Our health system: Babies are the “canaries in the mine”

Nineteen years ago Dr Glenda Gray, a young paediatrician based at the Chris Hani Baragwanath hospital’s then Perinatal HIV Research Unit, joined a picket at the hospital gates organised by the Treatment Action Campaign (TAC). The demonstration was to call on the government to provide the drug AZT for pregnant women with HIV to protect their babies from infection. It was March 1999 and we were months before an election. Gray called on women to be at the forefront of TAC’s campaign and famously shouted out “No AZT, No Vote!”

The TAC’s campaign was eventually successful. Now, almost all pregnant women with HIV have access to ARVs and fewer than 1.2% of infants are born with HIV every year. That’s only 3,000 babies – down from 40,000 in 2005. As a result HIV is no longer the leading cause of under-5 mortality.

But while we may be protecting babies from HIV at birth, neonates face another risk: severe perinatal injury or death during the birthing process. It is a horrible fact that up to 8,000 neonates a year lose their lives, primarily as a result of avoidable medical or administrative errors. Although this is less than 2% of total births — it accounts for 27% of under-5 mortality — the personal cost to families and the financial cost to the health system is enormous.

Today, Glenda Gray is President of the Medical Research Council (MRC). In a speech on Steve Biko day she likened babies who die at birth to the canaries that were once carried into coal mines as a way of detecting fatal gases. If the canary died, miners did their best to get the hell out — in other words they knew something was very wrong. Babies, according to Gray, are like the canaries of our health system.

Babies die in unacceptably high numbers because they are born at the confluence of several of the major problems that blight our health system: Human resource shortages accompanied often by a lack of basic training, medicine and equipment stock-outs, poor infection control and the lack of emergency transport, especially in rural areas. The triennial Saving Babies report (2014-2016) (which is not online) catalogues the causes of their deaths. It makes sad reading. For example, among what it terms the “personnel associated avoidable factors” are listed:

  • Delay in referring patient for secondary/tertiary treatment (2,118 records);

  • Nosocomial infection (1,101 records); and

  • Neonatal care: Management plan inadequate (795 records).

Among “administrative avoidable factors” are:

  • Inadequate facilities/equipment in neonatal unit/nursery (1,567 cases);

  • Lack of transport institution-to-institution (885 cases); and

  • No accessible neonatal ICU bed with ventilator (949 records).

Not listed are the “avoidable political factors” — MECs and former MECs who don’t care, among others Qedani Mahlangu, Brian Hlongwa, Peggy Nkonyeni, Benny Malakoane, Phophi Ramathuba and Sibongile Manana.

If our hospitals were mines they would be declared unsafe. Unfortunately, though, our canary-babies and their mothers can’t choose not to go into the mine.

From a health system that kills to a health system that heals

In the face of facts like these there is no longer any dispute that our public health system is haemorrhaging uncontrollably. Even President Cyril Ramaphosa admits it. The greatest tragedy, though, is that when it comes to the cause of the health’s system sickness we have the diagnosis, we have the knowledge, we even have the resources. We also have a mountain of barely considered expert reports suggesting solutions. But we don’t seem to have an algorithm between the problem and the solution.

Consequently, our health system is caught in a vicious circle, where each component of crisis has a knock-on effect on to another, and so on. The chain of disorder created by corruption is just one example:

  • Corruption in the health system robs us of billions of rand in resources which means we don’t fund critical posts.
  • At worst the shortage of nurses and doctors leads to high rates of peri-natal mortality and other harm; at best to poor health outcomes and pervasive inefficiency.

  • Then, death and disability at the hands of the health system leads to rising medico-legal costs which once more divert money from frontline health care. By 2017, according to the audited reports of provincial health departments, R51-billion was listed as contingent liabilities for medico-legal claims — that’s almost a third of the national health budget. And, to add insult to injury, in 2017 provinces spent nearly R1-billion on legal fees — more than the R820-million the government cut this year from hospital infrastructure maintenance and upgrades.

Medico-legal claims as at 31 March 2017

Total medico-legal claims (contingent liabilities)

% of annual budget

Amount spent on legal services

% of annual budget

Eastern Cape

R16,658,078,000

81.2%

R131,269,000

0.6%

Free State

R1,505,184,000

16.6%

R54,000

0.0%

Gauteng

R18,614,087,000

49.7%

R748,165,000

2.0%

KwaZulu-Natal

R9,230,309,000

24.9%

R34,843,000

0.1%

Limpopo

R2,115,529,000

12.3%

R20,168,000

0.1%

Mpumalanga

R547,469,852

5.2%

R0

0.0%

Northern Cape

R1,252,269,000

28.7%

R5,340,000

0.1%

North West

R1,285,126,000

13.2%

R31,886,000

0.3%

Western Cape

R32,040,000

0.2%

R22,168,000

0.1%

TOTAL RSA

R51,240,091,852

30.9%

R993,893,000

0.6%

  • Exacerbating this is extremely poor management and a high level of political interference in operations. This stifles initiative, causes a lack of accountability and demoralises health care providers.

  • Poor management and demoralisation causes us to lose lives and health workers and thus the cycle of corruption starts all over again.

It’s a perfect storm. We couldn’t have made a bigger mess even if we had held a health summit to try. Somehow we have to break this cycle. Where should we be starting?

Not another summit

Like other societal haemorrhages this weekend health will have its very own summit. I mean no disrespect to President Ramaphosa, but unfortunately, one has to doubt whether a summit will staunch anything (there will be a Presidential Health Summit on Friday and Saturday). It is bound to be another dither-fest.

As I have said, health workers have answers and interventions that will work. What they don’t have is leadership and permission to fix the system. They don’t have decisiveness. And it’s unlikely that another mass summit will provide that.

So where should we start?

Understandably we tend to fixate on what’s bad. My advice to President Ramaphosa would be: this time, start by identifying what’s good, what works and who works in our health system; affirm and consolidate it, and then build outwards. If you adopt this approach you may be surprised to discover, although it’s not often in the news, that there is a lot of residual capability and potential in public health.

Here are some pluses to work with:

  • We have a strong legislative and policy framework. Frankly, although Minister Motsoaledi presents the National Health Insurance Bill as a panacea, legislative change is not the place where we need to tinker at this point. Drop the Bill for now. It’s ill conceived, impossible to implement and will become a distraction.
  • Although our human resources base is severely overstretched and demoralised, we still have more health professionals than other developing countries have. We also have a small legion of community health workers and clinical associates who are desperate to be integrated properly into the system. If the policy logjam could be solved and there was more bravery and far-sightedness about budgeting for higher health returns, we could get better results — quickly.

  • The private health sector might be considered a bane to public health. But it’s also an asset. It has a precious infrastructure, resources and expertise. As recommended by Justice Sandile Ngcobo and the panel that conducted the private Health Market Inquiry (HMI), its services and management capability can be better integrated with public objectives to fill obvious holes in public services (like oncology) and with quick results.
  • We have the best research and surveillance capacity of any country in Africa, and in some respects the world; we have strong universities and teaching institutions; we have world-class institutions like the National Health Laboratory Services, whose ability to go to a massive scale in response to HIV and TB, has prepared them for almost any challenge.

  • Finally there’s a community of activist health professionals that wants to get it right and an active and engaged civil society that, as the response to AIDS has shown, is capable of mobilising behind a genuine plan to fix the health system.

But where’s the plan? Where’s the leadership?

Saving babies as a key to saving the health system

That question brings us back to our canary babies.

One of the first things we need is hope and self-belief. Our world-class ARV roll-out campaign has taught us that the best way to fix is by doing. Less talk and more mobilisation for targets and tangible outcomes.

There are nearly a million births a year in SA… a campaign that aims at saving babies and simultaneously improving the quality of care for their mothers would require us to zoom in on the health system at critical interfaces. It would focus us and we would be forced to target resources at a key place of delivery. Actually, saving babies would raise the morale of users and health workers.

If funding to implement such a plan is a problem, then we should rescue some the billions of rand that are siphoned out of the health system through theft.The money “saved” from corruption should be returned immediately to the coal face. And while we are at it could we please have an anti-corruption task force for health in the Hawks?

If expensive neo-natal ICU equipment is a problem, almost every doctor you talk to will tell you about the huge wastage in supply and procurement systems.

When it comes to human resources the problem is as much one of morale and scopes of practice as it is of staff shortages. If we fix the first two we buy time for the latter. For example, the Saving Babies report emphatically states:

“Evidence and experience amply demonstrate that community health workers in sufficient density can have a rapid and positive impact on neonatal and young child mortality, especially when allowed to treat common acute conditions.”

For God’s sake act on the evidence then!

Recently President Ramaphosa committed to “immediately fill 2,200 critical medical posts, including nurses and interns”. Please tell us which posts and when and where? This is a welcome stop-gap but it needs to be accompanied by a presidential instruction and time frame to the national departments of Health and Treasury to finalise the human resources for the health plan.

Human resource policy is one area where there is lots of unfinished business: If it was finished and properly implemented, it might quickly make a difference to service delivery. Take the issue of community health workers and clinical associates, where there has been policy stagnation for a decade. Community health workers, properly employed, trained and supervised as recommended by the World Health Organisation High Level Commission Health Employment and Economic Growth could make a huge difference to health outcomes.

Finally, as pointed out by the Health Market Inquiry, although our public hospitals are at bursting point, our private ones have space. Negotiate an agreement to use this space!

The measures suggested above are aimed at saving lives through treatment and care. However, as soon as possible we need to turn off the tap of non-communicable disease that is already overwhelming every level of the health system with preventable and costly disease.

There is a road to health, but to get on to it we need to do things very differently. A summit may be a start. Hopefully it will forge a new consensus. Hopefully people will leave their egos and political and election agendas outside the room and instead focus on what the Constitution demands we do to realise everyone’s right of access to health care services.

But President Ramaphosa, this is a war, the dead and injured are piling up, your generals have failed miserably. Ultimately winning this war needs a plan, a budget and a war room answerable only to the Commander-in-Chief.

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