FACT CHECK | No, MEC Ramathuba, poor management is killing Limpopo
hospitals - not immigrants
News 24 – 07 September 2022
Limpopo Health MEC Phophi Ramathuba has sparked a
storm of controversy after the emergence of a video showing her telling a woman
that migrants from Zimbabwe were a "huge strain" on the provincial
healthcare system.
- Data from the Limpopo health department shows
it is not foreign nationals who are "killing" the health system,
contrary to Health MEC Phophi Ramathuba's comments.
- Poor management and lack of internal controls
- and not foreign nationals - are to blame for the limited
resources.
- Annual reports, analyses by the Office of the
Auditor-General and statistics show that Ramathuba's comments towards the
patient were incorrect and misguided.
Mounting medico-legal claims, lack of consequence management, irregular
expenditure and shocking vacancy rates is what is "killing" hospitals
and healthcare in Limpopo, official statistics and audit reports show.
This in contrast to Limpopo Health MEC Phophi Ramathuba's verbal assault
of a Zimbabwean patient in a local hospital in which she assailed a woman,
claiming an influx of undocumented foreigners are "killing"
hospitals.
"You are killing my health systems," she tells the patient, as
her colleagues cackle in the background, a video showed.
According to Ramathuba, out of 5.7 million people in Limpopo, 91% depend
on the state for medical services which, according to her, was instead eaten by
foreign nationals. "You are even illegal [and] you are abusing me.
It's unfair," she tells the patient.
"So, sisi, you won't be discharged until you settle your
bill," is her final parting shot.
According to annual reports, analyses by the Office of the
Auditor-General, and numbers and statistics in the public domain, however,
there were no indications of any significant adverse impact of foreign
nationals on the healthcare system in the province, but enough evidence of poor
management and weak financial controls contributing to a system in
distress.
The reports show:
- Since Ramathuba took up her position in 2015,
medico-legal claims against the department have increased to billions,
posing a serious threat to the province.
- Staff vacancies for critical posts, like
specialists and nursing, have also increased, yet more than half of the
department's budget is spent on compensating employees.
- While irregular expenditure is on a downward
trend, a lack of consequence management appears rife, opening the door for
continued deflection of resources.
- The money is there - billions allocated to the
department every year - yet consistent underspending per programme and a
deviation of money from critical resources means there is little impact in
clinics and hospitals.
Had Ramathuba taken a closer look at her own data, she would have
observed it is not foreign nationals who are "killing [her] healthcare
system", but her own management.
Enormous medico-legal claims - not foreign nationals - could potentially
put the department, and the province, at risk if not checked, and although
contingent, could land the province under administration, Risham Maharaj an MPL
and DA Limpopo spokesperson for health said.
The data shows an increase of billions from 2016 to 2021 relating to
medico-legal claims against the department.
Many of these cases are related to cerebral palsy at birth and,
according to Professor Alex van den Heever, chair of social security systems
administration and management studies at the University of the Witwatersrand's
School of Governance, the ratio of maternal deaths in facility per 100 000 was
a good indication of the state of health services.
According to the 2020/21 annual report, R9 billion in cerebral palsy
claims made up part of the R12 billion claims against the department.
"That is quite large, and it is liability to watch, and it might
be, although unconfirmed, suggestive of negligent practices within the
province. It does correlate with maternal mortality ratios as cerebral palsy
happens in delivery," Van den Heever said.
He added the international metric for maternal mortality ratios should
be between 30 and 40 per 100 000.
Limpopo's figures were not terrible - showing an improvement before
Covid-19 - the province's health services "are not a
catastrophe".
Van den Heever said there was uncertainty about what was really fuelling
the medico-legal claims.
While these claims have been increasing as a contingent liability (and
was dependent on the outcome of the claims), the number of claims paid was low,
according to him, especially compared to other provinces.
The extent to which medico-legal cases are hurting the department is
unclear, since settlement amounts paid to claimants are not reflected in annual
expenditures yet.
And Maharaj said no clarity had been forthcoming regarding these
claims.
"The response we get continually is that they have an action plan
and are working towards this. We stand at a risk, because of medical negligence
claims, where the province could be placed under administration … we cannot
afford to pay it."
While Ramathuba told the Zimbabwean patient 91% of Limpopo's population
relied on state healthcare, massive vacancy rates placed uncertainty on whether
the department could adequately service the population.
Since 2016, a year after Ramathuba's tenure, staff vacancy rates have
been increasing, with more than half of all posts going unfilled by 2021.
Critical occupations like specialist positions, professional nurses,
allied health professionals (like dental hygienists, dietitians and
occupational therapists) have continuously remained half-staffed.
Yet, according to Maharaj, the department had spent 70% of its resources
on compensating employees, despite this staff shortage. This leaves little
resources for services.
Data shows since 2016, the department has been operating at half its
capacity, leading Maharaj to conclude "the MEC's statements are
irrelevant, uncalled for and incorrect".
"The fact is that the department is spending 70% of its budget on
the cost of employees - salaries and wages - and yet the vacancy rate is
extremely high. This is because staff that are appointed are employed at the
highest salary brackets.
"This is eating into the budget. When the MEC says that foreign
nationals are eating into the budget, she does not take [this] into
account," Maharaj said.
According to Van den Heever, while the staff profile was unusual, it
indicated the department had not adjusted its organisational structure to be in
line with its budget.
"It does not imply that they actually have a 50% vacancy rate, it
means they do not have proper organisational structural - it is not clear, and
they are not using the vacancy rate as part of the strategic management of the
system.
"[This is because] having organisational structures that are double
what you can afford is problematic," he said.
While a chunk of Limpopo's budget is spent on employees, resources
suffer further when internal controls over finance are lacking.
The department's annual reports reflect weak consequence management for
accounting failures, with continuous recommendations from the province's
standing committee on public accounts (Scopa) to discipline the accounting
officer and chief financial officer for material misstatements and anomalies in
the finances as per the Public Finance Management Act (PFMA) and failing to
develop and implement an adequate system of internal controls.
Only "corrective action" had been taken although not
specified. Despite this, irregular expenditure and fruitless and wasteful
expenditure has decreased since 2016.
"There is very little consequence management," Maharaj
said.
"In my opinion, this relates more to malicious compliance in the
department - a rap on the knuckles irrespective of the transgressions that have
occurred."
Without consequence management, the department will continue to rack up
irregular and wasteful expenditure - critical resources wasted, however, not at
the hands of foreign nationals.
The data is a reality check for the MEC and an indication her statement
to the Zimbabwean patient is misguided.
Maharaj said:
We have a health system that is failing in the
province. We have a huge vacancy rate, equipment that is malfunctioning and
poor infrastructure, so for the MEC to make these statements is not factual.
It was not the MEC's place to berate a patient, Van den Heever said,
regardless of the issue.
"It is not that patient's fault, it had nothing to do with her. The
MEC is out of her lane - a doctor or nurse can talk to the patient, but not
her," he added.
"It is not up to her to judge that patient, embarrass her and sit
in a position of power and lord it over her. It is completely appalling. To
feed into the xenophobic narrative is deeply problematic and
prejudicial."
Van den Heever said the issue of migrants using South Africa's public
health services and cross-border compensation had been discussed since the
country's transition, but not having taken any action on it by 2022 was not the
fault of the patient - it was the government's fault for not creating a
solution.
"The fact that government don't even collect [patient] data shows
that they have no interest in solving this problem. If you don't get down to
doing your own job, don't go shout at a patient."
Governments have the money and ability to change things, individual
patients did not, he added.
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