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Foreign patients: a burden on the system, or scapegoats for poor management?

Limpopo Health MEC Phophi Ramathuba's verbal assault on a Zimbabwean patient at Bela-Bela Hospital, has again thrust forward the contentious issue of foreigners' access to healthcare in SA.

With South Africans either slamming the MEC for her insensitive treatment of the Zimbabwean patient (with some calling for her removal), or commending her for highlighting what they say is a real crisis, the question is whether foreigners are indeed adding to the healthcare burden in SA, or whether foreign patients are being made the scape-goats for a more complex healthcare problem, notes MedicalBrief.

As Ramathuba remains unapologetically firm about her stance on foreign patients, the Young Nurses Indaba Trade Union (YNITU) has called for her removal and the South African Medical Association (SAMA), among others, has issued strong statements deploring her behaviour.

In a widely circulated video, the MEC is seen telling the patient an influx of undocumented foreigners was “killing” hospitals and her “health systems”, while an accompanying team of officials chortles behind her.

Ramathuba told the Sunday Times she would not say sorry for taking out her frustration about the influx of foreigners on the patient.

She said calls for her axing came “from the middle class, who do not use public hospitals”, and that her views had the support of the majority of Limpopo citizens.

“The constituency I represent is suffering. I am the voice of the 91% of Limpopo citizens using public healthcare and if they say I must go, I will go. But I cannot be told by the less than 9% who know they are comfortable.”

However, health experts said there was a tendency to “scapegoat” foreigners and blame them for the failings of the SA health system.

Ramathuba said she would be steadfast in her mission to deal with “illegal migrants” from Zimbabwe who crossed into Limpopo seeking medical care.

“They are abusing the system and collapsing medical healthcare. They cross the border illegally, go from one clinic to another collecting medication and selling it in their country.”

She said Zimbabweans had “to be “stopped” because even those who used private healthcare in their country refused to pay when admitted in SA.

The Limpopo Health Department was owed R500m by patients, mostly as a result of illegal Zimbabweans, she said.

In the past two years, the department had treated 23 000 Zimbabweans who had been billed but could not be traced because they were undocumented.

“They are collapsing our system. In their own country they can pay but they come here and do not want to pay.”

The MEC said the department had received one qualified audit opinion after another, because it could not explain how it spent money on foreigners who could not be accounted for.

Ramathuba said she had merely implemented ANC policy, which her counterparts were scared to do.

The Zimbabwe Government, she added, had said illegal immigrants in SA were criminals and “must be treated as such”.

Ramathuba said Messina Hospital in Musina near Beitbridge was “under siege” from Zimbabweans.

“Some months, 60% (of patients) are Zimbabweans and 40% South Africans.” South African women were delivering babies on the floor while undocumented Zimbabweans occupied beds, she said.

This month, 22 illegal immigrants without identity documents had died in Limpopo hospitals, and mortuaries were inundated with “unknown” bodies, she claimed.

National Health spokesperson Foster Mohale said the department was aware of the challenges in some provinces regarding access to healthcare by foreign nationals.

“These have been discussed at government-to-government (level) as part of bilateral meetings, and also multilateral meetings through SADC (Southern African Development Community) forums.”

Mohale said the department was not investigating Ramathuba for her comments, that “the issues are genuine and a long-term solution is needed to address them”.

Meanwhile, reports News24, a private hospital in Zimbabwe has offered to pay the patient’s medical bill, with Harare’s Arundel Hospital asking anyone with information on the woman to contact it.

Professor Alex van den Heever, chair of social security systems administration and management studies at the University of the Witwatersrand’s School of Governance, described the MEC’s behaviour as appalling. “To feed into the xenophobic narrative is problematic and prejudicial.”

Ramathuba said: “You are even illegal (and) you are abusing me. It’s unfair.” “So, sisi, you won’t be discharged until you settle your bill,” was her parting shot.

However, reports News24, mounting medico-legal claims, lack of consequence management, irregular expenditure and shocking vacancy rates were actually responsible for “killing” Limpopo’s hospitals and healthcare.

Annual reports, analyses by the Office of the Auditor-General, and numbers and statistics in the public domain give no indications of significant adverse impact of foreign nationals on the healthcare system in Limpopo, but enough evidence of poor management and weak financial controls contributing to a system in distress.

The reports show:
• Since Ramathuba was appointed in 2015, medico-legal claims against the department have increased to billions.
• 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, lack of consequence management is rife, opening the door for continued deflection of resources.
• The money is there – billions allocated to the department annually – yet consistent underspending per programme and deviating money from critical resources means there is little impact in clinics and hospitals.

The data show an increase of billions from 2016 to 2021 relating to medico-legal claims against the department.

News24 reports that many are related to cerebral palsy at birth and, says Van den Heever, the ratio of maternal deaths in facility per 100 000 was a good indication of the state of health services.

The 2020/21 annual report shows R9bn in cerebral palsy claims made up part of the R12bn claims against the department.

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, vacancy rates have skyrocketed, with more than half of all posts unfilled by 2021. Specialist positions, professional nurses, allied health professionals (like dental hygienists, dieticians and occupational therapists) have continuously remained half-staffed.

Data show since 2016, the department has operated at half its capacity.

The department’s annual reports reflect weak consequence management for accounting failures, with continuous recommendations from the province's Standing Committee on Public Accounts to discipline the accounting officer and chief financial officer for material misstatements and anomalies in the finances and failing to develop and implement an adequate internal control system.

Ramathuba's actions have also called into question her ethics as a medical professional, notes MB. SAMA said Ramathuba “has a duty and responsibility to comply with the ethical conduct befitting a healthcare professional who took an oath”, reports IOL.

Despite the need for a national dialogue to tackle the matters, SAMA said it “deplores the manner of addressing this issue by MEC Ramathuba to a patient”.

As a leader in the province, she “is aware of the appropriate channels where such matters should be raised”, said SAMA chief executive Dr Vusumuzi Nhlapho.

“Additionally, she has a duty and responsibility to comply with the ethical conduct befitting a healthcare professional who took an oath clearly stating ‘first do no harm’.

“Foreign nationals, such as refugees and migrants, are one of the most vulnerable groups of society. Discrimination in the healthcare sector is unacceptable and a major barrier to global socio-economic development.”

Nhlapo added that Section 27 of the Constitution states that no one should be refused emergency medical treatment.

“The Refugees Act of SA sets out rights for asylum-seekers and refugees … who have the same rights to healthcare as South Africans.”

The Young Nurses Indaba Trade Union (YNITU) has said the MEC should be ousted.

“Our Constitution afford citizens and non-citizens the right to be treated without discrimination. The MEC was grandstanding and the public display was unwarranted,” said YNITU general secretary Lerato Mthunzi.

“This was not the place, time or audience to address these issues. The patient is in a sick bed and in dire of need of assistance from caring staff.”

While the South African Health Department said health workers should have a high moral obligation toward their patients, it conceded the sector was under strain, reports News24.

"Limpopo is one of the affected provinces: despite challenges, staff must ensure they maintain moral obligations and standards, in line with the Hippocratic Oath, the National Health Act and the Refugee Act of South Africa," the department said.

Adding its voice to the fray, the National Education, Health and Allied Workers' Union (Nehawu) said the Limpopo public health system issues could not be blamed on Zimbabweans and that the whole provincial Health Department system needed overhauling.

Provincial secretary Moses Maubane said: “We can’t attach the challenges to the people of Zimbabwe.. We must change the system. They (Zimbabweans) have the right to be taken care of when sick.”

Simultaneously, the Health and Other Service Personnel Trade Union of South Africa (Hospersa) called on Ramathuba to apologise.

The union’s Limpopo chairperson Bongani Ngwenya said: “The union notes the MEC’s views but also cautions against the stripping of a patient’s dignity, regardless of nationality and status in the country. Hospersa will engage the MEC’s office to find solutions to this problem, which cuts across patients’ rights to healthcare services and the available resources.”

The Limpopo Government said it would not take any action against Ramathuba, and the provincial ANC has come out in full support of her. Executive committee spokesperson Jimmy Machaka said they aligned themselves “with the sentiments and comments made by Phophi Ramathuba”.

“We appreciate the burden encroached by illegal foreigners on the health systems in Limpopo, and people should not sensationalise the issue.

"We don’t have a problem with them coming to the country. However, they must be duly documented.”

Medical staff in Limpopo say the entire province’s health system is about to collapse due to the strain from foreigners.

“We have raised this issue with the past two Health Ministers,” said Dr Michael Ndwambi, senior clinical manager at Thohoyandou’s Tshilidzini Hospital. “We are overrun by foreign patients and barely have the budget for our South African ones.

“Primary health care is free here and we do not turn sick people away. But what if people from neighbouring countries abuse our constitutionally guaranteed access to primary care in ever-increasing numbers? We are supposed to have 32 doctors. We have 19. We are already struggling. The constant influx of patients from other countries is exacerbating an already crisis situation and budget.”

Ligege said outrage at Ramathuba ignored the fundamental problem.

What the laws say about access to health care by foreign nationals is fairly clear, but Gauteng has enacted its own guidelines and policies, which show “a shocking lack of clarity”, says health rights NGO Section 27 in recently filed court papers.

SADC citizens, documented or not, are supposed to be treated alike with South Africans. Where the services are not free they must, like South Africans, do a means test and pay according to what they can afford.

However, Limpopo health spokesperson Neil Shikwambana said: “If we apply these principles on a means test basis on individuals in the country illegally without documentation, how do you conduct a means test? How do you follow up … for collection where they have no money and must sign debt acknowledgment but have no documents?”

The provision for SADC citizens is in line with a SADC health protocol, said Sasha Stevenson of Section 27. Non-citizens from further abroad who are not refugees must pay the full price, she added.

In Gauteng, regulations that came into force in December 2021 appear to set up a payment regime that mirrors the national fee schedule insofar as SADC citizens go.

However, a policy that came into effect in 2020 creates a category of “full-paying patients”, which includes “non-South African citizens”. This seems to contradict the regulations and requires all non-South African citizens to pay full fees.

The Gauteng regulations are unclear on whether fees must be charged for pregnant women and children under six. It is this focused issue that Section 27 has gone to court over, saying this has meant inconsistent application by hospitals.

The NGO wants the Gauteng Government to clarify to its hospitals that hospitals are free for pregnant women and children under six “irrespective of nationality and documentation status”. The government has not yet filed its answering court papers.

Meanwhile, reports The Citizen, public health lawyer Safura Abdool Karim said while the Constitution guaranteed the right of access to healthcare, it was not limited to South Africans.

She said there were judgments after a previous constitutional case stating that even if there were resource constraints, there should not be discrimination between citizens and non-citizens.

News24 article – FACT CHECK | No, MEC Ramathuba, poor management is killing Limpopo hospitals – not immigrants (Open access)


IOL article – ‘First do no harm’. SA Medical Association reminds Dr Ramathuba of healthcare professionals’ oath (Open access)


News24 article – Zimbabwean hospital offers to pay medical bill of migrant woman berated by Limpopo MEC


News24 article – Nehawu says Zimbabweans not to blame for Limpopo health system problems, Hospersa wants MEC to apologise


News24 article – Nehawu says Zimbabweans not to blame for Limpopo health system problems, Hospersa wants MEC to apologise (Open access)


Sunday Times PressReader article – ‘I’m the voice of 91%’ (Open access)


Sunday Times PressReader article – SA law clear on health care for migrants (Open access)


TimesLIVE article – Inside Limpopo hospitals: The desperate flood of foreign patients who can’t be turned away (Open access)


See more from MedicalBrief archives:


Limpopo MEC under fire over migrants comments


The rights of foreign nationals in accessing SA healthcare


Health Department disowns instruction on turning away foreigners


NHI also for foreign nationals and asylum seekers, says Mkhize


Unsafe, ageing Limpopo hospital sends laundry 30km away for washing




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