Thursday 22 February

3 JULY 2014, BLOEMFONTEIN: An effective moratorium has been placed on certain public health services in the Free State, a Treatment Action Campaign (TAC) investigation has revealed.

For over a year we have released alerts, stating our concern over a slowly collapsing public health system, the evidence of which is borne out of the many stories we receive on a frequent basis from those who are dependent on this crumbling health system.

The TAC has over time used formal channels to bring our serious concerns to the urgent attention of the National Health Minister, the Premier Ace Magashule and the Health MEC Dr Benny Malakoane. While the National Health Minister indicates that his hands are tied in terms of intervening, the Premier and MEC have responded by launching witch hunts against activists and making it clear to health workers that if they speak out, they will be fired. Both Mashagule and Malakoane have shown no willingness or commitment to addressing the collapse of the health system in the Free State.
Despite this, a number of health workers have spoken to us, even though they are fearful of victimisation. The dire conditions under which they work has left them with no choice.
We have in our possession stories from among others Bloemfontein, Bethlehem, Thaba Nchu, Winburg, Harrismith, QwaQwa, Ficksburg, Welkom and Brandfort.
Common themes have emerged which point to a moratorium on certain health services and speak to an ever-deepening crisis in the province.

1. Some facilities have no equipment and supplies to conduct life-saving tests and monitoring of conditions such as diabetes, hypertension and heart disease.

2. Stockouts and shortages of drugs for many chronic conditions such as TB, HIV, diabetes and epilepsy.

3. No laundry services in several hospitals which means there is no bedding, no theatre gowns, which in turn translates into a suspension of services such as surgery.

4. A shortage of staff with some facilities reporting for example situations where two nurses care for more than 75 ill patients in a ward.

5. Some hospitals have no budget, leading to a suspension of services.

6. No HIV counsellors with dispensing of medication either suspended or prescribed with no counselling.

7. Shortage or complete lack of doctors in hospitals with patients turned away.

8. Lack of water, electricity and toilets in facilities including a maternity clinic.

9. Patchy or non-existent access to emergency medical services such as ambulances.

Unfortunately these concerns are not new. In 2008/09 the TAC revealed a moratorium on enrolling new patients on ARVs that lasted for five months. We also drew attention to other deep problems with the delivery of health services. Essentially the same concerns as exist today were outlined in the 2009 Integrated Support Team investigation that was commissioned by then Health Minister Barbara Hogan into the Free State health system. There seems to be no evidence that its recommendations have been implemented.

Premier Mashagule cannot credibly pretend to have been unaware of the collapse around him. That he has responded by appointing and keeping on a MEC as controversial and unpopular as Benny Malakoane is a serious indictment of his leadership.

The Treatment Action Campaign has called this media briefing to make the following demands:

1. The National and Free State governments must with immediate effect make a full and complete disclosure of the state of the province’s health finances.

2. Free State Premier Ace Magashule must with immediate effect follow the lead of his counterpart in Mpumalanga David Mabuza and release a frank and detailed assessment of the state of the province’s health system and what his plan is to turn it around.

3. The 2009 recommendations of government’s Integrated Support Team investigation into the Free State health system must be implemented (see appendix).

4. Health MEC Dr Benny Malakoane must be suspended with immediate effect with an independent investigation into his conduct and failure to act.

5. The National Department of Health must urgently intervene in the province to bring an end to the effective moratorium of some healthcare services. The longer we wait for a strong intervention, the more lives will be placed at risk.

For more information and to arrange interviews please contact:

Mary-Jane Matsolo 079 802 2686

Lotti Rutter 021 422 1700 / 081 818 8493


The crisis in the Free State dates back to November 2008 when a moratorium was imposed to stop initiating antiretroviral treatment for new patients. This has dire consequences for people’s health in the more than four months that it was in place.

At the time it was understood to be due to an apparent over-expenditure of the provincial health budget, health services in general had been scaled back in the province. In particular, the Free State health department took a decision on 3 November 2008 to stop initiating new patients on ARV treatment. Many other services were also affected at the time.

Barbara Hogan, the National Health Minister at the time sent a task team to the province and an Integrated Support Team (IST) produced a 102-page report in April 2009, setting out in detail what the systemic problems were and what had to be done to remedy the situation, avoiding future crises.

The priority findings of the report at the time included:

  • the presence of material unfunded mandates at provincial level contributing to overspending. Financial management practices were in need of improvement. They warned that unless there was radical measure put in place to remedy the situation, there was likely to be forced cuts in service delivery again.
  • lack of cohesion between policy formulation, budgets and resources to implement policies and planning.
  • the unsustainability and unaffordability of the current model for scale-up of anti-retroviral therapy for people living with HIV.
  • the dearth of national guidelines, norms, standards and targets.
  • the need to overhaul recruitment and HR processes and synchronize budgets and planning with organizational structure and staff establishment.
  • inadequate monitoring and evaluation at all levels with managers paying lip service to M&E.
  • a disjuncture and lack of integration between planning, budgeting and implementation.
  • senior management are pre-occupied with bureaucratic functions, especially financial and are not focused on service delivery which is the core responsibility of the Free State Department of Health.
  • drug budgets have not been prioritised leading to shortages.

The IST, which included a number of health experts, made a number of key recommendations.

Unfunded mandates

• The operational impact of national policy decisions should be determined and must be agreed with the provincial health department prior to implementation.

• There should be alignment between political decisions and operational implementation and agreement reached for any proposals on increases of service levels prior to their announcement. The availability of funding should also be confirmed.

Lack of cohesion between policy and budgets

• The budgeting process needs to be seen and used as an extension of the annual performance plan, and needs to follow an iterative process.

• All operational units (cost centres) need to have a realistic budget that can be used as a guideline for the financial year’s activities. Operational plans need to be aligned with available funding to deliver the services.

ART Model

• The current national and provincial models of monitoring and delivering ARVs needs review to ensure that it is sustainable, affordable, equitable and addresses issues of access.

National guidelines, norms and standards

• Clear national guidelines, norms and standards should be produced by the NDOH to cover all areas of functioning within the available resources.

Human resources

• Restructuring, with a view to establishing minimum staffing levels, should be undertaken based on a number of factors including objectively agreed benchmarks, the provincial disease burden profile, optimal application of scarce skills and service delivery priorities as well as on available resources.


• M&E needs to become a central component of all managerial activity with the use of objective information being the basis for decision making. This applies to all aspects of management, including financial and HR, and not only service related data. There needs to be an iterative link between planning, implementation and monitoring.

• Regular formal monitoring of key indicators needs to take place with analysis and questioning of variances (in much the same way as financial management variance analysis should take place).


• The STP should be reviewed, revised, costed, endorsed politically, communicated to all relevant stakeholders and then used as the basis to guide all strategic decision making in the FSDOH.

Service delivery focus

• Senior management meetings need to focus more on strategic issues, and service delivery needs to be one of the priority strategic issues.

• Performance agreements should be clearly linked to clear delegations, organisational priorities and key indicators that drive organizational performance

• All planning processes in the department should be simplified and aligned with each other and well communicated. There should be a limited number of key targets for each area of operation for which managers are responsible and accountable.

The full report can be accessed at