The ending of a private contract to fund patients who are dying and in need of palliative care at Johannesburg’s three main public hospitals has exposed a lack of contingency planning by the Gauteng Health Department, writes Chris Bateman for MedicalBrief.
An outraged Association of Palliative Care Centres (APCC) said the lack of forward planning, plus the freezing of clinical and non-clinical posts in Gauteng hospitals are to blame for the crisis.
According to Professor Adam Mohammed, Clinical Head of Internal Medicine at Charlotte Maxeke Hospital, just three nurses and a doctor in his nine-person palliative care team are retained – with the remaining social and auxiliary workers let go, leaving the hospital with under 50% of its former palliative care capacity.
He said a combination of post freezing, lack of maintenance, non-Eskom-related power outages and palliative care funding drying up means sub optimal patient care and far greater risk for patients.
The private three-year funding contract for palliative care at Helen Joseph Hospital, Chris Hani Baragwanath and Charlotte Maxeke Hospital was with the Bristol Myers Squib Foundation and ended on 1 November for the first two hospitals, and at the end of June for Charlotte Maxeke – which secured a month-on-month funding extension to 1 November. It had already been extended from an earlier three-year period when Covid hit South Africa.
Dr Mpho Ratshikana-Moloko, Director of the Wits Centre for Palliative Care, (attached to Chris Hani Baragwanath Academic Hospital), confirmed that the contract had not been renewed.
However, she said palliative care at Chris Hani Baragwanath hospital continued unaffected because management had interceded. She was ‘unaware’ of the situation at Charlotte Maxeke or Helen Joseph hospitals.
“We’ve been offering palliative care at Chris Hana Baragwanath for 25 years and nothing has changed,” she asserted.
It’s unclear whether the BMS Foundation might agree to again extend what they called the Multi-hospital Palliative Care Project when it became obvious that the Gauteng Department of Health was not going to step in effectively. According to one source, a multiple local stakeholder meeting was planned with the provincial department this month at which attempts would be made to secure funding going forward. The BMS Foundation, based in Princeton, New Jersey, could not be reached for comment.
Said Mohamed: “They (the Gauteng Department of Health), knew very well we were coming to this over the past six months but did nothing about it. It’s not about money, but about planning. The reality is the system is broken. There’s a moratorium on our appointing new people, patients are staying here for between four and six weeks as-in patients just to get a CT scan, repairs to a whole block damaged by a fire we had here in April 2021 won’t be completed until well into the 2025/26 financial year. That means our psychiatry wards will remain closed and the cardio-thoracic ICU which moved to another wing, remains at reduced capacity. Post fire, we’re back at full patient capacity but with reduced space.”
Lawrence Mandikiana, Advocacy Manager for the APCC, said palliative care has historically been a low-priority funding item which tends to get squeezed out of consideration – or not funded at all.
“It’s a responsibility of the state to provide access to palliative care; a service that every person in the country may ultimately need, but this responsibility is not being fulfilled,” he said.
Mandikiana said the recent freeze by the Gauteng Health Department of clinical and non-clinical posts for budgetary reasons was followed by a freeze on new equipment purchases.
“The Department of Health must be held accountable for the current situation. We demand urgent resolutions to enable sustained provision of palliative care services as well as the implementation of integrated palliative care policies and frameworks into the public healthcare sector. Palliative care is provided from the point of diagnosis of a life-threatening condition and access to palliative care services should be considered a human right.
He said outside palliative care funding was symptomatic of the long-standing low priority given to palliative care, as evidenced by the National Department of Health neglecting to update the 2017-2022 National Framework and Strategy on Palliative Care.
“There is currently no national plan in place for palliative care,” added Mandikiana, who served as an externally funded Deputy Director-General for Palliative Care in the National Department of Health.
Mohamed said Oncology and Outpatient services at Charlotte Maxeke Hospital have been severely affected by the austerity measures with overall service delivery in his hospital down by 20%, a direct result, he believes of ‘neglect and corruption.”
Hospital CEOs in Gauteng internally notified staff about the posts freeze. Mohamed said there was also no funding for routine maintenance, gas and oxygen, and generators. Charlotte Maxeke had experienced four or five power outages due to local municipal electricity cable or transmission boxes failing this year. “It’s only a matter of time before a back-up generator fails, costing lives,” he believed.
It’s reliably learnt that the Wits Health Consortium advertised for medical officers and professional nurses in a palliative care tenders for the three hospitals – shortly before the Bristol Myers Squibb contract ended.
The source said that when it came to Chris Hani Baragwanath Hospital, the Health Department intended providing a medical officer and social worker, a psychologist, and an administrative clerk to ensure unbroken palliative care there.
Mandikiana said palliative care priorities vary widely between provincial governments, with the Western and Northern Cape leading the field with joint initiatives. He worked for the Chris Hani Baragwanath Palliative Care Project before taking up his current job with the APCC last month.
“There’s a need to raise awareness for palliative care services in provinces. This can be achieved by focusing on strategic aspects, such as developing monitoring and evaluation elements for palliative care, which could be integrated into the Department of Health’s Health Information Systems (DHIS). A useful example is the tracking of "loss to follow-up" indicators in HIV projects, which enables provinces to monitor this metric effectively,” he added.
Mandikiana said engagement with the Gauteng Department of Health on palliative care funding for both resources and training was "ongoing".
He likened palliative care advocacy to, “a big circle, there’s a need for continued engagement with provinces to make sure they carry the palliative care baby with them.”
Head of Communications for the Gauteng Department of Health, Motalatale Modiba, said Chris Hani Baragwanath Hospital continued to provide palliative care services via its staff and internal resources.
At Charlotte Maxeke Hospital, palliative care continued “through its employed nurses and the doctor,” with a retired matron sourced to continue providing spiritual support. However, there were no posts for the ‘patient navigator and other resources – “which we can’t help.”
At Helen Joseph Hospital staff were "upscaled/trained” to render palliative care and necessary space was identified and renovated. However, due to limited staff and already overstretched personnel, these staff members could not be redeployed to palliative care.
Modiba said a general review of the Gauteng DoH organisational structure was underway, pending approval. “The structure makes provisions in accordance with the current service delivery gaps and seeks to ensure that critical areas are resourced to enable better care to patients,” he added. He provided no timeline nor staff-to-palliative care patient ratios.
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