Mention the state of health care in South Africa and people are most likely to relay experiences at government hospitals. Despite the fact that there is much more to health than hospital care, this is the aspect that forms people’€™s opinions when they talk about the state of healthcare in South Africa.

Only too aware of this fact is Dr Laetitia Rispel, Chief of Operations in Gauteng, a province whose hospitals serve a large chunk of South Africa’€™s public health patients.

“Patient satisfaction and patients’€™ perceptions tie in with a whole lot of things. It ties in with how people feel they are being treated when they go to a facility. It also ties in with the ‘€˜hotel’€™ facilities ‘€“ how clean the place is, whether there is clean linen and whether people wear name tags,” says Rispel, who took over the portfolio shortly before the Commission of Inquiry into Hospital Care Practices released its report at the end of 1999.

“The difficulty is that four years ago we were at a very different stage than we are now. This is a huge and complex organisation. We have 43 000 employees and that in itself provides challenges.

“Many of the things we are trying to achieve are a process and it doesn’€™t just happen overnight. Our key challenge lies in the area of implementation – how do you actually build capacity and ensure there is an enabling environment to take forward some of the policies, because I think our policies are good,” says Rispel.

But what has Gauteng achieved since 1999, which started with an unprecedented press conference at which senior specialists painted a doom and gloom picture of the hospitals and ended in a report by the commission that was highly critical of many aspects of hospital care?

In Febuary last year, the Gauteng health department launched a service pledge in Soweto. It was called the “health rights revival” and, according to Rispel, focused both on the duties of health workers and the responsibilities of patients.

The department ran a series of workshops as they realised that the pledge and the Patients’€™ Charter, that had been launched by national department, wasn’€™t going to happen “unless we created an enabling environment for it to happen”.

In less than a year Gauteng managed to train 1 000 frontline managers and tried to encourage the establishment of help desks.

“Key to this was the recognition that information was empowering and that sometimes when you look at the complaints relayed to the commission, it highlights the sense of isolation that people feel when they come to our facilities,” Rispel says.

The department also launched service excellence awards in 1999 and chose help desks as the theme. An amount of money was made available to the hospitals and clinics to put the help desks together.

“The judges posed as patients and judged them according to set criteria. Some hospitals did very well, with Leratong walking off with the first prize, a sum of money.”

Another initiative that will produce more long-term results was the setting up of an accreditation committee by Health MEC Dr Gwen Ramokgopa.

A minimum set of criteria has been released with which all hospitals need to comply.

The team of external evaluators includes representatives from the professional doctor and nursing organisations, the Medi-Clinic group, Qualsa and others.

Rispel said the group was still debating as to which rating system they would use, but she said it could end up being similar to the hotel system.

“This is really an attempt to ‘€˜grade’€™ the hospital and provide them with feedback, advice and guidelines,” Rispel added.

On the subject of hospital boards, another fairly recent initiative, Rispel said they were “really amazing”.

“They often challenge us on how we do things. They are a tremendous asset and offer us unique insights,” she said.

One of the biggest gripes relayed by hospital staff on various occassions, was the poor state of equipment.

“We recognise that in many hospitals the equipment is old, not the most updated technology and often breaks down,” Rispel acknowledged.

As an interim measure, Gauteng used a contingency fund of R5-million which had to be split among 17 hospitals.

“It wasn’€™t a lot of money, but they were able to buy small pieces of equipment with the money they got (between R60 000 and R150 000). In some hospitals, a sonar machine makes a huge difference”

Rispel said they have tried to increase the equipment budget for this year as a priority, but pointed out that there was a huge need and backlog.

Rispel believes that the department has managed to stabilise the financial aspects of the hospitals with the first major achievement in March last year, when the department came within budget.

The hospitals also managed to raise R19-million over the target for revenue collection. Hospitals were given an incentive and in the end it paid off.

It was agreed in accordance with the treasury what the target would be. All money raised over and above the target was returned to the department with 80% of that money returned to the institutions.

Johannesburg Hospital managed to raise R25-million, R5-million over their R20-million target.

“There is a quite a bit you can do with R4-million (80% of R5-m),” Rispel said.

Last year, Rispel’€™s department also created a service improvement fund. This was linked to seven hospitals targeted as the beneficiaries.

The seven hospitals were mostly smaller institutions, which would take a load off the bigger hospitals if they improved their services.

Each hospital was given a sum of money that had to be linked to a target.

Natalspruit used the money to activate the psychiatric ward, Edenvale used it to convert to a 24 hour obstetrics and gynaecology facility and to beef up medicine, surgery and casualty. Leratong used it for extra staff which led to the opening of an extra internal medicine ward while Mamelodi used the money to employ extra staff.

“The money was given as an incentive, but it had to be linked to defined outputs,” Rispel said.

In terms of management, chief executive officers were appointed at Chris Hani Baragwanath and Johannesburg hospitals.

An amount of R25-million was also given to the department by Treasury at the beginning of the financial year.

Rispel said this money was utilised in four areas:

• To improve financial management;
• To build capacity;To increase efficiency;
• To generate additional revenue.

Zooming in on these four areas led to training of staff in financial management, the counting of assets, barcoding of equipment and the drawing up of a detailed asset register.

Consultants were also appointed to analyse four central and four large regional hospitals in terms of financial management, capacity building and efficiency, especially human resource management.

In terms of budgeting, Rispel said the department had achieved a much more participatory approach. “I don’€™t think we got it perfect last year, but there certainly is a lot more awareness in terms of budgets,” she said.

Rispel said HIV/AIDS was placing increasing pressure on internal medicine and paediatrics.

She said the next financial year would see an increased emphasis on step-down beds. “It clearly doesn’t make sense for someone to be in a tertiary institution when they should really be in a step-down facility,” Rispel said.

A major focus would be homebased care, but it would be done jointly with social services.

Rispel said Gauteng’€™s AIDS strategy was without fault and needed to be internalised by the institutions. The department was also working closely with clinicians to look at the guidelines around clinical care.

On the issue of nursing, Rispel said the turnover was very high, but that they were planning to increase the posts for student nurses.

“Unless we do this, we will run into problems four years down the line,” Rispel said.

She said the fact that institutions managed their own budgets, also put them in a position to address the nursing shortage.

In the area of theft, Rispel said they were looking at placing close circuit television in high risk areas such as pharmacies, kitchens and stores (linen).

Rispel also wanted to see the selection of more women to top posts as well as more representativeness in the selection criteria.

“At the end of the day we need to make sure our facilities are used appropriately. We need to look at whether it is appropriate for someone with a headache to sit in a queue at a tertiary institution as Bara when they could have been seen elsewhere.

“But I get a sense that morale seems to be better than the previous years. There is not that general sense of doom and gloom that prevailed in 1999 when you spoke to staff.”