The Life Esidimeni Hospital Tradegy: Lessons for Universal Health Coverage implementation in Africa


By Tshepho Mokwele


The provision of Universal Health Coverage (UHC) has emerged as a priority for many countries around the world because the disparity between the rich and the poor still determines who may or may not receive quality healthcare. In 2016/17, more than 100 psychiatric patients died after being transferred from Life Esidimeni Hospital, South Africa to un-registered and inadequately resourced non-governmental organisations (NGOs) around Gauteng province in South Africa. The transference was an outcome of the termination of the private-public partnership the Gauteng Health Department had with Life Healthcare which owned the hospital. The patients’ death calls into question the country’s commitment to the achievement of UHC through the proposed National Health Insurance (NHI).


According to the Health Ombudsman report, the Gauteng Health Department’s decision to terminate the contract with Esidimeni Hospital and transfer the psychiatric patients to local NGOs was a cost-cutting measure as well as a deinstitutionalisation process of the patients. However, the quick and haphazard implementation of this decision was in violation of the National Mental Health Policy which recommends gradual deinstitutionalisation of patients. This policy also notes that concomitant to the process of deinstitutionalisation, there should be an adequately developed and capacitated community care service. However, the Health Ombudsman’s report revealed that the patients’ deaths was a result of the violation of their basic human rights because the NGOs lacked basic necessities such as infrastructure, food, clothing as well as trained caregivers, proper medication and medical records. For this reason, many patients developed pneumonia, uncontrolled epilepsy, stroke, sepsis and dehydration.


The Esidimeni scandal may be indicative of a bigger problem within the South African health system, particularly with regard to mental healthcare. Mental healthcare has been “chronically underfunded” and it is also characterised by a lack of primary and community healthcare facilities. A 2001 report by the World Health Organisation (WHO) found that, in three provinces, insufficient national health budget (5%) goes to mental healthcare. This translates shortfalls in the supply of appropriate and sufficient medication for psychiatric patients. If one in three of South Africans is likely to suffer from a mental disorder in their lifetime, 75% of these would not receive any form of healthcare services because of the current mental healthcare under-funding. A 2010 comparative study by Arvin Bhana et. al on integrating mental health into primary health care in South Africa, Uganda, and Ghana using the recommendations of the WHO report found that this integration process is a challenge because of uncoordinated implementation strategy of primary health care and mental health care  policies. This situation is compounded by inadequate drugs for mentally ill patients as well as lack of mental health specialists.


While the NHI aims to provide healthcare services to everyone in South Africa irrespective of their financial or socio-economic status, its potential success remains weak in an environment where policy implementation is still compromised. The haphazard implementation of decisions evidenced with the Life Esidimeni Hospital phenomenon is a classic example of weak policy implementation. To ensure NHI’s success, emphasis should be placed on appropriate policy implementation mechanisms which would ensure that the policies as well as their implementation processes can stand scrutiny.

This scenario in South Africa is not an isolated case. In many settings in Africa, fragile relationships between public and private sectors compromise service delivery. Areas like mental health care and service provision are always less-resourced in all aspects, including human resources and finances.

As countries like Uganda are crafting their UHC agendas and strategies, the South African case offers valuable lessons. Especially in terms of equitable distribution of limited resources, coverage for special categories of patients and funding models.


Tshepho Mokwele is a Junior Researcher at the Human Sciences Research Council in South Africa.