Mama G doesn’t like to complain, she says. But enough is enough. It’s lunchtime in Mdantsane and she and about 30 others are waiting outside the small clinic at NU13 as storm clouds gather.

“The nurses sometimes have an hour for tea. They can close again at 12 and only open at 3pm while we must sit outside like dogs, rain or shine,” the bespectacled pensioner says clutching her walking stick in one hand and a plastic-covered exercise book in the other.

Other patients gather, clamouring to tell their stories but reluctant to be identified. Lungile says that patients must buy their own exercise books. These function as patient clinic cards and need to be kept carefully as they record blood pressure, medication given and the date of the next visit.

Those without books pay 50c for a tiny scrap of paper notifying them of their next clinic appointment, he says. Those who need to be taken to hospital a few kilometres away pay R5.

“It is worse, worse, worse now than a few years before,” says Lindiwe, her face screwing up with disgust. She says she no longer bothers with the clinic for herself as it “only has Panado”, but brings her children.

While patients are telling their stories, the clinic re-opens and Mama G gets her turn. After less than five minutes she returns holding out the package of paracetamol tablets. “For arthritis!” she says, clicking her tongue in disgust.

Not far from the clinic is Cecilia Makiwane, the biggest hospital in the province with almost 800 beds.

Superintendent Dr Zamani Ndindwa, dressed in a University of Natal blazer and tie, ponderously reads out recent achievements from extensive hand-written notes in reply to our pre-faxed questions. But most relate to infrastructure.

“TB is the most common disease in the medical wards and every day there are two or three deaths from HIV-related infections,” says Dr Ndindwa.

While all health workers mention the impact of HIV/AIDS, none know much about the anti-retroviral programme or even if the drugs will be supplied there.

Matron K Tsipa and Sister Noluntu Somana, who escorted me on a tour of the hospital, say that while there have been definite improvements, especially in psychiatric care, there is a “shortage of staff like never before”.

“Last year we lost about 80 or 90 nurses. As fast as you employ them, so faster they leave. There is also a shortage of porters and cleaners so you have nurses doing jobs that they should not be doing, like taking patients for various tests,” says Matron Tsipa.

According to Treasury figures for February 2003, the province has the greatest shortages of nurses and doctors. There is one doctor per 8 825 people (national average is 3 928) and one professional nurse per 1 278 people (average 916).

Sister Somana adds that the patient load has increased greatly since 1994.

“This is partly because of primary health care not taking off. The whole of the Eastern Cape is referring patients here. We often see people who should have been attended to by the clinic nurse but because of the problems there, they end up coming here,” she says.

Senior nurses gathered in a small office off one of the medical wards poured out their frustrations. They all asked not to be named.

The key concern is overwork. Four nurses in outpatients department (OPD) deal with 100 to 150 patients a day. Doctors only get to OPD after 11am as they first have to attend to patients in the four medical wards. But patients prefer to wait than go to clinics where there are “no doctors or medicines”, added one.

There are only six nurses to run the 40-bed male medical ward day and night, yet 14 are needed.

“Almost every day, somebody will be absent. We are tired and burnt out. You work hard all night and then you don’t want to think about it starting all over again,” said one.

A doctor, who also asked for anonymity echoed the view that the root of the problem lay at primary level.

“The authorities are denying that there is a problem with primary care. But if you go to clinics, especially in the former Transkei, you will see that there is a major problem with drug supply,” he said.

The Eastern Cape spends R91 per capita on primary health, the second lowest in the country after Limpopo and way below the national average of R158.

Fourteen doctors are needed to run the four medical wards at this hospital but there are only four.

“People are so overworked that they can’t cope with day-to-day responsibilities let alone an anti-retroviral programme. We have seen nothing in writing about the programme and most doctors haven’t even seen the protocols for managing opportunistic infections,” says the doctor.

While Cecilia Makiwane staff are demoralised about 250km west in the former Transkei capital of Umtata, health workers have had an injection of enthusiasm caused by the opening of the magnificent Nelson Mandela Hospital, a shining tertiary institution that cost around R500-million to build and equip.

Nurses at the dilapidated Umtata General Hospital describe their new neighbour as “heaven” and all are clamouring to transfer there.

However Rod Allen, the CEO of the Umtata Complex which oversees four hospitals in the town, says the staffing of the new hospital is being carefully managed to ensure that services at the other three hospitals don’t collapse. In the past, hospitals worked in isolation and there was little information sharing let alone sharing of staff or resources.

“Nelson Mandela is a referral hospital so we need highly skilled staff, but it is difficult to attract such people to Umtata. There are 600 beds at present but there will be 1 100 once the hospital is fully commissioned,” says Allen.

To make the Umtata complex, including the new hospital, fully functional, around 600 nurses and 100 doctors are needed. But even for those prepared to come to Umtata, there is a shortage of suitable housing and schools which undermines recruitment.

Some have suggested that the hospital should rather have been built in East London or Port Elizabeth, but acting head of provincial health Mike Fraser says Umtata is the correct location as 60% of the population lives in the former Transkei.

In addition, the hospital will be a training ground for students from the University of Transkei’s medical school, which the education ministry initially planned to close but has now agreed that it should continue to function.

Allen, who has been CEO for two years, is a hands-on man who pays attention to detail. Describing conditions at Umtata Hospital as “pathetic” and “unacceptable”, he says a lack of staff and resources are the main problems.

He has come up with a number of creative ideas to address staff shortages. Retired nurses have been given six month contracts to help out, while staff have been allowed to “moonlight” in their own hospital since last April. While “moonlighters” have yet to be paid, he says that they will be.

Umtata General’s superintendent, Dr Lungi Linda-Mafanya, says over-stretched staff deal with referrals from around 20 district hospitals, often for simple procedures as these hospitals lack the staff to do basic surgical procedures.

Dr Dan Eghan, Umtata’s principal anaesthetist with 15 years’ service at the hospital, says that none of the district hospitals in the former Transkei are even performing Caesareans as they lack anaesthetists. “There has been a threefold increase in my work over the past three or four years,” says Eghan.

Umtata General’s maternity ward deals with 400 to 500 deliveries every month, and new mothers often have to share beds.

Every day around 350 people crowd into the small, hot, dirty outpatients department. On the day of Health-e’s visit, three doctors were attending to patients who waited in a long queue. The tiny treatment room was jammed with six stretcher beds and around 20 people. The sister in charge, a tired-looking Nonzwakazi Motsilili, says that the workload is heavier than before because of HIV and staff shortages.

However, Motsilili, who has been working in the hospital for the past 15 years, says conditions are slowly improving, pointing out the ceiling fans and new patients’ toilets in OPD as evidence.

Allen adds that Umtata General is being downgraded from a regional to a district hospital and a number of its departments are in the process of being transferred to Nelson Mandela. This will ease the pressure and congestion, he says.

In addition, while Nelson Mandela is supposed to be strictly for referrals, management has decided that all accidents and emergencies will be seen at the new hospital as Umtata’s casualty department is cramped and under-resourced.

As Allen leads the way though the hospital, he points out where he would like more wards to be built and how he eventually plans to turn an old section into office space. However, the only building taking place at present is of a new 58-bed psychiatric wing as there is simply no money for other improvements.

On the 5th floor of the tallest building in Bisho, the provincial capital just outside East London, the province’s health officials don’t try to pretend that all is well.

It will take more than a decade to address the mess, and it is the province’s smallest citizens who are suffering most.

Mike Fraser, the acting provincial head of health, says that the infant mortality rate in parts of the Eastern Cape is among the highest in Africa and a “cause for great alarm”.

More babies die in the province than anywhere else in the country, with 61.2 out of every 100 000 babies under the age of a year and 80.5 of those under the age of five dying. This is way higher than national averages of 45.4 and 59.4 respectively.

The paediatric wards of district hospitals are full of malnourished children, who slowly recover in the shelter of the institutions but on discharge go back to homes where food is in short supply.

Fraser also says that the high infant mortality rate is also due in part to difficult terrain, particularly for mothers carrying small sick children. Mountains, rivers, ravines and a chronic lack of transport means that many people still battle to access healthcare, despite the fact that 131 clinics and 16 health centres have been built since 1994.

“There has been a massive haemorrhaging of staff and the least resourced areas have suffered the most. There has only been funding in the last two years to employ new staff. This has also affected health services,” adds Fraser

In addition, new appointments were put on hold while a human resource audit of existing staff was conducted – in a process referred to as “Resolution Seven”.

Dr Litha Matiwane, head of hospital services management, says the province is grappling with a number of options, including using retired nurses and “moonlighting”, to make the most of health staff still left in the province.

In addition, says Matiwane, the province was in the process of getting the private sector to manage the distribution of medicines, which should improve drug supplies to the clinics.

Dr Thobekile Mjekevu, head of the district health system, adds that there were no longer any hospitals without doctors as there were two years ago. But a few district hospitals only have one doctor, while many rural hospitals are dependent on Cubans and community service doctors.

One of the most striking system improvements is that hospitals are now grouped into clusters, so instead of Bisho dealing with 47 district hospitals that are run by the department, it is now dealing with 18 clusters.

Grouping hospitals not only improves management but, by pooling resources, means that there is more money to employ management. Staff shortages are also being addressed by rotating staff in the cluster. So, for example, surgical staff in East London rotate between Frere and Cecilia Makiwane hospitals.

A number of management functions, including staff disciplinary hearings, have also been decentralised to the clusters. A key complaint from hospital management in the past was that they could not act against corrupt or disruptive staff as this was Bisho’s responsibility and there was a massive backlog in cases.

While progress at primary level has been slow, the seven-year EQUITY project, a joint initiative of the health department and the US-based Management Sciences for Health, has made inroads.

The most dramatic impact has been the improvement in immunisation services. When EQUITY was launched in 1997, only half of clinics could immunise children. Last year, when the project closed, 92% could do so.

EQUITY also trained over 5 000 health workers in both clinical and management skills.

National government’s Interim Management Team (IMT), sent to the province to help restore service delivery and assist four target departments including health, has also played a role in stabilising health systems.

Key findings of the IMT include that trade unions have “undue influence over managers” and that there was a culture of ill-discipline and a poor work ethic.

However, the National Education, Health and Allied Workers Union (Nehawu) has declared that it wants to “push the IMT out of the province” as it seems to have taken over from provincial government and has undermined collective agreements.

Health is the only department that has been able to meet targets set with the IMT and from March no national health staff will be deployed in the Eastern Cape. Provincial health officials say it has been useful in unlocking resources and in addressing corruption.

Fraser believes that the province has already hit rock-bottom and is now on its way up. Many hospitals that had deteriorated badly have been refreshed, management systems have been improved and resources are slowly starting to flow from the better resourced west to the former black homelands in the east.

But unless basic health services at clinics and district hospitals are improved, pressure will continue to build up on the larger hospitals. Staff will leave and the downward spiral will begin again.

The Health ministry’s rural allowances announced recently may help to stabilise staff exoduses from some areas, but do not apply to doctors and nurses in the province’s small towns.

As one professional nurse with 12 years’ service at Cecilia Makiwane said: “I don’t want to go overseas because I trained to help my people. But if the conditions don’t improve, I will have to think about it.” .

*  The Eastern Cape health department encourages people  to call 08000 32364 tollfree if they have a problem with health services in the province.

Eastern Cape Vital stats

Population: 6,300,000 (15,5% of total SA), 63.4% live in rural areas.

Area (km ²): 169 580 (13,9% of country’€™s land)

Lowest in the country:

·               people living in formal housing (46.9%)

·               access to electricity (31.3%)

·               households with tap water inside the dwelling (24.4%).

Worst:

·               Infant mortality rate (61 per 100 000 vs. national average of 45.4)

·               under 5 year mortality rate (81 per 100 000)

·               Doctor: patient ratio (one doctor per 8 825 people)

·               Dentist: patient ration (1 per 190 117)

·               Occupational therapist: patient ratio (1 per 554 507)

Unemployment: 48.5%

Maternal mortality: 1.33/ 100 000 deliveries in 1999 (but the DoH believes under-reporting)

Teen pregnancies: 14.8% (1998)

HIV prevalence in pregnant women: 23.6% (2002)

TB cases: 201 per 100 000 (1998)

Stunted children: 6months ‘€“ 5 ½ years: 28.8% (1994)

Health facilities

653 primary health clinics, 124 mobiles, 64 district hospitals, 12 regional hospitals and 18 specialised hospitals.

Patients

A total of 14,375,842 patients visited PHC and mobile clinics in 1999, In addition, some 1.5 million visits to hospital outpatient departments are annually. Over 14 million PHC visits in 2000.

Staff Only 65% of doctors’ posts and 50% of program managers’ posts are filled.

Patient load has increased from 19 per nurse per day in 1997 to 24 in 1999.

During the past three years, over 5 100 personnel been trained in PHC clinical and management skills by the EQUITY Project.

References: SAHR 2000, EQUITY project, Census 1996, Antenatal Survey 2002, 2003 Intergovernmental Fiscal review

E-mail Kerry Cullinan