There are plenty of spanners in vast machinery of public health
Over the past decade, "crisis" has been used to describe the provision of public health services in SA. But it would be unfair to describe the entire system as crisis-ridden. Certain sectors of the system are approaching a dysfunctional state while in others achievements have been made.
For some years now, a string of research reports have pointed to various crises in the health sector. In 2016 an Econex report warned that the number of doctors available was half the average in a middle-income country. The Office of Health Standards Compliance concluded in a 2016 study that most public hospitals were not functioning even close to adequate levels. The Future Health Index ranked SA last among 19 nations in a global survey that measured healthcare system efficiency.
Since 2011, due to the financial crisis that began in 2008, per capita expenditure on health has been static or negative, the 2017 South African Health Review published by the Health Systems Trust reads.
The sector has responded to lower budgets and rising costs by limiting or cutting personnel; securing savings on medicines tenders, administration and expenditure; reducing capital spending on buildings and medical equipment; and prioritising primary healthcare.
These cuts seem to have created the formula for producing the Life Esidimeni tragedy, in which about 144 psychiatric patients died at ill-equipped nongovernmental organisations, when there was little consideration for the human cost of trimming budgets.
The government wants to change the system, mainly through improving primary healthcare and the proposed National Health Insurance (NHI), which many stakeholders warn is unworkable. The NHI is meant to kick in from 2025 but may take 10 more years to launch.
The NHI will require policy makers, actuaries, insurance experts and others to create a workable system, but even that enormous effort will depend on administrative efficiency in the public health system.
The system is largely not working well. Some say public healthcare has deteriorated under Health Minister Aaron Motsoaledi. Cosatu is calling for him to be replaced.
Motsoaledi has an unenviable job. He has to transform and modernise an inadequate system and somehow get nurses to tackle their jobs with enthusiasm while they are easily tempted by more lucrative offers from elsewhere. The crisis in the nursing profession will be difficult to unravel.
Motsoaledi comes across as someone who is always complaining: about the inefficiencies in his sector; ineffective partners and employees; and inappropriate legislation.
Perhaps he protests too much or perhaps there is some logic to his complaint that it is impossible to get all the parts of the vast machine of public health — managed at three levels of government — working efficiently together.
The public health system requires many key players to function smoothly: doctors, nurses and other health workers; and managers and administrators of hospitals, clinics and other health systems at city, town, district, provincial and national level.
A central plank of national government policy is to improve primary healthcare, which suffered drastic reversals under apartheid. Primary healthcare is a move from a curative model to one that prevents disease. It is not an outcome that can be achieved by the health department alone — it also requires basics such as the provision of drinkable water, secure housing and safe living conditions.
The success of primary healthcare also depends on immunisation programmes and school feeding schemes that could contribute to reducing the high infant mortality rate and the low rates of life expectancy (51 years for black males), which have been stubborn problems since the apartheid era.
As many of these programmes are municipal and provincial functions, recent failures of local authorities have had drastic effects on the health of the nation.
SA spends 8.8% of its GDP on healthcare — one of the highest health budget ratios of middle-income countries — yet infant mortality rates have recently been rising. Many health facilities and provincial departments have been placed under national administration, including the North West health department in April.
SA does not have enough nurses, as many leave for the UK or Saudi Arabia to earn pounds or dollars and the government is unable to compete with those wages. The Department of Health does not have accurate figures of these sojourners.
There are not enough doctors either. SA’s eight medical schools produce about 1,300 doctors annually, not counting any number of pharmacists, microbiologists, radiologists, laboratory technicians and other health professionals.
There are not enough doctors either. SA’s eight medical schools produce about 1,300 doctors annually, not counting any number of pharmacists, microbiologists, radiologists, laboratory technicians and other health professionals
Only 30% of physicians work in the public sector, despite it serving more than 80% of the population, and public primary healthcare centres are overburdened. Doctors are leaving the public sector due to poor working conditions, poor salaries, high workloads and limited opportunities for advancement.
This becomes a vicious circle: every doctor who leaves the public service makes conditions more difficult for those who remain. This crisis extends to academia, with teaching doctors leaving academic hospitals, depleting the number of teachers who are able to pass on skills in anaesthesiology, haematology, orthopaedics and all other specialities.
Rural clinics do not have enough doctors, and the department is failing to place doctors in rural areas as part of its community service apprenticeship scheme.
SA also has its peculiarities. It has a high rate of motor vehicle accidents, with an astronomical toll in injuries and deaths; and violence and injury are the second leading causes of death. With high unemployment rates, these factors have increased the number of people suffering from mental health disorders.
The AIDS crisis began to emerge only when democracy arrived. The apartheid government turned a blind eye, probably because it seemed to affect only black people. It gained recognition only after the period of Thabo Mbeki’s denial.
An epidemic of huge consequences, HIV and AIDS will continue to tax the health sector for decades. As many as 4-million people are now taking antiretroviral medication, which they will have to do for the rest of their lives, and they will have to be monitored for the regimen to work with any success. SA has one of the highest rates of HIV infection, with one of the largest number of people suffering from AIDS.
Drug-resistant tuberculosis is rife, as is the older variety of TB, often linked to HIV. In 2014, TB was the leading cause of death in SA. Strangely, cardiovascular patients presenting at many clinics exceed the number with TB, while diabetes and other chronic illnesses are also showing up.
Movement of populations within the country pose problems for regional health systems. It causes large fluctuations in the number of people requiring treatment, complicating resource planning.
Among the successes of the system is the rollout of antiretrovirals and especially the prevention of mother-to-child transmission of HIV. Rates of infection have plummeted from about 25%-30% before 2001 to an estimated 1.4% in 2016.
SA has excellent healthcare facilities, but they are available to a very small segment of the population. It could be argued that democracy itself prompted the crisis in the health sector: a system built for 4-million people suddenly had to service the entire population.
The system that caters to the majority of the people — 50-million of them, with 5-million enjoying private care — is semifunctional, littered with intermittent breakdowns at hospitals, spates of baby deaths and cancer sufferers left untreated. This system nevertheless lurches on, the nurses doing their duty — some sullenly, some with compassion — the doctors taking naps when they can during 24-hour shifts.
It works as well as it can under the weight of SA’s history, politics and divisions. But it could do much better.