Many ills of the public health sector

By Kerry Cullinan Time of article published May 5, 2016

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There is a human resource crisis in care that is driven partly by the government's tolerance of incompetent staff, according to the Health Systems Trust’s SA Health Review 2016. Kerry Cullinan reports

You are least likely to see a dentist or a doctor in North West’s public sector health facilities, which has the lowest rates of both in the country.

While there is a dire shortage of dentists in the public sector with about 1 100 practising throughout South Africa, the situation is worst in North West where there is only one dentist for every 50 000 people.

Although public sector doctors are also in short supply, at least there are over 13 600 of them in the public sector. But again, expect to wait in a long queue in North West, which has 21.3 doctors per 100 000 people (nine below the national average).

This is according to the Health Systems Trust’s SA Health Review 2016, which was launched last night and paints a picture of massive differences in the quality of health services between provinces.

The Eastern and Northern Cape, Free State, Mpumalanga and Limpopo continue to deliver below-par services, while the Western Cape’s health service is head and shoulders above other provinces in almost all indicators.

Free State is the only province with fewer doctors last year than the previous year – losing a massive 177 doctors in a single year (now down to 539 doctors for the entire province).

Medical specialists are in shortest supply in Limpopo (1.5/100 000 people), while if you need counselling, don’t live in Mpumalanga, which only has one psychologist for every 100 000 residents.

Between 2010 and last year, the infant mortality rate increased in the Eastern Cape, where there are 43 deaths per 1 000 babies – almost three times the rate of 16.5 deaths per 1 000 in the Western Cape.

Pregnant women or those who have recently given birth are most likely to die in the Northern Cape, where there were an astonishing 254 maternal deaths per 100 000 births in comparison to 54 deaths in the Western Cape.

Wits University’s Professor Laetitia Rispel blames the government’s tolerance of incompetent staff as a key reason for the poor performance.

Over a period of four years, there was R24 billion in “irregular provincial expenditure” but it is hard to measure whether this was due to corruption or incompetence, says Rispel, who heads the Centre for Health Policy.

In 2012/13, irregular expenditure gobbled up 6 percent of provincial budgets.

She blames the government’s inability to “deal decisively with the health workforce crisis” and the lack of a fully functional district health system as the other main factors contributing to poor performance.

“There is a crisis of unprofessional behaviour, poor staff motivation, sub-optimal performance and unacceptable attitudes of health workers towards patients, all of which compromise quality of patient care and health service efficiency,” says Rispel.

“These problems are exacerbated by a general lack of accountability, reported by health service managers in several studies.”

Aside from poor leadership, health workers are poorly distributed between urban and rural areas and there are huge staff shortages (more than 100 000 public sector vacancies in 2010).

As a result of the nursing shortage, the government spent R1.5 billion in the 2009/10 financial year to hire temporary agency nurses for public sector hospitals.

Meanwhile, 40 percent of government nurses admitted to moonlighting for private health facilities and reported that they were often too tired to work at their main jobs in public facilities.

While the health system is failing to deliver adequate services, South Africans are battling a multitude of sicknesses. By mid-2015, almost one in three deaths were related to Aids. People with TB as well as HIV were almost twice as likely to die as people with TB alone.

We are also getting fatter and this has brought with it an epidemic of hypertension (high blood pressure), which can cause strokes and heart attacks.

While there are about the same number of obese girls and boys under the age of 15 (13.6 percent), in adulthood, women tend to balloon – almost 40 percent of adult women are obese compared to 10 percent of men.

In men and women over 65, hypertension is the norm, affecting almost 80 percent of women and 70 percent of men.

“Men and women, of all ages and all population groups, whether living in urban or rural settings, and regardless of educational level, have self-reported high levels of physical inactivity (being active less than three times a week), ranging from 78 to 97 percent,” reports the SAHR.

“In South Africa, the ultimate success of the National Health Insurance will require immediate and effective action to address the critical human resource challenges,” argues Rispel.

“Addressing the leadership, management and governance failures requires political will; meritocratic appointment of public service managers with the right skills, competencies, ethics and value systems; effective governance at all levels of the health system to enforce laws; 
appropriate management systems; and citizen involvement and advocacy to hold public officials accountable.”

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