AIDS burden worsens ailing service

by Claire Bisseker

Review warns poor skills and conditions undermine system

At The Mntwana clinic in former Transkei there is no electricity, though it was promised three years ago. A satellite phone was installed in February but it worked for only a few days. There is no other form of communication. The clinic has run out vaccines, but a sister comes down the road carrying a cooler box filled with new stock on her head. At her own initiative, she has caught a taxi and fetched the stock from nearby Mount Frere Hospital. So the clinic limps on.

The health system is crying out for better management and governance. This is the gap that has to be plugged if better care is to be delivered.

There are pockets of excellence within the public health system and many facilities function well, but government is battling to make a difference in rural, disadvantaged areas, says Antoinette Ntuli, an editor of the annual SA Health Review. Published last week, the 2002 review warns that inadequate management and skills, work overload, poor working conditions and emotional burnout all add up to undermine the quality of care in the public sector. It is also fuelling the brain drain.

The same shortcomings are identified each year, but are particularly worrying when the challenges keep mounting.

The review finds that HIV/AIDS is having a devastating effect on the public health sector. Disease burdens are rising sharply and disproportionately in areas with few services, while health workers are feeling the effects of the epidemic in their own ranks. Moreover, staff are leaving in large numbers to work in the private sector or abroad.

Health workers are carrying the mounting disease burden but must often implement new initiatives and policies without additional staff or training.

A study conducted recently by the Centre for Health Policy found that the tuberculosis patient load (a good indicator of the changing clinical load related to HIV) had increased by almost 30% in the six months to January 2001.

The review says the system lacks the clinical and management skills to deal with a host of healthcare issues, not just HIV/AIDS. For instance, another study into severe malnutrition found that high fatality rates among children in rural hospitals could be attributed to a lack of resources as well as poor management and the use of outdated, inappropriate treatment.

The review also found that the shortage of doctors, particularly in rural areas, was reaching crisis proportions. Many posts cannot be filled because of a lack of applications. This sets up a vicious cycle that is accelerated by the impact of HIV/AIDS, since remaining staff become overburdened, burn out and eventually leave.

The review also suggests that community service, introduced in 1998 to provide staff for underserved areas, may be defeating its own ends. Three years after its introduction, the hospitals that are most difficult to staff remain without doctors, the turnover of junior doctors burdens senior staff, and the coercive nature of the scheme engenders negative attitudes in many junior doctors.

The review discerns two alarming trends: the number of junior doctors who have just completed community service and intend to work overseas rose from 34% in 1999 to 43% in 2001, and the number planning to remain in the public service fell from 42% to 38%.

However, 70% of those planning to work overseas said they intended to return to SA, only 5% said they would not return and 25% were undecided. The latter group amounts to 300 young doctors a year who could be persuaded to return to SA. Most significant is the finding that 20% of community service graduates (200 doctors annually) would consider working in underserved areas in the future.

Given the right incentives, this voluntary cohort could achieve the primary purpose of the whole programme of community service at a much lesser cost than coercing all medical graduates into grudgingly filling posts, most of which are in large urban hospitals, concludes Steve Reid of Natal University's Centre for Rural Health, who wrote the chapter on community service.

The finding is particularly relevant given that community service is being extended this year to seven other groups, including physiotherapists and occupational and speech therapists.

On a more positive note, the review finds there has been considerable progress in controlling TB and malaria, some improvement in the population's nutritional status and a great improvement in health information systems.

But without better human resource management, it will be hard to raise the quality of the service.

Say the authors: Health workers need to be better cared for, listened to and looked after. While this has been acknowledged on paper, it is now time these pronouncements are translated into concerted action. (Source: The Financial Mail, 4 April 2003)