medical and nursing services

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.