R 171304Z MAR 09
FM AMCONSUL CAPE TOWN
TO SECSTATE WASHDC 3007
INFO SOUTHERN AF DEVELOPMENT COLLECTIVE

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. 
 
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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. 
 
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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