Limping behind in health care

The most northerly of South Africa’s nine provinces, Limpopo, is a land of contrasts. It is a vast area of more than 120 000km2 where the extreme poverty of local inhabitants is contrasted starkly with world-famous game lodges where tourists and visitors enjoy the rugged landscape in fantastic luxury.

For Limpopo residents, visiting a clinic or hospital could mean an entire day’s travel or waiting hours for taxis to fill up. Waiting for an ambulance could prove fatal.

One of the poorest provinces in the country, Limpopo spends only 16% of its budget on health. This is in contrast to an average of 22% in other provinces.

Health spending in Limpopo last year totalled R637 per capita — almost 30% below the national average — and the figure continues to decrease.

It shows. Primary health care use is low, access to termination of pregnancy services is scant, ambulances are few, the HIV/Aids programme is trailing behind other provinces, inequity is rife, malnutrition is endemic and staff turnover in the health sector is high. HIV-related tuberculosis and lower respiratory tract infections are among the leading causes of death.

Although still unacceptably high, the province has managed to lower its infant mortality rate from 57 per 1 000 live births in 1994 to 37 in 2000. The infant mortality rate refers to the number of children younger than 12 months who die annually and is generally used as an indicator for measuring the success of a health-care delivery system. The mortality rate for children younger than five has also decreased from 83 per 1 000 live births in 1994 to less than 53 six years later.

The recently announced increase in the rural allowances for doctors and nurses will attract health professionals to Limpopo.

Presently, one doctor in the public sector must serve a population of 8 544 while a professional nurse must serve 1 001 people. Provincial minister of health and welfare Sello Moloto has admitted that the below- average allocation for health is “an issue we are battling with”.

Compared with the rest of the country, Limpopo has recorded the highest expenditure on social grants — 90% of the provincial social development budget. With almost 63% of people in Limpopo living in poverty, most rely on old-age pension and child-support grants.

But some like Dr Paul Pronyk, director of the Rural Aids and Development Action Research (Radar) programme based in Limpopo, believe that more money is not necessarily what the province needs, more important is better planning and management.

Radar is attached to the University of the Witwatersrand’s school of public health that has been working with Tintswalo hospital, Limpopo’s second- largest hospital, for the past 20 years. Situated in the former Bushbuckridge homeland area, Acornhoek is historically inhabited by Shangaan and Sotho speakers. The area presents an interesting profile of factors that influence HIV transmission. These include migration, gender inequality and extreme levels of poverty and underdevelopment.

About 750 000 people have settled in the area, a quarter of whom are Mozambican refugees. This has resulted in ongoing transmigration between Acornhoek and southern Mozambique. Also, 60% of the local men migrate to work, mainly to the mines and other industries in Gauteng and Mpumalanga, though some work as labourers on Limpopo farms.

Visitors to Tintswalo hospital cross a small bridge over a railway track. Before 1994 the bridge divided the area into Shangaan and Sotho speakers. If you happened to be Sotho and fell ill, you’d be treated at Mapulaneng hospital, about 30km to the south. The struggle to define district boundaries and rationalise referral patterns still continues, says Pronyk.

One of the most pressing issues in the province is hunger and starvation. The nutrition ward at Tintswalo, is often filled with children with kwashiorkor or marasmus.

The 2000 South African Health Review rated Limpopo as the province with the worst levels of stunting in the country — 34,2% of children between six and 71 months. Malnutrition and diarrhoeal disease are the primary causes of death in young children in the area. Professor David Sanders of the University of the Western Cape’s school of public health agrees that implementation of health policy is very poor across the country. But there are glimmers of hope.

Primary health-care nurses are currently receiving intensive training, enabling them to deliver services equivalent to those offered by doctors in the rural areas. This is crucial as the bulk of health services in the province are located far from urban centres and usually driven by nurses.

About three hours north- west of Acornhoek is the provincial capital Polokwane, the economic hub of the province with an impressive health infrastructure. There are two large hospitals, Polokwane hospital and the national Department of Health’s flagship, Mankweng, which is 25km out of town.

A gateway to South Africa’s northern neighbours Mozambique, Botswana and Zimbabwe, the town accommodates the majority of the province’s urban dwellers.

Dr Zola Ntshona is an obstetrician at Polokwane hospital, a massive 450-bed teaching institution run in collaboration with the Medical University of Southern Africa.

“I used to work at Umtata General hospital. Most of the time I was frustrated and angry. My patients were lying, two, three in a bed. When I arrived at Polokwane I was given the assurance that this would never happen in this hospital and it hasn’t,” she says.

“Yes, there are many frustrations here as well. The equipment is old, the knives and scissors are blunt and the referrals are never-ending. But then I hear we are sending back R3-million of unspent funds,” she says.

According to Ntshona, at least 50% of her patients are HIV-positive. She, however, believes that the provision of anti-retrovirals will bring hope.

But does the province have the capacity to dispense antiretrovirals in line with government’s plan?

The provincial government claims that all eight regional hospitals and 33 district hospitals offer Nevirapine for the prevention of mother-to-child transmission. The programme is running at both Tintswalo and Polokwane hospitals, but uptake seems low.

“People don’t want to know their status, so it’s a real battle. They tell me that they have so many problems already,” says Ntshona.

For the full version of this story visit www.health-e.org.za

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