3 hours 30 minutes
(It could take longer depending on how lunchtime is used)

Aims

To help us to:

• Develop empirical perspectives on the social and structural determinants of health, with a specific focus on the public health system, labour, land, mining-affected communities, water struggles and living conditions
• Learn from social movements and communities struggling against socioeconomic precariousness
• Use political economy as a tool for analysing the health system and its social context

Task 1
Four site visits in and around Polokwane

Fellows will be divided into four groups for the site visits – one group per site. Each group of Fellows will be hosted by one facilitator and/or one Tekano team member (see below). The sites are all in the wider Polokwane area. 

The four sites were chosen because each offers important empirical knowledge about the connections between key dynamics of South Africa’s political economy. We will have lenses into socioeconomic precariousness, rurality, black cheap migrant labour, perilous living environments, and public hospitals in rural working-class communities (one district and the other tertiary). The four sites are the following and short site briefs are included on the pages that follow:  

• Lebowakgomo Hospital with Thandokazi Tabata
• Mankweng Hospital with Funzani Mthembu
• gaMasodi mining village with Masana Mulaudzi
• The Molemole community with Crystal Dicks

Before setting out or en route

Before heading off on the site visit (or while en route), we’ll remind ourselves of key demographic features of the province by looking back at the Limpopo – A Brief Overview as the first section of this Fellows guide. This is really important for our understanding of the complexities and challenges that we’ll come up against. 

Once at the site

We encourage Fellows to: 

• Apply critical reflection and thinking skills to observe, learn about, discuss and reflect – this means a critical eye, a keen ear, listening to understand and learn, and asking genuine questions to understand what may not be clear 
• Combine critical enquiry with respect, fairness, and being reasonable in engaging with our hosts at each site 
• Be fair and just in giving each other opportunities to observe, learn and engage 
• Be reasonable and conscious of the short time of the actual visit at each site – the actual time we will spend at each site will be no more than 3 hours. 

Some angles of questions to pose at the site: 

We will have indicated to our hosts the kinds of questions that we are interested in exploring. We note them here, not to limit you or prescribe, but for transparency reasons and in case there are questions around the reasons for your group’s visit: 

1. What are the three most important health outcomes improvements that you are striving for, with and for your institution/community? 
2. What are the three biggest obstacles that you face in striving for health equity in this institution/community and why are they not being addressed? 
3. What do you see to be the root causes of health inequity in this institution/community? 
4. What are the concrete developments that give you the greatest hope that any of the obstacles can be overcome in the next three to five years? 

Story-telling reflection questions for after the site visit: 

These questions are for your group, to help you reflect on what you saw, learnt and understood. If you have time at the end of the visit, answer them then, or take the time to answer them on the drive back to the hotel. 

Story-telling will be the method your group will use to present your group’s reflections on the site visit. This is no ordinary story telling! We will use the technique of political economy story telling that is outlined in the Framing Document on page 32 in the last part of Section I and also in Activity 4 below. This will be an early evening after-dinner plenary session. Use these questions to guide your story-telling structure:

1. What have you observed and learnt about the economy, livelihoods and the social dynamics at the site visited?
2. Were there angles to the site visit that helped your understanding of the burden of illness and disease? How are these shaped by rurality, poverty and underdevelopment?
3. What did you learn at this site visit about health outcomes in relation to race, class, gender, ability, and sexual orientation? 
4. What from the visit contributed to your understanding of health as a human right? To what extent is this right being upheld?
5. How has this visit affected your understanding of health inequity? What are your views on root causes of health inequities based on the site you visited? How are these inequities shaped today?

Remember that others have not visited the site, so include in your story an audio picture of the site you visited. 

Site 1 
A district public hospital: Lebowakgomo Hospital

Lebowakgomo district hospital is located in Lepelle-Nkumpi sub-district in Limpopo. According to a recent report it has 220 beds.

From April 2007 to March 2008 the hospital was part of a project aimed at transforming a rural district hospital into a Health Promoting Hospital according to standards developed by WHO-Europe. The intervention used a diagnostic approach and baseline needs assessment of hospital staff, patients, and their relatives to identify health education and promotion needs. Activities included empowerment training and skills development, implementation of health education and promotion activities, and the integration of health-promoting standards and values in the hospital structure and culture. The project indicated applicability of the model in a resource-limited setting, based on staff empowerment, local leadership, and stakeholder engagement. By the time of putting together this brief, it was not possible to find out whether health promotion activities at the hospital continues.

Lebowakgomo hospital has made the news frequently, and never for good reason. Some of these news reports include:

Earlier this year (2022) it made the news for a food crisis, when Lebowakgomo patients reported only being offered dry bread with no tea or juice.

• In December 2021, the family of a 34-year-old woman who died with her stillborn baby on 1 December at the hospital reported that they plan to lodge a case of medical negligence against the Limpopo Department of Health.
• In 2017, services at the hospital were shut down by protests from The Democratic Nursing Organisation of South Africa in Limpopo for irregular appointment of nursing staff.
• In 2016, a Limpopo doctor was accused of raping a teenager at the hospital. The doctor was arrested after the victim complained she was raped by the accused when she visited the hospital to consult him about an undisclosed sickness.
• In 2012, patients needing X-rays at the hospital reported suffering because the X-ray machine broke down. The X-ray machine has been dysfunctional since November 2011, making it difficult for orthopedic surgeries to be done. Limpopo and Gauteng were struggling to pay service providers on time for the maintenance of critical equipment, leading to delays in diagnosing illnesses, ascertaining the true nature of injuries and deciding on appropriate methods of treating them.

One news article reported a patient saying, “I don’t blame the hospital I blame the government at some degree for poor service delivery. Sure, the person who runs the hospital is also to blame for incompetence, I don’t even know how that person got that promotion. This hospital is poorly managed by the people on top.” 

Site 2 
A public tertiary hospital maternal unit: Mankweng Hospital

Mankweng Hospital is a Tertiary (Academic) Hospital, which is considered a Level 3 facility aimed at providing subspecialist care due to it being a provincial hospital. The hospital is one of two Tertiary (Academic) Hospitals that provides services for patients referred by the five Regional Hospitals in Limpopo Province. The hospital was built and commissioned on 1 July 1988 and was officially opened by the Chief Minister of Lebowa Government at this time.

A number of specialist’s clinical departments existed at the Mankweng Hospital.  These range from –  Anaesthesiology; Paediatrics and Child Health; Neonatal ICU; Internal Medicine; Family Medicine; Phela O’Phedishe (ARV Clinic); Clinical Forensic Medicine; Clinical Psychology; General Surgery; Trauma Surgery; Psychiatry: Adult and Paediatric;  Orthopaedics and Prosthodontics’; Clinical Support Services; Optometry;  Occupational Therapy; Physiotherapy; Clinical Social Work; Oral Health; Radiography; Speech and Audiology; Pharmacy; Dietetics; Clinical Engineering; Laboratory Services; and Blood Bank.

Two investigations have been undertaken at the hospital. One by the Public Service Commission (PSC) in 2016 following a number of verbal complaints regarding the allegedly poor delivery of services for ‘day-visit’ patients at the Outpatient Department (OPD) within the Mankweng Hospital. News reports also pointed to overcrowding in the maternity ward with expectant mothers being forced to sleep on floors and frustrated patients complaining that conditions at the hospital are ‘unbearable’.

The second was a visit by the Portfolio Committee on Health as far back as 2011. Their reports surfaced the following:

• Members observed that infection control would be a problem as there was an absence of hand sprays, shoe gloves and other protective measures. In response, the Infection Control Officer noted that infection control was not standardised in South Africa. The 2007 National Policy and Strategy did not specify that hand sprays were mandatory.
• Staff shortages were reported in the wards. The nurse-to-patient ratio was 1:3 or 1:4. The Ward had 32 registered nurses, eight enrolled nurses, 80 nursing assistants and seven general assistants.
• Equipment and consumables were not always available: Electrocardiogram (ECG) machines had to be rotated as there was a shortage.
• The hospital did not have an isolation ward, but used a side ward, when needed.
• Maintenance of equipment and infrastructure was a challenge. The hospital’s own maintenance unit was used for this instead of the Department of Public Works. For four to five months no water was available, and the hospital had to improvise. This was due to a water reticulation issue at the hospital.
• The hospital was still waiting for transport incubators, which were ordered in March 2011, and four out of seven were being repaired. Procedurally, first the Clinical Engineering Unit undertakes in-house repairs and, if needed, it is then sent to a company for repairs. If new incubators need to be procured, the Bid Committee would handle the matter.
• The procurement process at the hospital was very slow, and this resulted in the hospital having to return unspent money to Treasury.
• The pharmacy served 21 clinics, including 10 outreach clinics, as well as the wards at the hospital and outpatients Section. It was staffed by 13 pharmacists, including five community service pharmacists as well as nine interns and nine pharmacy assistants. Six staff members go out daily to clinics. Five vacancies were reported for pharmacists, including one for a community service pharmacist position. The average waiting time for service was between 24 minutes to 2 hours.  
• The ARV clinic needed a CCTV but there were too many zones to cover.
• The pharmacy itself also needed a CCTV. The process was going to take approximately six months, which was going to be a challenge to its accreditation; and
• The pharmacy struggled to obtain stock as amounts over R150 000 had to go through an adjudication process, which was quite slow.

While both these reports are dated, they are useful in providing a sense of what things were like and allowing an assessment of how things have changed since.

Site 3 
A Mining Town: gaMasodi Village

Numerous studies conducted on people who reside next to dust producing mines and industries show major health risks. Air pollutants from the mine and industries are inhaled by exposed miners and people who live in the vicinity. This was confirmed in a 2006 study which used over two hundred questionnaires coupled with four dust deposition gauges in Limpopo. 

There are additional studies on how land, water and other natural resources are seized to facilitate capital accumulation through mining operations. A 2016 study on mining operations in Limpopo shows how one platinum mining company acquired land through non-voluntary mechanisms by disregarding South Africa’s Interim Protection of Informal Land Rights Act (IPILRA) set to protect the lawful occupiers and users of land.

A more recently (2022) released research report by civil society organisations Amnesty International SA, the Centre for Applied Legal Studies and Mining-Affected Communities confirmed this and more. The findings, based on the responses received from people living in the communities affected by the mining operations in the area sees community members share how the mining operations caused disruptions to their livelihoods, ways of life and human health.

Issues surfaced include mining operations contributing to:

• Contaminated water sources
• Soil and water pollution
• Losing livestock, a chief source of income
• Rural women being drawn into transactional sex agreements with mine employees, in exchange for employment opportunities. 
• The removal of gravesites

Mining companies are required to submit to the minerals and energy department how a mine will benefit communities affected by the mining operation. The report found that mining companies investigated had failed to comply with obligations which arose.

According to the report, communities lacked proper representation due to the co-option of their elected representatives by the mines.

The report also found that the department of minerals, resources and energy failed to adequately regulate mines and carry out its oversight role to ensure the implementation of community development plans.

The report recommended that the department establish well-resourced financial and human local community department of minerals, resources and energy offices in minerals complexes and an independent, impartial, and thorough grievance mechanism for mining-affected communities.

Site 4 
Molemole: A Community Mobilised Around Water 

Molemole covers about 3,347.25 km² with a population of 100,408, or 9.48% of the district.

As far back as 2014, several parts of the Molemole area faced a serious water crisis despite the Capricorn District Municipality’s (CDM) allocation of more than 11 million rand to supply water to these villages. This despite an academic study by the University of Limpopo in 2013 in which participants were asked to state the six main services that should be provided by their municipality. The results indicate that the main services expected are water, electricity, sanitation, road tarring and maintenance (especially gravel roads), housing, refuse removal and health services. According to the findings, water is the residents’ first priority.

Basic water supply in terms of the Water Services Act, 1997 (108 of 1997) requires that prescribed minimum standards of water supply services are necessary for reliable provision of sufficient quantity and quality of water to households to support life and personal hygiene. People depend on water for drinking, producing food and maintaining basic standards of hygiene. Lapses and even the non-delivery of certain services related to water supply and sanitation can have disastrous consequences such as cholera and diarrhoea. It could also have a direct impact on the everyday livelihoods of communities.

The Molemole Local Municipality has been challenged in supplying water to all the communities and villages that fall under its jurisdiction. Significant problems and challenges include incompetent staff, financial sustainability of service providers and the lack of service providers and the problems of proper maintenance and sustainability of water resources.

A Molemole resident commented that prior to 1994, villagers used to get sufficient water from street and yard taps, but things became worse when the system of local municipalities was introduced. Molemole residents complain that the municipality did not maintain the water pipes and boreholes and that the pump operators did not attend to the machines on a regular basis. Boreholes in the Molemole Local Municipality were dry. Many villages rely on water from rivers and wells, posing the threat of water-borne diseases.

In March this year (2022) Molemole became a ghost town. The streets were deserted, and shops, businesses and banks were closed ahead of expected protests. More than 100 protesters from Dendron gathered from 5am to block roads leading to the town centre. Later, protesters marched from the taxi rank to the office of the Mayor of Molemole Municipality.

In the memorandum, the community demanded the provision of drinking water to all households and the scrapping of debt on services since 2017 because the municipality has not rendered basic services other than dustbin collection. Thomas Mudau, a community leader, said the municipality had not honoured an agreement it had reached with the community years ago.

Handwritten minutes of a meeting held on 2 September 2019 with the mayor and municipal manager, suggest that it was agreed that the municipality would not disconnect electricity for non-payment of water bills, that existing bills would be scrapped, that a flat rate would be introduced until water services were properly restored. Water supply has been intermittent and often not at all since 2012, according to residents.

The community also wants tarred streets; parks, sports and recreational facilities; and a shopping mall.

But the major unhappiness remains around residents distrusting the billing system.

“We have not seen any officials walking around to take water readings for the month but surprisingly we get billed every month,” said Nare Makgoka. Makgoka said there are Jojo tanks dotted around the villages which are rarely filled. Individuals have therefore drilled boreholes and sell the water.

If you have time, read the following short article as well:

Modisha, N & Mtapuri, Oliver. (2013). A crisis of expectations versus legislative mandate: The case of Molemole and Blouberg Municipalities in Limpopo, South Africa. 48. 267-281.