In December last year, Sydney Mokoena* (38) "dropped everything" to attend a memorial service in Bloemfontein for "the father of free healthcare", Nelson Mandela. The poster that advertised the service remains stuck to the large window at the entrance to Mokoena's tiny house in Thaba 'Nchu, about 100km from the Free State capital. The notice is beneath two green and yellow ANC stickers: one with the party's logo; the other bearing a smiling Jacob Zuma and the words "I am voting ANC, 2014 elections."
Mokoena says he has been a "lifelong" ANC member who has never voted for another party. But he is now considering resigning from an organisation he "no longer loves".
Earlier this year, he briefly met provincial leader Ace Magashule when the premier visited Mokoena's village.
"The ANC people gave us stickers and some people got T-shirts but I'm no longer happy with Ace," says Mokoena. "He broke Mr Mandela's promises". Mokoena said he was concerned that the health MEC [Benny Malakoane] had been appointed for a second term despite facing corruption charges.
Arrested for corruption
Earlier this year, Magashule appointed Malakoane for a second term as the Free State's top health official. This was despite Malakoane's arrest in July last year on charges of corruption, relating to crimes allegedly committed when he managed Matjhabeng local municipality in Welkom between 2007 and 2010.
He and five co-accused are scheduled to appear in the Welkom regional court in August.
Mokoena shakes his head and clicks his tongue disapprovingly. He has experienced the "brokenness" of provincial health services first hand.
He fetches two clinic cards from his room and places them on the cracked blue counter in his kitchen.
The emaciated man's cupboards are empty because he lost his only source of income in January – a monthly disability grant of R1 200. He says the loss was a "direct result" of him not being able to access a doctor for more than eight months.
"This whole year I've been begging for food from people here. My family in Bloemfontein can only send me R100 a month," Mokoena mumbles. He looks down, his eyes fixed on the crumbling cement floor.
"I'm so, so hungry. I don't know what to do," he whispers, fingering his tattered faux leather jacket.
Mokoena is HIV positive and also suffers from a chronic psychiatric condition. In January, he needed a doctor to sign the annual renewal of his grant.
According to national health guidelines, a doctor is required to evaluate patients with psychiatric conditions like Mokoena's once every six months to assess whether their medication is effective and, consequently, if their prescriptions should be continued or adjusted. In May this year, Mokoena's doctor was scheduled to visit his local clinic, Mafane, after he had seen a doctor in November.
"I arrived at 5am to join a long queue of people who waited for the clinic to open at 7am," Mokoena says.
"We were 50 people in the special doctor's line [the other patients were there to see a nurse], and we all had appointments that the clinic sister had booked for us. It was written in our clinic cards."
Mokoena opens his clinic card and points at the inscription. "At one o'clock, after we had been waiting for six hours, the nurse announced that the doctor wasn't going to come and told us: 'Go home'. Just like that. No explanation."
Mokoena begins gesticulating, waving a hand in the air.
"We were very, very angry. Some patients shouted and tore up their files!" he says, clenching his clinic cards. "I threw my file on the ground. The nurse looked at me angrily and said: 'You are osile [silly].' I just walked away, home."
Last month, Mokoena again walked for 30 minutes to Mafane clinic, for a "new appointment". Again, he says, "no doctor turned up".
He spits: "I'm angry. I'm very, very angry."
His next appointment is on July 8. "I have no idea if a doctor will arrive. But I have to try. What else can I do?"
Mokoena's psychiatric medicine has been reissued by a nurse without the required approval of a doctor. He receives his antiretroviral (ARV) medication for his HIV infection monthly, but it is constantly switched between a three-in-one pill, known as a fixed-dosed combination drug, and three individual tablets.
"This confuses me; I'm scared I am taking my medication incorrectly," he sighs.
Health department recommendations determined last year that eligible HIV patients on antiretroviral therapy were to receive the all-in-one pills by October 2013.
When the Mail & Guardian spoke to the national health department's chief director of procurement, Gavin Steel, at the launch of fixed-dose combination ARVs, he explained that the pills were cheaper, easier to store and simpler to take.
"The fixed-dose combination … takes up less shelf space in pharmacies and clinics. This will enable us to stock more medication at a time [and help to prevent drug stock-outs]," he said.
But thousands of HIV patients in many Free State districts only benefitted from fixed-dose combinations for two months last year before the pills ran out – including in Thaba 'Nchu, and at Mafane clinic.
The crisis isn't new to the province. Last month, an investigation by the advocacy groups Treatment Action Campaign (TAC) and Section27 revealed that more than 200 essential drugs and supplies were out of stock at the provincial depot – including HIV tests and several ARVs.
The Democratic Alliance (DA) considered the situation so dire that it reported the Free State health department to the South African Human Rights Commission last week.
In November, the pressure group Stop Stock-Outs found that the Free State had the most severe drug shortage of HIV and tuberculosis (TB) medication in the country – more than half of all facilities surveyed reported drug stock-outs.
In 2008-2009 the Free State health department said it was so short of cash that it placed a five-month moratorium on starting new patients on ARVs.
According to the Human Sciences Research Council, the Free State has the third highest HIV infection rate in the country, with one in four adults between 15 and 49 infected with the virus.
Call for suspension
Yesterday Section27 and the TAC called for Malakoane's immediate suspension and stated their concern about a "slowly collapsing health system" in the Free State.
But it appears that quality, timeous access to the province's public health services depends on who you are.
This week, doctors told the M&G how Malakoane "personally intervened" this past weekend to instruct a Free State hospital to allocate an intensive care unit (ICU) bed to an ANC official.
According to the doctors, the patient didn't qualify for an ICU bed as his prognosis was "extremely bad" (see "How a dying woman's bed was taken by ANC official").
Wandering around in the weak sunlight outside his home, Mokoena is confused by this revelation. "I wonder how I can access the same services, because I don't have a connection in the government. They are discriminating against people like me. People of nothing."
Anele Yawa, TAC secretary general, is furious, and his fury is not confined to the Free State.
"Why does nothing happen to corrupt MECs? It's not just in the Free State. You go to the North West and you find that the health MEC [Magome Masike] bought a new Mercedes which costs almost R1-million. That money could have bought ambulances," he fumes.
"Those who are in power don't have the interests of the people at heart. They only know them as 'voting animals'. After being voted into power, they don't care about what happens. All they care about is themselves and their families."
For the past three years Elisa Tsamai and her son, Isaac (13), who has cerebral palsy, have been late recipients of their monthly supply of ARVs. Sometimes, says the mother, they go without their medication for a week at a time.
Research has shown that interruptions in ARV treatment allow HIV to become resistant to the medication, so it is no longer effective. Isaac was infected with HIV at birth, when the virus was transferred to him from his mother.
Tsamai is adamant that one of the two nurses at their local clinic in Thaba 'Nchu, Goa clinic, "always" refuses to help them. "The nurse tells me I'm a drunkard and so she will not talk to me," she says.
Nono Motsumi, a TAC volunteer in Tsamai's village, says she has witnessed the nurse's "irrational" behaviour. "I can honestly tell you that Elisa doesn't drink. This nurse just doesn't help Elisa and others because she simply doesn't like them, for reasons only she knows."
According to Tsamai, when she visited Goa clinic for the first time three years ago she didn't know she was supposed to have blood tests to determine the efficacy of her ARVs.
"It was written on a piece of paper but I can't read. So this same nurse shouted at me when I wanted to leave without the tests and told me: 'You are arrogant.' When I spoke up and told her there was no way for me to have known about the tests without her telling me, she never helped me again."
Twice a month, and sometimes more, Tsamai walks to Goa clinic, pushing her son in his wheelchair along a gravel road. It's a sweaty, arduous journey – even in the freezing cold – that lasts at least an hour and a half. Tsamai can't afford a minibus taxi.
She says she has reported the nurse to the sister in charge at the clinic, "but this made things worse". She adds that she and a few other patients have confronted the nurse when she refuses to help them, but have then suffered public humiliation.
'Not uneducated like you'
"She would laugh at us and shout: 'My children don't have HIV and they're not uneducated like you! They go to good schools and I don't care what you do! I'll get my salary and live a better life than you no matter what you do!'"
This situation has outraged Yawa. "It seems like if you're a poor man you get a poor man's service, but if you're politically connected you get service of a totally different kind. How is it possible that Benny Malakoane makes one phone call to get someone into an ICU, but hasn't been able to sort out the behaviour of a nurse such as this, and many others like her, in three years?" he asks.
"The entire system in Free State seems to be corrupt – from top to bottom."
Two weeks ago, Irene Mafikeng* gave birth to a daughter late at night at JS Moroka Hospital in Thaba 'Nchu. When she wanted to wash herself the next morning, there was no water at the hospital. She was released the next day without having been able to wash off any of the blood and bodily fluids on her body.
Mafikeng had a difficult pregnancy as well as previous birth complications, so she was admitted to the hospital a week before her due date. During this time she underwent several procedures, blood spilling frequently on to the sheets of her bed.
"Not once did the nurses change my sheets," says Mafikeng. "Sometimes they covered the blood with pillow cases; mostly I had to lie in the blood and the stains."
Eyes downcast, Mafikeng continues: "When I got on the taxi from the hospital to my house, I smelt like rotten blood. Everyone smelt me and looked at me strangely. Some passengers even moved away. It was so, so humiliating."
At night and in the early morning, when Mafikeng and her fellow maternity ward patients rang the bell for help, she says the nurses wouldn't attend to them.
"They were sleeping during the night; I saw them," she says.
'You deserve it'
"One night a woman rang the bell because of severe labour pains. When they didn't come she shouted loudly. No one came. This woman delivered her baby all by herself on her ward bed. When the security guard saw that and went to fetch a nurse, the nurse shouted at the woman for spilling blood during her delivery on the sheets.
"Then the nurse discovered the woman's placenta didn't come out and shouted more. 'You deserve it because you pushed too hard,' she said. That woman had to be transferred to Pelonomi Hospital in Bloemfontein. I wonder if she and her baby are still alive …"
Yawa says: "We have free supposed maternity care, and the right to healthcare enshrined in our Constitution. But all these promises are reduced to useless pieces of paper when the people in the driving seats are ineffective. We can draft as many good policies as we like. They'll all be fiascos in the face of the people on the ground if their custodians are lazy and corrupt."
Oupa Mohutsioa doesn't work any more. He was once a community health worker in Thaba 'Nchu district but hasn't been paid his R1 400 salary for two months.
In April, Malakoane's office sent a memo to Free State community health workers, branding them all "ghost workers" and effectively cancelling their contracts.
"Without us many people default on their TB and HIV treatment, because that's exactly what we do: we provide that much-needed support," Mohutsioa says.
According to health department figures, only 60% of TB patients in South Africa are cured. In cases where patients have drug resistant TB, the figures are as low as 20%.
Studies around the world have shown that community health workers help to increase patient's drug adherence significantly, as well as boosting the uptake of antenatal services.
Last week, furious community health workers staged a sit-in at the provincial health headquarters in Bloemfontein. They were frustrated at the ongoing crisis and its effect on their lives and those of the people they're supposed to help.
But most public health personnel in the Free State, especially doctors and nurses, are afraid to speak out.
Threats if they talk
Many say they have been instructed they'll lose their jobs, and possibly more, if they speak to anyone about the crisis. Some said they had been told by certain health officials "our lives will be in danger" if they disclose details about the breakdown of Free State health services.
The TAC maintains that both Magashule and Malakoane have shown "no willingness or commitment" to preventing the "collapse" of their province's health system. Instead, says the group, the two have launched "witch hunts" against people trying to solve the crisis.
"This government needs to realise that providing public services is not a favour. It's our basic right," says Yawa.
"All of us who were in the apartheid struggle fought equally hard for access to services. But now the government labels activists 'counter revolutionaries' and makes us scapegoats. They want to make us silent in the same way the apartheid government tried to silence people like Steve Bantu Biko. It will not work. They should know that …"
The TAC's Free State chairperson, Sello Mkhaliphi, says he continues to receive several "threatening" phone calls, in which unknown people accuse him of "denting the image of the ruling party".
He says he's not scared … Instead, he plans to "dig deep" for "deep secrets" to uncover the reasons behind the "inaction" in the Free State health sector.
Mkhaliphi says: "We need to find out why Zuma's keeping quiet about this collapsing public system in our province? What makes him quiet? Is it his relationships with Benny Malakoane or Ace Magashule? Why is no one in power paying attention to what is happening here?"
The Free State department of health had not responded to questions by the time of going to press. Health Minister Aaron Motsoaledi said he would only respond once he studied his task team's report on the state of the province's healthcare.
*Not their real names
Have something to say? Tweet us on @Bhekisisa_MG or Facebook us on @Bhekisisa.Health
We invite you to our Policy Dialogue at the 9th annual Aids Conference.
Since the country’s rollout, less than a quarter of people who’ve started taking the HIV prevention pill are young women — despite high HIV rates.
Bhekisisa editor Mia Malan asks reproductive health doctor Tlaleng Mofokeng why older men prey on younger women.
Bhekisisa means "to scrutinise" in isiZulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.