/ 11 September 2013

Comment: A blueprint for recovery

Former minister of the Eastern Cape health department
Former minister of the Eastern Cape health department, Trudy Thomas, said the system is at an "all-time low". (Oupa Nkosi)

In my 77 years on this earth, I can hardly recall a time when I was not involved in health care in one form or another. In total, I have practised medicine for more than 35 years, the majority of which were spent in the Eastern Cape in both rural and urban areas. 

In 1994, I became the first minister for the Eastern Cape department of health and welfare (renamed the Eastern Cape department of health in 1997), a position I held until 1999. 

Over the last 15 years, I have witnessed the progressive deterioration of the province's health department and the services it offers. This trend grew most acute in 2012 and has culminated in a full-blown catastrophe. The Eastern Cape is now threatened by a health crisis the likes of which I have never seen before. 

The human resource crisis has, obviously and inevitably, resulted in the people of the Eastern Cape suffering. At the heart of this problem is the department's failure to properly budget and manage finances and human resources.

A totally unpredictable twist in the progress of the health services in the Eastern Cape is that – except for the Transkei between the missionary and the Mandela days – all the services were good to excellent pre-1994, but have spectacularly crashed under the ANC regime.

When I took office, the Eastern Cape inherited three main administrations – the Eastern Province, Ciskei and Transkei. It also inherited their budgets; calculated at R250 per person in the Eastern Province, R70 in the Ciskei and a paltry R40 in the Transkei.

Urgent budget report 
One of my first tasks was a survey of health services, which culminated in a report entitled "Urgent Additional Budgetary Needs-Transkei Health Services". The report revealed a striking correlation between budgets and service quality in the three administrations. 

Part of the investigation focused on the staff and health facilities, which included site visits to all hospitals. It showed that the western part of the province, which was mostly white, was short of some health professionals but otherwise its services were good to excellent. In the Ciskei – a former homeland – some services were grossly overcrowded but its hospitals and clinics were mainly functional to good.

The conditions in these areas were in strong contrast to those in the Transkei. Twenty years earlier, mission hospitals in the area, founded on the principle that you found whatever funds you needed for the job, rather than doing only what you could with what you had, had been exemplary. Sadly, by 1994, they were collapsing. 

The investigation showed that almost half (40%) of people lived between 20 and 60km from any health facility, with only one clinic for 18 000 people (the World Health Organisation recommends one clinic for every 5 000 people). 

The problems identified by the survey included: health facilities in poor repair and accommodated in makeshift structures, without adequate services or supplies; untenable and dangerous conditions for patients and staff; overcrowding was the norm; work and trauma loads were extraordinary; and already critical staff shortages were exacerbated by the high resignation rates of demoralised staff.

Comprehensive plan for the way forward
To turn this situation around, we devised a comprehensive plan that covered full staff accommodation, new health posts, new and upgraded clinics, and critical equipment and infrastructure improvements. Three years later, despite a tight budget, the "patient" started showing signs of recovery and order began to emerge from the chaos. 

We led the country in district development but, while all this was encouraging, it was not enough to reduce the apartheid backlogs in the Transkei to deliver basic health needs to all citizens of the province within a reasonable time frame.

In August 1997, in a document entitled "Determining the Backlog Factor in the Eastern Cape", I tabulated and costed the backlog service and infrastructure needs of the health department, and distributed it widely. The report recommended that an extra R500-million annually for five years – under a separate, dedicated administration, used exclusively to close the service deficits in the Transkei – would lay the foundation for dignified, functional health services across the province.

Unfortunately, the proposal clashed with the national treasury's decision, under advice from the World Bank, to avoid international borrowing to reduce the huge apartheid debt that South Africa had run up before 1994. Instead of an extra half a billion rands for five years, the already inadequate health service budget was sliced further. 

This was catastrophic. By March 1999, at the end of the new government's first five years of office, there were escalating frequencies of medicine shortages, equipment failures, infrastructure deterioration, lack of transport, and huge staff vacancies.

System at an "all-time low"
Conditions in the Eastern Cape healthcare system are now at an all-time low. The decrease in budgets continues in a context where the superintendent general for the health department reports a staff vacancy level of 46%, six hospitals condemned but still operating, 17 hospitals without water, more than 42 health facilities without electricity, 68% of hospitals without essential equipment, 16% of hospitals without telephones, and many clinics that are only physically accessible in good weather.

It is outrageous that, while conditions continue to decline, treasury is proposing another budget cut. 

The current budget is divorced from the reality of the health needs of the Eastern Cape's residents. We are on the path towards total service collapse. While there are external reasons for the looming and inevitable collapse, many of the problems are of the province's own making. 

My experience tells me it is possible to reverse the course and begin, once again, to improve the quality and availability of health services in the province.

The elements of the solution are basic, and should not take more than three months to establish: 

  • Appoint a tiny team of three to five inspired, committed and sacrificial people to conduct a quick-and-dirty situational analysis of the infrastructure, supplies, equipment and staffing of all Eastern Cape hospitals and clinics; 
  • Calculate the cost of bringing those facilities up to minimum acceptable standards; and 
  • Scan the financial landscape to source the necessary funds. 

With the necessary information at hand, the team must establish the absolute minimum cost to supply the services, supplies and infrastructure necessary to provide reasonable access to healthcare services, and draw up a "just-enough" budget for a three-year phased plan to achieve minimal, but real and respectful, functionality for the whole province. This is the minimum that government must provide.

But, note well, success is not measured only in monetary terms. Once there are nearly enough nurses in the clinics, and medicines in the pharmacy; when ARVs don't run out, and tuberculotics start fattening up; when dehydrated babies sit up and smile as a drip starts putting back life in their little shrunken bodies – then sulky, stolid nurses will start bustling and smiling, and injecting much more service into the system for the same money.

The principles and practice are really this simple. The health and finance ministers and their relevant subordinates know all these things. As do their managers. As do the Cabinet and Legislature. 

There is just one option: They must take responsibility for the collapse of the system and take the steps necessary to fix it. 

The Eastern Cape Health Crisis Action Coalition will hold a march on September 13 in Bhisho, starting at 11am at the Bhisho Stadium to demonstrate frustration at the collapse of health care services in the Eastern Cape and to hand a memorandum to the  Eastern Cape minister for health.

Dr Trudy Thomas was the Eastern Cape minister for health from 1994-1999.