Ten years later: Reflecting on the successes and challenges at Khayelitsha Hospital
The AMBITION-cm trial was conducted in eight hospitals across Africa, including the Khayelitsha and Mitchells Plain Hospitals in Cape Town. It found that a single dose of L-AmB infused over a few hours, followed by two weeks of flucytosine and fluconazole is as effective as the WHO’s previously recommended standard of care. PHOTO: Nasief Manie/SpotlightUpon entering the Khayelitsha District Hospital one is still met by that ‘new hospital feel’ despite its tenth anniversary coming up in April. Floors are shiny, all the wood finishes are still intact and polished, walls are adorned with neat health posters and eye-catching murals, and there is light – lots of natural light. The colourful plastic benches where people wait, feature modern, hip designs. The green of indigenous plants jumps out from a courtyard hemmed with mosaic tiles. On the face of it, the wear and tear often seen at older public hospitals have not yet set in.
Yet, since the hospital officially opened in April 2012 it has at times been a bumpy ride. In 2018, the hospital made headlines when patients reportedly had to sleep on the floor due to a shortage of beds. The hospital has also in recent years been under close scrutiny from the provincial legislature, where hospital management and the Provincial Department of Health most recently had to report in February.
Massive need
Hospital CEO David Binza suggests that the hospital’s difficulties are mostly due to the population growth in the area having outstripped the hospital’s resources. When the hospital opened StatsSA figures put the population of Khayelitsha at just over 391 000 in the last census.
Back in 2018, Dr Gio Perez, Chief Director for Metro Health Services said in the Western Cape Provincial Parliament based on the census data of 2011, it was estimated that Khayelitsha’s population was 391 749. “The figures given by the census are the official StatsSA figures. If they extended the population to today (2018), it is estimated the population has grown just under 500 000 people. However, these numbers are hotly disputed in some circles. The population quoted in the media ranges from 500 000 to 1.5 million people in 2018,” Perez says.
In a circular of the Western Cape Department of Health, the official population estimate for Khayelitsha by 2022 is 451 616.
Still, although the population numbers may be disputed, Binza says there is a definite increase in the number of patients they have to attend to. “Yet there is not enough staff. We have a lot of pressure, especially in the trauma unit on weekends, month ends, or when there is a derby between Kaizer Chiefs and Orlando Pirates. We have our hands full and with limited resources. Most people who end up on the chairs or floors are in the trauma [unit],” he says.
Nolitha Mazwayi, provincial manager of the Treatment Action Campaign (TAC – an HIV activist organisation), agrees that population growth has impacted services at the hospital and contributed to overcrowding. The TAC’s provincial headquarters is in Khayelitsha.
“The hospital’s infrastructure cannot handle the patients that have to be serviced by the hospital,” she says. “Staff shortages affect service provision to patients.”
Mzwanya Ndibongo, Khayelitsha Health Forum chairperson, also points the finger at population growth. “Now, with [the] area growing we have a lot of people and it has put so much pressure on the hospital. The main challenge is in the trauma unit and psychiatry. Due to not having enough beds, people end up sleeping on chairs and the floor. In other wards, there is no problem,” he says.
Staff shortages
The hospital has 650 staff members in total, with just over half (336) being nursing staff, but Binza says this is not enough. He says they need an additional 18 speciality nurses, 55 professional nurses, 67 enrolled nurses and 106 enrolled nurse assistants.
Grace Mashaba, head of nursing at the hospital says they plan on a daily basis on how to best utilise the nurses that are there against the beds that are occupied. “We have to decide who do we move where and who do we discharge. At times we have to escalate patients but you find out that the ward is full to capacity [but] you have to admit a patient [so] what do you do? We improvise because we can’t chase patients away and some don’t want to be sent to other hospitals as it is far,” says Mashaba.
“We don’t even have enough cleaners or even porters,” says Binza gesturing to a porter pushing a patient. “Look, under normal circumstances we must have two porters with that patient but we only have one. So, this is a challenge. We need more porters, cleaners, clerks, scrubs, and others. We can’t even do theatre time properly because there is not enough staff.”
Binza says they have a surgery backlog, which varies from service to service. The waiting list for a hysterectomy is around two months, 22 patients are waiting for gastroscopy, 40 for colonoscopy, and 20 for orthopaedics. “So, we end up relying on agency staff to do the work which sometimes causes tensions between our staff and the agents,” he says.
Not enough beds
While most of the hospital’s challenges relate to staff shortages, bed capacity is also a problem. The official bed capacity at the hospital is 340, but Binza says they often have to accommodate nearly 450 patients, which is why patients sometimes end up sleeping on chairs or on the floor.
Binza says what adds to this pressure is people who can be helped at the clinic level that come straight to the hospital.
On this Binza says they still need to do more community awareness and education because patients that can use the clinic end up at the hospital. “This is a hurdle we need to still get over. Some patients come to the hospital instead of going to the clinic because they trust the hospital more or it’s just closer so they can walk there. This then increases the pressure at the clinic. We need to make the community aware of where they need to go for what services,” he says.
New services
The pressure on the hospital is not only determined by the number of people who depend on it, but also by the healthcare needs of the specific population. Binza says Khayelitsha faces a quadruple burden of disease – violence, trauma and injury, mother and child’s health, communicable diseases like TB and HIV, and non-communicable diseases such as hypertension and diabetes.
When it opened ten years ago, the hospital had six specialists, which included three family physicians, one emergency physician, one obstetrician, and one paediatrician. With the hospital now serving a larger community with a high disease burden, Binza says they had to go back to the drawing board.
Being a district hospital means it receives referrals from and provides generalist support to clinics and community health centres but the hospital now also provides services that could be accessed at a regional level. Today, there are 14 specialists who provide services including internal medicine, emergency services, surgery, orthopaedics, obstetrics, gynaecology, paediatrics, psychiatry, and anaesthesiology. Binza says these services are meant to be offered at a regional level by hospitals that receive referrals from and provide specialist support to a district hospital.
Among the expanded services they now provide, he emphasises the commissioning of the computerised tomography (CT) scanning service in 2017, the opening of an on-site blood bank in 2019, and the commissioning of overflow psychiatry beds at Lentegeur Hospital in 2021.
“Patients were going to Tygerberg Hospital, and they had to be [put] on the waiting list. Having our own CT Scan has helped us a lot. It also saves on transport costs and we are thankful for that. There are needed health services coming closer to the people,” says Ndibongo.
Money troubles
The staff shortages at the hospital appear to be largely down to funding. Binza says they have 222 principal posts, which are approved positions that have to be filled but due to financial constraints cannot be filled.
In the last financial year, the hospital was allocated a budget of R430 million but Binza says for it to function optimally they need an additional R150 million.
“We are busy now with a document to the Khayelitsha Eastern sub-structure that details our needs, how, and where we will be using that additional money which we desperately need,” he says.
Responding to questions in the Western Cape Provincial Parliament’s (WCPP) Standing Committee on Health in February, Dr Saadiq Kariem, Chief Operations Officer in the provincial health department acknowledged the budget pressures. Kariem explained that the provincial Treasury allocated R114 million to fund additional services such as mental health, palliative care, and surgery backlogs, among others, not only for Khayelitsha Hospital but health facilities throughout the province.
Safety Concerns
Apart from funding, high crime rates in the area are also a likely obstacle to attracting and retaining staff. Ndibongo says people do not want to work in Khayelitsha due to crime.
It is something that worries Binza as well. “Sometimes our staff members are robbed at gunpoint at bus stops or as they are coming to work, resulting in shift cancellations. Also, it’s a challenge when the residents are protesting which means roads are closed. Sometimes cars are stoned making it difficult to get to work,” he says.
“But we have a WhatsApp group for such things. We inform each other on which road is safe to take. When there is a protest or a staff member is robbed that means we are short of hands to do the work. This adds to the challenge as we are already short-staffed,” he says.
Impact of COVID-19
Binza says it is emergency and mental healthcare services that were under the most pressure with the COVID-19 pandemic.
“Mental health challenges is something that has been coming for a while and just increased during the pandemic,” he says. “We know what COVID-19 has done to our people. They are frustrated that they can’t put food on the table. Some lost their jobs. We have 51 psychiatric beds which, at times, had to increase to 171. Tell me, where do we put all these people?” he asks. “We had to make do with what we had. The demand for psychiatry beds had taken the hospital to 140% of what it could manage with the little resources it had.”
Mazwayi says when they (TAC) met with Binza in November last year, he told them that psychiatry patients are supposed to be kept for observation for only 72 hours at the hospital, but they end up staying for up to 22 days, which leads to bed shortages.
Dealing with community dynamics
One of the things that they are proud of as a hospital even in the face of the pandemic is its death rate, which is between 2% to 4%. This, Binza says, is fairly comparable with other big hospitals that take on as many patients as they do.
“You know, we had this death rate even during COVID-19. One of our biggest challenges when talking about death rates is actually death on arrival. We work in a community where parents or guardians believe that when a child is sick, it’s an evil spirit. So, the patient must first be taken to a sangoma to help them before coming to the hospital. The hospital becomes a last resort and in most cases, these patients get to us very late or when they are dead most of the time,” he says.
“By seeking professional healthcare late, we are denied a chance to intervene while there is still time to save the patient. This is what is actually inflating our death rate,” he says, adding that when looking at the people that actually die in hospital after being admitted, the number is very low.
To combat this, Binza says they are pulling in all the community stakeholders like the community policing forums, Khayelitsha Development Forum (KDF), school governing bodies, and traditional healers.
“We want the community to know that we are here to help them.” He says they often have community health imbizos to hear their frustrations about the hospital. “We also want to tell them our frustrations so that we all work together,” says Binza.
Mixed reactions
Azola Dlamini, who is 32 weeks pregnant, comes to the hospital for her antenatal care visits. It is a service that she can get at the clinic but she prefers to come to the hospital as it is closer. “The staff is friendly and quick,” she says.
Another healthcare user, Goodman May says nurses must pay attention and love what they do. “Each time I come here it’s like some nurses are forced to be here. Some are not even sure what they are doing here, which makes you wonder if you will get the proper service. For me, the most important thing is for the nurses to be present and attend to you with full attention. This is something that I’m not getting at this hospital,” he says.
But Binza says that despite various challenges they are all trying to make it work and provide the best service for those that use this facility. “Everything has to be done with respect, no question is too big or too small. We want to have those difficult conversations with the community so that we can improve the service we provide to them,” he says. Gesturing to a wall with several awards, Binza says the hospital got another clean audit for the 2018/2019 financial year. “You see, this wall is a statement of the incredible work we have done, that shows we are doing something right,” he says. “I must say, everyone pulls their weight. Because we don’t have enough staff, one person ends up doing the work of two or three people. With that mistakes are bound to happen but you know, even under so much pressure and little resources we have upheld the standard. Very few patients are dying in our hands.”
