A line of women and children snakes out the Port St Johns community clinic’s doors. Many wear old dirty clothes and some are bare-footed, a testament to their poverty.
Pearl Matoti makes her way down a hallway lined with plastic chairs, each occupied by a sick patient who will wait hours to be seen by an overworked and underpaid nurse.
She is the senior nurse at this desperately under-resourced clinic.
South Africa has one of the world’s highest rates of HIV/Aids, significant numbers of tuberculosis and malaria cases, a large population living in poverty and a legacy of inequality.
The health-care sector is a story of contrasts. Private high-tech urban hospitals serve the rich, but understaffed, underfunded community clinics barely make do in rural areas.
Port St Johns is a typical rural town in the Eastern Cape and many of the 60 000 residents rely on public health care.
The Port St Johns clinic employed Matoti when it opened in 1988.
“We had doctors when it started, two doctors,” Matoti says 15 years later. “Now we have none.” Matoti and her nurses handle everything from gunshot wounds to delivering babies.
“I’m working as a doctor, I’m working as an administrator and I’m working as a nurse,” she says. “There is a gross shortage of nurses and doctors. There are no medicines.”
The clinic’s only ambulance broke down months ago and its other ambulance was stolen. In emergencies the nurses must call the closest hospital, about 40km away, for an ambulance that takes an hour to reach the town and an hour to return.
So patients often die waiting for attention: “They die because of lack of doctors and lack of transport and lack of medicine,” she says. “The staff are demoralised. We’re stressed out.”
Across town Siviwe Mahlakata-Vilakazi is preparing to go home. She is one of three doctors with private clinics in Port St Johns and was the last doctor to work at the public clinic full-time.
“It wasn’t a happy clinic and all the districts have the same problems. It doesn’t encourage doctors to stay in the public arena.”
After two years she’d had enough. Six months ago she packed up at the clinic and started her Ugqirha surgery.
Mahlakata-Vilakazi says the only reason she has not taken a job overseas is because the university she graduated from is not well-known overseas. Starting her own clinic was the only feasible alternative, she says, though she still hopes to work abroad.
Bernard Kehoe graduated as a doctor from the University of Cape Town in 1979 and worked in the United Kingdom and Canada through most of the 1980s.
“South African doctors love going to Canada,” he says. “Now it’s almost a rite of passage for a South African doctor to go to Canada.”
Kehoe has practised medicine for 20 years and is disturbed by the state of South Africa’s health-care system.
“Twenty years ago South Africa was probably one of the best countries for medical services,” he says. “Now public health care [in South Africa] has gone from being the best in the world to the lower end.”
In 2000 the World Health Organisation ranked South Africa’s health-care system 175th of the 191 member countries.
“The health-care system is in a precarious position,” says Kgosi Letlape, chairperson of the South African Medical Association. “A lot of money is being spent in the country, but it’s not going in the right place.”
Letlape says the public sector is grossly underfunded. Still, the government has done what it can.
“There are a lot of things [the government] has done right,” Letlape says. “No one can say they haven’t tried … We’ll continue doing what we can.”
Ayanda Ntsaluba, Director General at the Department of Health, says that change has not been easy for the public health-care system.
“The South African public health system has ridden a difficult road in attempting to throw off the apartheid legacy in a short period,” Ntsaluba says. “The stresses of transforming the health system itself have been considerable and they are far from over.
“In major urban areas, the inequity of apartheid … has been overcome to a fair extent. This is not true, however, when one looks [at the situation] more broadly.”
“The clinic system — particularly in remote areas — was hundreds of facilities short of what it is now,” Ntsaluba says. “There were service fees that constituted a barrier to care at clinic level … These services are now free.”
Many immunisation programmes have been successful, new facilities are continuing to be added and an additional R500-million has been budgeted this year to attract health professionals to rural areas and to keep specialists in the public sector.