Heroism in adversity - SA’s heart-rending rural health story

Public sector rural healthcare in South Africa is politically mismanaged, understaffed, underfunded and under-supervised, with unions reigning supreme, intimidating competent and suitably qualified leaders into shunning the top hospital jobs.

That’s the consensus among rural veteran doctors, their over-represented junior colleagues and the outgoing National Health Ombudsman, Professor William Malegapuru Makgoba, in a wide-ranging survey conducted by Axess Health recently.

The rural comparison was prompted by Gauteng’s current grim tally of corruption, crumbling infrastructure, patient neglect, criminal syndicates, equipment failure, theft, arson, and organizational chaos, (alongside staff work overload), at tertiary level - and an intern expose of the Port Elizabeth Hospital Complex in recent weeks.

In an exclusive interview with Med Brief Africa (AxessHealth), National Health Ombudsman, Professor Makgoba put abysmal public health care delivery in all but the Western Cape, Limpopo and KwaZulu Natal, (“where they have at least found a little direction,”), down to dismal provincial and hospital leadership, infrastructural decay, and an almost universal lack of human resource capacity.

“Because of understaffing at every level, you have little institutional knowledge about the disciplines being practiced in those hospitals. Everything has suffered and everyone is overworked and overstretched. Seniors become irritated with the human resource leadership and infrastructure of the hospital,” he adds.

Under 10% of graduates go rural

There are very few islands of rural excellence left in a sea of otherwise ideologically correct, semi-functional provincial health administrations. Despite a change in funding policy to get more money into rural areas (38 of the 52 health districts are considered rural), the money is almost always poorly or wastefully managed while just 200 of the estimated annual 2 500 medical graduates are employed in State hospitals, (post community service), often not in rural areas – a function of ever-diminishing budgets.

Over the past 21 years of health reporting, I’ve seen the best values of the medical profession lived out in far-flung, relatively hostile environments where basics like transport, proper shelter, nutritious food, and employment are viewed as luxuries by most local people.

Vocation-driven doctors settle, start families, and dedicate their lives to building teams, uplifting communities, and attracting colleagues who benefit from fast-track learning, often developing special interests and/or nearly always acquiring multi-disciplinary skills. After a few years they find themselves highly marketable globally, never mind locally, able to turn their hand to most patient presentations, let alone fix a faulty generator, speak an indigenous language, or perform a C-section by torchlight.

Conversely, I’ve seen the worst in cynical, political breaches of clinical care with award winning rural doctors, clinical managers, chief medical officers, and CEO’ summarily evicted from their positions, served with trumped up charges or even frog-marched from their offices by striking healthcare union members.

Health MEC’s, particularly in the Eastern Cape, often turn a blind eye to union excess, some even defying court reinstatement orders. In rare cases, community gratitude has translated into protests supporting the healthcare team - against politically correct and/or cadre-deployed hospital managers rendered unpopular by interfering clinically. Throw in the odd multi-million-rand hospital expansion, (ironically often prompted by a stoically built, highly functional healthcare service), and local politics quickly turn toxic. Opportunistic local civic leaders jostle for tenders, currying favor with politically appointed hospital chiefs and blindly supporting non-patient-centric agendas.

Juniors’ ‘carry’ rural healthcare.

Observes Professor Steve Reid, a founder member of the Rural Doctors’ Association of South Africa, (RUDASA), and Head of Family Medicine at UCT, “I don’t think the main challenge is the quadruple burden of disease. We’re in another era. Rural hospitals are staffed mostly by young South Africans and too few older medics, many of whom are foreign. So, the ethos has shifted. There’s still that sense of making a difference; what you could perhaps call heroism, but it’s much more transactional. The community service brigade has changed it from a voluntary choice to a compulsory year.

Many see out their Comserve years and contracts, take their experience and leave. There’s a different organizational culture in many places, based on that kind of configuration. You get a few long-term leaders, like at Mosveld or Mseleni (northern KwaZulu Natal) or Zithulele (Eastern Cape) where that ethos of service continued,” he says.

Dr Lungile Hobe, Mseleni District Hospital’s Medical Manager, is a product of the Umthombo Youth Development Foundation, set up to help address the healthcare staffing crisis by recruiting local youngsters for medical training. Today she’s also the re-elected chairperson of RUDASA where she’s been at the helm for almost six years.

She adds patient transport and hospital IT to the major shortfalls listed by her senior academic colleagues.

Because of the isolation of rural hospitals and poor dirt roads, the ambulance fleets (five, plus an advance life support vehicle for your average 185-bed hospital if you’re lucky), are often out of commission, sometimes all at once and for months at a time. For patients living at the edge of an average district health drainage area and needing referral to a regional hospital, this can mean an 800-kilometre round trip.

“They borrow money from neighbours just to get here,” says Hobe.

She’s enthusiastic about preventative care, which to really work means getting community healthcare workers, (CHW’s), permanently employed instead of on year-to-year renewable contracts. This would be fairer practice and prevent the current ageing, (no pensions), of the cohort. With the bulk of budgets currently misdirected at curative care, billions could be saved.

A much-touted national ‘re-engineering” of primary healthcare in 2018 resulted in a poorly, implemented, (if at all), ward-based outreach team policy. This systemic failure is epitomised by Mseleni where two vehicles and two outreach teams work from just two of eleven clinics, resulting in huge pockets of undetected diseases and screening failures. The downstream costs are incalculable - and avoidable.

Basic IT for Wi-Fi is often absent, resulting in huge mentoring and learning gaps for medics, one being a glaring absence of management mentoring.

“Our province recently introduced a CEO pack which took off like wildfire, but because some hospitals are incommunicado, they’re ignorant of its existence. Same for equitable distribution of equipment. One hospital ends up with all the good stuff and others don’t even know they’re eligible. The IT paucity impact is as wide as it is varied, including an inability to reach doctors on call or to properly refer patients,” Hobe says.

Load shedding and cable theft merely aggravate matters.

She had no hospital manager to show her the ropes and has since introduced a system where junior and senior doctors are paired per ward.

Of the anchor/vocationally driven doctors too seldom acknowledged, she says that’s precisely why some rural hospitals thrive, “because there’s someone there with a willing heart.”

“But it shouldn’t be like that. The system should be able to support everyone. When it falls apart people tend to lose heart - and their drive. Even those who want to do amazing things get discouraged after time. The are so many examples of those who stayed on for years, but eventually it got too much. Others very soon find themselves saying no ways,” she warns.

Administrative ‘guile.’

In KwaZulu Natal a new healthcare staff establishment norm was set in 2013 – but has never been implemented or translated onto the Persal (human resources and payroll) system. This means the true vacancy rates for healthcare professionals, cleaners, kitchen staff, porters and admin staff are impossible to establish. The current standing instructions from KZN DoH are that if you cannot fill a post, you abolish it – a slashing of staff numbers via administrative guile.

“So, the vacancy rate will show as, say twenty percent, when it’s actually sixty percent,” Hobe adds.

Madeleine Muller, a Family Physician / Senior Lecturer at Walter Sisulu University in Mthatha, exemplifies many a heroic teacher-physician whose work is akin to a small but powerful medicinal drop in a large body of water.

Like many of her peer educators seconded to rural hospitals where a specific clinical supervisory gap is identified, (often funded by philanthropic outfits like the Discovery Foundation), she teaches interns, but more importantly, seniors, on how to mentor.

“I want to improve the mentoring and training skills of senior doctors in various departments. They may be clinically OK, but often they don’t know how to teach and train, whether it’s Emergency Medicine, Family Medicine, or Psychiatry. How do you mentor interns? I’m training the consultants to do that,” she explains.

She’s co-ordinating this year’s RUDASA conference in East London where the theme will be “Celebrating Rural Service,” – a sorely-needed bid to lend moral support to juniors, particularly interns and community service officers.

The quality of mentorship however was not the top issue according to nine interns I interviewed 14 months into their rotation at the Port Elizabeth Hospital Complex, (including the more rural Uitenhage Hospital), in April this year. The paucity of it was.

They said their seniors were so overworked and stressed that they had little time to teach them skills, oversee procedures or help them build confidence – the core purpose of their two-year tenure in HPCSA-accredited hospitals. All was drowned in a flood of patients, staff shortages, admin failure, resulting in sub-optimal patient care.

Caught between overworked seniors, understocked basic medical supplies/equipment and turf-protecting nurses, the routinely exhausted interns, were toughing it out.

They spoke of unavailable porters, having to wheel patients around, dysfunctional lifts, fighting over basic essential medicines and equipment and patients crowded into ‘overflow’ rooms awaiting procedures, several spending many nights sleeping on chairs – or being sent home unattended.

Makgoba singled out the turnstile hospital CEO’s, the lack of quality replacements and low-criteria top job specifications as major hurdles.

Rural Health Advocacy Project, (RHAP,) Chief, Russel Rensburg says their mission is equitable access to quality healthcare for rural communities. It’s a primary healthcare approach, a health-seeking approach.

“At the end of the day, if we do not create a system that uses funding equitably, prioritizing people with the greatest need, we won’t achieve the kind of outcomes our country so desperately needs,” he says.

An activist with a background in economics, finance, and health systems, Rensburg and his team engage directly with ministries of health. They co-authored the national strategic plan of human resources for health and have introduced a prioritisation framework that tries to get funds and the less than ten percent of graduates whom the state can afford into the most deprived former homelands and Bantustans.

He says the lack of health seeking behaviour by rural communities (or often dangerously or futilely late presentation) aggravates the human resources crisis and resultant outcomes.

Allow a patient led approach.

“Every district and community are different, and you need to give doctors autonomy and support, coupled with good governance. The biggest challenge is not the younger doctors, but how people value health. So, the oven is broken and we’re not baking the cake. We have the leadership and the framework to do it. We just have to get better at adopting what works, not default to a centralised, ‘one-size-fits all,’” he adds.

He'd love to take people like Ben and Taryn Gaunt and Karl and Sally le Roux, two doctor couples who transformed Zithulele Hospital, near the coast one hundred kms from Mthatha over 20 years and pay them to tour deep rural hospitals country-wide, mentoring others.

“We need preventative, curative, and palliative care in a network of clinics anchored by the district hospital - and to create an institutional culture. I mean Zithulele created charitable foundations, did Mother to Mother outreach, set up and ran a school and created a research centre. They and Madwaleni Hospital created the most successful community driven Covid vaccination program in the country at nearby Bulungula. At Manguzi and Mseleni (northern KZN) they did the same. We need to build narratives of hope,” he said.

Innovation born.

He cites Dr Will Mapham, now an ophthalmologist but a ‘graduate’ of Madwaleni Hospital, having invented the Vula cell phone referral app to address more timely and efficient referrals, as an example of innovation born of rural necessity. The app is now in use country-wide and saved countless lives during the Covid pandemic.

He cites the million AIDS deaths between 1996 and 2001 and Manguzi Hospital doctors being among the first to respond with ARV’s (resulting in a vindictive government response). “On the back of that, the Treatment Action Campaign could go out and educate people that the drugs were in fact not toxic. We have to draw on that collective action again, work with communities to empower them and demand the kind of care they need. This is a crisis we can’t afford to miss.”

Makgoba believes that healthcare professionals have relinquished their power to politicians, aggravating a dysfunctional system. While there has been push-back by bodies such as the RUDASA, the Junior Doctors Association of SA, (JUDASA), and the SA Medical Association, (SAMA), those doctors at the sharp end of politics in deep rural areas seldom benefit from such collective assertion, taking cold comfort from strongly worded media statements decrying their ill-treatment.

Gauteng-based rural healthcare veteran, Professor Jannie Hugo, who leads the academic development and implementation of Community Oriented Primary Care (COPC) and the highly effective CHW-driven AITA Health mobile data system, is sceptical about the oft-cited reasons for systemic dysfunction.

“I don’t think it’s as simple as a lack of competent CEO’s. A crucial element is pure criminality. How do you run any organisation if there’s a high level of criminality? People get harassed, murdered. Just look at that Mid-Rand story where a court-appointed curator of Bosasa was meticulously probing crooked companies. He and his son were murdered in an obvious hit. I have first-hand experience of contacts of mine not being paid by both national and Gauteng Health. If you take the attempted assassination of the highly effective former Eastern Cape DG, Dr Siva Pillay, several years ago and extrapolate it to most of the country - that’s the situation today. My point is that health is not spared in this process. Our former minister of health is an excellent example,” he adds.

Luckily, South Africa has its medical heroes and tireless advocates and activists who see the half full glass. As Ben Gaunt, whose book, “Hope, A Goat and a Hospital,” chronicles his core team’s remarkable Zithulele journey signs off on his e-mails, “If you don't have a dream, how will you ever have a dream come true?”

• Chris Bateman was News Editor of the SA Medical Journal from 2000 to 2016 before turning to freelance healthcare writing. He is now part of the Medbrief Africa/Axess Health team.