A 37-year-old fruit packer from the Paarl region relaxes visibly as his doctor, Nelis Grobbelaar, speaks to him.
The HIV-positive father of two has previously been treated for tuberculosis and anaemia and is back at the clinic because he is finding it difficult to maintain the energy levels he needs to work at a nearby warehouse.
“Don’t worry, we won’t be able to take the HIV away, but we are able to control it,” Grobbelaar reassures him.
In his checked shirt, jeans and running shoes Grobbelaar is no average small-town doctor. As the son of a fruit farmer he grew up in the area and graduated from the University of Stellenbosch 10 years ago. He now works as a state doctor running an HIV/Aids clinic that offers anti-retroviral treatment.
“It has been incredibly empowering for me to be able to offer anti-retrovirals to patients. Previously I would really only counsel my patients towards their funerals,” he says.
While other provinces have been slow to provide anti-retrovirals in the state sector, the Western Cape has “aggressively pursued HIV and Aids”, according to provincial health director general Professor Craig Househam.
In 1999 pregnant women in Khayelitsha were able to access the drug AZT and two years later, highly active anti-retroviral therapy was introduced to the area.
Currently, 2 000 people have access to anti-retrovirals at 16 public-sector sites. The Paarl clinic is run by the government in collaboration with the United Kingdom charity ARK, which has set up similar clinics in Langa, Hout Bay, Worcester and Somerset West. The charity pays for the treatment of up to 1 500 mothers, but the province will take over funding after three years. With its current HIV rate topping 12%, the province aims to treat 35 000 patients by 2010.
The Western Cape is one of the best-resourced provinces in the country and spends a healthy R1 377 per capita on health, second only to Gauteng, which spends R1 668.
Househam and his team are under pressure to maintain this level of expenditure with the reconfiguration of the National Treasury’s conditional grants to provinces, which began in 2001. The aim is to ensure a more equitable distribution of resources among provinces, especially those that do not have tertiary hospitals and that have historically not received grants. The migration of people from neighbouring provinces seeking health services has also stretched the budget.
The province’s infant mortality rate stands at about 27 out of 1 000 live births, which is significantly lower than the national average of 45.
The most common causes of death in the province are trauma injuries, heart disease, stroke, diabetes and tuberculosis. Programmes to address these as well as mental and reproductive health exist.
The Cape Town Equity Gauge — a collaboration between the University of the Western Cape, the city and provincial health department and several organisations — has conducted extensive research into developing a practical strategy for the equitable allocation of resources between the city’s 11 health districts.
Househam, a paediatric specialist who was director general for health in the Free State before venturing south in 2000, believes that a different dynamic exists in the Western Cape.
“The health system is very well-established, there is a strong tradition, you have well-established universities with medical schools, but there are also a lot of entrenched views that makes management challenging,” he says.
Shortly after taking up his position Househam launched the Vision 2010 plan, a blueprint for future health-care delivery in the province. Essentially the plan will ensure the transfer of health services from tertiary level (super-specialists such as cardio-thoracic surgeons) to primary health care with secondary- level hospitals sandwiched between.
Its success hinges on an efficient referral system between the different hospitals and clinics and appropriately staffed institutions. Statistics suggest that the province is “super specialised” with one specialist per 2 746 patients. This compared with the Free State where there is one specialist per 11 342 patients or Mpumalanga, which has one specialist per 143 698 patients.
The medical superintendent at Groote Schuur hospital, Dr Saadiq Kariem, supports most of the principles of Vision 2010, but says it is going to be difficult to convince doctors at tertiary hospitals to move to secondary-level hospitals.
At Groote Schuur, patients have to wait four years for a hip-replacement operation and there are also long waiting lists for other complicated surgical procedures.
Although Househam does not believe there are too many specialists or that they are a major expense in terms of salaries, he agrees that the current mix of specialists and medical practitioners is not ideal with specialists concentrated in the province’s two large, central hospitals. Doctors will be lured to secondary hospitals if they are provided with incentives, he says.
The Vision 2010 formula is for 90% of patients to be seen at primary health-care level, 8% at secondary level, where they will have access to specialists, and 2% at tertiary level where they will have access to super-specialists.
Seven hospitals will be built in the Cape Peninsula and one in the Khayelitsha/Mitchells Plain area. These will become district hospitals with specialist outreach. Some of these hospitals will either be re-sited or upgraded. The regional hospital for the Cape Town Metro region will be situated at Tygerberg Hospital.
Currently the province employs about 24 000 people with no increase planned. In an effort to boost the nursing complement, the province offers bursaries totalling R11-million to students in the hope of attracting more professionals. Nurses are not required to repay the bursaries but must work for a set number of years in return. The province has also invested in the upgrading of lifesaving and critical equipment and has spent R200-million over four years.
For a full version of this report visit www.health-e.org.za