hospital services

The report is intended for health managers in the Eastern Cape Province managers at Provincial level but especially for Regional managers as the information is set out in a format which defines and compares the resources and services of the five regions. The information was obtained from ReHMIS (Regional Health Management Information System) by the Eastern Cape ReHMIS team and some additional sources were also used. Data was collected from all public (provincial and local authority) health facilities using national definitions. Maps and tables of population distribution are provided. These assist in defining the problems of reorientation from the previous administration (of South Africa and two so-called independent states Transkei and Ciskei) to a unified, integrated, decentralised, equitable health service based on Primary Health Care, and the health priorities of the Reconstruction and Development Programme.

Public hospitals continue to account for over 60% of public health sector expenditure. The rationalisation of hospitals has been high in the Department of Healths priorities and this chapter reviews some of the changes that have occurred with respect to expenditure, hospital beds and general efficiency gains with the public sector hospitals. There have been reductions in the number of beds in use in most provinces, and in particular in the Western Cape and Gauteng. These reductions have not been accompanied by significant increases in bed occupancy rates. Expenditure on hospitals since 1992/93 has increased at a rate slower than that of the public health sector as a whole, but in the last three years increases in funding to tertiary hospitals have outstripped those for other hospitals. There continue to be large inter-provincial variations in spending, bed availability and staffing of hospital services.

This report is intended primarily for health managers in KwaZulu-Natal, and all those involved in the collection of ReHMIS data. The information was obtained from ReHMIS, a health management information system implemented by the KwaZulu-Natal ReHMIS team. Data was collected from all health facilities (public and private),and related to available resources, and the nature and extent of services rendered. As standardised national definitions were used, the information is comparable across regions and across provinces in South Africa. Background information about KwaZulu-Natal relates to boundaries, populations and administration. Maps and tables of population distribution are provided as reference material. The report is placed in the context of decentralisation, the move toward equity, reorientation to primary health care and the health priorities of the Reconstruction and Development Programme, as these are the prime tasks facing managers.

This is a report which makes use of the data stored in the ReHMIS data base. It should be of use to all who collect and make use of data about the health of people living in Mpumalanga Province, and about its health services. The report is written with the approach that health services should best be provided in relation to human needs. Therefore it attempts to demonstrate the extent of human health needs across the province and to relate the actual provision of services to these needs. In many cases a normative approach is apparent, and this is inevitable since otherwise it would not be possible to form an opinion about the equitable distribution of available resources in response to need.

This report is intended primarily for health managers in Northern Province, and all those involved in the collection of ReHMIS data. The information was obtained from ReHMIS, a health management information system implemented by the Northern Province ReHMIS team. Data was collected from all health facilities (public and private), and related to available resources, and the nature and extent of services rendered. As standardised national definitions were used, the information is comparable across regions and across provinces in South Africa.

When I first worked in South Africa, it was as a medical officer in a 280 bed (but 400 patients) rural hospital in northern KwaZulu. There were five other doctors, and I was asked to look after the male medical ward as well as several OPD/casualty and theatre sessions. When on call, there were obstetric, surgical and paediatric responsibilities to deal with as well. The case mix was varied, interesting and challenging. But it was also a responsibility that at times was a source of great stress. The reason for this was that in a rural area one quickly becomes aware of how important hospital services are to the local population. A bad hospital service can lead to a high perinatal and maternal death rate children dying on the wards from preventable diseases surgical patients dying from post-operative bleeding or sepsis a fractured limb being permanently disfigured because it wasnt properly reduced a young boy losing a leg from a snakebite because a fasciotomy wasnt performed or an infant crying in agony because inadequate analgesia was provided for his/her second degree burns. In many parts of the country, the lack of skilled staff and equipment, as well as the unavailability of a back-up service means that there is a low margin for error. As a result, because of the inadequate standard of care in some district hospitals, there are many patients dying from treatable conditions, and from omissions or mistakes in health care. On the other hand, a good District Hospital is a source of pride for both staff and with community. In addition, my experience in Kwazulu also made me realise that a really effective District Hospital was one that did much more than provide medical and nursing services within its four walls. Amongst other things, the hospital that I worked in was central to the success of a district-wide TB programme using community-based supervised treatment points, and an obstetric service that provided support, training and referral guidelines to clinic nurses and midwives. The hospital also provided clinics with drugs, equipment and administrative support. This was how many District Hospitals, especially in the former homeland areas operated, and which explains the use of the term mother hospitals. Hospitals were actually seen as playing a maternal and nurturing role to clinics and mobile services. Ideally, the District Hospital, clinics and community-based health activities (such as CHW programmes) would be considered as different parts of a single and integrated system of Primary Health Care. In contrast, having separate management structures for your hospital and for clinics would be like a human body having one brain that controlled your legs and another brain that controlled your arms - it could work, but it would never be as good as one brain coordinating all limbs. However, in our move to establish the DHS in South Africa, there has been a tendency to draw a line between the District Hospital and Primary Health Care (PHC). This may be due to confusion between the terms Primary Health Care and primary level care. The former is an approach or philosopy whereas the latter refers to health care provided in clinics and health centres. Because of the confusion, PHC often has been mistakenly equated with clinic care, and there has been a misconception that the District Office is only for primary level care. While it is often argued that you need to separate the hospital from the primary level facilities so that the hospital will not end up consuming most of the districts resources at the expense of clinics and community-based health care, there are many other ways of ensuring that hospitals do not function to the detriment of clinics and comunity-based services without creating an artificial and inefficient line of separation between District Hospital services and the other PHC services. The tendency to separate hospitals from primary level care may also be due to the fact that as a whole, hospitals consume too much money. However, the major culprits for this are the academic, tertiary and secondary hospitals, and not District Hospitals. It would be much better to draw a line between Level 1 hospital services and other higher levels of hospital care, than to draw a line between Level 1 hospitals and primary level care. Finally, a message to any junior doctors or senior medical students who may be reading this. This country really needs fewer specialists and a greater number of generalist hospital-based doctors who can perform a range of different functions. At the moment, I cant think of many more satisfying jobs than to work as a District Hospital medical officer providing clinical services, training and support for other health workers and giving medical input into PHC planning and district development.