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Gauteng province ‘€“ Taking Strain

Written by Health-e News

Migration is taking its toll on health services in Gauteng, South Africa’€™s economic powerhouse.

The country’€™s economic powerhouse, Gauteng province is often referred to as the ‘€˜place of gold’€™. Small wonder ‘€“ this is the country’€™s wealthiest province, the most densely populated region in the country, the place where people come to make their money. But the province is not just a financial hub. People flock here for another reason ‘€“ to gain access to what they perceive as better health-care.

The Gauteng provincial health department seems to be getting it right, if the findings of a 10-year review on its health services are to be believed.   According to the survey, commissioned by the province, public confidence in Gauteng’€™s health services is improving and more people are accessing these facilities. In April Gauteng became the second province after the Western Cape to begin the roll-out of antiretroviral treatment in five public hospitals in Johannesburg and Pretoria.

With the province spending R1668 per capita on health last year ‘€“ up to 3 times as much as a poorer province like Mpumalanga – it’€™s not difficult to see why all roads lead to Gauteng.

It’€™s evident at Kalafong hospital, one of the province’€™s largest regional facilities, situated west of Pretoria in Atteridgeville.   Ambulances from other provinces ‘€“ especially Mpumalanga ‘€“ constantly pull up in the hospital courtyard bringing in patients ‘€œlike a conveyor belt’€, according to the hospital’€™s CEO, Dr Hanlie Dafel.

Even more simply walk through the gates, without referrals.

‘€œPeople come from as far as Mozambique and give an address of a relative living in Pretoria or give us a fake address. They believe it’€™s better to be treated in Gauteng,’€ says Prof Marianne Kruger, head of the paediatrics department.

Essentially all referrals from other provinces should be handled by tertiary hospitals. Although it was previously a tertiary institution, Kalafong has, since 1997, been downgraded to offer secondary-level services.

‘€œWe are now just a very good regional hospital’€¦with remnants of tertiary services, but operating on a secondary-level budget. But I don’€™t think people [from other provinces] realise this,’€ Dafel pointed out.

Consequently, too many unnecessary referrals from Mpumalanga have placed a  strain on the hospital, making it difficult to provide adequate care to Gauteng residents.

Dafel admits that the hospital’€™s budget is under pressure. Kalafong is the only regional hospital in Pretoria at this stage and services the greater part of Northern Gauteng.

Although it has a capacity of 1113 beds, staff availability, resource constraints and reduced bed occupancy rates have meant that the hospital is only able to provide 849 beds.

But this could also be interpreted as a good thing says, Dr Letitia Rispel, head of Gauteng’€™s health department.

According to Rispel, the review commissioned by the provincial health department, revealed that there was now an expanded range of services available to inhabitants of the province.

‘€œPeople are moving away from hospital-based health-care service because they can now access health-care in their own communities,’€ she said.

The review found that 95 percent of the province’€™s inhabitants had access to basic health-care services.

Nevertheless, primary health care in the province remained ‘€œa mixed bag’€ and it would take time before everyone would be satisfied with the care they received at clinics, she warned.

Tony Adams, a patient standing in the long queue snaking around the Kalafong hospital waiting area, is a case in point. Adams had been in the queue for about half an hour and said he didn’€™t mind waiting, as it was easier to come directly to the hospital.

‘€œThe hospital is better, they have medicine and they have doctors.   Some clinics in Laudium are a waste of time,’€ he said.

According to Dafel, curative primary health care services in the residential areas surrounding Kalafong, had been virtually nonexistent ‘€“ Kalafong was the only place to go.

The hospital is now faced with a dilemma. ‘€œNow it’€™s how to get the public not to prefer us, without being rude. So it’€™s a question of guiding people away but not chasing them away,’€ she said.

Outside the waiting area, three white minibuses or Mpumalanga Patient Transporters, as they are known locally,  pull up outside the emergency entrance. Adams and the rest of the queue will have to wait even longer before they are attended to by the harassed-looking hospital staff.

Justifiably, the staff were growing  frustrated with the ‘€œtrans-provincial traffic’€, the deputy director of nursing, Mohau Motloung commented.

Reduced numbers of staff now have to cope with larger workloads and less resources. But the province still fares better nationally in terms of human resources. There is one doctor per 3436 people (national average 3928) and one nurse per 734 patients.

But these figures camouflaged the critical shortages of specialised nursing and medical staff who had been lured by the private sector, Dafel said.

The 852 nurses working at Kalafong however, don’€™t feel they are better off. ‘€œOf course we are frustrated, we are working under pressure at all times,’€ Motloung noted.

Equally frustrating, according to Motloung, was ‘€œknowing what you should be doing only to discover you can’€™t do it because of budgetary constraints’€.

This, according to Kruger, who also sits on the executive committee of the University of Pretoria’€™s School of Medicine, is where Gauteng is not getting it right.

Although she praised the provincial department’€™s ‘€œgood business plan’€, Kruger expressed concern that their budget was ‘€œdriven by resources and not the needs of the staff and facilities’€.

The provincial department has had to rein in the overspending of hospitals, including two of Gauteng’€™s biggest hospitals ‘€“ Chris Hani Baragwanath and Johannesburg General.

A directive from Johannesburg General management to its surgeons last year indicated that no elective surgery, which includes hip replacements, hernia operations and other procedures, would be done for six months due to the lack of funds.

At Chris Hani-Baragwanath, similar measures have had to be introduced. Only operations that were ‘€œnecessary’€ would be done, the hospital’€™s management ordered last year.

Rispel attributes this to the ‘€œextraordinary demands’€ placed on the province’€™s hospital services. Gauteng’€™s population had increased by 20 percent between 1996 and 2001, patient admissions were high and the impact of HIV/AIDS could not be ignored. This combination, coupled with ‘€œinflationary pressures’€ was causing enormous stress on hospitals.

But she warned that hospitals had to take a more ‘€œbusiness-like approach’€ to the management of hospitals. ‘€œThe potential for improved efficiency and an improved system is there.’€

Dr BJ Schoeman, a consultant surgeon working in Kalafong for the past 21 years, cuts through the ‘€œpolite management speak’€ and says the biggest drain of hospital resources is trauma and violence.

‘€œIf we can address trauma, then we can go very far with our health budget,’€ he says in a firm tone.

Trauma and violence are  leading causes of death in the province and placed strain on the  recourses of  all major hospitals in Gauteng.

 ‘€œIt’€™s a dangerous province no doubt about it. Crime, car accidents’€¦that is why at least 30 percent of our general surgery intake is taken up by trauma,’€ says Dr Schoeman.

As Dr Hanlie Dafel explains, these types of injuries require various types of doctors.

 ‘€œA road accident case will usually need surgery, orthopaedics, maybe plastic surgery. It is never a simple case to treat,’€ she said.

Inevitably, neighbouring provinces rely on the expertise of Gauteng hospitals. Most of Kalafong’€™s multi-trauma patients are referred from Mpumalanga. ‘€œThey can’€™t handle them because their skills are not up to standard yet,’€ she says diplomatically.

But there is more to the province’€™s health-care system than the doom and gloom of violence, Kruger revealed.

 The provincial department’€™s goal of providing free medical care to children under six has been a significant achievement while up to 76 percent of the province’€™s children have been immunised.

Kruger’€™s department includes a small paediatric oncology ward and it had been ‘€œheart-warming, seeing children who wouldn’€™t be able to afford such treatment, being cured of cancer’€ she says.

Interestingly, paediatric oncology was one of the tertiary level services that Kalafong was still providing ‘€“ on a secondary level budget.

Almost two-thirds of the cases in the ward are from Mpumalanga, 15 percent from Limpopo and the rest from northern Gauteng.

But Kruger is worried about the hospital’€™s ability to continue providing these services. For Kruger, and the rest of the staff in the paediatric ward, the province’€™s biggest achievement in the last 10 years, has been the decision to implement an ARV treatment programme in public sector.

In 2002, the national antenatal survey found that 31.6 percent of the women attending antenatal clinics in the province were HIV-positive ‘€“ the second highest figure in the country. National figures for 2002 stand at 26.5 percent.

The province’€™s second annual report on HIV/AIDS released in December lists some of the achievements of the province’€™s AIDS programme.

The PMTCT programme is now available at all health-care centres across the province. About 12 500 mothers have received nevirapine, since the project kicked off.

But TB poses a major problem. There has been an increase in the number of new cases ‘€“ from 255 per 100 000 in 1998 to 304 per 100 000 people in 2000. Although this could be partly blamed on the rising HIV prevalence, the overall TB cure rate could still be worked on, Rispel admitted.

In Kalafong’€™s paediatric ward, 80 percent of the general admissions are as a result of HIV-related illnesses. ‘€œProviding ARVs for children is one of the best things that could have happened,’€ she said.

The decision, though, was 10 years too late.

 ‘€œThe Sunday before Thursday’€™s roll-out, I struggled to convince the mother of an HIV-positive patient who was ill with pneumonia to allow her child to be admitted to the hospital. I told her that if the child was well enough on Thursday, she would be one of the first children in the country to receive treatment. But she died on Wednesday night, she missed the boat.’€

Five hospitals in the province have been selected as sites for the ARV roll-out. Kalafong is the only site in Pretoria. But a week after the rollout began, things were ‘€œstill manageable’€ Dafel said.

Fifteen people had started taking the treatment and another 15 would follow a week later. Nine children had so far received the drugs.

Dafel hoped that surrounding provinces would kick off their treatment programmes soon. ‘€œIf people become frustrated they are not getting the drugs where they live, and start coming to us, it might not be so manageable.’€

Gauteng Indicators

  • Population ‘€“ 17.9% of total population
  • Unemployment ‘€“27%
  • Households with no toilet ‘€“ 0.8%
  • Households with piped water inside ‘€“ 58.8%
  • Medical Practitioners per 100 000 population ‘€“ 28.7
  • Professional Nurses per 100 000 population ‘€“   138.7
  • Life expectancy ‘€“ 54.8
  • Infant mortality ‘€“ 36.3 per 1000 live births
  • Maternal mortality ratio ‘€“   8.29 per 100 000
  • HIV prevalence (% antenatal)   ‘€“   31.6%

 E-mail Kanya Ndaki

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