In the past decade, the best-equipped hospital in Africa, the new Inkosi Albert Luthuli Central Hospital, has been built in Durban along with almost a third (125) of the province’s 366 clinics.

In addition, two new district hospitals are being built in the eThekwini area (Durban metro) to cope with the demand for healthcare. Yet health department research shows that almost two million out of the 9,4 million residents, mostly in rural areas and informal settlements, still don’t have adequate care in South Africa’s most populous province

Demand for healthcare has been exacerbated by epidemics of HIV/AIDS, malaria and cholera, while poverty ensures that 88% of the population depends on the public health sector.

The malaria epidemic, which peaked in 1999 in the sub-tropical north of the province, has been brought under control through a combination of spraying households at risk with DDT and treating patients with a new combination drug.

The World Health Organisation has praised the way in which the department dealt with the 1999-2000 cholera epidemic, which infected over 120 000 people yet resulted in 0.2% of deaths.

But the only safeguard against further outbreaks is to improve communities’ access to clean water and sanitation. Only 34,6% of households have piped water inside while, in  1999, 12,7% of households had no toilet at all.

HIV/AIDS remains the province’s biggest challenge. Virtually every family has been affected by the epidemic, including those that are powerful and well-known, as demonstrated by the recent death of Chief Mangosuthu Buthelezi’s son, Prince Nelisuzulu.

Yet at times the epidemic has been a political football kicked around between the Inkatha Freedom Party and the ANC.

Traversing this difficult terrain is health Superintendent General, Professor Ronald Green Thompson, the midwife of transformation in the province for the past decade and who has earned respect but collected opponents along the way.

Green Thompson, who runs a tight ship and does not tolerate fools, concedes that at times the political power-sharing between the IFP and ANC has hampered service delivery. However, he believes that, with the ANC’s victory, “that is behind us now”.

Some 36,5% of pregnant women tested HIV positive in 2002, the highest rate in the country. A number of hospitals around Durban now report a rate of over 40%.

To address this, the province launched the “biggest prevention of mother-to-child HIV transmission (PMTCT) programme in the world” in June 2001, says Green Thompson.

Pregnant HIV positive women can now get the anti-AIDS drug nevirapine at any clinic or hospital. Some 233 000 women have been counselled about HIV, while around 34 000 women and their babies have been given the drug, which is believed to cut the HIV transmission rate by 50%.

Treating AIDS is far harder, yet up to 1,8 million people are living with HIV and an estimated 450 000 of these need anti-retroviral treatment.

However, until now, training of health workers on the use of ARVs has been uneven. In addition, different levels of health workers have been trained separately rather than as teams, which has caused problems when they return to facilities and are unable to work together.

In addition, the national health department chose not to accredit the Greys Hospital complex in Pietermaritzburg, which has been running one of KZN’s most successful HIV/AIDS clinics for a number of years.

However, Green Thompson says efforts are being made to co-ordinate the training and he believes that Greys will soon be accredited, as  it had to simply  attend to few  minor issues. This will mean that all health districts will have at least one site where ARVs are available.

However, it is sobering to note that the province’s TB cure rate in 2000 was 48,9%, the lowest in the country. TB treatment is for six months only, while ARV treatment is life-long.

One of the obstacles to effective TB treatment, says infectious disease expert Dr Ayo Olowolagba, is that it is hard to follow up patients to ensure that medication is taken correctly.

Olowolagba, who runs the province’s biggest TB clinic that oversees 5 000 patients a month, says that the majority of patients who default live in informal settlements.

His clinic, based in the busy transport hub of Warwick Triangle in the heart of Durban, has employed a team of fieldworkers with cars to go out and find patients, deliver their medication and link them up with people who can observe them taking their medication each day.

Such an approach has not yet been adopted for the ARV programme, although Green Thompson says his department will soon issue a tender for organisations that can train community workers and volunteers to support those on ARV treatment.

KZN’s population is almost evenly split between rural and urban areas, with a third of residents living in eThekwini.

This has put pressure on the ageing hospital stock of the metro, many of which also act as referral centres for rural patients who need more specialised care.

To ease this pressure and facilitate equal access to care for patients from outlying areas, Empangeni’s Ngwelezana-Lower Umfolozi complex is being upgraded to offer tertiary care.

More specialised care will also become available at the Madadeni-Newcastle complex, and Ladysmith, Port Shepstone and Stanger are being upgraded to regional hospitals.

But the operation of the new clinics and hospitals, as well increasing access to specialised care, is being seriously undermined by a lack of healthcare staff.

Health MEC Dr Zweli Mkhize says KZN is short of 8 000 nurses and 2 000 doctors. The province is trying to address this by doubling its intake of student nurses, and encouraging institutions that train health workers to do the same. It is also allowing those who want to do stints overseas to take unpaid leave.

Many rural district hospitals are run by people with strong religious beliefs and this has in turn resulted in few of these facilities offering terminations of pregnancy (TOP). Only 17 facilities in KZN offer TOPs yet teen pregnancy is a serious problem.

Green Thompson says that while there is a need to improve patients’ access to TOP, “you can’t force a person to perform an abortion”.

“Health workers are a microcosm of the society, and many people in communities have moral and religious objections to abortion. But we need to open up the debate and explore a range of options including establishing a relationship with private organisations such as Marie Stopes, which do TOPs,” he says.

Although the needs are still great in KZN, progress has been made and long-term plans been laid. But as with other provinces, the health of the people depends on ensuring that there is the staff to implement these plans and ensure further progress.

E-mail Kerry Cullinan