hospitals
Ann Eveleth
Horror stories of South African public hospitals abound, but perhaps none more poignantly than recent claims by paediatric staff at Durban’s King Edward Hospital that “children have died because of insufficient staff being available”.
The hospital’s paediatric department has battled “for years” to convince provincial health authorities to give it more nurses, but documents in possession of the Mail & Guardian suggest they are losing the battle. Fourteen senior paediatrics professionals at King Edward signed a letter last month to hospital management threatening to reduce admissions if last year’s 30% to 40% staff cuts are not reversed by March 1.
But provincial health authorities say the hospital is “sufficiently staffed with a nurse:bed ratio of 1,32:1”. Not so for paediatrics, says department head Professor Jerry Coovadia.
Coovadia says his department has suffered staff shortages “for years, but I am sorry to say things are worse now than before the new government”.
So whatever happened to Minister of Health Nkosazana Zuma’s bold new vision of universal basic health care for all?
National Department of Health Director General Olive Shisana is adamant the vision remains the guiding force of government policy. But, she says: “A policy can only be real if you have enough money to implement it.” Shisana estimates the R20- billion annual health budget needs a “R4- billion to R5-billion” top-up to ensure universal health care.
In the meantime, her department has had to respond to “real budgetary cuts” in recent years by shifting resources from apartheid’s hospital-centred approach to primary health care clinics in underserved areas.
Coovadia, a veteran African National Congress health care activist, says he supports this policy, but argues that its impact on some hospitals is “phenomenally negative”.
“In theory it sounds great, but you can’t consider all tertiary hospitals the same. We were not all born equal under apartheid. King Edward was underfunded by apartheid as a black hospital. It is the final referral centre for the whole of KwaZulu-Natal’s eight million population,” he says.
The numerical pressures on central and district hospitals are reinforced by the now common sight of hundreds of patients queuing for hours for treatment. But Shisana interprets these scenes differently.
“If you are coming from an area that had no health care in the past, getting care after waiting in a queue is better than no care at all,” she says.
Progressive Primary Health Care Network general manager Khathatso Mokoetle says the recent Gauteng hospital closures must be seen in this context, but adds that a lack of public education about the new referral system is adding to hospital bottlenecks.
“People go to Johannesburg [General Hospital] directly, without knowing they can still go to Hillbrow’s community health centre for many things. People aren’t used to going to clinics for minor ailments,” she says.
In terms of the new national health care system, patients with minor ailments are expected to attend local clinics or 24-hour community health centres first. Nursing staff at these institutions will then refer seriously ill patients to district, regional or central hospitals, depending on the type and level of care they require.
That is the vision, but again reality falls short. The government has nearly halved its estimated national clinic shortfall of 1 000 with the construction of 493 new clinics since 1994. But at least 117 of these are not yet operational, due mainly to financial, equipment and staff shortages.
Shisana says rural clinics have been the most difficult to staff, due to a preference among health professionals to work in urban centres. South Africa’s doctor:patient ratio ranges from 1:500 in some urban areas to 1:30 000 in some rural districts.
Some provinces are worse than others. Of the 113 new clinics built in KwaZulu-Natal since 1994, for example, only 46 are open for business.
Even where clinics are up and running, they may not have the necessary medicine and equipment to treat their patients. Shisana says real medicine shortages are “rare” and are usually due to anomalies in the pharmaceutical industry, a lack of capacity among those ordering supplies, or patient preferences for brandname drugs over generic drugs.
But she admits nurses are often not empowered to dispense the medicines their patients need. Moves to allow wider dispensing registration are afoot, but until then the primary health care vision’s main providers are unable to dispense everything on the primary essential-drugs list.
Shisana says provinces are expected to reduce hospital over-use by charging a “bypass fee” for patients who jump the referral queue in non-emergency cases. But the public education needed to jump-start this system will only begin later this year, when district and clinic health committees are formed.
Doctors like Coovadia dismiss this explanation for overcrowding as “total rubbish. They must show me one patient in my department who shouldn’t be there.”
Coovadia’s department is the tertiary-level supplier of the government’s three-year-old policy of free health care to children under six. Demand for health care has apparently simply outstripped supply.
Shisana is quick to concede serious national staff shortages, with provinces reporting a total 2 426 vacant health posts by December 1997, a gap she says prompted the new compulsory community service requirement for doctors beginning July 1.
While 1 706 of these vacant posts are approved for funding, many have not been filled simply because nobody wants them. An estimated 1 000 new interns are expected to help close the gap when they begin their service. Shisana also hopes to include nursing, pharmacy and physiotherapy students in the programme.
But many interns have been dragged kicking and screaming into their service. When voluntary service came into effect on January 1, only 62 interns joining the public system declared their voluntary status.
Coovadia says the underlying problem is low morale. “Vacillation on salaries and overtime for doctors has brought morale plummeting. That professional ethos we had which made us work five or six days without worrying about better pay is gone. It doesn’t exist among the new crop of interns. It may be gone for ever.”
The government has spent more than R2- billion in health care salary increases in recent years, but Coovadia says public salaries still compare poorly with those in the private sector who often earn three times as much. “The dominance of the private sector has serious effects on the ability of the public sector to operate effectively.”
Shisana agrees the dual public-private health care system remains skewed. Sixty- four percent of health professionals are ensconced in the private sector, to which barely seven million medical aid beneficiaries have easy access, leaving only 36%to treat the remaining 30-million South Africans with a per capita health allocation of less than R600 a year.
Shisana says the only option is to integrate the two more effectively. Getting private doctors to do sessional work in the public sector, sharing expensive medical equipment and sending public patients to private hospitals for an agreed fee are some of the plans under discussion.
But Coovadia says King Edward’s probelms could be solved simply by greater consultation and better management at the hospital and provincial government level.
Shisana says this, too, is understood by the national government.
“We are looking at ways to reduce waste, improve planning information and tie hospital managers to performance contracts.”
“The problems we know, the solutions we know. The problem is money,” she adds.