Limpopo to release health workers despite massive shortages

Whistle blowers have alerted the Rural Health Advocacy Project to a decision by Limpopo’s Health Department (LDoH) to release provincial bursary holders from their contractual obligations. RHAP has in its possession a letter circulated to health professionals inviting them to a meeting to discuss the decision which will affect approximately 540 health professionals who have received funding from LDoH. The affected health professionals include medical doctors, professional nurses, pharmacists and allied health professionals (occupational therapists, physiotherapists, speech therapists and audiologists.)

The decision to release the bursary holders from their Bursary Contractual Service Obligations will have severe implications on health service delivery and does not ensure the protection of the core right to health. It will ensure that the reported ratios of 10 pharmacists per 100,000 people will not improve nor will the 3 physiotherapists and occupational therapists, respectively, per 100,000 people, thus underservicing the population in Limpopo and failing to progressively realise the right of access to health care services.

The LDoH has under half (47% – 33,848 of the 63,460 posts) of the personnel it requires to function effectively. To fix the broken provincial health system, LDoH developed a Recruitment and Development Strategy (“Strategy”) to formalise the bursary scheme and ensure that it can attract and retain health professionals. The Strategy is also intended to address some of the factors that result in the high attrition rate, these include a lack of opportunities for career-pathing, inadequate infrastructure, inadequate and non-functional equipment as well as poor working conditions.

It is therefore counter-productive that the LDoH, which has historically suffered from low healthcare worker figures would opt to let go of 540 health professionals whose services are obviously needed. Typical rhetoric would lay blame on the economic recession and austerity measures taken by state departments. However, we should be wary of austerity being the catch-all net for all decisions that fail to meet the Constitutional standard envisioned in section 27 of the Constitution. The International Covenant on Economic, Social and Cultural Rights (ICESCR) to which South Africa is a signatory is explicit when it comes to austerity. It cites the implementation of austerity measures may only be justified when a) less restrictive measures have been exhausted, b) austerity measures must be temporary and that any other course of action would be more detrimental to the realisation of rights and that c) they cannot be intentionally or unintentionally discriminatory, amongst others.

In late 2018, President Ramaphosa released a Stimulus Package for Health. This constituted a significant boost of 5300 posts (clinical and support staff) into the public health system distributed across all 9 provinces. The LDoH, in particular, received 227 medical officer posts (for post-community service doctors), 68 pharmacist posts, 309 professional nurses’ posts and 57 allied health professional posts. A total complement of 701 new posts were funded, in addition to the number already budgeted for by the LDoH. It is curious that a decision to forego the services of 540 health professionals be implemented with such haste. Surely, the lack of available funding was anticipated earlier in the year. If so, a large portion of the 701 new posts could be used to offset the 540 posts that will be lost. There has been no information on how many of the posts created by the Stimulus Package have been filled.

We are also unsure how the LDoH intends to staff the state-of-the-art central level hospital whilst failing to adequately implement its Strategy and retain 540 skilled and willing health professionals whose studies the LDoH has already funded. The current state of Primary Health Centres (PHC) and district level hospitals also leaves much to be desired and it does not seem that this decision will improve services at these facilities.

Only 25% of Limpopo’s clinics meet ideal clinic status, the second lowest of all provinces, competing for last place with the Eastern Cape; another predominantly rural province. Spending by LDoH shows a strong focus towards district hospitals. Consequently, it would appear that the bulk of health services are provided at this level. Over the 2017/18 period, 51.3% of District Health Services was spent on district hospitals. However, this contrasts starkly with the investment in PHC services with Limpopo being the lowest spender in the country. Over the 2017/18 period, per capita spending on PHC was R352, which is almost R100 less than the national average. And therefore, incongruent decision making and spending is not isolated solely to the 540 health professionals who are soon to lose their jobs but rather is characteristic of Limpopo Department of Health. The investment in the studies of 540 health professionals to improve health services in Limpopo will be lost to other provinces or the private sector.

Due consideration must be given to the inherent challenges that rural provinces, such as Limpopo, face. The government must take into account factors such as low population numbers that are spread across large areas and resultant diseconomies of scale which make providing services to these provinces more expensive, and budget accordingly. The users of the healthcare system will bear the brunt of the loss of personnel most and the figures reported by LDoH will not allow for increased access to health care services.

There is contradicting information on the number of posts in LDoH and the number which has been filled and how many remain vacant. There has been no explanation as to how the LDoH funds bursary holders but fails to ensure that there is funding for their posts in order for them to continue working once after their community service. There are also no reports on the progress in implementing the Strategy.

As a coalition of social justice organisations committed to the protection and advancement of socio-economic rights, we appeal to:

  • the Minister of Health to support the development of costed provincial Human Resources for Health plans that consider the varied implementation contexts in different provinces;
  • the Minister of Finance to consider rural adjustments starting with HRH to be included in Equitable Share Formulas;
  • the Premier of Limpopo to amend the framework that informs how the province distributes its unconditional provincial equitable share allocation in order to increase the portions dedicated to health and education.
  • the MEC for Health and the administrative heads of health to work together to ensure that the decision to release bursary holders is reversed in order to fulfil their Constitutional obligations of ensuring access to health care services so that the wellbeing of the people of Limpopo is placed at the centre of all decisions.

This open letter has been endorsed by the following social justice organisations:

RHAP, SECTION27, the Treatment Action Campaign, People’s Health Movement, Rural Rehab South Africa, Rural Doctors Association of South Africa, Institute for Economic Justice.

Five health policy priorities for the new administration

Under Health Minister Dr Aaron Motsoaledi’s watch government has made generally good HIV policy over the last decade. Treatment guidelines kept up with international best practice, newer medicines with fewer side effects have been introduced, and the malicious compliance of the last years of the Mbeki presidency was replaced with real political will and commitment to ensure people get the treatment they need, at least at national level.

But, while HIV and some aspects of TB policy has been good, there have been important failures in other areas. Below we highlight five important government policies or plans that have been stalled, are out of date, or simply never got off the ground. We recognise that National Health Insurance constitutes a major area of policy uncertainty, but we will not discuss that in this article.

These five health-related policy areas are not only areas that we hope will receive higher priority in the new administration, they are also areas in which we urge government to communicate its plans more clearly and more timeously.

  1. Human Resources for Health Strategy

People, or human resources if you will, are critical to the functioning of the public healthcare system. We need to have enough nurses, doctors, pharmacy assistants, managers and so on where they are needed most. This involves ensuring that enough people are being trained, but also ensuring that there are jobs and careers for these people in which they receive enough support. To make all this happen we need an over-arching plan or strategy.

Government’s key human resources strategy document for healthcare in South Africa is the HRH strategy for the Healthcare Sector 2012/2013-2016/2017 – in other words, it expired around two years ago. When we recently contacted the Department of Health to ask for the HRH plan, this outdated plan is what they sent us. They did point out that work is underway on a new plan, but did not say when it would be finished.

  1. Community Healthcare Worker policy

Community healthcare workers play an important part in the provision of primary healthcare services. Particularly in South Africa, where people with HIV or tuberculosis often only go to clinics or hospitals when they are very sick, CHWs can help get people into care earlier. This benefits both the individuals who are linked to care, but also helps prevent further transmission of HIV or TB.

Over the last decade provinces have gone about the employment of CHWs in very different ways. Salaries or stipends differ widely, required qualifications have differed, many provinces essentially outsourced the employment of CHWs to NGOs, training and job functions were not standardised across provinces, in one instance over 3 000 CHWs were dismissed without warning.

The need for a single, coherent national policy was recognised as far back as 2010 when the Health Minister and MECs went to Brazil and returned with a vision of a wide-reaching CHW cadre integrated into the health care system. Between 2011 and 2018, policy development and implementation moved at a glacial pace until the Policy Framework and Strategy for Ward Based Primary Healthcare Outreach Team 2018/19 – 2023/24 was published.

We now finally have the policy but adaptation to local needs and implementation is up to provinces. It should be made a top priority as new provincial administrations come into power. While having the right policies in place is essential, implementing policies is often another matter altogether.

  1. Policy on Occupational Health for Health Workers in Respect of TB and HIV

Healthcare workers are at a much greater risk of contracting tuberculosis than the general public. It goes without saying that we need to have good policies in place to ensure that as many healthcare workers as possible stay healthy.

By the end of 2016 a policy on “Occupational Health for Health Workers in Respect of TB and HIV” was completed. According to sources involved in the drafting of the policy, the policy was to be released on World TB Day (24 March) 2017. However, more than two years later the policy has still not been published.

  1. The National Drug Master Plan

The National Drug Master Plan is supposed to guide South Africa’s response to addiction and drug use – everything from tik to injecting heroin. A progressive, evidence-based plan is particularly important given that HIV and hepatitis rates are much higher among injecting drug users.

South Africa’s last National Drug Master Plan covered the period from 2013 to 2017 – in other words, it is now out of date by about two years. In April 2019 cabinet approved an evaluation report of this plan.

When a new plan will be published is not known – although we understand that drafts have been around for well over a year.

  1. Guidelines for Sexual and Reproductive Health Rights, Contraceptives, Abortion, PrEP and Cervical Cancer

Everyone has a right to reproductive health care services. Exercising that right is beset by difficulties, however, including health workers who refuse to provide abortions, contraception stock outs, the non-availability of pre-exposure prophylaxis outside of a limited number of donor-funded pilot sites, and oncology crises across the country.

A Guideline on Abortion is in its sixth or seventh draft currently and, we understand, has been approved by the technical sub-committee of the National Health Council. When it will be passed by the National Health Council itself and whether it will be implemented is not known. We are also aware of pending draft guidelines relating to SRHR, Contraceptives, PrEP and Cervical Cancer but are uncertain as to the status of these guidelines.

Setting priorities

Apart from finalising all the above guidelines and policies, making those guidelines and policies that have been finalised easily accessible online should be a priority.

In addition to all of the above, there are areas in which clear national policies are needed, but where we are not aware of any sufficiently far-reaching policy processes that are underway. So, for example, emergency medical services and planned patient transport services in many provinces appear to be in a constant state of crisis. New EMS regulations came into effect late in 2018 and EMS is often mentioned as a key element of NHI, but beyond that there appears to be very little planning, leadership and public consultation on how to fix our chronic EMS and planned patient transport problems. If NHI is to be part of the solution, then maybe the EMS element of NHI should be fast-tracked and prioritised. Either way, we need publicly available and consultative plans and policies to address urgent crises such as those in EMS.

 

#FootSoldiers: It’s a bloody affair, but we are all human.

“In 2017 a young girl called *Akeelah showed up at lady Michaelis Clinic one morning to see a Termination of Pregnancy (TOP) nurse. The nurse on duty was busy attending to another patient at the time. While she waited Akeelah  kept shifting anxiously in her seat, eventually she popped her head into the office and asked the nurse if she was going to be long, as she was in a rush. The nurse explained that she had to see everyone in the queue and referred her to the local hospital, if she couldn’t wait. A few hours later Akeelah returned , still  visibly anxious. This time she managed to consult with the nurse. They discussed the option of an abortion and agreed that Akeelah would come back to the clinic.

The next day Akeelah’s aunt arrived at the clinic to enquire about her medical  situation as she had tried to take her life the night before. The nurse did not disclose the reason why Akeelah had come, but just confirmed that Akeelah had presented herself at the facility.

Just as Akeelah’s aunt  left  the clinic , Akeelah  was back again. This time she had a drip needle hanging from her arm and a hospital tag around her wrists – she had  gone to the hospital, but ran away to come back to the nurse.

She told the nurse she was sure that she wanted an abortion. The nurse provided her with the medication she needed to perform an abortion at home, and informed her to call her if she was uncertain about what was happening to her body during the abortion process.

The call never came.

Instead, the aunt returned to the clinic to see the nurse and deliver some news.

Akeelah, had thrown herself in front of a train and died.”

Fourty-eight-year-old nursing Sister Judy Ranape is in tears by the time she finishes narrating this story. She was the nurse on duty the day Akeelah first turned up at the clinic.

It is this harrowing memory that keeps the Cape Town abortion  nurse doing her bit within the corridors and wards of hospitals, and in the lives of people in her community.

Ten years ago, Judy made the decision to become an abortion (Termination of Pregnancy) nurse. A staunch Catholic woman, somehow she navigated a way through her religious beliefs and faced the stigma of being viewed as a person who allows people to take away lives instead of saving them. “I come from a background where abortion Is a sin, it took me sometime before I said to myself, what the heck, I need to help people anyway,” she says   If ever she feels uncertain, she repeats the following mantra to herself “These patients may have chosen whatever, but they are human and above all else, I am pro-human and that also means looking past my own discomforts,”she said.

By April 2019 Judy Ranape estimates she had facilitated around 10 000 abortions – both surgical and medical (dispensing of a pill).  “I never imagined that this is where I would be today,” she reflects.

“The idea of abortion is still very taboo in our communities, people won’t speak honestly about it, and even people in the health system share stigma themselves, I’ve heard of abortion providers not being spoken to at work or being actively avoided,” said Judy.

“When I started my career in TOP, I saw many of my colleagues fail to complete the training course. Many put on brave faces, but were paralysed with fear when it came time to perform the procedure. It’s a scary thing, some woman are screaming in pain, others are desperately fearful, it’s a bloody affair and it takes a lot to be brave and go through with the process of providing a surgical abortion ,” she says.

Judy herself has faced challenges in her own home due to the path she has chosen. Her husband is also a staunch Catholic.

“My family knows about the work that I do, but we don’t talk about it at home,” she says.

Despite sometimes facing judgement and criticism, Judy wakes up every morning to attend to patients who require abortions. “When these woman walk through the door, they usually need two things. An abortion and to talk. Every woman has a story,” says Judy.

Judy quietens for a moment, and tears well up in her eyes. She is thinking about Akeelah again.

“I can’t help but think, that if I had just made the effort to speak to her more, to listen to her, I could have been able to help her.”

After the experience with Akeelah, Judy has become intent on providing a holistic approach to her patients. “It’s important to me that I speak to these women, there is a reason every single one of them come, it’s not just for an abortion.”

Judy has worked with the community of Lady Michaelis to break the taboos around abortion, she speaks openly about it and encourages others to do the same. Initially Judy’s patients would shy away from acknowledging her or speaking to her in public, but now, everywhere she goes, people shout her name and always want to stop for a chat.

“It brings me such great joy, to see people from the community interacting so freely and genuinely with me,” she says.

While access to abortion remains controversial in much of the world, Judy refuses to get caught up in the politics. She is clear that her role is to provide support to her patients and give them the option to make a choice about their lives, after all- her only concern is providing help to those who need it”

“If I don’t do it, who will?,” she grins.

*Name changed to protect identity of the patient and her family.

  • Foot soldiers of the health system: It’s election time which means men and women in party regalia take to the streets, podiums, loudhailers and stadiums. Invariably they tell people about all the good and wonderful things they have done or plan to do in the health system. SECTION27’s Nomatter Ndebele and photojournalist Thom Pierce travelled the roads of South Africa in search of the foot soldiers of the health system, the men and women who quietly get on with doing the job and saving lives, often without any acknowledgement.

 

 

 

 

#FootSoldiers: Do the work that nobody wants to do

Dr Marlisa Van Rensburg is known to many in Klerksdorp as the “TB Expert” To date, she has seen over 5 050 patients. Here she is photographed with Sam, one of the children who are being treated at the Tshepong TB unit. Photo by Thom Pierce.

Dr Marlisa Van Rensburg keeps a meticulous register of every tuberculosis (TB) patient she has ever seen. To date, she has seen 5 050 patients at Tshepong Hospital in Klerksdorp in the North West province. She has the names of each and every patient. “It helps me track if patients are coming back,” she says nonchalantly, but from the way she speaks about her work, one can tell these are more than just numbers to her.

At the start of the nineties, very few doctors were willing to take up the fight against TB. Faced with the option of Oncology or TB, Van Rensburg opted for TB. “I believed that there was hope with TB, it’s curable, with cancer it’s not so easy,” said Van Rensburg. But more than just taking the “easier” path, Van Rensburg chose to follow the words of businessman Anton Rupert who she recalls saying the following soon after the end of apartheid: “Things are changing, and you must accept that change. You must find the work that nobody wants to do, and when you find that job, you must do it well.”

It was those words and the need to spread hope that Van Rensburg took to her work in treating TB patients. Later, she carried the same attitude towards drug resistant TB patients.

In 2000 the Department of health opened a TB unit at the Tshepong Hospital.  Since then Van Rensburg has worked alongside her colleague Dr Hannetjie Ferreira. The two doctors and a complement of dedicated nurses and admin staff started to cure patients who arrived at the unit on deaths door. In that first year the clinic saw 56 patients, and now in 2019, the unit sees at least 56 patients in a month. Later, Van Rensburg reveals that her register also contains data on their yearly death and cure rate at the facility. She says that in 2015, the Tshepong  XDR TB unit had the best cure rate in the country at 80%.

Although the TB Unit is attached to Tshepong hospital, it is not part of the main hospital building. At the TB unit patients and the unit staff interact as old friends, little children are playing together, and there are patients seated outside in a garden lapa that is surrounded by white roses. The nurses jokingly refer to the facility as “our holiday resort” .

As we walk through the unit, there are very few patients lying in the wards. Those that are in the wards, are there for a simple lie down, not because they feel ill. There are patients milling about the communal cooking space, walking about the corridors and chatting to each other cheerfully. But perhaps the most striking thing about the “resort” is that in both the MDR and XDR sections of the unit- there isn’t a single healthcare provider who walks around in a TB Mask.

Instead, the unit is kitted out with Ultraviolet germicidal light (UVC lights that kill the TB bacteria within a 3 metre radius. There are no curtains in the facility , as a practical measure to ensure that windows are always open. The patients are highly educated about infection control as well as the importance of taking their treatment. Although the patients are referred to as patients, they are not made to feel as though they are just another number. The hospital staff and the patients are a tight knit group who know each other by name and are always stopping during their rounds to enquire about how the patients are doing, not just medically, but also emotionally and socially.

Other than being a TB expert, Van Rensburg also doubles up as a social worker. Often times her patients come from impoverished backgrounds, facing many social ills. Van Rensburg then takes it upon herself to engage the department of social development to ensure that her patients have access to which ever kind of grant that will assist them the most.

“Many of our patients come from the surrounding areas, and we know how difficult things are there for them, so we try to do more than just assist them medically,” explains Van Rensburg.

One such patient who has required extra social support is a little 14-year-old boy called Sam*. Sam has been at the Tshepong TB unit for the past two years. One afternoon, Sam came home from school feeling unwell, with a constant cough. Eventually his father took him to Tshepong hospital to be seen to, but he never came back for him.

Sam has now been at the facility for the past two years, diagnosed with drug-resistant TB. During his initial admission Sam was diagnosed with TB. When he was discharged into the care of his mother, he stopped taking treatment. By the time he made his way back to the facility he had drug-resistant TB.

“Sam is a troubled boy, he comes from a very bad background, we tried to put him in a foster home, but he would always run away to go back to his mother. We’ve decided to keep him at the facility until the end of his course, but I do not know what we’re going to do with him after that,” says Van Rensburg.

Sam’s tiny frame balances delicately on a hospital bed in the ward, he is very small for his age, his forearms are covered in mosquito bites, and he keeps his forefinger to his lips, moving it only to answer questions very quietly. “My mom has never come to see me, not once. And I really miss her. The nurses look after me here, but I do get bored. All I ever do is lie around, watch TV, sometimes I want to play pool, but nobody really wants to play with me,” he says.

Surprisingly, his face lights up when he starts to speak about politics. He is quite assertive in his beliefs “If I could vote, I would vote for Cyril Ramaphosa, I hate Zuma. Actually, Zuma should have died, not Nelson Mandela,” he says.

Under the care of  Van Rensburg and the staff at the Tshepong TB unit, Sam is expected to make a full recovery.

“The greatest thing is that when these people come, they are at deaths door, but by the time they leave, they are dancing out of here,” said Van Rensburg

But with the 2018 North West strikes and other chronic problems in the public healthcare system the job is not always easy. Last year Van Rensburg did not receive a salary for a period of three months, due to complications with the renewal of her contract. Despite that, she showed up for work every single day. Her reason?

“Some sucker has got to do it”

*Name has been changed to protect the patients identity as he is a minor.

  • Foot soldiers of the health system: It’s election time which means men and women in party regalia take to the streets, podiums, loudhailers and stadiums. Invariably they tell people about all the good and wonderful things they have done or plan to do in the health system. SECTION27’s Nomatter Ndebele and photojournalist Thom Pierce travelled the roads of South Africa in search of the foot soldiers of the health system, the men and women who quietly get on with doing the job and saving lives, often without any acknowledgement.

 

 

#FootSoldiers: Umsebenzi wama CHWs – Bringing hope and life to the community of Sweetwaters

Foot soldiers of the health system: It’s election time which means men and women in party regalia take to the streets, podiums, loudhailers and stadiums. Invariably they tell people about all the good and wonderful things they have done or plan to do in the health system. SECTION27’s Nomatter Ndebele and photojournalist Thom Pierce travelled the roads of South Africa in search of the foot soldiers of the health system, the men and women who quietly get on with doing the job and saving lives, often without any acknowledgement.

A story of life and death, of love and compassion. Of caring. Gogo Tholana and Doris Ntuli. Photo by Thom PIerce

Umsebenzi wama CHW. (The work of CHW’s) – Bringing hope and life to the community of Sweetwaters

Three years ago Doris Ntuli and her fellow Community Healthcare Workers (CHWs) Nhlanhla Makhaya and Sindi Zondi took Spotlight from house to house on a tour of Sweetwaters  in KwaZulu-Natal where the trio worked for a paltry R1 800 per month,  caring for extremely ill people in their homes. They had no resources, which means they had no gloves, no soap, no bandages, and no support from those in power. At the time Spotlight published an iconic photograph of CHWs using old bread bags as gloves as they washed patients at home. Last week Spotlight returned to Sweetwaters and found the trio.

The last time we saw  78-year-old Gogo Tholana in July 2016, she was living alone in a bare rondavel in the hills of Sweetwaters. She had been ill for two years, suffering from a serious and possibly fatal kidney infection.  She was bed ridden, her skin was ashen, she was stick thin and was wearing nappies. When she spoke she was almost inaudible, and was barely able to sit up. Day in and day out, she lay on a thin mattress in her rondavel, a few meters away from a fire place. Her only source of heat in the rondavel. She would have to wait until Doris Ntuli or another CHW came to check on her, to ask them to light a fire for her.

This time, almost three years to the day we met Gogo Tholana, we are led a little bit further down the hill, her rondavel is still there, but there is a gold latch dangling on the door. A few hundred meters from the rondavel is a big four-roomed house, and in bedroom number two (all the doors are numbered) we hear a loud voice saying “ Ah, you’re here”. We wait while the CHWs enter the room 2, and now there are sounds of laughter and excitement emanating from it.

Doris Ntuli and her fellow Community Healthcare Workers (CHWs) Nhlanhla Makhaya and Sindi Zondi with Gogo Tholana in the blue gown. Photo by Thom Pierce.

The trio of CHWs file out of the room, with a sparkle in their eyes and finally a large ever present woman, dressed in a baby blue gown stands up straight in the doorway.

The person standing in the door way is a healthy weight, her skin is bright and she has a wide cheeky smile on her face. It is almost unbelievable, that this was the helpless woman lying in a bare rondavel, whose only access to healthcare was through three dedicated CHWs who never missed a single day in attending to her, feeding her, bathing her, clothing her, washing her sheets, washing her clothes and telling her silly jokes to keep her spirits up.

The woman who stands in front of us now, clearly cheated death.

Umsebenzi wa Labantwana ongivusileyo (It is the work of these kids that bought me back),” says Gogo while she points at the three CHWs. My skin was black, I couldn’t move, I tried my best to shuffle across the room to try and relieve myself, but I could not move to urinate, so I had no choice but to urinate on the mattress I was lying on,” she recalls.

From this single example it is clear how Doris Ntuli and her team of CHWs have impacted on lives in the community.  However, on the flipside, sadly very little has changed for the CHWs themselves. Other than a salary increase implemented earlier this year,  shiny name tags, and branded backpacks from the department of health, not much else has changed.

The backpacks cling limply to their backs, as the women make their rounds by foot, visiting the 60 households they look after. There is nothing in the bags  to assist them in doing their work. The CHW’s still don’t have the resources they need, they do not have a transport subsidy, not an airtime subsidy, there are no masks to prevent them from contracting communicable diseases, and often times, they still don’t have gloves to wear. This while they care for patients the public health system no longer cares for in any other way.

“A few months ago, we did a TB program, we walked up and down these hills collecting sputum, with no masks or gloves. We then had to walk a long way to the central point where we had to deliver these (sputum) bottles. So many of our colleagues have died, and many more continue to die from contracting TB and other diseases, as we have no means for infection control,” says Nhlanhla .

In meetings and workshops in roundtables, politicians and health department workers will speak of war rooms and the importance of CHWs, but ask these CHWs and they will tell you that when they report their challenges to the “war room” the only ones who respond is the Department of Agriculture. The departments of health and social development are mostly no shows. Many of the issues the CHWs encounter require the assistance of social workers in order to assist the community in attaining ID documents, grants and food parcels. As it was three years ago, Doris and the team still take food from their own homes to feed their patients.

“The patients will hold their medication in their hands and say, I have no food- How can I take this medication,” says Sindi.

From their salary of R3 500, they must look after their own families, as well as all their patients. “By the time we get paid, the money Is already gone,” said Sindi

“When we arrive at a household, if there are ten people living there, we attend to every single person. We check the elderly for chronic diseases, we ensure that babies in the household have been immunized, we check their growth, and after all the health aspects, we deal with the social issues- some are being abused, most are unemployed, others have no means of accessing a grant- and all of that is on us,” says Sindi .

As they walk along the streets, community members wave,  shouting greetings at them, “Hello Nurse, Hello social worker!”

“That’s what they call us, but our actual titles are just CHW’s,” says Nonhlanhla.  The community has so much faith in the trio, that sometimes the terms of endearment weigh heavily on them, particularly when they are unable to provide the assistance people need. Never  due to a lack of effort on their own part, but rather because the system they are made to work in, provides them with no support. The situation begs the question, why do they bother?

Each of the CHW’s are bound to their work by this inherent need to help. The idea of community and care is one they hold in high regard, “You cannot see trouble next door and just look away,” says Nhlanhla.

For Sindi though, it was the death of her cousin who died from AIDS that lead her to caring for the community. “My cousin was so ill, he bled from everywhere possible, his ears, nose, mouth, he bled from every opening in his body, he never told us what was wrong, he died from the disease, but it was also the way he was treated that killed him. He started to notice that he was being served with the same dish and spoon everyday- we didn’t know better then. But when he died, I vowed to myself that I was never going to let another person die like that, not under my watch”

And so she joined Doris and Nonhlanhla in taking care of the community of Sweetwaters. The trio is unstoppable, there isn’t a hill they won’t climb, not a story they won’t listen to and not a single house they will pass. Unknown to the high ranking officials of the Department of Health, these three woman live and breathe the principals of Batho Pele.

With what little they have, they ensure that the community comes first in every way. And while the country prepares to mark a change with an (x) these foot soldiers are committed to bringing change and hope that is far more tangible, than that of a ballot box.

North West doctors release open letter calling for end to closure of health services

Over 70 North West doctors have released an open letter expressing their concern over the impact the ongoing labour action is having on the delivery of health services. Although they support the grievances of the protestors, the doctors said that as “care givers, we have been silent for too long. We have taken an oath to “do no harm” and in our silence, we have contributed to harm. This cannot go on as we are concerned about methods used which include closure of health care facilities that affect the health of our society.”

Read the full letter here: Letter of Concern Health Crisis NWP (iii).

SA’s new AIDS plan falls short on community health workers

By Sasha Stevenson

South Africa’s new National Strategic Plan (NSP) on HIV, TB and STIs will be launched on March 24. It presents a unique opportunity to start correcting the rudderless management of community health workers (CHWS) in the South African public healthcare system in recent years. (For in-depth background on CHWs, see Spotlight’s recent special investigation.)

The draft of the new NSP states: “HIV, TB and STI prevention, treatment and care is labour intensive and requires diverse cadres of human resources from multiple sectors.” And, “Community health workers need to be formalized as a cadre, appropriately trained and supported, and fully integrated into the health system.”

These are promising statements on human resources for health in general, and community health workers in particular, being key enablers for NSP 2017-2022. The question, however, is how far the new NSP goes in advancing the discussion around and demand for the development and integration of community health workers as a vital cadre of health care worker for the implementation of the NSP and strengthening of the health care system. The answer, unfortunately, is not far enough.

Focus on prevention

The new NSP puts prevention at its centre. In doing so it supports the new ‘test and treat’ policy which is aimed at reducing HIV-related morbidity and mortality and significantly reducing TB incidence and TB mortality. It envisages a comprehensive multi-sectoral prevention programme focused on high incidence hot spots in the hope of changing individual risky sexual behaviour. It sets ambitious targets and lays out detailed indicators.

Disease prevention, health promotion, and linkage to care are at the core of CHW programmes the world over. Health behaviour and social welfare promotion, preventive health care service and commodity distribution, diagnosing and management of common illnesses, assistance during birth, and community organising are all traditional CHW functions.

Despite the broad statements made, and despite what would appear to be the natural alliance between the needs of the new NSP and the need of the health system more broadly for the employment and integration of CHWs, the NSP is low on detail and does not get into any hard numbers in relation to CHWs.

Important targets missing

The NSP 2017-2022 should set targets for the number of CHWs employed or WBPHCOTs developed. It should set targets on CHW capacitation for TB case detection and for preventing loss to follow up for HIV and TB patients. It does none of this.

Goal 2 of the NSP expressed the need for guidelines on the role of, and tools for the use of, CHWs in HIV testing and counselling, linkage to care, and initiation on ART. The implementation and expansion of “community and peer-led programming” is aimed for under Goal 3, without acknowledgement of the direct role of CHWs in such programming. Clinics will open for longer hours – undoubtedly positive – but it is not clear that CHWs will be appropriately supported in the ongoing provision of home based care.

At a time when CHW policy has stalled; when posts for other health care workers are being frozen; but when there is a renewed focus on HIV and TB and the need to treat 5.5 million people, the incorporation of a properly trained, managed and integrated CHW cadre into the HIV and TB programme is vital. Unfortunately, it looks as if the drafters of the latest NSP are missing this opportunity.

The work of a nurse

By Mary-Jane Matsolo

‛There is a huge difference between a clinic nurse and a government hospital nurse. Clinic nurses usually do referrals, unlike us, we have to deal with it all – drips, oxygen tanks, two to four injections required to treat a patient with meningitis. We do all of it, from documenting how many patients we’ve seen, to arranging medicines to give to the patients, and monitoring and taking their vitals before doctors do their rounds in hospitals. That’s if a patient doesn’t come in that needs serious medical attention, which is also the work of a nurse – to resuscitate the patient, which could take anything from two to three hours,’ explains Sister Elinor Mpulo (name changed) .

A public hospital nurse’s day starts in the early hours, at 7 am, and usually doesn’t end until the late

hours of the evening. A double shift is also required in a 40-hour-week. The functions mentioned above should be completed before the doctors do their rounds at 8 am; whatever hasn’t been completed before has to be done after the doctors have left. Many days, come 12h00, a nurse hasn’t even had a tea break.

‘The conditions we work under strip away a nurse’s calling’

The TAC visited the Far East Rand Hospital in Springs after pictures of substandard conditions were sent in by field workers in the area. The images showed patients sleeping on the floor, beds with patients sleeping in passages, patients sleeping in bathrooms with non-functioning flushing toilets, and visible unprotected electrical wiring coming out of the walls.

We went to the hospital with the intention of questioning the CEO. He was not on the premises, and so we visited the wards to see the conditions for ourselves. What we saw, confirmed the evidence in the pictures.

Hoping to get information from patients about their experiences at the hospital, we found that a majority of them were mental health patients and unable to give us any substantial input. We asked to see to the nurse in charge of the ward who, unlike many in her position who are reluctant to open up about conditions they work under for fear of losing their jobs, or to protect the department, was willing to speak to us.

Sister Mpulo, who began nursing when she was 18 and who will soon retire at the age of 55, has seen it all. She spoke to us from the heart, listing the challenges at the hospital and with the entire system. She explained that the main reason behind the overcrowding at the hospital, resulting in some patients having to sleep on the floor and patient beds being moved into the bathroom area, is due to renovations that have been ongoing since 2014. Many patients that come through casualty are told the wards are full and there is a shortage of beds. They are given an option of being given medication and to go home, or to sleep on mattresses on the floor. If they agree to stay, they are made to sign a consent form, to cover the hospital. Up to 62 patients are squeezed into a ward with the capacity to take 31-46 people. Sometimes, the hospital closes admissions to regulate bed capacity.

Patients, regardless of their illness, and including mental health and TB patients, share wards. Some

A nurse walks down a Gauteng hospital passage way with a child in this file photo.
A nurse walks down a Gauteng hospital passage way with a child in this file photo.

TB patients waiting for test results don’t know their status when admitted, putting other patients and nurses at risk of contracting TB. Even the hospital’s TB wards, Sister Mpulo says, are overcrowded, with little to no ventilation. The only way nurses can protect themselves from being infected with TB is to wear their TB masks, something they are reluctant to do because they usually come in one size, are uncomfortable and, when temperatures are hot, it’s very hard to breath while working with them on.

Furthermore, the wards don’t have enough oxygen points, and there are not enough drip stands. All these conditions make the nurses’ work very difficult, and the people that suffer the most are the patients, says a visibly exhausted Mpulo.

When new doctors are employed, they know nothing about the patients and it’s up to the nurses to bring doctors up to speed on the patients’ records and to ensure that everything runs smoothly so the doctor doesn’t make a mistake.

‛We become burned out and our concentration levels are low. At least, in the last two months, the department has employed some nurses and doctors, which is good. We can only do so much – many nurses take sick leave before they reach a state of burnout. A nurse at a clinic is required to see one to eight patients but at a hospital level we see anything from 12-20 patients a day. The conditions we work under strip away a nurse’s calling,’ she says.

 

Getting the system to work

By Ufrieda Ho

Staff shortages remain a massive challenge for the public health service.

The Gauteng Department of Health earlier this year released information in response to questions

Patients are left in hospital corridors for long periods.
Patients are left in hospital corridors for long periods.

from the Democratic Alliance. The Department reported that state hospitals need 1,151 Grade 1 medical officers, 110 medical registrars, 78 community service medical officers, 160 Grade 1 medical specialists, and 58 intern medical officers. There are 17 clinical unit and department head vacancies and a dire shortage of nurses. The report noted 1,184 vacancies for Grade 1 nursing assistants, 1,340 Grade 1 professional nurses, 141 speciality nurses and 88 primary health clinical nurses.

 

The pressure of getting doctors and nurses into the system is complicated by the lure of private

sector salaries and employment conditions. This year, the system has come under additional significant strain as student protests rock the higher education institutions. If interns and qualified doctors are prevented from entering the system it will severely compromise the service offered at the province’s academic teaching hospitals.

In October, however, the Gauteng Department of Health announced that it had seen a ‛net gain of 2,227 nurses by the end of August, and 1029 medical professionals’. Earlier in the year, the Department also announced that 25 Cuban doctors would start working in the province. The Cuban doctors will focus on maternal, infant and child care. Infant mortality and maternal deaths remain a priority even in the country’s economically dominant province. Meanwhile, currently, there are 400 South African medical students being trained in Cuba as part of government’s initiative to plug the gap of doctors in South African public health care.

In June, the MEC for Health, Qedani Mahlangu, said a new double-storey paediatric unit at Chris Hani Baragwanath hospital should be completed next year. The unit will cater for children under the age of 10 and the target is to treat 3,000 inpatients and 2,000 outpatients a month at this facility.

The Gauteng Department for Emergency Medical Services budget has increased to R1,2 billion for

No sign of improving, a sign flippantly tells patients that their long waiting times means “they’re not dying”
No sign of improving, a sign flippantly tells patients that their long waiting times means “they’re not dying”

the current financial year. This amount will go towards the procurement of an additional 150 ambulances, 25 primary response vehicles, 11 rescue vehicles and five mobile emergency communications and command vehicles.

The provincial government has shown some positive initiatives, though the long term test lies in ensuring that good projects and recruitment drives are sustainable, adaptive and have the commitment of properly trained staff, to make them effective.

According to Mahlangu’s 2016-17 budget speech, recent successes include the Stock Visibility System (SVS). This is a phone app-driven system that allows nurses and staff to scan medicine barcodes to track stock levels of ARVs, TB medicines and vaccines, to be entered into a stock levels database. By the middle of this year 110 clinic should have been connected to the SVS system, with a roll out to all primary health clinics to be completed by the last quarter of this year, the Department reported.

The Gauteng provincial government’s own scorecard of its districts, meanwhile, identifies Tshwane as the best performing district in the country this year, with Laudium and Calcot Dhlephu clinics rated as Gauteng’s top clinics.

Furthermore, the Department said some of their facilities improved their national core standards rating, with Steve Biko Academic Hospital scoring 96 percent, Kalafong Hospital 81 percent and Mamelodi Hospital 73 percent. Declines in performance were noted at Charlotte Maxeke and George Mukhari Hospitals.

Community health workers: A Spotlight in-depth feature

The role of community health workers in the South African public healthcare system has been

A community health care worker cleans an elderly woman during her visits around the community of Sweet Waters in KwaZulu-Natal. She resorts to using bread bags in the absence of gloves.
A community health care worker cleans an elderly woman during her visits around the community of Sweet Waters in KwaZulu-Natal. She resorts to using bread bags in the absence of gloves.

unclear and controversial. How many do we need? What exactly should their role be? Who should employ them? What should they be paid? Is there good evidence to inform policy? Sasha Stevenson of SECTION27 lead Spotlight’s in-depth investigation into these pressing questions.

The structure of our health system and the nature of our healthcare workforce are unsuited to the goals that we have set ourselves: universal health coverage; an ‘end to AIDS’; and the reduction in non-communicable diseases through preventative and health promotion services. These goals can’t be reached in a hospital-centric health system with unsupervised, NGO-employed and underpaid community health workers (CHWs) serving as the only community-based services in the absence of capacitated and reliable clinic and hospital outreach programmes.

For some time, the national and provincial departments of health have been discussing and partly implementing a CHW programme. There have been multiple policy documents and there has been some action from provincial departments but we remain a long way from establishing a standardised CHW programme, let alone one that is capable of meeting the objectives of the health system, the National Strategic Plan (NSP), and the population.

2: Why do we need CHWs?
3: History of CHWs in South Africa
4: What should CHWs do?
5: How many CHWs do we need?
6: How should CHWs be employed?
7: How much will the CHW programme cost?