Dr Nelis Grobbelaar leans over and pats the 37-year-old fruit packer on his leg.
‘Don’t worry, we won’t be able to take the HIV away, but we are able to control it,’ he says reassuringly.
Grobbelaar is no average small town doctor. In his checked shirt, jeans and running shoes he could pass for a local Paarl wine or fruit farmer. The slight man opposite him relaxes visibly while Grobbelaar speaks. Married with two children and a pregnant wife, the man has been treated for tuberculosis and anaemia. Now he is finding it difficult to maintain adequate energy levels needed to work at a nearby warehouse.
Son of a fruit farmer, Grobbelaar grew up in the area and graduated at the University of Stellenbosch 10 years ago. He now works as a state doctor running an HIV/AIDS clinic that offers anti-retrovirals.
‘It has been incredibly empowering for me to be able to offer anti-retrovirals to patients. Previously I would really only counsel my patients towards their funerals,’ he says.
While other provinces have been slow to provide anti-retrovirals in the state sector, the Western Cape has ‘aggressively pursued HIV and AIDS’, according to health Director General, Professor Craig Househam.
Pregnant women in Khayelitsha were able to access AZT during birth in 1999. Two years later, highly active anti-retroviral therapy (HAART) was introduced.
Currently 2000 people access ARVs at 16 public sector sites. The Paarl clinic is run by the state in collaboration with the UK charity, ARK (Absolute Return for Kids), that has set up similar clinics in Langa, Hout Bay, Worcester and Somerset West. The charity pays for the treatment of up to 1 500 mothers. Province will take over funding after three years. With it’s current HIV rate topping 12%, the province plans to treat 35 000 patients by 2010.
One of the best-resourced provinces in the country, the Western Cape makes up almost 10% of the total South African population and is home to 4,5-million people. The majority live in urban areas (89%) compared to the national average of 54%.
Overall, the health system functions well with the average person accessing health services at least four times a year. This compares favourably to the national norm of three. The province spends a healthy R1377 per capita on health, second only to Gauteng which spends R1668.
But Craig Househam and his team are under pressure to maintain this level of expenditure with the reconfiguration of treasury’s conditional grants to provinces, which began in 2001. The aim is to ensure a more equitable distribution of resources among provinces, especially those that do not have tertiary hospitals and that have historically not received grants. The conditional grant funding to the Western Cape has decreased from 23,9 percent to 18,5. Migration of people from neighbouring provinces seeking health services has also stretched the budget.
The infant mortality rate in the Western Cape is 26,9 per 1 000 live births, significantly lower than the national average of 45,4.
The most common causes of death in the province are trauma injuries, heart disease, stroke, diabetes and tuberculosis. Programmes to address these and other areas including mental and reproductive health exist.
Less than 20% of Western Cape residents live in poverty, significantly lower than provinces such as neighbouring Eastern Cape where 63% of people are poverty stricken. But there are many areas in the Western Cape, Khayelitsha for example, were levels of poverty are greater than the Eastern Cape.
The Cape Town Equity Guage, a collaboration between the University of the Western Cape, the city and provincial health department and several organizations, has conducted extensive research aimed at developing a practical strategy for the equitable allocation of resources between the city’s 11 health districts.
In Khayelithsa and Nyanga, graphs measuring indicators such as mortality, tuberculosis, HIV/AIDS death rates, homicide, maternal mortality rate and infant mortality rate are alarming.
‘When you look at the graphs you realise that for many people the sad reality is that they may survive X and end up dying of Y,’ says Gavin Raegon, a University of the Western Cape epidemiologist.
Househam, a paediatric specialist who was Director-General for Health in the Free State before venturing south in 2000, believes there is a different dynamic in the Western Cape.
‘The health system is very well established, there is a strong tradition, you have well established universities with medical schools, but there are also a lot of entrenched views that makes management challenging,’ he says.
Shortly after talking up his position Househam launched the Vision 2010 plan, a blueprint for future healthcare in the province. Essentially the plan will ensure the devolution of services from tertiary to primary health care with secondary level hospitals sandwiched between. Its success hinges on an efficient referral system and well-staffed institutions.
Convincing doctors at tertiary hospitals to move to secondary level, where specialist services are part of the basket of services, could prove to be one of Househam’s biggest challenges.
Statistics suggest that the province is ‘super specialized’ with one specialist per 2 746 patients. In the Free State there is one specialist per 11 342 patients while in Mpumalanga one per 143 698. Medical superintendent at Groote Schuur Hospital, Dr Saadiq Kariem, supports most of the principles of Vision 2010, but says it is going to be difficult to convince doctors to move.
At Groote Schuur patients wait four years for a hip replacement and there are also long waiting lists for other complicated surgical procedures.
Although Househam does not believe there are too many specialists or that they are major cost drivers, he agrees that the current mix of specialists and medical practitioners is not ideal with specialists concentrated in the province’s two large, central hospitals. Doctors will be lured to secondary hospitals if they are provided with incentives, he says.
Dr Breslau Kruger is Chief Executive Officer at Paarl Hospital, a large secondary hospital serving the Winelands West Coast area, which stretches from Stellenbosch to Vredendal.
‘I do get lots of calls from doctors wanting to work here, from inside and outside the country,’ says Kruger who worked as a private practitioner in Paarl for 25 years before joining the hospital.
In the past white patients were treated at Paarl Hospital while everyone else used the TC Newman Hospital on the other side of the Berg River, he says.
‘I was not allowed to see my patients in Paarl Hospital as I was not allowed to instruct a white nurse,’ Kruger recalls.
He believes the success of Paarl Hospital is due to the quality of service.
The Vision 2010 formula is that 90 percent of patients will be seen at primary health care level, eight percent at secondary level, where they will have access to specialists and two percent at tertiary level where they will have access to super specialists such as cardio thoracic surgeons.
Seven hospitals in the Cape Peninsula plus a new hospital to be built in the Khayelitsha/Mitchell’s Plain area will become district hospitals with specialist outreach. Some of these hospitals will either be re-sited and/or upgraded. The regional hospital for the Cape Town Metro region will be situated at Tygerberg Hospital.
Currently the province employs about 24 000 people with no increase planned. In an effort to boost the nursing complement, the province offers bursaries totaling R11-million to students in the hope of attracting more professionals.
Nurses are not required to repay the bursaries but must work for a set number of years in return. The province has also invested in the upgrading of lifesaving and critical equipment and has spent R200-million over four years.
Househam admits that there may be long waiting times, but that they are ‘working on it’.
‘I speak to people in queues and they are happy to wait as long as they know that they will receive quality service. It is unacceptable if people wait for hours only to be told that there are no drugs,’ adds Househam.
Western Cape Statistics
- Total population: 4,5-million, 11% live in rural areas
- Personal income per capita (annual): R21 593
- Poverty rate: 19,2%
- Literacy rate: 95,4%
- Life expectancy: 67,8 years
- Unemployment rate: 18,8%
- Access to electricity: 84,9%
- Access to safe water: 96,8%
- Access to sanitation: 90,5%
- Contribution to GDP: 15,6%
- Percentage of persons in poverty: 20%
- 2 979 patients per doctor
- 796 patients per professional nurse
- 691 patients per radiographer
- TB incidence (1998): 292 per 100 000
- TB prevalence (1998): 699 per 100 000
- Wasting: 2,8%
- Stunting: 13,8%
- Teenage pregnancy: 16,4%
- Smoking in adults: 48%
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