Fixing the health system

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Patients wait to be treated at Chris Hani Baragwanath Hospital, Soweto. Picture: Dumisani Sibeko

Ramaphosa wrestles control of NHI. This was reported in the Sunday times Business section on August 26, 2018. What followed shortly thereafter was a two-day health summit held at a Boksburg hotel which proved the President’s intent and determination to deal with the problems plaguing our healthcare system. But, before we go into that perhaps it is important to reflect on the issues that led to the President taking that decision which for many years was the sole responsibility of the Minister of Health, Dr. Aaron Motsoaledi. For many years, serious concerns were raised by many journalists in our daily and weekend newspapers about the dysfunctional state of our health services.

The biggest outcry was over critical shortages of all categories of health professionals due to the continued exodus of doctors, nurses, radiographers, physiotherapist and many allied health workers which crippled especially our public health institutions. The government was urged by some individuals to encourage repatriation of those who had opted for overseas placements, but there was generally no desire to appoint them, leading to many of those who had wanted to be reunited with their families to be forced to keep going back to their jobs in the foreign countries. The situation was exacerbated by a huge backlog in the training of health professionals with the government blaming it on budgetary constraints. Working conditions were also making this field of study less, and less attractive, making recruitment of prospective students difficult.

Overcrowding at health facilities around the country is another huge problem that has been cited as a contributing factor in the failure of healthcare services. Wards become so overcrowded that some patients sleep on the floor, stretchers or wheelchairs for hours while waiting for the next available bed. Medical and other resources quickly run out, while infection control is compromised. Under these chaotic conditions it becomes virtually impossible for nursing and medical staff to maintain high standards of care.

Shortage of linen was another area of the biggest concern in all hospitals around the country. We have heard of many instances where theatre operations have had to be cancelled because there was no linen creating a huge backlog in operation lists and prolonging patient’s stay in hospital. Besides, patients cannot lie on dirty, wet, soiled or torn linen. It is completely un acceptable, that is why nurses were assaulted at one public hospital by relatives who found their elderly mother lying on cold wet linen because they thought that was due to the uncaring attitude of the nurses.

Shortage of equipment, food, medication, crumbling infrastructure were also mentioned as reasons for poor standards of care. Poor management, lack of basic things like oxygen, gloves, and syringes. Who could have thought that hospitals could run out of necessities such as toilet paper and paper towels for weeks? Patients having to buy their own bread, and a new East Rand Hospital serving patients soft porridge with no sugar for supper because it had run out of funds. Shocking!

High medical negligence claims amounting to more than 56 billion rand, mostly related to babies that were brain damaged at birth because of the dire shortage of doctors and nurses. Corruption, fraud are all kinds of ills that make our healthcare the worst in the world since 1994. The Life Esidimeni tragedy sealed our fate. Inspections conducted by the OHSC in the 2016/17 financial year found that of the 696 health facilities that were inspected, only 5 were found to be compliant ,691 failed the inspections. Following the many investigations conducted by the health Ombudsman, he found that the appointment of Health MECs and Premiers at the helm of healthcare delivery when most of them are not medically trained was to blame for the collapse of our health system. He recommended that there was a need to revisit our constitution as the Health Act of 1973 had been amended by the Health Act of 2003 which removed the powers of regulating health services from the Minister of Health who is the right custodian of health.

A 2013 research study by a US research group, assisted by Professor Letitia Rispel found that SA was short of 45000 registered nurses, a number that has now grown to 47000 nurses according to recent statistics, crippling our health services. Faced with these shocking challenges, the Minister of Health called for submissions from the public regarding the NHI and the Medical Schemes Amendment Bills. True to the nature of South African citizens, they did not disappoint. Many submissions were published in the newspapers with the general agreement being that the government must fix all the problems that have brought our healthcare to its knees before the implementation of NHI which is scheduled to take place in 2026

I was pleasantly surprised and intrigued by one submission which was to me an eyeopener as I had always believed that the ANC was the exclusive champion of Universal Healthcare Coverage in South Africa. From the submission published in The Star on September 6, 2018 written by Yogan Pillay titled: Let’s learn from past when planning NHI. I learnt that many attempts had been made since 1940 to provide health for all. In a nutshell, Henry Gluckman introduced a motion in Parliament in February 1942 proposing that the government should appoint a commission to investigate ways to provide health services to all. He noted problems in the system that were no different to those we are faced with today. SA Trades and Labour Unions and the African General Workers Union supported the establishment of an NHS, as did the ANC and the Communist Party, and, the business sector. Prime Minister Jan Smuts proposed the gradual implementation of the recommendations, starting with the establishment of community health centres. But he argued that the state could not remove hospitals from provincial control. The rise of the National Party stopped implementation of the recommendations. Fast forward to 2018 we are still grappling with the pros and cons of Universal Healthcare Coverage.

Grabbing the bull by its horns as promised, President Cyril Ramaphosa held a two-day health summit at a Boksburg hotel toward the end of October 2018. The question that had brought together scores of health managers, health practitioners, heads of Medical Schemes, civil society organisations and activists was, how can the country fix the many and varied challenges present in its ailing healthcare system?

The Presidential Health Summit marked a crucial departure from many years of indifference and a deafening silence from the Department of Health in the face of a fast deteriorating health system. We must applaud the President. However, it seems that only high-profile individuals were invited to the summit. The little man on the ground was excluded. These are the people who bear the brunt of angry communities who accuse them of bad attitudes for rendering a substandard service, unaware that their hands are tied as they function in an extremely under-resourced environment. Had they been included in the discussions valuable information would have been gained that would yield a clearer picture as they would vent their daily frustrations which have culminated in a grossly dysfunctional health service.

Those attending the summit were divided into planning communities to help identify pressing issues and outline a way forward to rebuild the health system. I would also like to put forward a few suggestions. Strengthening border control. The first and most important step to address overcrowding in our health facilities is effective control of our borders as the huge uncontrolled influx of foreign nationals has placed our resources under tremendous stress. Xenophobia is not the point here. Countries around the world protect their sovereignty.

Building more hospitals is not the answer when we have no capacity to man the existing health facilities. This would only lead to the emergence of many white elephants and wasteful expenditure. Purchasing more beds will only cause chaos. All hospitals were built to accommodate only a specific number of beds; that is why we speak of 320 bed hospital, a500 bed hospital and so on. You cannot push in extra beds, there are international standards of hospital bed types and spacing in-between beds which must be maintained for easy movement of patients and health professionals as they carry out their duties.

It is good to know that the problem of linen received so much attention that a company was appointed at the summit to provide health facilities with linen. However, we hope that it is a reputable company long enough in the business to know what specifications are to be met. This is especially important in theatre, the draping towels and gowns should be of 100% cotton, green in colour and the design of gowns for the scrub team should meet international standards. I am making special mention of this because we were once supplied with theatre gowns by a BEE company that were only used once because the cuffs could not withstand the extremely high temperature of the autoclaves during the process of sterilization. The gowns came out of the autoclaves with all cuffs shrunken and no one could wear them anymore amounting to waste of financial resources.

De-centralisation of laundry services, with each hospital having a laundry on-site would help curb linen losses and theft while eliminating transportation costs and item by item charging for laundry. The cost of running a health service. Every year I have often wondered why the Education Department always receives the lions share of the budget while the Health Department trailed far behind it. Not all South Africans are students, but all the inhabitants of this country get sick many times in a year and need treatment either as inpatients or out-patients. Acute and chronic conditions involve many investigative procedures before you can even count the cost of treatment. Hospitalization is very costly.

Immunization of all children is an ongoing and ever-present process that is very costly, so is the training of different categories of health professionals We have district, tertiary and academic hospitals and community health centres. To have a realistic idea of the kind of budget that should be allocated to the Department of Health a thorough investigation of the different levels of hospitals and their scope of healthcare delivery and a genuine cost-analysis should be conducted. The few billions of rand that health receives every year are nothing but a drop in the ocean; small wonder we end up with billions of rand in medical negligence claims.

Appointment to leadership positions.  Managers of health facilities, financial and procurement managers should have leadership qualities, honesty, integrity, and professional skills to be able to lead their teams effectively. Instead of meritorious promotions it has been the norm in many health institutions to reward long service with a promotion regardless of what weaknesses the person might have. Such a manager will obviously surround himself/herself with equally incompetent deputies who will also be next in line for promotion in the succession process leading to the demise of the organisation. The yardstick for promotion should be merit, relevant qualifications and experience. There is no point in appointing a person with a PHD when they lack the other qualities.

Corruption in all its forms must be stamped out and the billions of rand lost to it must be recovered. We are extremely poor today because of the billions of rand expatriated to Dubai and India. The spread of HIV/AIDS. If we are serious about combating the spread of HIV infections and teenage pregnancies which have become so rife, the government must scrap the legalization of consensual sex among 12-year-old-children. It is unthinkable that any country could come up with such a bizarre decision. Adults are supposed to protect children and not give them to the vultures.

Government Employees Medical Aid Scheme. I was diagnosed with diabetes in May 1997, and since then I have never been hospitalised for the condition. I am on oral medication and against the advice of my doctor, I refused to be moved to insulin because I lost my husband and my grand son to hypoglycaemia due to insulin. My physician prescribed another drug to control my diabetes and Clicks told me I needed to apply for authorization as this was an exclusion. I applied on December 3 and Gems told me to allow them 5days to review my request. I also had to pay 437 rand in cash at Clicks on the same day as I had consulted for flu and Clicks told me my benefits had been suspended which was a mistake by Gems. I paid because I needed the medication and I tried to claim for a refund from Gems. It is over a month and I am still waiting for both the authorisation and the refund. What is the point of belonging to a Medical Aid Scheme if you will not get assistance when you need it? Medical Aid Schemes should start showing more interest in the well-being of their members than their money. I am a pensioner, on Emerald paying R1285 monthly.

Repairs and servicing of medical equipment. This service should be given to companies that have  the knowledge and skill to deal with it , otherwise it becomes a huge waste of money as it might be found that coming back from repairs, the equipment is still not functioning. Ways to deal with the nursing crisis. It seems that what we dreaded all along over the years has finally caught up with us. As early as June 2007, some individual urged the government to find a way to repatriate South African nurses working abroad because it had become clear that the exodus was continuing non-stop, while those who had left were not coming back. No one listened. Those who did apply for jobs back home never received responses to their applications.

The training of nurses was also very slow with only one intake of students annually by the few nursing colleges that were left after closure of colleges by the ANC. Now South Africa is said to be short of 47000 registered nurses according to the latest statistics. Previously, in the 2013/14 financial year this number stood at 45000, so the situation is deteriorating. Of the nurses that are still in the system only 4,5% are under the age of 35, 57% are 50 years and above. This is scary. We are facing a future without nurses unless drastic innovative steps are taken without lowering standards to avert the catastrophe. At the next summit, the government, the South African Nursing Council, and Heads of Nursing Colleges must put their heads together and come up with workable solutions.

There were no advertisements in 2018 for the student intake of this year, most probably because of the government’s assertion that it has no money. Recruitment strategies must be reviewed and the admission requirements. Two school- leavers who desperately wanted to undergo nursing training had after many attempts of applying since 2012 without ever receiving any response to their applications approached me wondering what was happening. I asked for their Matric results and promised to investigate on their behalf. One of them had the following results; English 68% Afrikaans 47% Mathematics 38% Life Orientation 75% Geography 67% Life Science 58% Physical Science,60%. 

The second one had the following; Isixhosa 73% English 54% Mathematics 46% Life Orientation 71% Geography 37% Life science 41% Physical science 46%. Bearing in mind that our Basic Education Department sets the bar very low for a matric pass with only a 20% pass in mathematics if the student passes all other subjects, one is left confused as this becomes a situation where the left hand does not seem to know what the right hand is doing, if these applicants were rejected because of their matric results. If there are any good Samaritans out there, especially those who benefited from the government BEE policy, could they perhaps save the nation and finance the training of health professionals.

The training of medical students. While the government’s initiative to send SA medical students to Cuba and now Russia for training might have its merits, it has also had some unintended consequences. An article in the City Press on July 15, 2018 titled, Cuba trained doctors face  challenges, revealed that their studies in Cuba did not prepare them for the worst in SA hospitals. According to Steve Pheeha , an alumni of the programme, the first challenge  they had to contend with was language. In Cuba they had to spend the first year studying Spanish because they would be taught in it throughout their training. Coming back, they must adjust to understanding medical terminology in English.

Secondly, Cuba has a comprehensive approach to healthcare which focuses mainly on disease prevention, health promotion and rehabilitative treatment, which presented a training challenge. Students who train there are not exposed to trauma and severe illness beyond text book theory. These are rife in this country and the state hospitals they will be entering have backlogs in surgeries and overcrowded emergency rooms. Cuba is a protected environment and when you come back to Bara, you see illness in its worst form. There you rarely see a person go into hospital with a bullet wound.  At Bara you may see 10 people come in with these wounds in a matter of hours.

It is also rare to get any practical experience in birthing a child that side. These cases are handled by senior doctors and specialists, students are last in the line for any opportunity to help deliver. Pheeha said, “in SA we don’t run short of training opportunities in hospitals, in a way our country’s problems are good for learning.”

A group of medical students from Mpumalanga studying in Russia vowed not to return to Astrakan State University, claiming it was like a “sangoma’s hut”. The 53 students and their parents marched to the Mpumalanga government demanding to be removed from the university, they also demanded the removal of a middle man facilitating the process. The students who are in their third year of study, said they had never had practical lessons at the university, it has no laboratory and it looked like a dump site. “There are no functional labs, no English as a medium of instruction, medical student Sibusiso Sikhosana said. “We have written to the department of education in the province but they are not coming forward to help.”

“It’s like we have been dumped at this university while other students in other universities are studying serious things. We don’t want to come here and kill people instead of healing them.”

The road to recovery for healthcare in South Africa will be long and arduous but there are flickers of hope that there will be light at the end of the tunnel. We have started hearing positive reports from the Minister of Health Dr Aaron Motsoaledi who has announced a cash injection of 2billion rand which will be used to hire 15000 health professionals for hospitals countrywide starting this month. This might not be enough, but it is encouraging. It is a step in the right direction.

The big question is, where will the thousands of health workers come from? We have no health workers just sitting at home unemployed at present. The government might have to consider embarking on an aggressive repatriation of all those who are serving foreign countries while this country is bleeding. While training of more health professionals is urgently needed, it takes many years to produce fully trained health professionals. Hiring care-givers to take care of frail and helpless patients might help as they will take care of ward hygiene wash, feed and change the frail and helpless under the supervision of registered nurses, they are sometimes called ward helpers. The continued contractual assignments of retired nurses could also help.

It was interesting and confusing to learn from the article in the City Press that there are about 640 trained nurses that are sitting idle, unemployed some of them for about three years or more while the country is reeling from severe staff shortages. It is shocking to say the least and I just do not know what to make of it. One can just hope that reason will prevail and those in charge of health services will get a grip and turn things around.

Cometh Dube Makholwa trained in General Nursing, Midwifery and Theatre Nursing  Science. She holds a Degree in Nursing Education and Nursing Administration.