On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.2 Cape Town Feb. 2009
Health services battle as kzn's budget implodes
A 'top-heavy' KwaZulu-Natal health department will overrun its budget by at least R2 billion this financial year (08/09), yet tertiary hospitals there continue to function with doctor shortages of more than 60%, seriously compromising service delivery.
Head office at Natalia is also mired in a debilitating corruption scandal involving Health MEC Peggy Nkonyeni, a friend who secured a lucrative cancer scanner tender and a senior official.
Former head of department, Dr Busi Nyembezi, resigned last year when the scandal led to ongoing enmity between her and Nkonyeni. The leadership vacuum has been plugged on an ad hoc basis ever since.
An Izindaba review of annual reports from 2006 to 2008 shows a growth in departmental staff numbers of 13 360 people and a budget spending increase of R5.5 billion (including a R1.2 billion overspend for 07/08). In spite of the heavy spending, the average of medical specialist vacancies at Pietermaritzburg and Durban's tertiary hospitals stands at 70% and 63% respectively. Medical officer vacancies at the two hospital complexes are 28% and 63% respectively. Any claims that tertiary service delivery has at least been maintained over recent years are dramatically belied by these figures.
In spite of the province's mounting disease burden, overall specialist and registrar numbers have dwindled from 570 in September 2006, to 567 in September 2007 to 551 in September 2008. Medical officer numbers looked slightly better at 2 453, 2 694 and 3 075 for the same periods.
When it comes to actual appointments at tertiary hospitals (in Pietermaritzburg and Durban only), fewer and fewer medical officers and specialists were appointed between 2006 and last year, dropping from a total of 1 340 in 2006 to 905 for 2008 (until 15 November last year).
Medical officer appointments at these two hospital complexes for 2006, 2007 and 2008 numbered 1 183, 1 145 and 860 respectively, while specialist appointments tallied 157, 89 and 45 respectively. The net shortage of medical staff came to a head in November last year, after 5 months of angry finger pointing between senior public sector clinical and political health leadership over post 'freezing' outlined in a June departmental circular.
No freeze? So where are the doctors?
Clinicians angrily rejected official denials that any moratorium on clinical staff appointments existed, pointing to the lack of posts being filled in spite of their continual, exhaustive motivations and applications. Departmental spokesman, Leon Mbangwa, denied that medical officer posts had 'ever been closed'. Instead hospital managers were asked to 'prioritise posts they believed to be critical'. These would be filled 'immediately and the remainder later', he said. He explained the glaring discrepancies by saying, 'some civil servants are too lazy to follow the right channels'.
In late November a crisis meeting led to a mutually agreed upon appointment process. However, by then it was so late that many doctors who would have been welcomed with open arms had made applications elsewhere, resulting in at best, weak mitigation.
So where is the money going? Dr Jim Muller, head of the Pietermaritzburg Hospital Complex and Chairman of the KwaZulu-Natal Midlands SAMA branch, believes there is too much fat at head office, citing the explosion of 'technical advisors' and other highly paid civil servants in the last 5 years, which he described as 'staggering'. Well-placed Izindaba sources at national treasury tend to agree and cite a lack of management capacity.
They said KZN's Finance Department was 'tearing its hair out over Health - historically their provincial treasury has been fairly generous to them, if anything Education is now under-funded, yet they (Health) have got themselves into such a hole. You've got huge overspending and a simultaneous breakdown in service delivery'.
The situation is so serious that the adjustment budget of a further R740 million this year will 'hardly make a dent'. 'Anyone who overspends by this much should be out of a job - I think the national minister would probably agree,' one source added.
Muller said the recent advertisement of 9 posts at Head Office for nonclinical personnel paid the same salaries as clinical specialists reinforced the impression of a top-heavy 'gravy train' administration. However, he quickly added that he had some sympathy for administrators as they were managing the country's worst HIV/AIDS and XDR-TB pandemics, with 16% of the province's population (or 1.6 million people) HIV positive.
Here's why we overspent
Ramping up expenditure is a 44% under-estimation of people receiving ART (146 537 versus the 81 614 budgeted for), extra medicine needed to treat AIDS opportunistic infections, vital XDR-TB crisis control measures and the new occupation-specific dispensation (OSD) skills retention incentives, carried out amidst widespread initial confusion (overpayments of R28 million). A nursing strike last year resulted in many patients (especially in Durban) being 'farmed out' to the private sector, costing the fiscus 'several additional millions'.
Besides these factors, the department justifies the cost over-runs by saying national treasury allocated too little money to begin with. Whatever the truth, its subsequent hurried and clumsy bids to slash costs led to serious clinical vacancies and worsened service delivery at top public hospitals.
Muller said all the posts they had asked to be 'unfrozen' had now been unfrozen. 'The difficulty is that it's late in the year and we're struggling to fill them. We're doing what we can in a hurry to try and maintain services,' he said in mid-December.
He cited the biggest problem as sourcing anaesthetists (who traditionally have a high turnover), upon whom so many other disciplines relied, while paediatrics and surgery found themselves 'to a lesser extent in a similar situation'.
The health department was either unable or unwilling to supply Izindaba with vacancies by discipline or by hospital in the Durban and Pietermaritzburg hospital complexes. Asked what their strategy was for filling doctor posts given the paucity of doctors, a KZN health department spokesman, Sibonelo Msomi said it included employing foreign doctors for 3 years in consultation with the national health department's Foreign Workforce Management Project (FWMP). (The under-staffed FWMP has itself been hit by corruption, with a long-serving pivotal deputy director-general suspended for allegedly taking money for doctor placements.)
Plenty policy, little delivery
Msomi said a policy had been drafted to help recruitment strategies of scarce categories of staff. Salaries were 'negotiable' while entry requirements for promotion posts had been reduced to a minimum of 2 years' experience.
Other incentives included scarce skills and rural allowances while the national health department was developing an occupation-specific dispensation for doctors 'and introducing careerpathing'.
Asked why 'technical advisors' were apparently so vital, Msomi responded: 'These posts are of an administrative nature and provide technical advisory services to institutions regarding identifying medical technology needs, developing innovative solutions and co-ordinating quality assurance arrangements inclusive of the development and maintenance of a departmental basic medical equipment list'.
He said repeated attempts to elicit a response from his Chief Financial Officer, Sipho Buthelezi, about how much money was being spent on administrative staff versus clinical staff now and 5 years ago, failed to bear fruit. 'First he was very busy and could not assist me and then he promised to get back to me,' Msomi sighed after a week of repeated reminders about e-mailed Izindaba questions.
MEC's court case
His MEC Nkonyeni, a teacher by profession, is on R10 000 bail after appearing briefly in the Pietermaritzburg Magistrate's Court on 8 December last year. She was not asked to plead to charges under the Prevention of Corruption Act and was due to appear again on 22 January, when the Scorpions probe is completed and a detailed charge sheet presented. The charges centre on her allegedly unlawfully influencing the awarding of a R1.5 million tender for the cancer scanner, reportedly worth about R400 000, to Lindelihle Mkhwanazi, with whom she allegedly has a 'personal relationship'.
Mkhwanazi, owner of the tender company, Rowmoor Investments and Mduduzi Ntshangase, a health department official, were additionally charged with fraud. Ntshangase faces an additional charge of contravening the Public Finance Management Act. These two were released on bail of R10 000 and R5 000 respectively.
Nkonyeni, still the MEC incumbent, is a strong candidate for the KZN premiership next year and her court case is heavily politicised. Noisy supporters and robust bodyguards tried to prevent reporters entering the courtroom, claiming the charges were part of 'political plot' and that the issue was 'merely an administrative matter' that she has nothing to do with.
The controversial MEC first hit headlines after hounding two Manguzi Hospital doctors Colin Pfaff and Mark Blaylock for their 'unofficial' early rollout of triple therapy, leading to their eventual resignations last year, and her defiant support of her ART denialist former national chief, Dr Manto Tshabalala-Msimang.