A ruling by a South African high court represents a significant moment in holding government officials responsible for their actions. With this decision, former Gauteng health minister Qedani Mahlangu and former mental health director Makgabo Manamela can face prosecution for nine out of the 144 deaths that happened following the relocation of individuals with mental disabilities from Life Healthcare Esidimeni facilities in 2015 and 2016. In October 2015, Mahlangu declared the end of the health department’s agreement with Life Esidimeni, which was in line with the Mental Health Care Act and aimed to reduce costs. This move led to one of the most disgraceful episodes of the last three decades. On 10 July 2024, Judge Mmonoa Teffo stated that Mahlangu’s decision to end the contract and Manamela’s execution of the project were directly responsible for the disaster. They can now both be criminally charged.
A psychiatrist with extensive experience in academia and community work notes that this is the first instance, to their knowledge, in South African democracy where government health officials are being held personally accountable for the outcomes of a political decision. This situation also underscores the severe repercussions of neglecting the care of the nation’s most vulnerable populations and prioritizing cost savings over positive outcomes. The residents of Life Esidimeni facilities were exceedingly vulnerable, dealing with chronic conditions like schizophrenia, bipolar disorder, intellectual disabilities, cerebral palsy, epilepsy, and dementia—often a combination of these. Their illnesses made living in conventional community settings challenging. One individual suffering from chronic schizophrenia reportedly resided at a Life Esidimeni hospital for 40 years. Most residents at Life Esidimeni were admitted as “assisted mental health care users” under the Mental Health Care Act, meaning their care decisions were made with the help of family members or guardians and two mental health practitioners. Terminating the contract effectively overturned decisions made by families and trained professionals, ostensibly to cut costs.
In October 2015, Mahlangu announced the Gauteng health department would cease its long-standing contract with Life Esidimeni, a group of privately run mental healthcare facilities. This contract had provided medium- to long-term care for individuals with severe mental disabilities. Mahlangu described the termination as a “project” to align with national deinstitutionalization policy, primarily due to the contract’s high cost. Ending it forced around 1,700 mental health patients to be moved from Life Esidimeni hospitals to alternative care. By June 2016, some were sent back to their families, over 200 were relocated to provincial tertiary academic psychiatric hospitals, and more than 1,200 were transferred to either state-run care centers or one of 27 residential homes operated by non-governmental organizations (NGOs). The transition was chaotic, as many NGOs were ill-prepared, losing records or subjected to fraudulent licensing and insufficient support from the health department. The former head of Gauteng’s health department, Tiego Selebano, later admitted to backdating NGO licenses under oath, even after deaths had occurred. Patients, with varying diagnoses and medical needs, were sometimes transported in open vehicles with their limbs bound, without their families being informed of their locations.
By September 2016, it was evident that the situation was tragically amiss. Mahlangu informed the Gauteng legislature of 36 deaths resulting from the policy. By the time the inquest led by Judge Teffo commenced in July 2021, the death toll had reached 144. During my time on the Sedibeng district mental health team amid the Life Esidimeni calamity, we received 63 mental healthcare users spread across five different NGOs. Users at Life Esidimeni previously received R320, roughly $18 per day. After relocating, aside from an NGO subsidy of R112, or $6 per user per day, no extra resources were allocated to our district. Despite limited staff, our team worked intensely with family medicine, primary healthcare practitioners, and NGOs to address the urgent needs of distressed individuals. It appeared that decision-makers and officials were not obligated to follow the eight Batho Pele, or “People First,” principles for public service, which include consultation, service standards, access, courtesy, information, openness, transparency, redress, and value for money. Alternatively, these principles seemingly did not apply to individuals with mental disabilities. The Mental Health Care Act advocates for treating patients in the least restrictive setting, promoting follow-ups in primary or community mental health services when feasible.
However, 20 years after the act’s introduction, government funding remains focused on standalone psychiatric hospitals, leaving primary care and community mental health services underfunded despite the harsh lessons from the Life Esidimeni tragedy. South African society does not provide a safe, secure, or supportive environment for people with mental disabilities; these individuals often face violence, poverty, and psychological stress, and they are the most vulnerable when unable to access long-term hospital care. Holding public officials accountable for their neglect and incompetence is a significant progression. While the Life Esidimeni ruling restores some dignity to people with mental disabilities, it also highlights the disastrous impacts of policies unaccompanied by appropriate funding.