Rich province, poor health care

By Ufrieda Ho

In money terms, Gauteng’s health budget looks plump and healthy at R37,4 billion for the 2016-2017 financial year – R2.07 billion more than the previous financial year. It represents a sizeable portion of the province’s overall budget. On the surface, this is money that could make a significant contribution to improving the health outcomes for the province’s patients.

But, even though it’s South Africa’s richest province, Gauteng is under pressure from a growing metropolis and is not future-proofing fast enough for its evolving needs. There are challenges of rapid urbanisation, with high migrant numbers and community members who are transient and difficult to track medically. The province also has to plan for accelerated environmental degradation, overcrowding, job shortages, limited resources and the yawning gap between the haves and have-nots.

The divisions are evident in data from Stats SA’s General Household Survey of 2015, which was released in June this year. For example, Gauteng is home to the highest percentage of medical aid members in the country at 27.7 percent, but this still leaves 70 percent of the population reliant on that R37,4 billion to be spend wisely and effectively.

The Gauteng Department of Health has its own hurdles to overcome, including proving that it is fit to govern. After being placed under administration in 2013, the department finally achieved an unqualified audit from the Auditor General for its financial management this year.

But the health issues continue to be a challenge in the province. On-going staff shortages, overworked staff, unreliable ambulance services, staff who don’t treat patients with dignity, and a disconnect between policy and plans and the reality on the ground. Increasingly, bureaucracy replaces communication, and there are more reference numbers and records of complaint than actual solutions or firm plans on how problems can be rectified.

In addition, a tangled web of social failings impact on the health-care challenges. There’s high unemployment and competition for scarce resources. Public works shortfalls mean infrastructure in hospitals and clinics is not upgraded or maintained. And the high cost of commuting, or lack of proper roads in new developments, represent very real barriers to accessing health care for many patients. The protracted drought in southern Africa has also made food security a great cause for concern among the most vulnerable people in the province.

It is a most distressing trend that already weak health-care standards are slipping further and that there are clear losses in areas where gains had previously been achieved. For Gauteng TAC leaders Portia Serote and Sibongile Tshabalala, these include noticeable deterioration in the way TB is being managed in many of the province’s clinics and hospitals.

Serote, who works mainly in the East Rand districts, says many basic good care and oversight practices are simply not adhered to.

‛We can walk into clinics and see people not using masks. Patients are all mixed up in the same small facilities – so you can see XDR and MDR patients with TB patients. There is no infection control, or the UV lights (that help limit the spread of infection) are not working,’ says Serote.

She says the TAC has had to step up its own outreach programmes after discovering in a spot sampling exercise recently, that out of 60 people, 10 had TB and three had MDR-TB.

Another growing concern, says Tshabalala, is the high number of ARV defaulters that they are noticing. Tshabalala says the target of getting patients to undetectable viral loads is slipping.

‛We did a workshop and survey in Orange Farm earlier this year and found that people default because they can’t afford the taxi fare to get to a clinic, and it’s too far to walk. They also have to wake up by 4 am to get to a clinic or hospital if they want to get help that day. There is a benchmark for waiting of 180 minutes, which is just too long,’ says Tshabalala.

The facilities that people rely on have no privacy, are often cramped and have not been properly maintained. Serote says she’s visited clinics where nurses have brought curtains from their homes so patients can have some privacy and dignity during their consultations.

And, Serote says, mental health patients are falling through the cracks in the province. The TAC has seen an increase in the number of patients who simply walk out of hospitals in hospital pyjamas, completely unnoticed, sometimes for days.

‛The nurses were just unaware in Pholosong in Tsakane, when a man who was mentally ill just got up from his hospital bed and left. He was living in really terrible conditions and that’s where we found him, still in his hospital clothes, but the nurses didn’t know anything,’ she says.

Both Serote and Tshabalala acknowledge the nurses are under immense pressure themselves. ‛Nurses are not just nurses; they are counsellors, they’re cleaners – they are expected to do everything. The Department of Health thinks that a benchmark of one nurse to every 40 patients is not being overworked, and very often the nurses see even more people than that,’ says Serote.

Even for a thriving economic hub like Gauteng, prosperity is shared by only a few. Money can buy many things, it seems, but clearly it can’t buy solutions that are inclusive, innovative or impactful for a health-care system that needs just these.