Gauteng Mental Health Marathon Project: A case Study of Gross Ethical Leadership Failure

Gauteng Mental Health Marathon Project: A case Study of Gross Ethical Leadership Failure
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The 1st of February 2017 was a very sad day for the almost 23-year-old new South Africa, because we learnt with disbelief from the country’s 1st Health Ombudsman, Professor Malegapuru W Makgoba of avoidable and reckless deaths of 94 of our compatriots (and still counting), when he released his comprehensive report into his new office’s in-depth investigation into reported deaths of vulnerable mental health patients after their transfer from a Life Esidimeni Hospital facility to 27 Non-Government Organisations (NGO’s) throughout the Gauteng Province, without the necessary professional or logistical capabilities to appropriately care for them in dignity in line with the relevant Mental Health Care Act (Act No 17 of 2002), and our overriding supreme law, the Constitution of the Republic Of South Africa (Act No 108 of 1996).

When the Health Ombudsman publicly released the report into these unfortunate deaths of the Gauteng Mental Health patients, I was glued to my laptop watching and listening via eNCA live streaming. I was so emotionally saddened whilst at the same time angered that such reckless human tragedies can happen under our new dispensation, whose Constitution is hailed worldwide as a benchmark for the protection of human rights, especially for the most vulnerable in our society. It has taken me days to make sense of it all, and this morning I mustered enough energy and courage to read the full report on-line, and I must say by the time I concluded that exercise, my emotional rollercoaster feelings which I had experienced on the report release date had suddenly come back. A lot has been written on various media platforms on the horrific details behind this human tragedy, and more is still being unearthed and written about, for example that there are still 21 bodies that are still lying at the morgues in Pretoria, which if they are part of the transferred patients from Life Esidimeni, it will then take the total number of deaths well beyond 100 deaths, making it the equivalent of Marikana Tragedy threefold and more.

I do not plan to bore you with more of the same or similar details, I will, however, try to look at this regrettable loss of 94 lives during the Gauteng Mental Health Marathon Project which apparently went wrong, from a leadership failure point of view. The Health Ombudsman report clearly identifies three main actors or officials in this sorry saga of massive avoidable loss of lives, it says

Evidence identified three key players in the project: MEC Qedani Dorothy Mahlangu, Head of Department (HoD) Dr Tiego Ephraim Selebano and Director Dr Makgabo Manamela. Their fingerprints are ‘peppered’ throughout the project.  

The Health Ombudsman report makes the following allegations against the three main actors:

Available evidence by the Expert Panel and the Om- bud showed that a ‘high-level decision’ to terminate the Life Esidimeni contract precipitously was taken, followed by a ‘programme of action’ with disastrous outcomes or consequences including the deaths of Assisted Mental Care Health Users.

Further, the reports state that:

The decision was unwise and flawed, with inadequate planning and a ‘chaotic’ and ‘rushed or hurried’ implementation process. The decision to terminate the contract precipitously contradicted the National Mental Health Policy Framework and Strategy, the cost rationale could not be justified above the rights of the mentally ill patients to dignity and the state’s constitutional obligation to accessible health care. This precipitous approach was not supported by available research experience or legislative prescripts. The project has brought ‘pain and anguish’ to many families, it has also brought national and international disrepute and embarrassment to South Africa, particularly its Health System.

Gauteng Department Of Health, MEC Qedani Mahlangu

When one reads the Health Ombudsman’s report further, it becomes clear that there were serious multiple failures of leadership at various levels within the Gauteng Department Of Health, however, the relevant three named officials at the top leadership level have to shoulder most of the blame for what happened under their oversight or governance watch. The report highlights leadership failures at the decision-making level, at project planning and risk identification level, at NGOs selection levels, at patients transfer implementation levels, and at ongoing monitoring and corrective action levels. I was quite distressed by the Health Ombudsman conclusions that this Gauteng Department Of Health Leadership Troika failed to listen, and in many instances, they ignored sound professional advice from multiple internal and external stakeholders.

Let me focus on my understanding of what leadership is and is not, before we zoom into the specifics of the apparent leadership ethics failure, as a way to draw some lessons from these unfortunate mental health patients deaths saga, and hopefully for all of us take the lessons forward in order to avert similar leadership ethical failures in the future. Many definitions have been written on the concept of leadership, some very simple and others very complex, however, my preferred definition is:

Leadership is a process of social influence, which maximises the efforts of others, towards the achievement of a goal.

In looking at the above leadership definition, clearly the Leadership Troika within Gauteng Department Of Health failed in their leadership role to lead a process to provide effective leadership, clear project direction, and to optimally utilise available professional expertise internally and externally in order to enable a successful and disaster or deaths free professional transfer of mental health patients from Life Esidimeni to the various Non-Governmental Organisations (NGOs) across the province.

In my brief review of literature on leadership with a view to identifying the most common qualities or attributes of successful leaders, Integrity; Honesty; Openness/Transparency, and Trust always feature amongst the top as well as other key qualities or attributes like, Vision; Passion; Dedication; Humility; Risk Taking; Creativity; Fairness, and Listening Skills. Going through the Health Ombudsman report as a whole, what is clear is that the Leadership Troika at Gauteng Department Of Health individually and collectively did not cover themselves in glory when it came to issues of demonstrating Integrity, Honesty, Transparency. As a consequence the report informs us that there was a serious breakdown of trust amongst the three key players, and between them and the rest of the implementers within the department, as well as with external stakeholders who were advocating for a rethink on the seemingly poorly planned, chaotic and rushed project execution, instead of a phased cautious approach.

The issue of violation of key values of Integrity, Honesty, Openness and Trust by leaders brings me to the whole issue of the role of ethics in leadership. It is said that ethics are always at the heart of leadership, and that leadership power that comes with being a leader can be used either for evil or for good. Further, it is said that by assuming the benefits of leadership, we also assume having to deal with ethical burdens or ethical dilemmas. Ethical dilemmas usually involve multiple stakeholders (those affected by the ultimate decision), and the outcome is marred by uncertainty. In his book, Ethics and Leadership: Putting Theory Into Practice, William D. Hitt offers the concept of making “right good” decisions, or those that are right ethically and good from an economic perspective. Indeed, if the leader tries hard enough, he/she can make a decision that falls into both categories. Certainly, as evidenced by the Enron scandal and the Bernie Madoff debacle, while unethical decision making by the leader might “work” in the short term, eventually honesty and integrity are necessary for the long-term success of our leaders.

Good Character and Integrity are both very important in leadership, Kouses and Posner in 2007 identified honesty as the Number 1 most common character of successful leaders. In 1999, the Josephson Institute identified 6 Pillars Of Character in successful leaders, as follows:

  • Trustworthiness
  • Respect
  • Responsibility
  • Fairness
  • Caring
  • Citizenship
David Makhura: Gauteng Premier.

Looking at the above leadership character pillars, the Leadership Troika at Gauteng Department Of Health failed in almost all of them, as follows:

  • In the trust stakes, they failed very badly which led to a complete breakdown between the department and the external stakeholders, for example, families and NGOs like Section 27.
  • In the area of respect, it is clear from the report that the failure of the leadership to listen to other approaches and viewpoints led to a serious decline in the levels of respect within and beyond the department.
  • In the responsibility stakes, they again fared badly as they individually and collectively reportedly took no accountability when the deaths started piling up amongst the transferred patients, as well as failing to proactively consider and mitigate the risk of the possible consequences of the ‘rushed and chaotic’ implementation of the Gauteng Mental Health Marathon project.
  • On the area of fairness, the leadership failed to play by the rules and the relevant Mental Health Care Act No 17 of 2002, as well as the Constitution of SA, Act No 108 of 1996. Also, it is clear from the report that they took advantage of the vulnerable members of our society by violating their human rights, and when confronted by the Health Ombudsman, chose to blame each other or other external stakeholders, than to take full accountability for what had happened.
  • On caring, the Leadership Troika under the leadership of the Ex-MEC failed to display kindness, compassion and certainly did not act in a way that showed they wanted to minimise hardship and help others especially family members if one considered that in some cases family members were not consulted of the details of the transfer to NGOs, as well as the time delays in them being informed of the family members who has unfortunately passed on.
  • On citizenship, the Leadership Troika individually and collectively failed to apply the principles of Batho Pele as well as the spirit of our Constitution to ensure that the patients’ bill of rights were protected.

Now that we can see that overall, the Leadership Troika has also failed in ethical leadership, yet we also know that these are leaders who are normally upstanding members of society, with a good track record of differentiating between right from wrong. Also, they are highly learned professionals with above average IQ and EQ levels, why is it that they chose to be on the wrong side of ethical leadership with regards this Gauteng Mental Health Marathon Project? It is said that the leaders who fail the ethical test know the right thing to do, but choose to do wrong things anyway. Often short term gain, greed and other non-ethical values take precedence over traditional values like honesty and accountability. Reviewing literature, Kidder (2005) does offer us some insights by classifying ethical dilemmas into two different categories:

In the first type of dilemma, a right versus wrong dilemma, ethical issues emerge when a core moral value has been violated or ignored. When honesty is an important value to a person, and another person is found to be acting dishonestly, it is generally acknowledged that the action was unethical. In this case, ethics is simply the obvious difference between what is right and what is wrong.

In the second type of dilemma, a right versus right dilemma, however, ethical issues emerge when two core values come into conflict with each other. When one important value raises powerful moral arguments for one course of action, while another value raises equally powerful arguments for an opposite course, we must make a choice since we can’t do both. In such cases, ethics is a matter of right versus right.

In this case of the Gauteng Mental Health Marathon project, the Leadership Troika individually and collectively seem to have consciously made a decision to break all the relevant laws and even betray their own and organisational values and ethics, simply because the end justified the means, the cost savings that would be realised from the implementation of the project would justify whatever shortcomings and risks associated with the implementation of a poorly planned, and poorly executed patient transfer project away from a Life Esidimeni Hospital to NGOs province-wide.

Looking at this regrettable case study of the failure of ethical leadership in the Gauteng Department Of Health with regards to the Gauteng Mental Health Marathon project, it reveals one of the chronic prevalent challenges in the running of healthcare services in South Africa as a whole. Amongst many challenges, is the key challenges of the chronic shortage of quality leadership and management at various levels at both national and provincial levels, and this becomes even more acute at the provincial level where service delivery actually takes place to the majority of the people of South Africa. Often people are appointed into leadership or management positions, solely based on their technical and sometimes political credentials, with little consideration into the suitability of their leadership and management credentials in order to ensure that they lead and manage their portfolios effectively.This unfortunate tragedy should be a wake-up call to the fact that there must be a conscious leadership and management development programme for various levels of leadership and management, especially for the senior management services and top leadership. Issues relating to of ethical leadership skills acquisition should be prioritised, and there are many institutions that offer such development programmes, for example, University Business Schools, and private organisations like the Institute of Directors(IoD). At least if these skills are acquired by the senior and top leadership cops, such an investment in upgrading such critical leadership skills by the above leadership and management target group might go a long way in helping South Africa to avert a similar spectacular failure of ethical leadership.

Comments (10)

  • Morality has escaped our political leadership. This at the expense of narrow, selfish and most often financial interests.
    Sometimes I wonder why we should all be surprised and/or alarmed 😳
    It has, unfortunately and admittedly, happened in all of Africa post colonialism.
    I hope I’m wrong in this

    • You are very right Mpho, Morality as a key leadership quality is now non existent amongst a significant percentage of those who are in leadership position of public office.

      It seems, political expediency and other non ethical short term gains are more of a priority than servicing SA with integrity and compassion.

      Unless this rot is urgently addressed, as a country we are headed towards disaster, and a failed state.

      Thank you for taking your valuable time to visit and comment on this Blog…I hope it is the beginning of many more fruitful visits into the future.

  • The current mental health report conspicuously reveals how mental health care is the step child of the health system. I admit that I may not be objective in expressing this view, however, in an effort to illuminate my subjectivity as objective, I nestle this within the World Health Organization’s report which highlights a lack of dire comprehensive mental health policies as well as consequences related to these. These consequences include but are not limited to the challenge in the proper implementation and relevant coordination of ethical mental health services. This then perpetuates the current demeaning language used by majority of people in conceptualizing mental illness, which in turn promotes stigma of mental illness.

    However, South Africa is different in that we have a Mental Health Act, and I will highlight three crucial points:
     The State has a duty to ensure the provision of mental health care services and to promote the provision of community-based care, treatment and rehabilitation services.
     It must protect the rights and interests of patients and promote the mental health status of the population in general.
     Health establishments must provide the appropriate level of care or refer a person in need of care to a suitable establishment.

    From my understanding of the unfortunate report, it is discussed that the community-based facilities which the patients were referred to were not registered or rather, licensed facilities. If this is the case, this brings up the question of the credibility of the staff/personnel to appropriately take care of the patients? Furthermore, it brings to the fore the question of how the rights and interest of the patients were taken into consideration as the suitability of the establishments which the patients were referred to is very much questionable. As a qualified mental health practitioner, I can unequivocally attest to the fact that poor understanding of mental illness can highly distort ones abilities to provide adequate care for mentally ill. This problem is further compounded by situational barriers such as the lack of qualified mental health practitioners in our country.

    It is sad to read that the very system that is meant to provide a dignified, healthy life for all seems to be adding to the number of barriers faced by mental health users, a structural barrier. At the risk of writing a thesis from this, I will conclude by saying that South Africa is still alive with possibilities. Let us not forget the basics. Policies are there to guide us. It is disheartening to think that valuable lives have been lost in the process. As we mourn the deaths of our fellow brothers and sisters, let us use this time as a society to reflect on our views about mental health and how these views impact us, others and the society as a whole.

  • I cannot agree more with you Lerato, the State Of Mental Health Services in South Africa leaves a lot to be desired, especially when one considers the obligations to the State from both the Constitution of SA and the Mental Health Care Act.

    As much as the report from the Health Ombudsman did not really find fault with the National Government with respect to the disastrous Gauteng Mental Health Marathon Project, it would be disingenuous to conveniently take them out of the context within which the disaster happened.

    The reality is that in South Africa, Mental Health Services have since Apartheid days been a poor cousin or a stepchild to all the other areas of Physical Healthcare.

    One expected that things would be better with the new democratic government, whose Constitutional values include Right To Healthcare and Right To Dignity.

    23 years into the new democratic dispensation, nothing much has changed, in fact the situation on the ground seems to have worsened, as evidenced by our government’s decision to abdicate their responsibility for delivery of quality mental heath services to the Private Sector and NGOs.

    I do not see Mental health Services being prioritised in the near future, and the only hope is for Civil Society and Mental health Professionals to stand up, form a mass movement that will visibly and lawfully advocate for mental health services to be prioritised to ensure improved access and quality of services to all who require thone services in line with the Constitution Of SA.

  • Thank you Dr. Nyati. It seems I had missed the mark, on the issue of leadership. I thank you again for such an insightful blog which addresses the various health issues in our country from different angles. It’s a great initiative and a good reflective space. Thank you.

    • @Lerato, you have not missed the mark on this issue of leadership – Dr Nyati agrees with you completely: hence he said he could not agree with you more. You are both on the same page on this matter.

  • Hi Lerato, we are definitely singing from the same hymn page with regards to the role of leadership with regards to turning around issues of Mental Health Services, and the rest of your informed commentary. We must however soldier on and endeavour to make a positive difference to this critical area of healthcare.

  • My challenge with the present leadership is that all their reports are about numbers, finances and none about effectiveness of their interventions. There are no consequences for non compliance with set standards.

  • Well articulated Dr Nyati, this case shows monumental leadership failure at both the Executive and Administration arms of government. The three key players ignored all advice and counsel from various NGO’s, junior officials and medical experts. There are still other questions on leadership that will be asked over time:

    – what did the national and provincial government know, when did they know it and what action they take ?

    – what role was played by oversite institutions such as the national and provincial portfolio committees on Health ?

    – what has been done by the prosecution authorities to bring perpetrators to book ?

    – what role has been played by the leadership of the ruling party in holding these key players accountable; in insisting on prosecutions to occur and focusing on compensation for these families ?

    The stench of these deaths will not go away, this remains a stain on the leaders of our ruling party, governing authorities and the officials charged with the responsibility to look after mentally ill patients.

    Well done Dr Nyati 🙏

  • Lawu, you have raised very relevant points on oversight responsibilities from NDoH, National and Provincial Portfolio Committee, My_ANC and Law Enforcement Agencies.

    My reading is that maybe the setting up of the alternative dispute arbitration hearings was not so much about getting officials to fully account and for the law to take its course.

    My sense is that those oversight bodies, more so the political principals were trying to be seen to be acting and thru arbitration processes limit Civil Claims from bereaved families.

    The Arbitration Hearings has however taken a different route which has caused more anger from civil society and families especially with the lack of accountability from Gauteng Government under Makhura, Gauteng ANC, the Gauteng Health Leadership, and Affected NGOs.

    So, this will come back to bite all of them, including the National Minister who has conveniently washed his hands on this tragedy, being the ultimate custodian of the Health portfolio in S.A.


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