Emergency Medical Services (EMS) and right to access healthcare, fact or fiction

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By Tlamelo M. Mothudi, Health Researcher, PSAM

At 7pm on the evening of October 2012, my sister called me panicked and scared. She asked that I call an ambulance; her son was having a seizure, a fever and was vomiting. The ambulance was called but only dispatched to Ngqamakhwe village 5 hours after the call due to it responding to another call elsewhere. My nephew died before the ambulance reached the hospital.

-Anonymous Testimony from “People’s Stories” documented in Section 27 and Treatment Action Campaign’s report on mobile clinics in the Eastern Cape.

There are countless medical emergencies that happen across the Eastern Cape on a daily basis that stem from an EMS system that has failed to respond adequately and as such, has failed the people of the province. In 2015, the South African Human Rights Commission (SAHRC) held a public hearing on EMS in the Eastern Cape. In October of the same year, the SAHRC, having investigated the complaints surrounding EMS, published a report with key recommendations for the improvement of EMS in the province.

Two such recommendations were that the Eastern Cape Department of Health (ECDoH) clarify the standards it intends to comply with, the targets it intends to set to move towards compliance with said standards and how it intends to measure its level of compliance. It was further recommended that the ECDoH plan in a way that seeks to improve the EMS system.

Four years after the publication of the SAHRC’s report; what measures has the ECDoH taken to improve the conditions of EMS in response to the findings and recommendations?

More so in a Province like the Eastern Cape which is fraught with poverty, unemployment and a healthcare system that is failing its people.

The Constitution of South Africa affirms the right of all South Africans to access healthcare services and further stipulates that no one may be refused emergency healthcare services. The Constitution also mandates that the government take reasonable, legislative and other measures, within available resources, to achieve the progressive realisation of the right. The responsibilities for health are outlined in section 3 of the National Health Act which calls on the Minister to endeavour to protect, promote, improve and maintain the health of the population within the limits of available resources.

When tasked with taking all legislative and other measures to progressively realise the right to health, the government is mandated to take all reasonable steps to ensure the protection, promotion and fulfilment of the rights and that over time, access to quality and comprehensive healthcare is achieved. There is an obligation on the state to prioritise major public health needs more so, those which pose a threat to public health.

To this end – what is evident is the presumed response by the ECDoH to the SAHRC recommendations by the increase of the EMS fleet from 306 to 416 and the activation of a live tracking system for all the EMS vehicles.

However – many of the recommendations remain unresolved. Of additional concern is the province’s inefficient resourcing in relation to EMS.

The ECDoH has seen an upward trend in its budget allocations towards the EMS programme. Simultaneously, the department has also seen an increase in underspending within the programme. This underspending is a cause for concern and begs the question as to whether the department is progressively realising the right to healthcare services within its available resources. If it is neither able to achieve its strategic objectives nor effectively utilise the resources at its disposal – what measures has it taken to deal with the problem with EMS?

Year:                    Budget allocation:                    Underspend:
2015/16              R946 million                              R 25.6 million
2016/17              R1.1 billion                                R 27.8 million
2017/18              R1.2 billion                                R 496 thousand
2018/19              R1.3 billion                                R 52 million (as at February 2019)

In 2015, the SAHRC made several recommendations some of which pertained to planning and budgeting for the number of ambulances needed, the type and distribution of those ambulances and the factors considered in deciding the type and distribution, the equipping of the ambulances and their response times. The SAHRC recommended that when rostering vehicles and their distribution, the Department must consider the needs of different communities. The SAHRC rightly outlined that rostering and vehicle distribution would be a matter of prioritisation and resource management.

The recommendations of the SAHRC are important considering that currently there are more ambulances in repair than there are on the roads. The Department has reported that in the 2016/17 financial year, it had 416 ambulances in its fleet and of those, 250 were operational.

In the 2017/18 financial year, the Department reported that it had 416 ambulances in its fleet and of those, 50% operational at any given time. This translates to 213 ambulances to service a population of 7 million people, an unacceptable number of ambulance per population ratio.

In 2018, the Department confirmed that the conditions of state ambulances are affected by the bad state of provincial roads -resulting in EMS vehicles being taken off the road for repairs or service. The report fails, however, to outline the exact number of vehicles off the road, the reasons for them being off the road and the projected costs of putting them back  on the road.

The stark reality is that the ECDoH is still failing the people of this rural province through its continued inability to ensure that there are sufficient numbers of EMS on the roads which are operational and able to get to patients during times of emergencies. The Department is failing to achieve its urban and rural response time targets and has been for several years.

Additionally, the Department expanded its targets to respond to emergencies throughout the years from a target of 66% in 2015/16 to a target of 85% by 2019 without addressing the fundamental reasons that the response targets cannot be achieved – inadequate numbers of ambulances on the road. Consequently – the ECDoH is breaching its Constitutional mandate.

A deep evaluation and overhaul of the EMS programme is recommended for the 6th administration. This is the time to learn from previous service delivery failures of the programme and to ensure that there is a re-evaluation of the planning and resource allocation to this programme. The 6th administration must undertake rigorous community-oriented needs analyses.

For the EMS programme to achieve its mandate, it must become a priority, and this must be reflected in the Department’s planning and resource management processes.

Meaningful public participation is critical. In particular -the people that most rely on these services must be engaged to ensure that their needs are considered and met. It is imperative for the provincial administration to institutionalise the principles of transparent, participatory process to strengthen planning and service delivery in health. This is core to accepted primary healthcare paradigms.

Public officials and elected representatives of the 6th administration must consider and respond to the recommendations made by the SAHRC, four years after the fact. These recommendations were considered advisable for the adoption of progressive measures for the promotion of fundamental rights within the framework of the law and the Constitution.

The lack of implementation is highly lamentable.

Until urgent measures are taken to address the current problem of EMS in the Eastern Cape, the province will continue to place the lives of its people in detriment.

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