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Mpumalanga Health underspends budget despite chronic staff shortages

Despite more than 100 clinics in Mpumalanga having no visiting doctors, hundreds of people awaiting surgeries, and only 60 working ambulances to service a population of more than 4m, the provincial Health Department underspent its budget for employee costs by about 30% last year.

This was because of the “challenges of attracting new health workers across categories to the province”, it said.

The department also did not spend about 30% of its NHI grant allocation – apparently also due to recruitment challenges, nor did it spend about 30% of the Human Resources Training grant, although it did, by January, appoint 13 registrars.

In a third-quarter health committee report tabled in Mpumalanga’s provincial legislature in February, a number of human resource challenges, among others, were highlighted,writes Nthusang Lefafa in Spotlight,.

Apart from 16 senior managers, including a new head of the Health Department – Dr Lucas Khetani Ndhlovu – all appointed at the tail-end of the last financial year, the department’s response to the health worker shortages was mostly to roll over the problem to the current financial year.

Healthcare worker shortages

The report shows that 25 of 28 district hospitals had a full complement of executive management, but, for example, the Piet Retief Hospital did not have a CEO. The department said the post was advertised and the selection process was under way.

Sabie Hospital also had no CEO or a finance manager, but “interviews and shortlisting processes are under way”, while the Rob Ferreira Hospital was also minus a CEO.

A total of 34 primary healthcare (PHC) facilities were without operational managers and suffered from a drastic shortage of senior nurses.

“In some cases, operational managers cannot execute their duties because they have to do a lot of clinical work due to staff shortages,” the report stated. “Departmental requirements stipulate they should do 20% clinical work and 80% administration work, but they do more than 20% clinical work. Some of them do not even have laptops.”

The department had undertaken to fill these posts and was going through recruitment processes to replace operational managers: R14m has been allocated in its Ideal Clinic programme to ensure the managers have equipment to fulfill their duties.

In total, 180 clinics needed extra health workers across various categories, noted the report: 5 581 community health workers are part of the ward-based outreach teams, but the number of teams “is inadequate to cover all 402 wards in the province”.

The department said there was a high turnover of contracted doctors, affecting the number of primary healthcare facilities that are supported by visiting doctors.

The district specialist teams are also not at full capacity. In Gert Sibande District, for example, the team did not have a single specialist, including a gynaecologist, paediatrician, anaesthetist, or a family physician, noted the report.

These district clinical specialist teams are important to improve access to quality care and health outcomes at district level, especially for mothers, newborns, and children and usually include “seven specialists in each district: three medical and three nurse specialists from obstetrics and gynaecology, paediatrics, and family medicine/PHC, and one anaesthetist”.

Recruitment to fill these positions, the department says, is subject to funding.

The Department of Health is expected to table its budget for this financial year next month, which will provide some insight if these vacancies will be filled.

Yet, when Spotlight asked departmental spokesperson Dumisane Malamule about this, he said – referring to the visiting doctors supporting clinics – “only 114 out of 292 clinics are not supported by a doctor”. He said more sessional doctors would be recruited.

An enabling environment

Professor Andrew Ross, founder and trustee of Uthombo Youth Development Foundation, an NPO supporting the training of doctors from rural areas, said getting rural doctors to visit clinics while there is a shortage of doctors at district hospitals is a challenge.

“It is important to have enough doctors at a district hospital first so they will be able to visit clinics in outlying areas. If, for instance, you are supposed to have ten doctors at a hospital and there are only three, then they are definitely not going to visit an outlying clinic. It is vital to have trained locals as medical officers… then there is a possibility they might work at a rural facility.”

Ross said hospital management had the huge responsibility of creating an enabling environment for doctors to work and stay at certain facilities.

“If there are supposed to be ten doctors at a hospital and there are only two, those two will not stay because they are overworked. Senior management must provide a conducive environment for doctors, meaning there must be enough resources and proper accommodation.”

“Providing adequate human resources is a major challenge, as the state is limited by the available funding,” said Russell Rensburg, director of the Rural Health Advocacy Project (RHAP).

“Salaries or employment costs are the highest cost in most provincial budgets. Despite the increased populations, the numbers of healthcare workers have not increased significantly since 2012, despite South Africa doing well in producing new healthcare workers. In the past year, more than 2 200 new community service doctors were added but fewer than 10% will be employed in the public service after their community service year.”

Rensburg said budget and staffing structures should be reviewed according to the greatest need. “South Africa has good, routinely-collected health management information. Our budget allocations and staffing structures should be reviewed and reorganised toward the greatest need, with strong investment in district health services.”

Impact on services

The health committee report also shows a shortage of 19 specialists at Mpumalanga’s tertiary hospitals, aggravating surgery turnaround times.

Malamule said the department was “engaging with several universities to … train doctors to specialise in various fields with the hope they will work in the province”.

The planned intervention was to increase the intake of registrars by an additional 10 over the next three academic years.

“For the 2023 academic year, 14 registrars have been offered bursaries to train as specialists in universities across the country, bringing the cumulative total to 48 registrars. In the 2024 academic year, provision will be made to increase the intake by an additional 10 to increase the pool of specialists trained in the province,” added Malamule.

But according to Nehawu provincial secretary Welcome Mnisi, the Health Department needs to do more to ensure timeous replacement of nurses and doctors who leave.

“Management must ensure that whenever a doctor or nurse leaves the system they are replaced quickly,” he says. “You cannot have a vacant position for more than six months even though the the human resources department knows someone has retired or resigned… they take too long to fill some positions that are already funded.”

Slow disciplinary turnaround

Another highlighted snag was the slow turnaround times in disciplinary cases, the report noting that 30 cases under investigation have been delayed for up to one year, 20 cases were delayed for three months and are awaiting hearings, 12 employees are yet to be charged, and three cases were delayed for one year and six months but are currently being handled in consultation with the Special Investigating Unit (SIU).

The department blames the delays on budget constraints preventing it from appointing investigators.

EMS shortages

The province’s Emergency Medical Services (EMS) is also not spared, with the DA spokesperson for health in the province, Jane Sithole, saying ambulance shortages are “killing” the people of Mpumalanga.

“The department has lost another dozen ambulances within three months. In the third quarterly report it had between 60 and 72 ambulances operating on a daily basis. In the fourth quarter, there were only 60 for a population of 4.7m, which is far below the recommendations of the Emergency Medical Norms and Standards.”

There should be one ambulance per 10 000 people, meaning Mpumalanga should have 474 operational ambulances.

In her budget speech in June last year, Health MEC Sasekani Manzini said R60m would be set aside for EMS: to procure additional or replacement ambulances, equipment, and appoint advanced life support personnel.

But only 10 ICU ambulances had been procured, and due to financial constraints, no new staff were employed, although the moratorium on posts was lifted. No new EMS stations were established, and no obstetric ambulances and no emergency response vehicles were procured.

Sithole said the 10 ambulances and EMS staff recruitment had been shifted to this financial year, as well as the long overdue Emergency Management Centre System, which will improve call-taking and dispatching of ambulances. The department still uses a paper-based system to monitor the time taken to respond to an ambulance request, which makes data less reliable than a digital system.

Malamule said the department would be introducing 10 “dedicated inter-facility mobile ICU units to cater for patient transfers, three dedicated ambulances for mental health patients (one for each district) in the next two months, and operationalise the referral and handover policy to minimise the turnaround time for ambulances at facilities”.

They also plan to introduce rapid response vehicles to triage and initiate treatment.


Third quarter Health Committee Report (Open access)


Spotlight article – In-Depth: Mpumalanga’s healthcare worker shortage and what is being done about it (Creative Commons Licence)


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