Over 80% of South Africans have no medical aid, and have no choice but to seek treatment at the government hospitals and clinics that many patients interviewed felt were uncaring institutions.
Many desperately sick and injured people are not getting the care that they need because of a massive countrywide shortage of skilled nurses, who are the backbone of our health system.
A shortage of doctors and specialists is also undermining the quality of healthcare, particularly in rural areas.
Ironically, a number of nursing colleges were closed down in the late 1990s as part of governments cost-cutting measures while government has made it very difficult for foreign doctors to work in this country.
Approximately one-third of health posts countrywide are vacant, but some institutions are running with less than half the staff they need.
Psychiatric hospitals have some of the highest vacancy rates in the country. This is delaying hundreds of court cases countrywide where suspects have been referred to these institutions for observation.
The public health service is essentially running on the commitment of nurses and doctors to serve their communities, despite pathetic pay packages, enormous workloads and horrible working conditions.
Hospitals in urban townships are bearing the brunt of increased patient loads, and are battling to cope with the demand. Two factors are mainly behind the massive increase in patients: the AIDS epidemic and rapid urbanisation, where a large number of people are now living in unhealthy conditions in informal settlements.
At every hospital visited, AIDS is having a huge impact. AIDS patients tend to be very sick and need longer and more specialised care than other patients.
Nurses admit that they feel overwhelmed by the sheer number of very sick and dying AIDS patients they have to care for. In addition, a number of healthworkers themselves are HIV positive, while others live in fear of getting HIV from work-related accidents.
Dr George Abraham, acting senior clinical manager of Natalspruit on Gautengs East Rand, says the hospital used to admit between 10 and 15 medical patients a day a few years back.
Now, that number has gone up to 40 to 50 patients per day. And most of these patients have HIV-related complications, says Abraham.
Matron A Chinniah from Durbans Addington Hospital, says: We have 135 medical beds and they are always full, three-quarters with HIV positive patients.
At many hospitals, doctors and nurses have to make decisions about which patients to try to save and which to abandon based on time and available resources, rather than medical criteria.
Chris Hani Baragwanath is the biggest hospital in Africa, yet it only has 18 intensive care beds to serve the entire population of Soweto of over two million.
Because of the pressure on beds, doctors admit that patients are sometimes discharged prematurely and thus face the danger of relapsing or their wounds becoming infected.
The referral system in which patients are referred from clinics to district, regional or tertiary hospitals according to how serious their health problems are has also broken down in many parts of the country, with even a well resourced province such as the Western Cape facing serious challenges.
This means that patients who need more specialised care often cannot get it either because they get stuck within a dysfunctional system or because there is no space for them at more specialised institutions.
A severely traumatised young man with 40% burns on his body spent 24 agonising hours at Khayelitsha Day Hospital before being transferred to GF Jooste Hospital in Cape Town. He then lay in a general ward for over a week, his chances of survival rapidly diminishing, because Tygerburgs specialised burns unit said it had no room for him.
Conversely, many hospital emergency rooms are flooded with patients with relatively minor ailments because they dont want to queue for hours at poorly managed local clinics where basic medicines are often out of stock.
A young doctor based at Kimberley Hospitals described how he often had to go and fetch medicine from the provincial depot before attending to patients at a local clinic because the district health officials failed to get these to be delivered.
Professor Martin Smith, head of the department of surgery, describes healthcare at Chris Hani Baragwanath as a bit of a hit and miss, ranging from top-class to life-threatening care depending primarily on a range of issues, particularly the availability of skilled healthworkers and beds.
This description can be applied to virtually all hospitals in the country. Often the hospitals that are able to deliver adequate health services are run by determined rebels who have found creative ways to by-pass red tape and inspire their staff.
One such rebel is Dr Victor Fredlund. Frustrated with his arthritic patients having to wait months for hip-replacements when he referred them to the regional hospital, Fredlund learnt how to perform the operation himself on patients under local anaesthetic at rural Mseleni Hospital in northern KwaZulu-Natal.
But every hospital, no matter how well run, is under stress. Each day, health workers face huge workloads and increased patient deaths. They also face daily exposure to deadly infectious diseases such as multi-drug resistant TB as infection control in many hospitals is poor.
At the 784-bed Natalspruit Hospital, there were seven deaths in one day in the medical wards alone.Nurses work 12-hour shifts and have to treat large numbers of patients in this time. Many patients in the trauma wards are drunk and abusive.
A shortage of support staff such as nursing assistants, cleaners and porters means that nurses often have to carry, wash and feed patients, which keeps them from nursing responsibilities.
Absenteeism among health workers is rife, even at well run institutions such Durbans Addington Hospital. This is mostly due to stress, but nurses moonlighting in private hospitals to supplement their meagre salaries is also a factor.
At hospitals where management is weak, such as Cecilia Makiwane Hospital in East London or Prince Mshiyeni in Durban, nurses also turn up late, leave early and often neglect patient care such as regular monitoring of vital signs.
Hospital managers ability to take disciplinary action is severely limited by the centralised nature of provincial health bureaucracies. In many provinces, the provinicial head of health is the only person able to dismiss staff.
In addition, hospital CEOs and superintendents are unable to decide on staff numbers, draw up their own budgets or play any role in the procurement of goods and services.
President Thabo Mbeki recognised that hospital management needed more power in his State of the Nation address to Parliament in February when he announced: To improve service delivery in put hospitals, by September this year we will ensure that hospital managers are delegated authority and held accountable for the functioning of hospitals.
Provincial health departments would retain control over policy issues regarding training, job grading and accountability, added Mbeki.
However, so far only the CEO of Chris Hani Baragwanath, Arthur Manning, has been delegated the authority to run his hospital by the Gauteng health department.
An investigation of eight hospitals in Gauteng, KwaZulu-Natal and the North West commissioned in 2005 by the Department of Public Service and Administration describes nursing as a function in crisis due to staff shortages.
The investigation, conducted by Karl von Holdt and Mike Murphy for the National Labour and Economic Development Institute (Naledi), describes public hospitals as highly stressed institutions due to staff shortages, unmanageable workloads and management failures.
The investigators report that there is a dysfunctional relationship between hospitals and provincial head offices, which have centralised control over strategic, operational and detailed processes but are unable to deliver on these.
Clinicians and nurses in all but one of the hospitals studied state that staff shortages and
management failures compromise patient care and have an impact on clinical outcomes.
In many cases the result is increased morbidity (illness) rates, higher costs of intervention and longer hospital stays. In others it affects mortality rates, says the report.
Outbreaks of the hospital-acquired infection, klebsiella, have already killed 110 babies at Mahatma Gandhi Hospital in Durban over the past three years, according to the organisation Voice that is spearheading a class action case against the department of health.
In response to the hospitals crisis, government has developed a revitalisation programme, and is in the process of upgrading 48 hospitals. Health Minister Manto Tshabalala-Msimang said recently that the programme aimed to show that, contrary to popular belief, public hospitals can offer quality healthcare.
However, she conceded that the success of the programme will not be judged on the number of hospitals we have constructed or refurbished, but on how well we maintain and manage our facilities.
These are the key findings of a three-month investigation of government hospitals by a team of reporters from Health-e News Service and the Mail & Guardian who visited 26 hospitals countrywide.
The Naledi report recommends a radical reorganisation of hospital services, based on full authority for hospital managers and the establishment of clear operational units within hospitals to ensure that sections such as surgery are managed as a whole, rather than nurses, doctors and support staff being managed separately.
It also calls for considerable investment in management capacity, the employment of less skilled staff to free skilled staff to do what they are trained to do and the reopening of nurses training colleges.
The Naledi proposals were accepted by Cabinets January lekgotla, but it remains to be seen whether government has the will to implement the measures with urgency. Source: Kerry Cullinan, Health-e, 25 August 2006