When Victor Litlhakanyane became the first black doctor to qualify in the Free State he was not welcome to eat with his white colleagues in the dining room of the province’s biggest hospital, Pelonomi, in Bloemfontein.
Now, many of those who refused to eat with him have to report to him as provincial head of health.
Health services in this flat, often bleak, central province are stable, and the quality of care has been steadily improving despite a lack of expertise and massive challenges, many of which are the legacy of the mining industry.
A survey conducted by the Human Sciences Research Council (HSRC) and released in 2002 found that the Free State has the highest HIV/Aids rate in the country, while tuberculosis and malnutrition are also serious problems.
One of the keys to the Free State’s ability to provide stable care lies in the fact that it has built its health system from the primary level upwards.
“Free State developed a district-based system very early. It had leadership that believed in this approach and so it managed to move from a hospital-centred approach to a primary health approach,” says Health Systems Trust’s Dr Carmen Baez, who worked in the province for four years.
For Baez, the district-based approach — which other provinces are struggling to implement — has been successful, thanks to strong leadership and the early introduction of the Free State Health Act in 1999 that provided the legal framework for the district health system.
She credits Shadrack Shuping, executive manager of clinical health services, for driving — sometimes relentlessly — the district system.
As part of the reorganisation of health services, differentiated levels of care have been introduced and certain hospitals are now designated as referral hospitals, which means patients can only go there if they have been referred by district clinics.
The referral system works relatively well in Free State precisely because referral hospitals are able to turn away patients knowing that they will be able to get the care they need from their district hospitals.
Dr Marthinus Schoon, clinical head of Pelonomi, is proud of the fact that annual patient figures at his cash-strapped hospital have dropped from 27 315 in 2001/02 to 25 357 in 2003/04.
Beds in the hospital have also been cut by almost half since 1994 to enable resources to be redirected to the lower levels of care.
“On the clinical side, we push the concept that if the volume of patients is too great, we will be unable to provide quality care,” says Schoon.
The primary health care approach has also meant a reorientation of thinking. Nurses in the clinics have been trained to encourage patients to view their health holistically and consider solutions such as better nutrition rather than medicine only.
This change has also brought savings. Before 1999 an average of seven drugs was prescribed for sick children whereas today this figure is two or three.
Free State’s TB cure rate is over 70%, which gives a good indication of the province’s ability to monitor and follow up patients.
The Lejweleputswa district around Welkom is the jewel in the Free State’s health system and has won numerous awards, including best rural health district in the country in 2001. Bongani hospital (formerly Goldfields) in Welkom is the district’s regional hospital.
Bongani was recently one of a handful of hospitals countrywide to be accredited by the Council of Health Service Accreditation of Southern Africa the first time it applied.
The council is an independent body that assesses and accredits health care organisations. Bongani also has the best revenue collection record in the province.
Given this track record and the fact that it is in a high HIV prevalence-rate region, Bongani was the obvious choice for the launch of the Free State’s anti-retroviral programme, which takes place on Saturday, May 1.
Dr Ralph Nhiwatiwa, principal specialist, is particularly passionate about the treatment plan.
“I lost my brother to Aids in 2000. I nursed him here in this very hospital. It made me very sensitive to the issue. I don’t want anyone else to go through this experience. I want to spare others this pain,” he says.
Mining houses Harmony, Goldfields and Anglo American started anti-retroviral programmes in the district last year, but only for their own workers.
“There was starting to be a division in the town between the lucky ones who worked for the mines and had access to treatment and those who didn’t, often the wives and children of the mineworkers,” says Nhiwatiwa. “So I am very glad we are able to offer the drugs at the public hospital.”
Like every other province, the Free State is short of staff and money.
Schoon says almost 50% of Pelonomi’s specialist posts, particularly surgical positions, are vacant.
About 40% of Pelonomi’s professional nursing posts are vacant and the hospital uses nursing agencies during busy periods.
The provincial department has set aside R7-million to provide bursaries for local students to study medicine, and hospitals across the Free State encourage all staff to develop their careers.
“But even if we could get the people, we don’t have the money to pay them,” cautions Kibi Madolo, Pelonomi’s CEO, who estimates that the hospital needs an extra R70-million a year to meet the community’s needs.
To improve its financial prospects, Pelonomi has negotiated an agreement with Netcare that will see part of the hospital being transformed into a 153-bed private facility.
Netcare has committed itself to spending R20-million to upgrade Pelonomi and will pay rent for the buildings it uses.
A similar agreement has been reached with Universitas hospital and the department calculates that the two private deals will generate R206-million over the next 16 years. — Health-e News Service