FREE STATE
IN CHAINS
Report back from the People’s Commission of Inquiry
into the Free State Healthcare System – 7-8 July 2015
CONTENTS
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
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
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.
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FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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1. INTRODUCTION
1.1. WHY FREE STATE
According 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
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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-onyear 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
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-takenby-anc-official and; Mail & Guardian, 2015. Available here:
http://mg.co.za/article/2015-03-19-its-the-free-state-hospitalthat-killed-my-husband-frik/ and; Mail & Guardian, 2015.
Available here: http://mg.co.za/article/2015-06-12-crisiswhat-crisis-africa-check-tests-free-state-health-claims
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.
7. As reported in the Mail & Guardian, 2014. Available here:
http://mg.co.za/article/2014-07-11-free-state-health-undertreasury-care
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.
3. ibid.
8. Statistics South Africa General Household Survey 2014.
Available at: http://www.statssa.gov.za/publications/P0318/
P03182014.pdf
13. As reported in Health-E, 2015. Available here: http://
www.health-e.org.za/2015/10/21/exodus-of-free-statedoctors/
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
9. R75 312 per annum. Statistics South Africa Census 2011 at
page 42. Available at http://www.statssa.gov.za/publications/
P03014/P030142011.pdf
14. See Treatment Action Campaign, (2014). Available
at: http://www.tac.org.za/news/tac-charges-mec-bennymalakoane-corruption-1
2. Ibid.
6
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
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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1.3 THE COMMISSIONERS
COMMISSIONER THEMBEKA GWAGWA
COMMISSIONER BISHOP PAUL VERRYN
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
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FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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.
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
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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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.
1.4. METHODOLOGY AND PROCESS
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.
‘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.
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.
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.
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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 1996
Underpinning 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
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FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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.
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2.1.2 The National Health Act, No. 61 of 2003
The 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.
2.1.6. National Core Standards for Health Establishment in South Africa
The 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
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 capacitybuilding 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 Charter
In 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;
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• 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.
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
15
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 reliving 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
16
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
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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 faithbased 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.
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
17
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.
18
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19
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 callback 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.”
“They showed me my baby, it was
terrible, my child was rotten.”
20
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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.”
“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.”
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
21
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
“When I went to the toilet a piece of the
nurse’s glove came out of me.”
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FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
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.
Every time she called they just said
please hold on.
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
23
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.”
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.
“I’m expected to save lives but at the
moment I feel powerless”
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25
5. FINDINGS &
RECOMMENDATIONS
The 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
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27
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 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.
28
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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
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
RECOMMENDATIONS
4.1. 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
RECOMMENDATIONS
5.1. 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;
RECOMMENDATIONS
6.1. 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.
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.
30
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FOOTNOTES TO RECOMMENDATIONS
28. 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 costeffective” (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
32
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:
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/
• 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
31. According to the provincial Department of Health in its
briefing to the NCOP Social Services the province had 275
• Obligations in terms of the NHA, including:
» Section 25(2)(i) places an obligation on the HoD to
FREE STATE IN CHAINS – Report back from the People’s Commission of Inquiry into the Free State Healthcare System – July 2015
“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/nationalhealth-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”.
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
• 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
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33
NOTES
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.
34
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NOTES
36
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