THE UPHILL BATTLE OF HEALTH SERVICE DELIVERY IN

UNCLAS CAPE TOWN 000058 E.O. 12958: N/A TAGS: SF SOCI SUBJECT: THE UPHILL BATTLE OF HEALTH SERVICE DELIVERY IN EASTERN CAPE REF: 08 CAPE TOWN 000254 ¶1. (SBU) Summary: The administration of South Africa's Eastern Cape province is widely derided as the worst in the country, and the province's inability to effectively provide health services to its citizens epitomizes the challenges -- both self-inflicted and inherent -- faced by provincial government. The provincial government's ability to provide care is limited by the Eastern Cape's extreme poverty, low rates of urbanization, and a legacy of maladministration from the apartheid years. Although provincial leadership has made strides expanding access to health services during the past 15 years, it has been unable to address severe capacity shortfalls that have resulted in underspending, poor planning, abysmal record keeping, and high vacancy rates. Discussions in late January between Econoff and provincial health officials and analysts suggest fixing the province's severe management and administrative shortfalls is the first step to improving health service delivery, but few saw much light on the horizon that it would happen any time soon. End summary. -------------- EASTERN CAPE RURAL AND POOR -------------- ¶2. (U) Much ink has been spent by analysts and journalists in the past 15 years about the problems of Eastern Cape, which is widely viewed as the worst-governed and most inadequately-serviced province in the country. While neither national, provincial, nor local governments have adequately addressed the province's needs, it is worth taking into account the province's inherent disadvantages before properly assessing government shortcomings. Eastern Cape is South Africa's poorest province -- provincial statistics note that 69.6 percent ot ifs approximately 6.5 million people live in poverty. Furthermore, just 30 percent of the province is considered urban, a number that would be far lower without the inclusion of the Nelson Mandela metropolitan municipality (Port Elizabeth),the Eastern Cape's economic hub. Such low rates of urbanization limit the province's economic potential -- Eastern Cape has one of the country's highest unemployment rates -- and also the government's ability to deliver services in an effective manner. The lack of economic opportunity has also created demographic challenges, in that young people (men especially) have left the province in large numbers to seek work, leaving behind the very old and very young. 
¶3. (SBU) The Eastern Cape province birthed after South Africa's 1994 democratic transition also faced tremendous administrative challenges that still have not been solved today. The province was forced to amalgamate the administrations of the Eastern Province of the Cape province with the abysmally-run homelands of the Ciskei and Transkei in the province's west. Litha Klaas, the province's Director of Integrated Health Services, told Econoff that it took until about 1999 before health and other departments were somewhat effectively integrated. However, many civil servants from the old homeland administrations -- whose jobs were protected after 1994 -- remain on the job and are often problematic, non-performing employees who tend to be less qualified and motivated than those hired since. Although the department has a human resource strategy to address their underperformance, Klaas said that in practice it is highly difficult to enforce. -------------- HEALTH PROVISION ABYSMAL 15 YEARS ON -------------- ¶4. (SBU) Due to these and other factors, health service delivery in Eastern Cape in 2009 is abysmal, and most Qdelivery in Eastern Cape in 2009 is abysmal, and most observers say it is not improving. The provincial health department today operates 66 hospitals and over 700 clinics in the province -- many of which have been built or expanded upon since 1994 -- but the department's annual report acknowledges only 45 percent of households have access to hospitals and 70 percent have access to clinics. The primary reason cited for low access was that they were too far away. Citizens also complained about the quality of care; nearly half thought their care was inadequate, citing long waits, lack of medicines, and the absence of doctors as their biggest complaints. The vacancy rate for the department as a whole is 34 percent, while the vacancy rate for doctors, nurses, and other specialist occupations hovers around 46 percent. Jay Kruuse of the Grahamstown-based Public Service Accountability Monitor (PSAM) -- a watchdog NGO that closely monitors provincial government performance -- notes that difficult working conditions, low pay, and general frustration all contribute to keep this number high. Klaas said some staff go six months without pay, which drives many of them away. ¶5. (SBU) Most observers attributed the bulk of the blame to incompetence on behalf of the Department of Health. Observers, both inside and outside, of the department cited several key shortcomings: -- Lack of management capacity. While Kruuse acknowledged there are some talented people at the department in the provincial capital of Bhisho, the depth and capacity of management talent throughout the province is weak. Klaas acknowledged this as well, noting that he and other senior managers had to spend a lot of their time sorting out management issues in clinics and hospitals because administrators there are not up to the job. Because of this, Klaas said he cannot spend enough time on policy development, which is his actual responsibility. -- Terrible record keeping. Although the Health Department has in the past three years addressed problems with underspending, it remains unclear where this money is going. Kruuse questioned how a department with a 34 percent vacancy rate can spend almost 100 percent of its personnel budget, for example. The department has never received an unqualified (i.e., clean) audit in its existence, and Kruuse notes that the books are so bad that it is difficult to tell whether incompetence or corruption are to blame. Mike Bopasu, the former chair of the Health portfolio committee in the provincial legislature (who recently defected from the ruling ANC to the splinter party Congress of the People) said the problem is that most book keeping is done by clerks unqualified for the job, as accountants are almost impossible to find, while Klaas said an additional problem is that most reports are still paper-based because the province does not have money for a proper IT infrastructure. -- Poor planning. Kruuse and Klaas said the department does not have the skilled staff to do sophisticated strategic planning, putting them at a severe disadvantage when seeking funds and preventing the department from knowing how to spend what they have effectively. Kruuse cited the example of the province's provision of anti-retroviral treatment. While an independent 2006 report asserted that between 100,000 and 235,000 people in Eastern Cape would need such treatment in 2008, only 60,000 will be provided it because the province is simply increasing its targets by 20,000 per year through ¶2011. Mamisa Chabula-Nxiwini, the Executive Director for Public Health in the Nelson Mandela metro, noted that this lack of planning has hamstrung much-needed educational programs aimed at prevention, as the province is too often forced to be reactive rather than proactive. -------------- NO QUICK OR EASY FIXES -------------- ¶6. (SBU) Every interlocutor said that fixing health service delivery in Eastern Cape is going to be an uphill battle, though many pointed out the need to get the "systems" right before anything else. Klaas and Kruuse noted that meaningful standards and best practices are necessary to changing the culture of non-delivery that permeates the province. Over time, these systems will become ingrained and improve performance. To do this, money needs to be spent in the right way, with more focused on hiring effective managers, accountants, and other administrators. This will not be easy, however -- money is tight, and even at competitive salaries it is hard to lure skilled staff to a province with such a bad reputation. ¶7. (SBU) The province also has to retain the people it hires, as it loses many doctors and nurses to other areas of the country and the world. Klaas said that while higher salaries would probably help this, he thinks the frustrations over Qwould probably help this, he thinks the frustrations over inefficiency and poor working conditions were a bigger driver. Hence, implementing a comprehensive human resources strategy that addresses staff concerns would go a long way toward helping retention. Such fixes will not solve Eastern Cape's problems with deep-rooted poverty or capacity shortcomings, he noted, but they would help put the province on the right track toward addressing them. -------------- COMMENT -------------- ¶8. (SBU) Good project management and good administrative skills are seriously lacking in the Eastern Cape provincial government, as indicated by various contacts and by reftel. The continued shortage of skilled managers, especially those with financial management and accounting skills, in the provincial government will make any significant progress in health services delivery an uphill effort. The national government may find it necessary to second a number of its staff with the requisite skills to work with their Eastern Cape provincial colleagues to bring them up to speed. End Comment. MAYBERRY