State of Academic Health Complexes: by Universities of Western Cape, Cape Town, Stellenbosch, Free State Health Faculties

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20 October 2009
Chairperson: Mr BM Gogwana (ANC)
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Meeting Summary

A delegation from the Universities of the Western Cape, Cape Town, Stellenbosch and the Free State presented on the State of Academic Health Complexes. The academic sector drove all the elements of the rest of the health system and to create a sustainable health system, the Academic Health Complexes needed to function well. These Complexes were facing severe under-funding issues and called for urgent intervention to address the crisis. Recommendations included a national governance structure with national, instead of provincial, funding for research and training, and that these governance structures be formalised through Section 51 in the National Health Act of 2004.

Questions were asked about how national funding would solve the problem, implementation of training, research around primary healthcare, what was being done to address the problem of ageing researchers, communication with the various health departments, particularly in the Free State, and research on diabetes,

The Committee agreed to look into the issue of under-funding and would meet with the relevant authorities to discuss national funding of Academic Health Complexes.

Meeting report

State of Academic Health Complexes: Universities of Cape Town (UCT), Free State, Western Cape (UWC) and Stellenbosch University presentation
Prof Bongani Mayosi, Professor of Medicine, University of Cape Town, presented on the mandate, state of and performance of Academic Health Complexes in the Western Cape and Free State, with recommendations on what could be done to help the Complexes.

Academic Health Complexes were mandated to educate and train health care personnel and to conduct health research. The Universities and Departments of Health shared a joint mandate for the training of health care professionals and to provide health services. The relationship was governed by joint agreements that varied from institution to institution throughout the country. There was a need for a uniform national framework to govern the joint mandate.

The performance of Academic Health complexes was outlined. On a positive note, research of HIV/AIDS was dominant, however inequalities in health research were contributing to inequalities in health and research output was falling in the clinical category of health research. Research showed that there was a rising demand for acute and chronic health care and pressure on acute services was leading to unacceptable delays in the provision of care, alongside this there was evidence of under-funding of the Public Health Sector.

The Academic Health Complexes were key to achieving the National Department of Health’s 10 Point Plan, however the lack of appropriate investment was hindering the Complexes. Of concern was the fact that there were very few new researchers entering the field. Another concern was the lack of doctors and specialists. In South Africa there was less than one doctor per 1000 people compared to countries such as Brazil that had double this figure. The national infant mortality rate was rising and there was not a proper framework in place to train nurses. The Universities recommended:
▪ An inclusive process needed to be embarked upon to address the state of Academic Health Complexes in the interests of a sustainable health system.
▪ A national governance structure and an integrated framework funding for Academic Health Complexes was required.
▪ A process to determine the number of health professionals to be trained, the infrastructure and human resources requirements and the funding envelope.
▪ The proposed governance structures and funding mechanisms might be formalised through section 51 on ‘Establishment of Academic Health Complexes’ in the National Health Act of 2004.
▪ Urgent intervention was required to address the crisis of Academic Health Complexes in the Western Cape, Free State and other parts of the country.
▪ Academic Health Complexes need to be treated as national assets rather than provincial liabilities.

Free State Health Story: University of the Free State presentation
Professor Andries Stulting, Acting Head, School of Medicine, University of the Free State presented on the Free State Health situation.

Despite extensive correspondence and meetings with the Free State Department of Health from 2007-2009, there remained a financial crisis in the Academic Health Complexes in the Free State. There was a general collapse of health systems in the Free State including a decline in health care delivery, a decline in life expectancy, a perceived collapse of Primary Health Care, a crisis at Pelonomi Hospital and the destruction of training platforms. The Free State Health Department was lacking in a coherent plan or policy, inefficient planning and management, a lack of resource allocation which was resulting in disillusioned patients and staff and concerns about the future of the School of Medicine due to a lack of a training platform, a decreased number of students and the impact of the decrease in the National subsidy for training.

To meet health requirements by 2014, double the current figure of medical practitioners and specialists were needed to address the concerns of the country. Current vacant posts in the Free State stand at 30% and to fill this gap an increase of 34% in registrars was needed. As an example, Universitas Hospital had 36% of specialist posts vacant. Only 60% of theatre time was available and specialist clinics had closed from November 2008. In general, district clinics were running out of medicines resulting in more patients going to main hospitals, at these hospitals there was also a severe shortage of medical consumables.

Solutions for the problems facing the hospitals were put forward (see presentation), these included the need to address under-funding and deficiencies in all levels of service, to include all stakeholders in strategic planning, to restore the academic platform, to fill critical core posts such as registrars, specialists and professional nurses, to address outdated equipment, to ensure sustainable medical consumables, improve contract and tender management, address the maintenance backlog, do proper HR training and work together.

Oral Health Training and Human Resources: University of the Western Cape Presentation
Professor Hanif Moola, Dean: Faculty of Dentistry, University of the Western Cape (UWC) presented. He highlighted the urgency of training more dental practitioners, specialists, hygienists and dental therapists and assistants. In 2008 there were 5 430 general dental practitioners, 1 900 of which were working in the UK. There were 302 specialists. The current students output was only 220-250 dentists and 10 specialists in 2009. There were 88 specialist training posts in the four dental schools, 77 posts were filled nationally and the 11 vacant posts were all at UWC, the posts were unfunded by the Provincial Government of the Western Cape.

UWC trained as many African registrars as Medunsa, University of Pretoria and Wits combined and trained more coloured registrars than the other facilities combined. Specialist training at UWC was grossly underfunded with 31% unfilled posts. UWC produced the largest number of dental specialists and undergraduate students. A funding gap exists between UWC and the other dental schools.

Mr M Waters (DA) commented that when the budget was approved it was agreed that the Committee would engage the Department in talks about increased funding for healthcare, however this had not happened. If something drastic was not done, healthcare would collapse in South Africa. There was a need to engage the National Treasury on the healthcare budget and engage the Department on an HR plan as a matter of urgency. He asked why the universities would like the funding of Academic Health Complexes to be national and how it would solve the problem. He said he had gone to visit Pelonomi Hospital in the Free State a month ago and it was in a ‘shocking state’ and it seemed that the Health Department needed to be placed under administration and the Committee needed to suggest this.

Professor Mayosi replied on the request for national funding, that Academic Health Complexes deliver to the nation, so it was inappropriate to expect provinces to prioritise what was a national priority. Money out of the treasury should come straight to academic institutions with special fund rules to support clinical teaching and facilities for teaching. The academic institutions should be taken out of the provinces and created under the Minister of Health. The Universities represented would like the National Health Act to be instituted in full with regard to the Health Complexes.

Professor Stulting commented that a major frustration in the Free State was the Health Complexes’ inability to engage with government, because of provincial government’s unavailability. He said they had the solutions to their problems but could not implement them. In August a Health Summit was organised in the Free State and the Faculty of Medicine was not invited.

Ms E More (DA) commented that there were courses being run at universities to further medical staff’s training, but implementation after training seemed to be lacking. She asked what the universities were doing to ensure this training was used. What were the universities doing about staff leaving/resigning? What had their research recommended about the problems facing primary healthcare and had any of the recommendations been implemented? What was being done to attract and retain researchers? She recommended that the Committee look into the issue of water fluoridation.

Prof Mayosi answered that in regard to training courses, there was a need for more interaction between the academic institutions and the Department of Health when people came for training, so training would be done in light of a plan to move trainees to higher positions once training was completed. He said the Health Complexes stood ready to help and engage on all points of the 10 Point Plan.

On research and the impact thereof there were many successes, for example, simple research had changed the treatment of children with asthma

Regarding ageing professors the universities were doing a lot to attract private funders to be able to create posts, there were no new researches as there were no posts. They had raised over R100 million to create posts in academic institutions so graduates could spend time on research. But this was not enough, it needed to be part of the Health System.

Prof Heather Zar, Head of Department of Paediatrics and Child Health (UCT) and Dr Reno Morar, Health Services Advisor to the Dean (UCT) added that it was imperative to plan for the future and look to improving healthcare for children. South African children were getting sicker and the mortality rate was rising - academic centres had a key role to play here. Academic Health Complexes were often seen as ivory towers and not essential to good functioning of primary and secondary services, however they support/train and give guidelines to these services. For example, they had developed a low cost bottle spacer to replace the expensive inhalers for asthmatics, which was being rolled out internationally. A new way to diagnose TB in children had also been developed.

Training needed to be reviewed in the light of the relevance to the South African environment, particularly in the case of nurses. Graduates need to come back into an enabling environment and use their training. There were no coaching or mentoring programmes in place to provide help.

Ms P Tshwete (ANC) said she would have liked the Department to be present at the meeting to see what was being presented. She would like to know whether the University of the Free State had joint management meetings with the province’s Department of Health.

Ms M Dube (ANC) asked the Committee to take stronger action on the issues highlighted. Was there a structure in place for the universities to share information and help one another? What would the role of a national structure be and how would it be better? There was a need to monitor it so that the better facilities did not get dragged down by the worse ones.

Ms L Makhubele-Mashele (ANC) commented that to date the structure was not working and as a Committee they should be looking into a model of central funding for research. She suggested they engage with the Committee on Higher Education to come up with a model for central funding.

Ms T Kenye pointed out that the use of Afrikaans as a compulsory language in some colleges was a hindrance.

Ms Dube replied that Western Cape Colleges now had dual classes that dealt with both languages. Even the universities known to be Afrikaans were now going the extra mile to provide courses in dual languages.
Ms Dube asked what academics had found regarding diabetes becoming more prevalent.

Prof Mayosi answered that there had been a lot of good research done on diabetes. An increase in diabetes was as a result of unhealthy lifestyles, no compulsory exercise in schools and tuckshops with the wrong food. Specific action was being called for as it could be stopped if the population got moving and eating correctly.

The Chairperson commented that research and training by the Academic Health Complexes was done for use by the whole country so the Complexes were rendering services that went beyond provincial and beyond South Africa, but were funded provincially.

Professor Stulting replied that a Committee of Medical Deans had approached the Minister of Health and had submitted position papers to the Minister but to no avail. The Universities did not hold the purse strings and so could not influence delivery - that remained the mandate of the Department of Health. When budgets were tight, training posts fell off. He suggested training budgets were ring fenced so the institutions could execute their training mandate. He requested a follow-up on the meeting.

The Chairperson commented that the Committee could see one of the challenges was that Health was under-funded, it was a challenge they needed to take up. They also needed to look into poor communications between departments. He said the Committee would suggest that the Academic Health Complexes become nationally funded and they would meet with the relevant authorities on this. The Committee would report back at some stage.

The meeting was adjourned.

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