It’s lunchtime in Mdantsane and Mama G, along with about 30 others, is waiting outside the small clinic at NU13 as storm clouds gather. “The nurses sometimes have an hour for tea. They can close again at noon and only open at 3pm, while we must sit outside like dogs, rain or shine,” the bespectacled pensioner grumbles.
Another patient complains that they must buy their own exercise books, which function as clinic cards. Those without books must pay the clinic 50c for a scrap of paper and those who need to be taken to hospital a few kilometres away pay R5.
Not far from the clinic is Cecilia Makiwane, the biggest hospital in the province with almost 800 beds. Superintendent Dr Zamani Ndindwa says that TB is the most common disease in the medical wards and “every day there are two or three deaths from HIV-related infections”.
While all health workers mention the impact of HIV/Aids, none knows much about the anti-retroviral programme, or even whether the drugs will be supplied there.
Matron Kholiswa Tsipa and Sister Noluntu Somana, who work at Cecilia Makiwane, say that one of the biggest problems is the shortage of staff. According to Treasury figures for February 2003, the province has the greatest shortages of nurses and doctors. Somana adds that the patient load has also increased since 1994. “This is partly because of primary health care not taking off. The whole of the Eastern Cape is referring patients here. We often see people who should have been attended to by the clinic nurse — but because of the problems there, they end up coming here,” she says.
The key concern of nurses here is overwork. Four nurses in the outpatients department (OPD) deal with 100 to 150 patients a day. Doctors only get to OPD after 11am as they first have to attend to patients in the four medical wards. But patients prefer to wait than go to clinics where there are “no doctors or medicines”, says a nurse.
Fourteen doctors are needed to run the four medical wards at this hospital but there are only four, while as few as six nurses run the 40-bed male medical ward day and night (14 are needed). The Eastern Cape spends R91 per capita on primary health, the second-lowest in the country after Limpopo and below the national average of R158. “People are so overworked that they can’t cope with day-to-day responsibilities, let alone an anti-retroviral programme.”
About 250km west, in the former Transkei capital of Umtata, the opening of the R500-million Nelson Mandela hospital has boosted health workers. Rod Allen, CEO of the Umtata Complex, which oversees four hospitals in the town, says the staffing of the new hospital is being carefully managed to ensure that services at the other three hospitals don’t collapse.
“Nelson Mandela is a referral hospital, so we need highly skilled staff — but it is difficult to attract such people to Umtata. There are 600 beds at present but there will be 1 100 once the hospital is fully commissioned,” says Allen.
To make the Umtata Complex fully functional, about 600 nurses and 100 doctors are needed. The hospital will also be a training ground for students from the University of Transkei’s medical school. Allen, who has been CEO for two years, describes conditions at Umtata hospital as “pathetic” and “unacceptable”. Umtata General superintendent Dr Lungi Linda-Mafanya says over-stretched staff deal with referrals from about 20 district hospitals, often for simple procedures.
Dr Dan Eghan, Umtata’s principal anaesthetist, with 15 years’ service at the hospital, says that none of the district hospitals in the former Transkei are performing Caesareans because they lack anaesthetists. Umtata general’s maternity ward deals with 400 to 500 deliveries every month, and new mothers often have to share beds.
Allen says that Umtata general is being downgraded from a regional to a district hospital and a number of its departments are being transferred to Nelson Mandela. This will ease the pressure and congestion.
In the provincial capital of Bisho, Mike Fraser, acting provincial head of health, says the infant mortality rate in parts of the Eastern Cape is among the highest in Africa and a “cause for great alarm”.
More babies die in the province than anywhere else in the country, with 61,2 out of every 100 000 babies under the age of one year and 80,5 of those under the age of five dying. This is much higher than national averages of 45,4 and 59,4 respectively.
The paediatric wards of district hospitals are full of malnourished children. Fraser says that the high infant mortality rate is also due to difficult terrain, particularly for mothers carrying small, sick children. Mountains, rivers, ravines and a chronic lack of transport mean that many people battle to access health care, despite the fact that 131 clinics and 16 health centres have been built since 1994.
One of the most striking improvements is that hospitals are now grouped into clusters, so instead of Bisho dealing with 47 district hospitals that are run by the department, it is now dealing with 18 clusters. Grouping hospitals not only improves management but, by pooling resources, means that there is more money to employ management.
The national government’s Interim Management Team, sent to the province to help restore service delivery and assist four target departments including health, has also played a role in stabilising health systems. Many hospitals that had deteriorated badly have been refreshed: management systems have been improved and resources are slowly starting to flow from the better-resourced west to the former homelands in the east.
But unless services at clinics and district hospitals are improved, larger hospitals will continue to feel the pressure, staff will leave and the downward spiral will begin again. The Ministry of Health’s rural allowances, announced recently, may help to stabilise these exoduses from some areas, but do not apply to doctors and nurses in the province’s small towns.
The Eastern Cape Department of Health can be contacted on Tel: 08000 32364. For a full version of this article go to www.health-e.org.za
Vital statistics
63,4%of the Eastern Cape population lives in rural areas.
Lowest rates in SA of:
People living in formal housing (46,9%)
Access to electricity (31,3%)
Households with tap water inside the dwelling (24,4%)
Highest rates in SA of:
Infant mortality rate (61,2 for every 100 000 births vs national average of 45,4)
Doctor-patient ratio (one doctor for every 8 825 people vs national average of 3 928)
Unemployment: 48,5%
Maternal mortality: 1,33 for every 100 000 deliveries in 1999
Teen pregnancy: 14,8%
HIV prevalence in pregnant women: 23,6%
TB cases: 201 for every 100 000 people