Epidemics of HIV/AIDS, malaria, tuberculosis and cholera and the high rates of violent crime and accidents have all combined to put immense strain on health services in KwaZulu-Natal over the past decade.

However progress is palpable, particularly in regard to new facilities that have improved people’€™s access to health care. But the serious lack of staff could undermine gains made as the province is short of approximately 6000 nurses and 2000 doctors.

Dealing with epidemics such as HIV and TB are often labour-intensive. Patients need counselling and have to be followed up to ensure that they are taking their medication and return for check-ups.

It’€™s a difficult task. Take the prevention of mother to child HIV transmission (PMTCT) programme, which makes the anti-AIDS drug nevirapine available to pregnant women and their babies, should they test HIV positive.

Since the programme was launched in June 2001, some 233 000 pregnant women have been counselled about HIV and 179 000 (77%) agreed to have HIV tests. Of these, 63 000 tested positive and around 34 000 (60%) of these women and their babies have been given nevirapine.

Some 36.5% of pregnant women tested HIV positive in 2002, the highest rate in the country, yet large numbers of women are dropping out at every stage of the PMTCT programme.

The story is similar with TB. KZN’€™s TB cure rate of 49% is the lowest in the country. One of the biggest factors contributing to the low cure rate is the fact that patients disappear after getting their drugs so there is no way of knowing whether they have been cured or not.

The department’€™s difficulty in following up PMTCT and TB patients is serious when considered in the light of the antiretroviral programme, still in its infancy.

As Health Superintendent-General Professor Ronald Green Thompson says, the anti-retroviral rollout is “a different kettle of fish” from the PMTCT programme as it is a lifelong commitment that requires “total motivation from the patient and the department”.

Unless patients take their ARV drugs every day at the same time 90% of the time for the rest of their lives they are likely to develop drug resistance, which is very difficult and costly to cure.

KZN has the greatest number of people with HIV, around 1,8 million people of whom an estimated 450 000 need antiretroviral (ARV) drugs.

Ten facilities that have been accredited to provide ARVs are slowly preparing patients and expect to add 10 to 50 new patients each week, depending on their capacity.

However, training of staff is taking time and there has been inadequate preparation of patients in many areas.

Despite the daunting challenges, Green Thompson believes that the rollout will “develop its own momentum”, and is upbeat about the province’€™s prospects of controlling HIV/AIDS.

He points to how the province managed to bring both the malaria and cholera epidemics under control over the past decade as evidence that the province has the ability to run a successful ARV programme.

During the 2000 cholera epidemic, there were some 120 000 cases but the death toll was 0,2%, one of the best-controlled epidemics in the world according to the World Health Organisation.

However, while this indicates that the department has the ability to manage a crisis, the more important lesson is that thousands of people are vulnerable to disease because they lack clean water and proper sanitation.

Malaria is a huge success story, however. In the sub-tropical north east, 41 786 cases were reported in 2000. By 2003, only 1 548 cases were recorded, earning South Africa a well-deserved award from the WHO for the best malaria control programme in southern Africa.

This was achieved through a combination of spraying vulnerable households in the province and neighbouring Swaziland and Mozambique with DDT and treating patients with a new combination drug. Many of the malaria-carrying mosquitoes had become resistant to the old drugs.

Green Thompson’€™s department is acutely aware that its successes stand to be undermined by the “national problem” of a lack of healthworkers,

The department has thus doubled its intake of student nurses and is trying to accommodate healthworkers who want to go overseas by giving them unpaid leave rather than making them resign.

In addition, it has broadened the “rural” allowance announced recently by national government to include “inhospitable” areas such as Prince Mshiyeni in urban Umlazi.

KZN was also the first province to employ community health workers to conduct health education in communities.

The population of KZN is almost equally spread between rural and urban areas, yet many doctors in rural hospitals and small towns believe that the head office in Pietermaritzburg is urban-biased and that they are not consulted about decisions.

Some accuse Green Thompson of being “autocratic”, while others say that his firm hand was needed to transform the “shambolic” health services.

Green Thompson responds that while communication with rural facilities needs to be improved, his department’€™s entire philosophy is based on decentralising health services to the 11 health districts.

However, there is still a disparity between rural and urban health services, particularly because rural areas struggle to attract qualified staff.

The backbone of the rural health service in many areas is doctors who stick out the poor conditions because of their religious convictions.

But this poses a difficult challenge for the department, as such doctors are against terminations of pregnancy (TOP) and it is very difficult for women in rural areas to get TOPs. In fact, less than a third of the province’€™s public facilities offer TOPs although it is supposed to be part of the primary healthcare package.

While describing every TOP as “a failure of family planning policy”, Green Thompson concedes that the lack of access to TOP services is a challenge. He adds that the solution may lie in developing partnerships with private organisations performing TOPs, such as Marie Stopes clinics.

Rural district hospitals, particularly in the north, also complain that it is difficult to refer patients needing specialised care to regional and tertiary hospitals as these are overloaded and reluctant to accept more patients.

The department has responded by deciding to turn Empangeni’€™s Ngwelezane and Lower Umfolozi hospitals into a tertiary hospital complex, and upgrade Madadeni-Newcastle, Ladysmith, Stanger and Port Shepstone to regional hospitals.

At the same time, the ageing hospitals in eThekwini (Durban metro) have been struggling to cope with demand as more people flock to the city. To address this, two new hospitals are being built in KwaMashu and Inanda.

In addition, the state-of-the-art Inkosi Albert Luthuli Central Hospital (IALCH) was opened in late 2002 to offer the highest level of care.

IALCH, with its 19 operating theatres, 75 intensive care beds and 800 general beds, costs R25-million per month to run and is also a referral centre for half of the Eastern Cape.

“It is the most advanced hospital in the Africa, if not the southern hemisphere, with unsurpassed equipment and technology,” says Green Thompson, his voice warming noticeably.

IALCH’€™s head of medical services, Dr Maureen Joshua, says the hospital has introduced a number of services that were previously not available in KZN’€™s public sector, including infertility treatment, bone marrow transplants, a specialised burns unit and plasmaphoresis (filtering viruses out of the blood plasma).

Acting CEO Fikisiwe Zondi concedes that the hospital was built in an awkward place for those who rely on public transport. However, the hospital is adressing this by getting a taxi rank built opposite the gates and liasing with taxi associations in order to encourage them to introduce routes to the hospital.

IALCH has been established with a unique 15-year public-private partnership in which health department delivering health services only, while its private sector partner, Impilo, takes care of all non-health functions such as IT, maintenance, cleaning and catering.

While IALCH is the Rolls Royce of the department, at the primary care level 125 new clinics ‘€“ almost a third of the total stock — have been built in the past decade, mostly in communities that had poor access to health.

Clinic visits have increased from 10 million in 1996 to 16 million in 2002, evidence of both better access to care and the success of the department is moving from hospital-based to clinic-based care.

There are still many complaints about the standard of health services, and the department estimates that two million people still have inadequate access to healthcare.

But Green Thompson says that while the previous 10 years were devoted largely to improving access to healthcare and correctly the apartheid-era bias towards white areas, the next decade will be devoted to improving the quality of services offered.

KZN Statistics

• Population (2001): 9,4 million (21% of SA, the most populous province), and 88% depend on state health.
• Urban: 53%
• Unemployment:   46.7% (2002)
• Electricity access: 53,2%
• Water: Only 34.6% of households have piped water inside
• Sanitation: In 1999, 12.7% of households had no toilet (3rd worst in the country)
• TB cure rate (2000): 48.9% (lowest in the country)
• Infant mortality: 52 per 100 000 births (1998)
• Stunting: 15.6% (6 ‘€“ 71 months)
• Antenatal HIV prevalence: 36.5% (highest in the country)
• Health expenditure 2002/3: R7 534 000 (over-expenditure of R119-million). Projected budget for 2003/4 represents a 1.29% decrease in real terms and accounts for 24.48% of provincial budget
• Per capita: R850.32 (R163 for primary health care)

One public sector doctor per 4 362 people, one dentist per 145 607 people (2nd lowest in the country) one professional nurse per 901 people.

New CEO kicks ass at Prince Mshiyeni

“I’€™ve survived six attempts on my life that I know of,” says Dr Nomakhosi Gxagxisa, the large, lively CEO of Umlazi’€™s Prince Mshiyeni Hospital.

Long recognised as one of the province’€™s most troubled institutions, Prince Mshiyeni has been plagued by strikes, stock theft and factionalism, including staff being split between the ANC and Inkatha Freedom Party.

Yet the 1 200-bed hospital is an essential community resource that treats over 20 000 outpatients and facilitates the birth of 1 000 babies every month.

Gxagxisa waded into this mess two years ago as acting CEO after three of her predecessors were frog-marched from the hospital by protesting staff.

Not prepared to entertain failure, Gxagxisa, a single mother raising her own five children plus her late brother’€™s five, says it was “very tough” to begin with.

“But I believe in the people of this country,” she says. “If we can have a Codesa, we can do anything. As a doctor and a mother, I can’€™t just quit and not deal with problems because these same problems will then be passed on to someone else.”

Her approach was to “take the politics out” and get people to align with common goals”.

Hard work, a team approach that mobilised all staff around a “roadmap” for change and involvement of provincial politicians from both major parties, resulted in a symbolic funeral of the “Hospital of Death” in January.

A coffin bearing slogans such as “laziness, drunkenness, poor productivity and blaming” was burnt during a three-day conference involving all staff.

In March, after two years in an acting position, Gxagxisa was rewarded with the post of CEO. She is now working hard to get her hospital accredited with the Council of Health Service Accreditation of Southern Africa (COHSASA), an independent body that assesses and accredits healthcare organisations that meet certain set standards.

As part of her commitment to improving standards, Gxagxisa and her staff are monitoring waiting times of patients and establishing a hospital board that represents community interests.

She has managed to persuade the medical school to return to the busy hospital, and says there are now a total of 143 doctors, leaving a shortfall of just 17. An Employee Assistance Programme has been set up to give psychological support to staff.

But the shortage of professional nurses remains her “biggest headache”, while HIV/AIDS is increasing staff workloads and over 70% of patients in the medical wards are HIV positive.

Gxagxisa, who grew up between Soweto, Groutville and Umtata, spent a brief stint in exile in Zambia in the 1980s. She says her trust in people and her faith in God has enabled her to weather the tough times at Prince Mshiyeni.

Health Superintendent-General Professor Ronald Green Thompson, concedes that having the province’€™s government split between the ANC and the IFP has sometimes hampered delivery.

“But these problems are behind us now,” says Green Thompson, referring to the ANC’€™s recent narrow victory in the province which ended the 10-year power-sharing deal between the ANC and IFP.

E-mail Kerry Cullinan