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.

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.

Editorial: Three months to get it right

By Anso Thom and Marcus Low

Delays at the South African National AIDS Council (SANAC) has meant that the new NSP (National Strategic Plan) will now only be ready in March 2017. While the delay itself is not of any great concern, the kind of plan that will be produced by an unsettled SANAC and a weakened, unrepresentative civil society is concerning and brings into question the very idea of SANAC and the NSP. Already we are hearing rumours of a back-track on various things contained in draft zero of the NSP – including a back-track on the recommendation to decriminalize sex work.

There is a risk that over the next three months an NSP will take shape that will lack many of the targets and deadlines it needs to make an impact. It is understandable that government doesn’t want what they see as an external plan to interfere with their internal plans. But civil society should not accept this. We need leaders who can stand up to government, when needed work with them, but ultimately demand we do better on key issues such as sex work, condoms in schools, active case-finding for TB and community healthcare workers. Unfortunately, from what we’re hearing, civil society is capitulating on these issues without much of a fight.

Even though many critical issues will be mentioned in the eventual NSP, mere mentions are not enough. We need plans, timelines and budgets. We need an NSP that is highly focused and concrete. The decriminalization of sex work, for example, has been on the agenda for years – but simply having it on the agenda is not enough. We need to have a roadmap from where we are now to an actual amendment in our laws. Without such a roadmap, we do not in fact have a plan.

Similarly, setting targets for providing more people with HIV treatment and helping people adhere to treatment is all good and well, but targets are not a plan. How do we improve treatment adherence? Do we need to employ more community healthcare workers to provide adherence support and to trace patients who default? We think we should. How do we provide differentiated care through adherence clubs, if we don’t pay people to run those adherence clubs? How do we ensure there are no drug stockouts which endanger trust in the health system. How do we build a Medicines Control Council that can cope with the workload or registering new drugs and investigation unlawful treatment and activities? These are the issues the NSP must map out in detail and force action on. It should make the case so clearly and convincingly that the Department of Health and treasury has no option but to fund it.

In the same way, we can say whatever nice things we wish about active case-finding for TB (possibly the most critical TB intervention we are not implementing), but if we don’t map out what that means in the real world then it will be just an another aspirational target. The NSP has to make it explicit that we can’t do active case-finding without people and that we need to train and pay people to start doing active case-finding. In two words Community Health Workers.

Another critical area on which the new NSP must move the dial is HIV and pregnancy prevention in schools. We need a programme that is explicit about the right to comprehensive sex education and the right to access condoms – the latter being a right in terms of the right to access healthcare services. But again there appears to be no clear plan on the table on how we get from here to there.

If the new NSP doesn’t deliver on these critical issues with detailed timelines and budgets then it will be hard for us to support it. As has become clear in recent issues of Spotlight (previously NSP Review), our HIV and TB response is at code red. Our public healthcare system is in crisis. We need a plan that deals with this emergency seriously and based on the best available evidence. Anything less is not good enough.

A difficult political environment

The development of the new NSP comes at a very difficult time in South Africa’s history. Amid the Public Protector’s State Capture Report, the various scandals relating to the Gupta family, spurious charges against Finance Minister Pravin Gordhan and widespread calls for President Jacob Zuma to stand down, Deputy President and SANAC chair Cyril Ramaphosa has had a lot on his plate. In this fraught political context the new NSP has hardly elicited the national conversation or leadership that is needed – that it is needed is clear from the fact that around seven million people in South Africa now live with HIV and tens of thousands still die of tuberculosis every year.

To some extent, our HIV and TB response is also falling victim to the wider crisis in our politics. It is thus very encouraging that Health Minister Dr Aaron Motsoaledi and deputy Minister Joe Phaahla took a public stand against corruption when late in October they publically declared their support for Minister Gordhan. The spurious charges against Minister Gordhan have since been withdrawn. We trust that these leaders will not lose their jobs or be victimised for having taken this correct and principled stance. We will watch closely.

While the fight against corruption and state capture in South Africa is urgent and critical, the development of the new NSP is also critical. We urge the Deputy President, the Minister of Health, the rest of the national cabinet and all provincial cabinets to engage with both these urgent issues. Just like corruption, HIV and TB impacts the lives of millions of people in this country.

While the big picture politics are deeply concerning, there are also some signs that all is not what it should be at SANAC. The position of SANAC CEO Dr Fareed Abdullah was recently advertised amid rumours of a campaign to replace him with a person more compliant to the whims of some in government. Whether there is any veracity to these rumours we do not know, but it has reached us from various sources.

What is clear though is that in the current political context we need SANAC to be stronger than ever. Abdullah has done well in steering SANAC over the last five years and much of what concerns us at SANAC is beyond his control. Removing him now will threaten operational continuity at SANAC – something we cannot afford.

Civil society leadership crisis

While operational continuity is critical at SANAC, we urgently need new energy and ideas on the political side. This political energy has to come from civil society leaders at SANAC. Many people we have spoken to have expressed their disappointment with the failure of the current civil society representatives to raise critical issues impacting on ordinary people living with HIV and/or TB over the last five years. There is a strong feeling that SANAC needs a civil society sector that is fully representative, that speaks with the voices of the marginalized, speaks with the voices of the poor and that the only way in which this can happen is if the current civil society is disbanded.

The new NSP provides an opportunity to make a clean start where we avoid the pit-falls of the past and ensure that people living with HIV and TB in South Africa feel they are properly represented. One way to avoid these pit-falls is to set some guidelines of what we expect from our civil society representatives.

To start with, we should insist that civil society leaders must represent constituencies and not just themselves (academics and other technical experts can of course contribute in their personal capacities to technical questions). Ideally, we want people who have been elected by affected people and who must account back to those people on what they have or have not done at SANAC.

Secondly, we should insist on transparency regarding the financial affairs of all civil society representatives. Where people represent NGOs, the finances of those NGOs should be open for public scrutiny – as is the case with all NGOs. If people do business with government, then that potential conflict of interest should be disclosed.

Looking back, there is much to be proud of, but what lies ahead is what matters now and what we do in the next three months will set the course of the next five years.

 

New Emergency, New urgency

By Nomatter Ndebele

Following a 10 000-strong activist march on the first day of the International AIDS conference in Durban, the Treatment Action Campaign and SECTION27 hosted a press conference to outline the strategy of the activist groups beyond the conference.

SECTION27 executive director Mark Heywood said: “The Minister of Health said yesterday that his department is already working on our demands for a comprehensive plan to provide all people living with HIV in South Africa with treatment. We welcome this. But this is an easy commitment to make. We will only believe it when we see that commitment translating into real change.”

He also called for a more focused campaign to “turn off the tap on new infections”. While great strides have been made in the country, there are still high levels of new infections each day, particularly amongst adolescents and young women. Heywood said it was important to ensure that young children in schools have access to condoms, as well as HIV tests, together with comprehensive sexual education literacy to empower young people to make better and more informed decisions, which will have a direct influence on lowering the rate of new infections.

Stonewalled

Although there is still a lot of work to be done to ensure treatment for all, the activist group continues to be stonewalled by a lack of funding. The budget for the TAC, dropped by 14 million rand this year alone. Putting the group under great pressure. “Cars run on petrol, and we are the petrol, but we need money,” said Heywood. The TAC, will be calling on funders and sponsors to continue to support NGOs in order for lives to be saved.

Alongside funding issues, the Treatment Action Campaign addressed the plight of Community Health Care Workers. They asked for them to be at the forefront of the struggle for treatment for all. Executive director of UNAIDS, Michel Sidibe made a call for one million health care workers and 200 000 in South Africa. “For 10 years we have been fighting to get this issue heard,” said Violet Kaseke Paralegal at SECTION27.

Although Community Health Care Workers serve as the backbone of the Public Health Care System, they are forced to do so with minimal resources. Many health care workers, work without the basics like gloves and masks which often leads to them dying after contracting communicable diseases from the patients they treat.

“For the Treatment Action Campaign and SECTION27, this conference cannot be business as usual,” said Heywood. “We are looking for more than just commitment and rhetoric. They are looking for change, not just at AIDS 2016, but beyond that too.”

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