Low potential for NHI success in rural health

Simon Puttergill* is a clinical manager at a state hospital in an isolated part of the Eastern Cape. His colleagues describe him as exceptionally competent. Over the past seven years he has been instrumental in reducing by half the number of babies dying in the first week of their lives. He has helped to increase the number of infants delivered in hospital instead of the mothers giving birth at home by more than 50%.

Puttergill leads a team of doctors that has put thousands of HIV-infected patients on antiretrovirals and he recruited most of the 10 physicians who work at the facility. He goes out of his way to create the kind of conditions that will induce them to stay at his hospital, whereas some government health facilities in South Africa do not have any staff doctors.

Puttergill has achieved all this despite immense administrative challenges. Of the 22 healthcare professionals he appointed in his first two years, only two were paid the right amount at the end of their first month. The rest had to work for up to five months “for free” before they received a paycheck and some had to struggle for years to be paid correctly.

He has lodged “endless complaints” with the Eastern Cape health department and has spent days trying to “sort out” each employee’s salary. During Puttergill’s investigations, it emerged that a woman in the department’s human resources section was responsible for most of the chaos.

“She simply did not grasp the urgency of processing the relevant documents on time, or the importance of paying staff the correct salaries,” he said.

In another follow-up at the provincial health department, Puttergill was “horrified” to discover that the same administrative official had in recent years received annual performance assessments that earned her yearly notch promotions and a progressively more generous salary.

Puttergill and his doctor colleagues have never received such increases despite the remarkable improvements in care at the hospital. They have filled out the documents for such evaluations, but their diligence has never been acknowledged.

It is in this context that he views the implementation of the government’s National Health Insurance (NHI) scheme in the Oliver Tambo district of the former Transkei, where his hospital is based. It is one of 11 predominantly rural districts in which the health department started to pilot the scheme in April.

Puttergill steadfastly believes all citizens should have equal access to quality healthcare. But he strongly doubts the government’s “administrative ability” to make this a reality. “When you have worked in a broken, dilapidated system for this long, you wonder if it is possible to fix it. Everything is disjointed in our district, particularly the paperwork. It takes ages to sort out basic stuff. If they get the NHI to work here, it will work anywhere,” he said.

‘Strangled’ by red tape
Puttergill is concerned that the scheme will introduce more bureaucracy to a system “strangled” by red tape and that its administrators will not be sufficiently competent to prevent it from creating an “even bigger mess” of the health sector. “If the government cannot even sort out the salary payments of the few doctors in the rural Eastern Cape, how will it manage to process double the amount of payments for the healthcare workers needed for an effective NHI?”

Like other provinces, the Eastern Cape has a drastic shortage of doctors. Yet, health workers in the region said, the department regularly took longer than six months to approve their appointment. The delays often result in doctors finding employment in the private sector, overseas or in other provinces.

According to provincial health department spokesperson Sizwe Kupelo, 1 326 doctors work in Eastern Cape government hospitals, which need a minimum of 1 200 additional doctors. “We also have a serious lack of nurses. We have employed 24 000 nurses in state health facilities in the province, but we need at least another 6 500 for the NHI.”

A few months ago, rural health organisations** made a submission on the NHI green paper. They were adamant that the challenges the scheme would face in rural areas would be significantly more serious and different from those in urban settings. They recommended that the government revised its policies to allow more foreign doctors to work in rural areas.

According to Saul Kornik of Africa Health Placements, which recruits overseas doctors, about a quarter of the medical workforce in developed countries such as Canada and Australia are foreign.

“If rich countries have to rely on ‘outside’ resources, poorer countries cannot possibly make do with local doctors alone. Foreign doctors should not be seen as a short-term solution but rather as part of the long-term strategy to supply health workers to rural districts,” he said.

But Kornik warned that the processes foreign health workers have to follow to work in South Africa needed to be improved significantly. “Foreign doctors are required to physically send their documents to South Africa instead of allowing them to complete online applications … The Health Professions Council of South Africa also takes excessively long to register them,” he said.

Kupelo could not confirm how many foreign doctors were employed in the Eastern Cape, but said the government had allocated R100-million for students from rural areas to study medicine and nursing. “We have made their contracts watertight so they are compelled to work in rural areas when they qualify.”

Support teams
He said the provincial health department advertised for positions in NHI clinical specialist support teams in April and planned to have all posts filled by the end of June. Each health district will have a principal gynaecologist, paediatrician, family physician, anaesthetist, midwife and professional primary healthcare nurse who will travel to hospitals and clinics to provide support.

Marije Versteeg of the Rural Health Advocacy Project said the government’s planning should take the cost of accessing healthcare for rural patients into consideration. “To be able to benefit from a clinic or hospital, you need to be able to get there. One of the main reasons for missed doctors’ appointments in rural areas is the cost of transport.”

According to the submission by rural health organisations, one in five poor households live more than an hour from the closest hospital and about one in six families stay at least an hour away from the nearest clinic. “There are households in a rural Mpumalanga district that spend up to 60% of their monthly income on health expenditure, with travel costs being a significant contributor,” Versteeg said.

The submission demands that the NHI provides transport vouchers to rural patients and health workers visit patients at home more often. Studies have shown improved health outcomes after taxi tokens were introduced in China, Taiwan, Korea, Nicaragua and Mexico.

The South African health department does not assist patients to get to hospitals or clinics for doctors’ appointments. It only provides transport for referrals to bigger hospitals. In emergency cases it sends out ambulances to patients’ homes. But, even when patients are in danger of dying, doctors in rural areas report that ambulances take hours or days to arrive, if at all.

The Eastern Cape health department is not convinced that patient transport should be an NHI benefit. “We have no plans to introduce transport vouchers for Oliver Tambo district. Why would we do that? That would be spoiling the patients,” said Kupelo, adding that a “lack of information about their conditions” rather than poverty caused patients to default on chronic treatment. “We are dealing with a massive illiteracy problem in the Eastern Cape that has led to people not understanding their illnesses and taking their treatment incorrectly.”

According to the NHI green paper, only South Africans who have registered with home affairs will be eligible for coverage. Kupelo said the Eastern Cape Health department had set itself a three-year deadline to work with home affairs to help adults in the Oliver Tambo district to obtain ID books and, in the case of children, birth certificates.

According to the health organisation Philani, the cost of transport is also a major barrier for residents in the Zidindi district, in the former Transkei, in obtaining IDs. The non-governmental organisation Mentor Mother project has often arranged for social workers to visit the areas on set dates with the necessary application forms.

“But people still need to travel to their schools and the police station for affirmation letters and affidavits, something that many are unable to do,” said the project’s Ncedisa Paul.

Doctors who work at government hospitals in the Oliver Tambo district said no one had explained how the insurance would work. “Physicians do not understand how the NHI is planning to improve health systems, management and staffing,” said Karl le Roux, chairperson of the Rural Doctors’ Association of Southern Africa, who works at Zithulele Hospital in the district.

Le Roux said there was often a “fragile” relationship between clinicians and administrators, especially when administrators failed to order basic equipment and supplies for clinicians to do their jobs. “We are excited about the health minister’s new policy that doctors, not finance people without a health background, should run hospitals. But we are concerned about the quality of administrators that are available in the rural Eastern Cape and we are in the dark about how the government will attract better qualified people to work here.”

Several Eastern Cape hospitals recently lost medical staff as a result of the government’s failure to pay them for long periods.

According to the government’s NHI implementation plan for Oliver Tambo district, all hospital managers without a clinical background should be replaced by acting managers with suitable qualifications by the end of the month. Kupelo said this process was “on track”.

In their NHI submission, rural health organisations called for the immediate halting of the licensing of new private sector facilities in urban areas unless a “clear gap in existing service levels can be proven”.

Versteeg said the “mushrooming” of health facilities in urban areas was problematic. “To achieve equitable access to healthcare for everyone, the NHI would have to redirect some of the current urban resources to rural areas. But we are in the dark as to how that will work. Does it mean that doctors and nurses from cities will be expected to relocate with their families to rural areas that do not have adequate schools and proper roads?”

Kupelo admitted that a lack of recreational and education facilities, as well as accommodation, in rural areas were some of the main reasons that many healthcare workers refused to work there.

“We have worked with the transport department to fix several roads to hospitals and clinics, so that is improving. But to try and co-ordinate the building of schools with the education department on top of sorting out administration problems, corruption, the refurbishing of facilities and recruitment of doctors just becomes too much,” he said.

Puttergill said: “Most rural doctors I know are reasonable people and we do not expect the government to ‘do it all’. We know it is going to be little steps towards getting quality healthcare in reach of most South Africans. But what we do expect is that one of those little steps will be to inform doctors about how a system that they are expected to drive will work. What we do expect is that officials who cannot even process basic salary invoices do not form part of the NHI in any way. We want the NHI to take us forwards, not backwards.”

Mia Malan works for the Discovery Health Journalism Centre at Rhodes University.

*Not his real name

**The submission on the NHI green paper was made by the Rural Doctors’ Association of Southern Africa, Rural Health Advocacy Project, Wits Centre for Rural Health, University of KwaZulu-Natal Centre for Rural Health, Ukwanda Centre for Rural Health, the University of Cape Town’s primary healthcare directorate, Africa Health Placements and Rural Rehab South Africa

 Doctors avoid referring their patients to ‘the abattoir’

“The abattoir” or “death centre” are phrases that the residents of Mthatha in the Oliver Tambo district of the Eastern Cape regularly use to describe the Nelson Mandela Academic Hospital. Even local doctors call it so.

The district is one of the government’s 11 testing grounds for its National Health Insurance (NHI) scheme, launched in April.

The health department has allocated R2-billion for the refurbishment of the tertiary hospital as part of a drive to overhaul South Africa’s health facilities in preparation for the NHI.

But many patients, physicians and even government officials believe the province’s chief academic hospital is rife with such bad service and corruption that “all the money in the world will not be enough to fix it”, in the words of one pessimistic doctor.

In Mthatha, almost everyone one speaks to on the city streets has a horror story to tell about the hospital. One of the more common tales is that of a relative admitted to it for treatment of a minor ailment, only for the person to be declared dead relatively soon afterwards.

“How can such a place bear the name of the great Mandela? That hospital is not a place where you take someone to be healed. You take them there to die,” said a woman from Butterworth, whose 52-year-old mother was admitted with appendix-related complications earlier this year. “My mother was still talking to us the one day. Three days later she was dead. No one at the hospital could give me good reasons why this happened.”

An Eastern Cape government official, who did not want to be named for fear of losing his job, agreed. “It is a disaster. You should spend time there and investigate. There are 300 general practitioners and specialists who are practically never there because they moonlight at the city’s private hospital and have private practices on top of that. The public hospital and university are the last items on their agenda.”

Sizwe Nkosi*, a senior doctor from a hospital in the former Transkei, said he and his staff did their best “never” to refer a patient to the hospital. “How can we do that when patients who go there either do not get helped at all or they get so-called help and end up dying anyway?” he asked.

Nkosi said he had referred a young man with a sudden onset of high blood pressure, blood in the urine and signs of kidney damage to the hospital for a renal biopsy about six months ago.

The patient was admitted into Nelson Mandela Academic Hospital for three weeks but was neither seen by a renal consultant nor offered a biopsy and was sent home. After several phone calls to the facility, Nkosi managed to get hold of a renal consultant who agreed to readmit the patient. But the specialist pointed out that the man needed an ultrasound before a biopsy could be done.

“There was, however, only one available radiographer, so my patient could be booked for the scan only a month later,” Nkosi said. “He has returned another two times as an outpatient since without getting a scan.”

Shortly after this, while the man was still trying to get a scan, he had a stroke because of his high blood pressure and kidney problems. “He is a shadow of what he used to be,” said Nkosi.

Eventually, the patient got another ultrasound date, but the ambulance that was supposed to transport him from his nearest district hospital to Nelson Mandela Academic Hospital never arrived.

The patient has been rescheduled for a scan in August. But, Nkosi said: “I don’t think he’ll be alive then.”

*Not his real name

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Mia Malan
Mia Malan
Mia Malan is the founding director and editor of the Bhekisisa Centre for Health Journalism at the Mail & Guardian. She heads up a team of fifteen permanent and freelance staff members. She loves drama, good wine and strong coffee, not necessarily in that order.

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