system …
Aaron Nicodemus gives South Africa’s health care system a check-up and finds that on the whole the major surgery performed on the system has been successful – except for the Aids policy
Five years ago Hellen Mailula (30) of Pietersburg would not have had her baby in a hospital. As part of the country’s black, rural poor, she had almost no access to the health care system.
Things have changed dramatically since then. Pregnant mothers and children under six now receive free health care, and everyone else can access the system at significantly subsidised prices.
Mailula was transferred from a Northern Province hospital to Gauteng’s Ga-Rankuwa hospital, and is confident the improved medical care will benefit herself and her unborn child. “I feel better because of the hospital,” she says. Asked if she’s happy delivering her child at Ga-Rankuwa, she answers with a smile, “Yes.”
In 1995 the Department of Health assigned itself a daunting task: dismantle an existing health care system that favoured whites over blacks, urban over rural and rich over poor. In its place, create a system in which an unemployed Eastern Cape labourer, a Johannesburg stockbroker and a pregnant mother from Pietersburg would have equal access to health care.
South Africans who had never before visited a doctor would find that their new local clinic was accessible, competent and an integral part of their community. That was the dream.
Five years ago, hospitals in Johannesburg and Cape Town could perform quadruple bypass heart surgery, but the majority of South Africans could not receive inoculations for measles and polio.
The effort to revamp the system was nothing less than an effort to turn the tide of history, an attempt to wipe away the legacy of apartheid with one hand and cradle the country’s impoverished and marginalised citizens with the other. As with many of the government’s plans to turn around post- apartheid South Africa, the health initiative was far- reaching in its scope and optimistic at its core.
During this transformation the government grappled with large industries and lobbying groups. Legislation was passed to legalise abortion and warnings were placed on tobacco products. A law was drafted to shake up the medicine approval process by replacing the Medical Regulatory Council with a new regulatory agency, which is set to begin operations later this year.
A law that would allow South African drug makers to manufacture generic equivalents of much needed Aids-related drugs was hailed by Aids activists as particularly brave, especially in light of the crush of legal actions subsequently filed by Western pharmaceutical companies.
Health care experts have largely hailed the reforms as a success, and even the most pessimistic critic would concede that a solid foundation has been laid. If you eliminate the government’s dreadful response to the Aids epidemic, health experts say its achievements over the first five years are impressive.
“In general the health ministry hasn’t done too badly” says Alan Whiteside, an Aids researcher at the University of Natal in Durban. “In maternal and infant care, they’ve achieved results that are both desirable and reasonably successful.”
Department of Health director general Ayanda Ntsaluba highlighted the government’s achievements in an essay in a Health Systems Trust (HST) journal. Ntsaluba admits that free health care has increased the burden on existing staff and services, but that the pain is worth the reward. “In some communities those barriers were created because people did not have enough money,” says Ntsaluba. Now, he says, the barriers have come down.
In April 1997, the plan was described in the government White Paper for the Transformation of the Health System in South Africa: “The primary health care approach is the underlying philosophy for the restructuring of the health system. It embodies the concept of community development, and is based on full community participation in the planning, provision, control and monitoring of services. It aims to reduce inequalities in access to health services, especially in the rural areas and deprived communities.”
To that end, the government delivered. Since 1995, 495 new clinics have been built and almost 250 have received major upgrades. Almost 2 300 clinics received new equipment and minor renovations, and 215 mobile clinics were purchased and put into use.
This shift towards providing primary health care was especially apparent in some of South Africa’s poorest communities in the Eastern Cape, KwaZulu-Natal and the Northern Province. In KwaZulu-Natal, 139 new clinics have been built and 14 others renovated. These clinics are treating more than 130 000 people, of which 80% had never had access to a clinic before. Similarly, in the Northern Cape, services are now available in previously disadvantaged areas, bringing health care to over 95% of the population.
The supply of medicines is also flowing better than before. In the Eastern Cape, a 1994 departmental survey found that of the 10 essential drugs supplied to clinics only 25% reached their destination. In five years that figure has increased to 80%.
But the distribution of medicine continues to be a problem. In 1997, HST conducted a survey that examined the availability of 25 selected drugs in 160 clinics and hospitals nationwide.
The results were disheartening: while three-quarters of all institutions surveyed had ciprofloxacin, an essential drug in the treatment of sexually-transmitted diseases, less than three-quarters had drugs to treat tuberculosis and 25% did not have condoms to distribute. Stocks of other vital medicines were found to be either depleted or in short supply.
Dr Peter Barron of HST notes that while development of health care in rural areas has come a long way in five years, “things are still not in great shape. There’s a huge disparity in distribution of medical professionals compared to urban areas,” he said. “We need human resources to be following the buildings. The staff at rural clinics needs more training, more equipment and more support.” He also notes that many rural clinics still suffer electrical shortages and loss of phone service, which renders useless what equipment they do have. “It’s taken five years to put the basic framework in place,” says Barron, a specialist in rural health development. “Now we’ve got to build on that.”
The main issues now are funding and logistics. Trudy Thomas, MEC for Health in the Eastern Cape, told HST that the province faces huge financial hurdles. For example, in areas such as the former Transkei homeland, close to R1,3-billion is needed to restore hospitals. That figure does not include the building, equipping and staffing of desperately needed new clinics.
Hospitals feel the pain
Reprioritising the financing of public health care has not been painless. As Ga- Rankuwa medical superintendent Dr IS Ntuli puts it: “The challenge that health care has faced is to stretch the same budget that used to serve seven million to serve almost 40-million.”
Drastic cutbacks in staff and funding have left some of the country’s largest hospitals in a state of chaos. In June, the directors of Johannesburg’s four major public hospitals staged a public rebellion, claiming that a government-instituted hiring freeze was forcing them to close key segments of hospitals and severely curtail services in others.
Some intensive care units might only be open for regular business hours, they warned, while other units, like the neo-natal care unit at Chris Hani Baragwanath hospital in Soweto, would have to close. “Don’t have your car accident in Gauteng. Don’t get shot in Gauteng. If your child gets a peanut stuck in his throat, it’s tickets,” warned the intensive care director at Baragwanath hospital, Rudo Mathivha. “We’re already talking natural selection here. These policies are going to cause adults and children to die.”
In response to the warnings, the government unfroze posts and shuffled doctors between hospitals. Yet the moves do not mask the atrophy Gauteng’s public hospitals have endured.
Elaine Joseph, head of radiology at Helen Joseph hospital, says that the “fundamental decrease” in staffing in Gauteng hospitals “has left us unable to adequately treat patients. We can crumble in six months, but it will take years to rebuild.”
Baragwanath nursing matron Peggy Mhlambe said the morale of her nurses is very low, and that absenteeism is rife. “If you had to face a ward of 60 beds all by yourself, you’d stay home too,” she said.
At Ga-Rankuwa, situated on the edge of the North-West and Northern Province, the new health care scheme has created an administrative nightmare. A patient from Rustenburg, with an official government transfer document in hand, might receive care over a patient living right next to the hospital.
Ntuli explains: “We are supposed to encourage patients to enter the system at the lowest level, and to reserve the hospital beds here at Ga-Rankuwa for the most needed services.”
For patients living around Ga-Rankuwa, their ailments might not merit the hospital’s intensive, expensive brand of care. A patient with pneumonia could walk to Ga-Rankuwa, but they will be referred to Odi hospital, about 15km away.
What the government saves is money. A one- night stay at Odi costs the government R250; at Ga-Rankuwa, it costs R650. Either way, the patient receives the required care. But getting that care can be a confusing, frustrating process.
Taking health to the poorest
One of the government’s successes in providing health care to rural areas is compulsory service for medical school graduates. It brought qualified doctors to areas that did not previously have them, and gave young doctors some intensive on- the-job experience.
Dr Stephen Reid of HST has been conducting a survey of the 1 100 young doctors. He says that less than 30 ignored their commitment, and despite some initial complaining, many have found their first six months a rewarding experience.
“They’re making an incredible difference in these rural areas,” Reid says. “They’re junior doctors, but they’re still doctors, and the communities are ecstatic to have them.” Reid says most of the doctors intend to leave the communities after their term has ended, and chalk it up to life experience.
Dr David Tasker started his year of service last July, in Manguzi hospital in rural KwaZulu-Natal. He says that working in health care “at the grassroots level” has been rewarding, but that life in the former homeland has been tough on him and his new wife. They live in a mobile home near the hospital, and are itching to get back to the city. Tasker, who received his degree from Stellenbosch university, says communication with patients, almost none of whom speak English, is made easier by the nursing staff, who translate.
Other initiatives were undertaken to bring doctors to rural areas. Almost 3 000 foreign doctors, mostly Cuban and German, were brought in under agreements with those governments to work in rural areas. This stopgap measure was an innovative solution to a doctor shortage, but also highlights the fact that South Africa is not producing enough doctors to meet its needs.
South Africa’s medical schools produce about 1 000 doctors a year. While a substantial effort has been made to increase the number of African doctors, the majority of graduating medical students is still white.
Ga-Rankuwa forges on
Back at Ga-Rankuwa hospital, director of nursing Claudia Dlamini says that a decrease in staff and an increase in workload has sent morale among the nurses down. “The problem is that we have too many people in this hospital,” she says. “The health setting in some of the surrounding areas is very poor, so they flock here. We’re having a lot of trouble handling all the patients.”
Ga-Rankuwa’s problems are indicative of the new challenges facing South Africa’s health system. Doctors and medical facilities are still concentrated in urban areas; administrative problems continue to plague delivery of services; funding shortfalls force administrators to make stark choices about staffing levels, availability of services and quality of care. Ultimately, the decisions made affect real lives and real patients.
Mailula, who is preparing to have her child at Ga-Rankuwa, is the type of patient the government wanted to help most when it revamped the health system.
Through an interpreter she says: “Things have definitely changed for the better. I feel better because of the hospital. I get a good supply of medicine. The doctors are good. The food is free. It is good here.”