadership instability lead to R2-billion in irregular expenditure.

The Mpumalanga department of health incurred nearly R2-billion in irregular expenditure in the 2014-2015 financial year – making up more than 80% of the province’s total irregular expenditure, according to the auditor general’s report.

The report, released in November, reveals that the department failed to investigate the irregular expenditure identified in the 2013-2014 financial year.

The department "has [also] been struggling to address a qualification on assets for the past five years, even though consultants are appointed every year to assist".

A breakdown in the department’s controls "led to basic errors, such as assets owned by the department not being recorded in the books and assets being recorded in the books without proof of physical existence", according to the report.

The department has not been able to improve "audit outcomes due to instability in the leadership and the slow response by management to address concerns regarding the quality of the submitted financial and performance information".

Deteriorating state
Health activists believe this situation has contributed significantly to "the deteriorating quality" of the Mpumalanga health department’s service delivery and the consequent bad health indicators.

The province has the highest diarrhoea (5.3%) and pneumonia (5.2%) case fatality rates in the country and the severe acute malnutrition case fatality rate was extremely high at 19.1%, according to the 2014-2015 District Health Barometer of the Health Systems Trust. Only 12.4% of grade one pupils in Mpumalanga had access to school health services in 2014-2015, as opposed to 23.2% nationally.

The 2012 National Antenatal Sentinel HIV prevalence survey recorded a 40% HIV prevalence rate among pregnant women in the province’s Gert Sibande district; this is significantly higher than the national average of 29.5%.

A Bhekisisa investigation in Gert Sibande district has revealed that many people live more than 30km away from public health clinics. In some cases the facilities are so far away that residents are left with only one option: private healthcare, because those services are much closer to where they live than public health services. But most of these people cannot afford to pay for private healthcare (see "It’s only 32km to the state clinic but, for the poor, it’s a world away").

Leadership instability
Mpumalanga health has had more than five heads of department and chief financial officers, both acting and appointed, over a period of two years. Most did not last for more than six months. The auditor-general’s report also stated that two deputy director general positions were vacant at the end of the 2014-2015 financial year. 

The report warned that the health department "might not be able to meet [its] service delivery targets for the following year (2015-2016)" because of cash shortfalls.

The department’s annual report noted that nearly R1-million was used to pay the salaries of 19 health department officials who had been placed on precautionary suspension between April 2014 and March 2015. These employees comprised about half the total number of suspended officials across 12 departments in the Mpumalanga government.

Refuting claims
But Mpumalanga health spokesperson Dumisani Malamule has refuted claims of a crisis in the department, saying instead that the department is "doing well in terms of service delivery".

In a response to questions posed by Bhekisisa, Malamule said the province has taken drastic measures to address issues such as drug and staff shortages in public clinics and hospitals. These measures include increasing the number of medical students to study in Cuba, and a partnership with KwaZulu-Natal to train nurses to work in Mpumalanga.

Malamule said, contrary to the auditor general’s report, the department had had only two full-time heads of department in the past two years. A new head of department was appointed in April 2014, but resigned three months later in June 2014, Malamule said. An acting head of department was appointed from July 1 to September 7 2014. In September 2014 a new head of department was appointed, but he has been on sick leave since [September 2015]. An acting head of department has been appointed in the interim.

Malamule says the provincial health department chief financial officer has been on suspension since June 2014. An acting chief financial officer was appointed until the end of May 2014, after which a chief financial officer was transferred from the education department to the health department.

As far as the deputy director general posts are concerned, Malamule says there is only one vacant post at this level, and not two, as reported by the auditor general.

"The deputy director general for clinical services resigned in September 2014. Attempts were made to fill the post but suitable candidates could not be found," he said. This post was also advertised in November 2015 and the process of filling it is underway."

Good work
Malamule said Gillion Mashego’s appointment as health MEC in the province in May 2014 has brought "positive changes … Primary healthcare is at its peak". Some of these changes include the refurbishment of a number of clinics and hospitals, and the allocation of about R30-million to replace generators in all health facilities.

According to Malamule, the department has spent nearly R173-million or 60% of its hospital revitalisation grant.

"In a nutshell, the MEC has done a lot. Medical shortages in health facilities are now a thing of the past and the provision of food is also going well, together with provision of linen," Malamule said.

"The MEC has addressed the shortages of health professionals in the province. A number of health professional posts are being advertised to be filled before the end of the financial year."

Auditor GeneralNational Health Insurance (NHI)public health system