The South African High Court ruling marks an important milestone in holding public servants accountable for their decisions.
The ruling means that Gauteng’s health minister, Kedani Mahlangu, and the province’s mental health director, Makugabo Manamela, can be prosecuted for nine of the 144 deaths that occurred after the transfer of mentally ill people from Life Healthcare Esidimeni Hospital in 2015 and 2016.
In October 2015, Health Minister Malanga announced that the Department of Health would terminate its contract with Life Esidimeni to cut costs, in accordance with the Mental Health Act, which “encourages mental health practitioners to treat mental health clients in the least restrictive environment”.
What happened next was one of the most shameful events of the past 30 years.
In an oral judgment on 10 July 2024, Judge Mumonoa Teffo said Malanga, which decided to terminate the contract, and Manamela, which implemented the project, were responsible for the disaster.
Both men could face criminal charges.
Read more: Negligence bars criminal liability in South African deaths of mentally ill patients
As a psychiatrist with many years of experience in academia and the community, to my knowledge, this is the first time in democratic South Africa that government health officials have been held personally accountable for the outcomes of political decisions.
The report also highlights the dire consequences of prioritizing perceived costs over outcomes, without regard for the nation’s most vulnerable citizens.
Photo of Daniel and Lydia Malatele with Daniel’s sister Maria, one of the victims of Life Esidimeni. SADAG
The most helpless
It is worth remembering just how vulnerable the people admitted to Life Esidimeni Hospital are: they are living with chronic neuropsychiatric conditions such as schizophrenia, bipolar disorder, intellectual disability, cerebral palsy, epilepsy and dementia, and often have more than one of these conditions.
These effects were so profound that it became difficult to live in the community: one patient with chronic schizophrenia had reportedly lived in Esidimeni Hospital for 40 years.
Most people staying at Life Esidimeni facilities are admitted by trained health professionals under the Mental Health Act as “supported mental health care users”, meaning they are supported in making decisions about their care by a family member or guardian and two mental health workers.
In essence, by terminating the contract, decisions made by families and trained professionals were ignored, ostensibly to save money.
How the tragedy unfolded
In October 2015, Governor Mahlangu announced that the Gauteng health department would end its decades-old contract with Life Esidimeni, a group of privately run mental health facilities.
The contract guaranteed the provision of medium- to long-term inpatient care for people with severe mental disorders.
Mahlangu justified the decision as a “project” to deinstitutionalise patients in line with national policy, but said the reason for the decision was that contracts were unaffordable.
The termination of the contract meant that about 1,700 mental health patients had to be transferred from Life Esidimeni Hospital to alternative care facilities.
By the end of June 2016, some of the clients had been returned to their families, just over 200 had been transferred to the province’s tertiary university psychiatric hospital, and more than 1,200 had been transferred to either state-run care centers or one of 27 residential facilities run by nongovernmental organizations (NGOs).
The process was chaotic: poor planning meant many non-government facilities were inadequate, understaffed, and lacking the experience to provide the type of care needed.
It was later revealed that many NGOs had been fraudulently licensed by the Ministry of Health and had not received sufficient subsidies.
Gauteng’s former health director, Thiago Serebano, later admitted in an affidavit that he had signed and backdated NGO licences even after patients had died.
Some of the mental health care clients, with different diagnoses and medical needs, were transported in open pickup trucks to various NGOs.
Some had their hands and feet tied.
Families were not informed of their loved ones’ whereabouts, confidential patient records were lost or destroyed, and people were shuffled between multiple NGOs.
By September 2016, it was clear that things had gone tragically wrong, when Governor Malanga announced in the Gauteng Provincial Assembly that 36 people had died as a result of the policy.
By the time the inquest presided over by Teffo began in July 2021, the death toll had risen to 144.
Patrick Mpiti holds the identity card of his mother, Sanna Mpiti, one of the victims of the Esidimeni tragedy. SADAG
end of a line
During the Life Esidimeni tragedy, I was part of the Sedibeng district mental health team. We received 63 mental health care clients and placed them with five different non-governmental organizations.
Life Esidimeni was allocating R320 per user per day, or just under $18. Currently, apart from an NGO grant of R112 per user per day, or just over $6, no additional resources are allocated to our district (or any other district).
But the care we provided required close collaboration between mental health teams, family medicine and primary health care workers, and non-governmental organizations.
Already understaffed, regular clinical services were provided to meet the immediate needs of the extremely needy and vulnerable people from Life Esidimeni.
This process was as if decision-makers and government officials did not need to adhere to the eight Batho Pele principles for public services (“people first”): consultation, service standards, access, courtesy, information, openness and transparency, compensation and value for money. Or perhaps the Batho Pele principles do not apply to people with mental disabilities.
Is there any difference?
The Mental Health Act promotes care in the least restrictive environment possible. Wherever possible, mentally ill people requiring long-term care should be discharged to receive follow-up in primary care or community mental health services.
Yet 20 years after the act was promulgated, government funding continues to prioritise free-standing psychiatric hospitals, and despite hard lessons learned from the Life Esidimeni tragedy, primary care and community mental health services remain inadequately resourced.
South African society is neither safe, secure nor supportive for people with mental illness. Violence, poverty and psychological stress are widespread and people with mental illness are among the most vulnerable to these factors. Without access to long-term hospital treatment, they are often left to fend for themselves.
Holding public officials accountable for their callousness and incompetence is a big step forward.
But while the Life Esidimeni judgment provides a measure of dignity for people with mental disabilities, it also reveals the dire consequences of policies that are not backed up by adequate funding.
Read more: South Africa’s mental health watchdog needs to be given a voice and power