Data from the Limpopo health department shows it is not foreign nationals who are "killing" the health system, contrary to Health MEC Phophi Ramathuba's comments.
Poor management and lack of internal controls – and not foreign nationals – are to blame for the limited resources.
Annual reports, analyses by the Office of the Auditor-General and statistics show that Ramathuba's comments towards the patient were incorrect and misguided.
Mounting medico-legal claims, lack of consequence management, irregular expenditure and shocking vacancy rates is what is "killing" hospitals and healthcare in Limpopo, official statistics and audit reports show.
This in contrast to Limpopo Health MEC Phophi Ramathuba's verbal assault of a Zimbabwean patient in a local hospital in which she assailed a woman, claiming an influx of undocumented foreigners are "killing" hospitals.
"You are killing my health systems," she tells the patient, as her colleagues cackle in the background, a video showed.
According to Ramathuba, out of 5.7 million people in Limpopo, 91% depend on the state for medical services which, according to her, was instead eaten by foreign nationals.
"You are even illegal [and] you are abusing me. It's unfair," she tells the patient.
"So, sisi, you won't be discharged until you settle your bill," is her final parting shot.
According to annual reports, analyses by the Office of the Auditor-General, and numbers and statistics in the public domain, however, there were no indications of any significant adverse impact of foreign nationals on the healthcare system in the province, but enough evidence of poor management and weak financial controls contributing to a system in distress.
The reports show:
Since Ramathuba took up her position in 2015, medico-legal claims against the department have increased to billions, posing a serious threat to the province.
Staff 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, a lack of consequence management appears rife, opening the door for continued deflection of resources.
The money is there – billions allocated to the department every year – yet consistent underspending per programme and a deviation of money from critical resources means there is little impact in clinics and hospitals.
Had Ramathuba taken a closer look at her own data, she would have observed it is not foreign nationals who are "killing [her] healthcare system", but her own management.
Enormous medico-legal claims – not foreign nationals – could potentially put the department, and the province, at risk if not checked, and although contingent, could land the province under administration, Risham Maharaj an MPL and DA Limpopo spokesperson for health said.
The data shows an increase of billions from 2016 to 2021 relating to medico-legal claims against the department.
Many of these cases are related to cerebral palsy at birth and, according to Professor Alex van den Heever, chair of social security systems administration and management studies at the University of the Witwatersrand's School of Governance, the ratio of maternal deaths in facility per 100 000 was a good indication of the state of health services.
According to the 2020/21 annual report, R9 billion in cerebral palsy claims made up part of the R12 billion claims against the department.
"That is quite large, and it is liability to watch, and it might be, although unconfirmed, suggestive of negligent practices within the province. It does correlate with maternal mortality ratios as cerebral palsy happens in delivery," Van den Heever said.
He added the international metric for maternal mortality ratios should be between 30 and 40 per 100 000.
Limpopo's figures were not terrible – showing an improvement before Covid-19 – the province's health services "are not a catastrophe".
Van den Heever said there was uncertainty about what was really fuelling the medico-legal claims.
While these claims have been increasing as a contingent liability (and was dependent on the outcome of the claims), the number of claims paid was low, according to him, especially compared to other provinces.
The extent to which medico-legal cases are hurting the department is unclear, since settlement amounts paid to claimants are not reflected in annual expenditures yet.
And Maharaj said no clarity had been forthcoming regarding these claims.
"The response we get continually is that they have an action plan and are working towards this. We stand at a risk, because of medical negligence claims, where the province could be placed under administration … we cannot afford to pay it."
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, staff vacancy rates have been increasing, with more than half of all posts going unfilled by 2021.
Critical occupations like specialist positions, professional nurses, allied health professionals (like dental hygienists, dietitians and occupational therapists) have continuously remained half-staffed.
Yet, according to Maharaj, the department had spent 70% of its resources on compensating employees, despite this staff shortage. This leaves little resources for services.
Made with Flourish
Data shows since 2016, the department has been operating at half its capacity, leading Maharaj to conclude "the MEC's statements are irrelevant, uncalled for and incorrect".
"The fact is that the department is spending 70% of its budget on the cost of employees – salaries and wages – and yet the vacancy rate is extremely high. This is because staff that are appointed are employed at the highest salary brackets.
"This is eating into the budget. When the MEC says that foreign nationals are eating into the budget, she does not take [this] into account," Maharaj said.
According to Van den Heever, while the staff profile was unusual, it indicated the department had not adjusted its organisational structure to be in line with its budget.
"It does not imply that they actually have a 50% vacancy rate, it means they do not have proper organisational structural – it is not clear, and they are not using the vacancy rate as part of the strategic management of the system.
"[This is because] having organisational structures that are double what you can afford is problematic," he said.
While a chunk of Limpopo's budget is spent on employees, resources suffer further when internal controls over finance are lacking.
The department's annual reports reflect weak consequence management for accounting failures, with continuous recommendations from the province's standing committee on public accounts (Scopa) to discipline the accounting officer and chief financial officer for material misstatements and anomalies in the finances as per the Public Finance Management Act (PFMA) and failing to develop and implement an adequate system of internal controls.
Only "corrective action" had been taken although not specified. Despite this, irregular expenditure and fruitless and wasteful expenditure has decreased since 2016.
Made with Flourish
"There is very little consequence management," Maharaj said.
"In my opinion, this relates more to malicious compliance in the department – a rap on the knuckles irrespective of the transgressions that have occurred."
Without consequence management, the department will continue to rack up irregular and wasteful expenditure – critical resources wasted, however, not at the hands of foreign nationals.
The data is a reality check for the MEC and an indication her statement to the Zimbabwean patient is misguided.
We have a health system that is failing in the province. We have a huge vacancy rate, equipment that is malfunctioning and poor infrastructure, so for the MEC to make these statements is not factual.
It was not the MEC's place to berate a patient, Van den Heever said, regardless of the issue.
"It is not that patient's fault, it had nothing to do with her. The MEC is out of her lane – a doctor or nurse can talk to the patient, but not her," he added.
"It is not up to her to judge that patient, embarrass her and sit in a position of power and lord it over her. It is completely appalling. To feed into the xenophobic narrative is deeply problematic and prejudicial."
Van den Heever said the issue of migrants using South Africa's public health services and cross-border compensation had been discussed since the country's transition, but not having taken any action on it by 2022 was not the fault of the patient – it was the government's fault for not creating a solution.
"The fact that government don't even collect [patient] data shows that they have no interest in solving this problem. If you don't get down to doing your own job, don't go shout at a patient."
Governments have the money and ability to change things, individual patients did not, he added.