1. Access to medicine and consumables
‘How are we supposed to operate on our patients when we can’t even give them basic painkillers. It is inhumane’¦the problem is that our patients are far too forgiving.’ Doctor C, tertiary hospital.
* Basic consumables:
Academic hospitals: Shortages of basic consumables such as hand washing supplies (soap, hand towels and hand spray), specialized masks, alcohol swabs and sterile gloves.
Shortages of medical consumables such as drip sets, needles and suture material.
Quality of consumables was also flagged with sutures half the length they should be, bent surgical needles and needles that break easily requiring several attempts.
Shortage of non-essentials such as stationary with doctors forced to photocopy patient charts and forms at their own cost.
* Essential medicines:
There were shortages of medicines across all facilities, including a range of medicines on the essential drug list (EDL).
Doctors at one regional hospital estimated that they do not have access to about 25% of the medicines on the EDL, including paracetamol, aspirin and basic antibiotics.
* Vaccines: Staff, medical students and patients at primary healthcare clinics and hospitals reported shortages of vaccines for babies, including the one in five, rotavirus and pneumococcal disease vaccines. Paediatricians have reported cases of children with diseases they should have been immunized against. For example, a child presenting with pneumococcal meningitis had been taken for the 14-week immunization, but the vaccine was not available. Doctors also reported that infants were admitted to the intensive care unit with pertussis (a disease routinely vaccinated against), one of whom had not been immunized as the vaccine as out of stock.
* Antiretrovirals (ARVs): Stockouts were observed around Gauteng throughout 2012, particularly Tenofovir and Abacavir. Patients were often given a small supply, which meant they had to keep going back to the clinic or hospital, increasing the likelihood of people being non-adherent.
* Medicines for tertiary treatment: Tertiary hospitals are reporting that they are increasingly unable to offer specialized care as a result of not having the medicines they require. In May 2012 chemotherapy was interrupted at a tertiary hospital because they had run out of the medicines.
* The lack of medicines and consumables was attributed to inefficiencies in the supply chain, failure to pay suppliers and tender corruption.
2. Availability and maintenance of equipment
One of the key failures identified by health workers related to the purchasing and maintenance of equipment.
* Equipment budgets have been cut to pay suppliers for equipment bought in previous years with some hospitals (Chris Hani Baragwanath) having a zero budget for new equipment in 2012/3.
* There were also difficulties and delays in getting equipment ordered with long waiting times, sometimes years.
* Health workers reported that some of the equipment received was of a poor quality.
* Some equipment was non-functional due to delays in repairs or a lack of servicing.
The functioning of equipment is in many cases inextricably linked to the availability of consumables for that equipment, with for example functioning CT scanners unable to operate because of no contrast fluid.
This has had a significant impact on medical interventions that are equipment dependent such as anaesthetics, radiology and oncology.
At one hospital 30% of Intensive Care Unit beds were not functional due to a failure to service equipment, because of a lapsed service agreement.
A lack of wheelchairs, stretchers and beds is common in many Gauteng hospitals. In some wards there were no thermometers and blood pressure cuffs, meaning staff were unable to monitor vital signs.
3. Maintenance of infrastructure
* Power: There have been repeated power failures at various hospitals, notably Chris Hani Baragwanath. The power outages have led to instances where surgeons operated using headlights and cellphone lights.
* Buildings: Wards are reportedly in a poor condition, many hospitals have lifts out of order and in one hospital children who require oxygen on admission sometimes need to be carried to the third floor without oxygen.
* Temperature control: Equipment needed to regulate the temperatures were not working. In one incident the air conditioners serving the theatres at a large tertiary hospital stopped working and staff had to decide whether to cancel the procedures or continue to operate in unsafe temperatures exceeding 30 deg C.
* Beds and linen: There are generally insufficient beds, with patients forced to sleep on stretchers or in one instance share beds. There is also a shortage of linen and blankets with some patients left naked on beds for hours.
* Medical infrastructure: Problems include difficulties with oxygen supplies and sufficient water filtration to ensure that sterile water is used in haemodialysis. In one hospital it was cancelled.
* Sanitation: Bathrooms and toilets are often not maintained and are broken.
4. Human Resources
There are shortages of Intensive Care Unit nurses, radiographers, anaethetists and theatre nurses.
* The non-payment of nursing agencies, for example Khalipha nursing agency in late 2011 and January 2012 had a serious impact. It led to an acute shortage of midwives and maternity theatre staff. At Chris Hani Baragwanath where 13 midwives were required there were only 3 or 4 on duty.
* Prohibition on use of nursing and pharmacy agencies: Vacant nursing posts were not filled leading to a severe shortage of theatre and ICU nurses. The use of agencies was curtailed in March.
* Moratorium on the appointment of new staff: In May a circular abolished unfunded vacant posts, froze all funded vacant posts and instituted the approval by the Head of Department (HOD) for all funded posts that are not frozen. The HOD approval added long delays and led to hospitals having inadequate staff. At Charlotte Maxeke it caused the cancellation of between 20 and 25% of surgeries due to a shortage of anaethetists. At another regional hospital surgeries were reduced from six a week to four. – Health-e News Service