Rural Medical Doctors on challenges facing doctors; South African Health Review 2010 and Millennium Development Goals progress: Health Systems Trust briefing

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Health

07 February 2011
Chairperson: Mr B Goqwana (ANC)
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Meeting Summary

The Health Systems Trust (HST) briefed the Committee on the 2010 edition of the South African Health Review which focused on two issues: Reflections on the Millennium Development Goals (MDGs) and the Perspectives on a National Health Insurance (NHI) for South Africa. As is customary, the Review ends with the Indicators section which provides a range of indicators relevant to the Millennium Development Goals (MDGs) and NHI. In the section on the MDGs, a series of overview chapters on selected MDGs are presented. These overview chapters are accompanied by companion chapters or profiles which illustrate examples of successful methods or case studies in achieving the MDGs. The profiles also highlight problems and issues in relation to either achieving the MDG or measuring the related indicators. The provision of health in the country had improved but because of HIV/AIDS, the statistics would show a decline in health. Health Systems Trust informed the Committee that the SAHR indicators showed that it was unlikely that the government would be able to eradicate extreme hunger in the country, and they were unlikely to reduce child and maternal mortality by 2014. However, the SAHR showed that it was possible for the country to combat HIV and other diseases, and that environmental sustainability had already been achieved.

The Committee asked the HST why there had not been a SAHR for 2009, what the Department of Health was doing about the information contained in the SAHR, if Members of Parliament could serve on the editorial advisory board of the SAHR, and they requested copies of the SAHR so they could perform oversight on the District Offices. Members said that they would like to see the HST advising the DoH more and that proper documentation on the National Health Insurance (NHI) was long overdue. The Committee noted that the infant and maternal mortality rates were still increasing and that there was still a long way to go to improve the sector. Members wanted to know the degree to which the HST’s work was funded by the Health Department / government and what HST’s assessment was about whether the MDG’s would be achieved.

Members suggested the HST could not rely on the Health Department for funding and should look to the Health and Welfare Sector Education Training Authority (HWSETA) for financing. They said a “supermarket” approach was needed in primary health care so people could see different kinds of doctors on the same day and would not have to revisit the clinic on different days. Members were concerned that there did not seem to be a strategy around the MDGs. Many other countries with far less resources were doing far better than South Africa and were meeting their goals. The Committee decided it would meet with the Health Department to discuss the matter.

The Committee also spoke with rural medical doctors who informed them about the state of the rural hospitals in the Eastern Cape and how the provincialisation of hospitals by the Eastern Cape and other Provincial Departments of Health had negative effects on surrounding communities. Doctors were an extremely scarce resource in rural areas, it was difficult to get an ambulance to take patients to bigger hospitals, there was a lack of equipment and accommodation for patients. Most hospitals were allowed only one or two doctors that had to serve thousands of people in surrounding communities. Some of the hospitals that were taken over had been forced to take out an overdraft to run the hospitals due to the cutting of hospital budgets. Many of the hospitals were in financial crisis and there were situations where the banks wanted to take the hospital buildings. Most of the buildings belonged to the communities. So, when the process of provincialisation took place, many promises were made. However, after hospitals were provincialised, doctors’ sessions per week were cut down from forty to twenty hours. This meant that a doctor was only allowed to work for twenty hours whether they were on call or not. They argued that the government was creating a situation where small rural towns would not have a resident doctor as they did not have enough incentive to work there anymore.

Members noted that it was their duty to better the lives of the people. One of the ruling party's policies was that the rural areas had to take priority. The matter brought before them was urgent and needed to be discussed. It was decided that they had to hold a meeting with provincial departmental officials to discuss what was happening. The question was how they would be able to convince doctors to stay in these rural areas. Cutting down on the hours left the doctors with not enough money to survive on. Rural doctors would have no choice but to head for the cities to find work.

Meeting report

Health Systems Trust (HST) briefing
Ms Jeanette Hunter, HST Chief Executive Officer, said that the HST had always been a public asset in the country as it belonged to the people.

The South African Health Review
Ms Ashnie Padarath, Project Manager: SAHR, spoke about the genesis of the Review, saying that a meeting was held back in 1994 to discuss how health progress and challenges could be documented. A reputable resource was needed and the document had to be produced by a neutral organisation. The report needed to contain sold, valid and reputable information. A District Health Barometer (DHB) was also initiated.

The SAHR was established as an authoritative commentary on public health issues in SA. It is widely used by government, academics, donors and the media. The SAHR went through a rigorous production process, had an editorial advisory committee, and an internal and external peer review.

SA Health Review and MDGs (The Bird that Flies to the Past in Order to Lead us to the Future)
Ms Sharon Fonn, Guest Editor: SAHR, said that visits to the HST’s website had increased over the years and they received approximately 15 000 visits to the website per month. There were hundreds of people downloading the SAHR. The 2010 SAHR dedicated fourteen of its chapters to the MDGs.

The MDGs consisted of:
▪ Eradicating extreme hunger and poverty
▪ Achieving universal primary education
▪ Promoting gender equity and empowering women
▪ Reducing child mortality
▪ Improving maternal health
▪ Combating HIV/AIDS, malaria and other diseases
▪ Ensuring environmental sustainability
▪ Developing a global partnership for development.

The SAHR indicators showed that it was unlikely that the government would be able to eradicate extreme hunger in the country, and they were unlikely to reduce child and maternal mortality by 2014. In fact, child and maternal mortality had increased over the past few years. The SAHR indicators also showed that it was possible for the country to combat HIV and other diseases, and that environmental sustainability had already been achieved. As a whole, however, HIV was a significant barrier to achieving the MDGs, as treatment alone was not sufficient. The HST wanted to help create an enabling environment so that the country could deliver on quality health services. Leadership towards a common vision was essential.

The SAHR had dedicated five chapters of the 2010 Review to the concept of National Health Insurance (NHI). A resolution was made by the World Health Assembly (WHA) in 2005, which said that everyone should have access to health services and not be subjected to financial hardships in doing so. The mechanism for this was universal health coverage. It meant that the rich and healthy would cross-subsidise the poor and sick. The 2010 World Health Organisation (WHO) report noted three barriers to this. The first barrier looked at the availability of resources. No country had immediate access to every technology and every intervention. The second barrier was the over-reliance on direct payment at the time of illness, and the third barrier looked at the inefficient and inequitable use of resources.

Dr Margaret Chan, WHO Director-General, had noted that no single mix of policy options would work well in every setting and that any effective strategy for health financing had to be home-grown. The HST’s role with NHI was to enhance the performance of health systems for meeting the needs of patients and populations in an equitable and efficient manner. 

Discussion
The Chairperson said the Committee had to work with the HST to perform proper oversight. Members would need time to read the presentation documents as well as the SAHR as it was the first time they were looking at them. He noted that there had not been a SAHR for the year 2009 and asked why this was so.

Ms Hunter replied that there was no SAHR for 2009, nor was there a District Health Barometer (DHB) because there was no funding for it. The SAHR addressed broad policy and strategy issues and the DHB looked at the situation in each of the districts around health service delivery indicators. It was ironic that everyone praised the reports but nobody had wanted to fund it.

Ms M Segale-Diswai (ANC) said she appreciated the information given by the HST. She understood that the HST was an NGO involved in monitoring and evaluation and an advisory body. She asked what the Health Department (DoH) was doing about the information contained in the SAHR, as the report seemed to be a mechanism to improve health services at the end of the day. She wondered why the health sector did not seem to be improving and what impact the SAHR had on DoH’s strategic plan. She would have liked to see the HST advising the DoH more and to see the information in the SAHR contained in its strategic plan.

Ms Hunter replied that she was happy to report that over the last few years the HST's findings had been taken into consideration and translated into policy. For example, the Prevention Of Mother To Child Transmission (PMTCT) programme started in the country was taken from the HST's research findings. Also, the President's announcement on HIV counselling and testing campaign was directly related to the findings of the advantages of Highly Active Anti-Retroviral Therapy (HAART) versus just ARVs. There was definite evidence of the HST's work being translated into policy.

Mr G Lekgetho (ANC) asked HST if Members of Parliament could serve on the editorial advisory board of the SAHR. He was a little sceptical about it as Members were supposed to perform oversight on these entities. He said that it would be better if Members had access to the SAHR document because it would help them to understand the HST’s mandate better. He would be happy if the HST could give the Committee copies of the Report and the District Health Barometer so he could perform oversight on the District Offices. The Committee wanted the physical addresses of the District Offices. The NHI was long overdue and he noted the HST was upset that there were no documents available about the NHI in the country. The Committee needed to fix this problem. He asked what the Committee could do to fast track this process.

Ms Hunter explained that the invitation for Members of Parliament to serve on the SAHR editorial could be linked to Mr Kganare's question on the DoH's Ten Point Plan. It showed what the members considered as important and gave the HST guidance on what should be included or focused on in future reviews. In introducing the Review, the HST was aware that they had to keep a fine balance and stay as objective as possible. The HST employed independent authors for the SAHR as they did not want to make the review a vehicle to “flog” the DoH. The HST received a little money from the DoH, but they were also aware that they could not be “unduly pro the DoH”. The HST saw Members of Parliament serving on the editorial committee as a way of keeping the balance to stay objective. The HST also valued Members input on what they thought were relevant issues to address within the publications. 

Ms Hunter said that the HST would provide the Committee with the addresses of Health Districts around the country. The District Health Barometer could assist the Committee's oversight role by showing what was happening in the districts in terms of health outcomes.

Ms Hunter explained that there had been no documents on the NHI in the public domain except for the ANC's documents. But, now that the HST was working with the DoH, they saw that the DoH wanted to have a clearer and complete document out in the public domain to show what they were planning.

Ms Fonn added that all the relevant stakeholders were asking for a more comprehensive document on the NHI. It was important that the process was not delayed.

Ms Hunter addressed the question on what the HST wanted the Committee to do. She said that they wanted the Committee to exert some pressure so that communication of the processes of the NHI could improve.

Ms T Kenye (ANC) appreciated the work that the HST had done so far. She noted that the infant and maternal mortality rates were still increasing. There was still a long way to go to improve the sector.

Ms Fonn answered that the infant mortality and maternal mortality was very high. There was a decrease in child and maternal mortality in the 1980s and 1990s. However, from 2000 onwards, mortality rates increased because of the increase in HIV/AIDS. If it were not for HIV/AIDS, the country would be on track for meeting the MDGs.

Ms C Dudley (ACDP) thanked the HST for the SAHR saying that it was going to be very useful. She asked to what degree the HST’s work was funded by the DoH or the government. The HST spoke of haemorrhaging and poor quality care in the health sector. HeHebfjfjcfdkdkdkkskdskjHaemorrhaging was spoken of in very general terms. She asked the HST to elaborate on what was causing people to haemorrhage. On the MDG Chapter on the experience of the Tamil Nadu state in India, she asked how long it had taken with the step by step implementation until changes had manifested. She asked if the HST had any comments on the HIV testing in schools. She wondered how the findings of the SAHR would impact on the concept of the NHI and if the HST was going to apply its findings to the issues that needed to be looked at.

Ms Hunter replied that the HST received an annual grant from the DoH for certain research that had to be conducted within the health sector. The amount made up approximately 5% of the HST’s total budget. At the moment, the amount given by the DoH stood at approximately R2.7 million a year. The DoH did not really want to fund the SAHR and the DHB because they wanted the reports to be independent publications.

Mr D Kganare (ANC) said that the findings of the SAHR were very important and the Committee had to find a way to work more closely with the HST. The HST could not just rely on the DoH for funding; they should also look at the Health and Welfare Sector Education Training Authority (HWSETA) for financing. The DoH had its own ten point plan to achieve the MDGs. In the HST’s assessment of whether the MDGs would be achieved, how effective had the DoH been? What were the impediments to achieving the MDGs? The issue of health could not be handled by the DoH alone, it involved other departments as well such as the Department of Water Affairs (DWA) and the education departments.

Ms Hunter answered that donors were not as independent as they wanted the world to believe they were. Unfortunately, through the SAHR and the DHB, HST was not very popular with the DoH. Donors were scared to support the HST as they were not the “flavour of the day”. The HST also learnt, through actively seeking funding, that donors liked to fund projects that showed they had impacted directly at a community level. It was difficult to find donors that wanted to fund academic papers. However, she felt better about the future of the SAHR. The Minister had met with the HST and told them how often she used their reports.

Ms B Ngcobo (ANC) asked if the HST had been working with the education departments to visit schools. There seemed to be an increase in teenage pregnancies. She asked if the HST had done any studies on this matter. It had been said that learners became pregnant so they could receive the Child Support Grant (CSG). She noted that a “supermarket” approach was needed in primary health care so that people could see different kinds on doctors on the same day and so did not have to come on different days.

Ms Fonn replied that it was a very common thought that there was a relation between the child support grant and teen pregnancy. Research showed that there had not been an increase in the teen pregnancy rate. There was no difference in the rate of pregnancy if one looked at the rates from before and after the grant was introduced. There was no data to support the idea that grants made a huge impact on the rate of teen pregnancy.

Ms Hunter replied that the HST would support a move in the direction of a “supermarket” approach.

Mr M Waters (DA) addressed child and maternal mortality. He noted that the DoH’s Ten Point Plan addressed the matter, but he worried that even though there was a plan in place, there did not seem to be strategy. There did not seem to be a strategy around the MDGs. Many other countries with far fewer resources were doing far better than South Africa and were meeting their goals. He suggested that the Committee meet with the DoH to discuss what they were doing to achieve the MDGs.

The Chairperson agreed that the Committee would meet with the DoH.  

Ms Fonn addressed the question of the Ten Point Plan. One of the things that the DoH was doing was looking at how they could integrate services. The process of regenerating and invigorating primary health care was to try to build a health system that would look at the integration of health services. It was a complex task but she thought they were moving in the right direction.

Ms Hunter addressed the question of whether the DoH had a strategy and plan for combating maternal and child mortality. The HST had recently completed a project funded by Unicef and the DoH that looked at piloting a plan for improving the health of mothers and children under five. There was a lot of good happening, as the DoH was following the HST recommendations. However, there was still a lot that had to be done.

Ms Hunter noted that the Committee was aware of the service level agreement that the Minister had with the President. The DoH Director-General had called the HST in to discuss the strengthening of district health systems. She told the HST that she wanted them to focus some of their attention on that area so they could assist the DoH with the weaknesses regarding financing and planning for finances in the districts, as well as the management of health districts.

The Chairperson said that he hoped it was not the last time the Committee would meet the HST. There was a definite need for the Committee to interact with the entity and with the information they could provide. He thanked the HST for their presentation.

Rural Medical Doctors briefing
The Chairperson informed the Committee that the guests were from small rural towns in the country where there was one doctor for the whole community. This doctor would have his or her own private practice and would also be the only doctor in the town. However, some provinces had decided to cut down on the number of doctors and the amount of work they did instead of giving them more doctors. The guests would talk about the impact this was having on the hospitals and the health statistics in those areas.

Briefing by Dr Nqabisile Nyushman (Medical Superintendent: SAWAS Memorial Hospital)
Mr Nyushman informed the Committee that the Eastern Cape was mostly made up of rural farming towns and had 18 provincially aided hospitals. Provincially aided hospitals were not well known entities in South Africa. Recently, most of the hospitals were provincialised. The hospitals were strategically placed around communities; however, the problem was that they were not well-equipped and had limited resources. Doctors were seen as a scarce resource. It was also difficult to get an ambulance to take patients from the rural hospitals to the bigger hospitals in Port Elizabeth. In order to reduce this problem, the smaller surrounding towns decided to work together so that there was always an ambulance available if a town was need of one.

Most of the rural hospitals had facility problems such as a lack of equipment or they had outdated equipment. There was restricted accommodation for patients; there were only twenty beds for the thousands of people in the surrounding communities. Most rural hospitals were given an organogram that said they should have one doctor. This was a very difficult situation for the hospitals, as there would be one doctor for thousands of patients. It was a struggle for the hospitals to get permission to have two doctors present at a time.

Doctors usually worked forty hour sessions a week, but after hospitals were provincialised, the time was cut down to twenty hour sessions a week. This meant that a doctor was only allowed to work for twenty hours whether they were on call or not. So, what was meant to improve service delivery and keep doctors in the rural areas had now been changed and was chasing doctors away. Hospital managers usually knew how many sessions to assign to the doctors, as they knew what the influx of patients were. However, this had changed since the provincialisation of the hospitals. Doctors would only be paid for twenty hour sessions. This meant that there was no incentive for doctors to stay in the small towns or rural areas.

Briefing by Dr Susan Christiane (Resident Doctor: Dordrecht Hospital)
Dr Christiane stated that she had worked at clinics in the districts areas of Dordrecht in the Eastern Cape for many years. She concurred with everything that Dr Nyushman had said and told Members that this was not just happening in the Eastern Cape, it was happening all over the country as well. Many hospitals were told that there was no more money for provincially aided hospitals. This forced hospitals to become provincialised. Doctors complained that they would leave the rural hospitals if their sessions were cut down from forty to twenty hours per week. The government was creating a situation where small rural towns would not have a resident doctor. She argued that provincialising hospitals meant that it took away the impetus of the community to be interested in their hospital. People had to be encouraged to participate in their own health. Therefore, the reason they were at the meeting was to highlight the problem that the rural hospitals all over the country were having. They wanted to ask the government to support rural health and to support rural doctors to render the service that they were trained to do.

Briefing by Ms Jessica Johnson (Chairperson of Hospital Board: Association of Provincially Aided Hospitals)
Ms Johnson informed Members that eleven of the eighteen hospitals in the Eastern Cape had been provincialised by the Eastern Cape Department of Health. The doctors’ concerns stemmed from this process of provincialisation. Provincialisation also affected the benefits that staff received. Some of the hospitals that were taken over had overdrafts. They had been forced to take out an overdraft to run the hospitals due to the cutting of hospital budgets. Many of the hospitals were in financial crisis and there were situations where the banks wanted to take the hospital buildings. Most of the buildings belonged to the communities. So, when the process of provincialisation took place, many promises were made. Communities were promised that hospitals would be better run. However, this was not the case. Staff members still seemed to be “suffering” and the morale was very low.

Discussion
The Chairperson noted that there were certain things that the Committee had to educate themselves on. The Committee's duty was to better the lives of the people. Members agreed that there was a shortage of doctors. One of the ruling party's policies was that the rural areas had to take priority. He had hoped for more information or statistics on the rates of infant mortality in those areas and what happened when there were no doctors around. He summarised that the state-aided hospitals were owned by the people themselves and were run by the board. The government funded 90% of the running costs of these hospitals. The hospital boards decided who to employ and when to employ the person. These hospitals were now being taken over by the provincial health departments. The question that the Committee had to ask was whether it was the right time for the DoH to do so. Was this what the Committee and the people wanted? There was a shortage of personnel in these areas. The question that had to be asked was how they would be able to convince doctors to stay in those rural areas. There was no point in cutting down on the incentives that convinced the doctors to stay in those areas in the first place.

Ms Segale-Diswai stated that it would have been appropriate for the Members to have perused the presentations before the meeting. The Committee needed to understand what the guests were talking about.

The Chairperson replied that the Committee was not going to make recommendations yet; they were only supposed to listen and then decide what they would do.

Mr Lekgetho added that the matter brought before them was urgent and needed to be discussed. The Committee had to hold a meeting with provincial departmental officials to discuss what was happening.

The Chairperson said that the Committee would discuss the matter further.

Dr Nyushman replied that he had suggested that they compile certain statistics. At the end of their budget reviews, there had been statistics. They would supply the Committee with this information.

Mr Kganare stated that the issue of incentives for rural doctors had to be revisited.

Mr Waters said that he did not want to detract from the seriousness of the situation in the Eastern Cape, but the Committee also had to focus its attention on the other provinces. The Committee had to speak to provincial departments as well as the DoH to get an understanding of the severity of the problem and what was being done in each province. Local people knew best how to run hospitals and could probably do it more cost effectively.

Dr Nyushman answered that the local doctor could probably handle certain things better than the province could. For example, the hospitals did not have a problem with maternal mortalities. The infant mortality rate was also quite low.

The Chairperson informed the Committee that the DoH had been informed that rural medical doctors were going to appear before the Committee. He had also tried to find someone to represent the Eastern Cape Provincial Department. However, it had been short notice and the Easter Cape Provincial Department had not been able to attend. 

Dr Christiane stated that she did not think that government should feel that it had not done a good job. It was not the government's responsibility for so many people having HIV/AIDS. The government could not take responsibility for peoples actions; people had to be asked to take responsibility for their own health. This meant that all statistics would be marred. Health in the country had improved but because of HIV, the statistics would show a decline in health. She was sorry that they did not have the statistics to give to the Committee.

Ms Johnson added that the hospitals could prove that they could render a cheaper service than the government. They had compared one of their rural hospitals to one of the state hospitals and it was found that the rural hospital was more cost-effective even though the state hospital received more funding. 

The Chairperson stated that the Members would look into the issues presented to the Committee by the rural medical doctors. Something had to be done for the hospitals at the primary healthcare level. His experience was that hospitals run by their communities were better run than most hospitals. The Committee was there to question certain policies if they thought these did not benefit the communities. They would interact with the DoH to find out if the policy was moving the country in the right direction. After this interaction, a recommendation would be made.

The meeting was adjourned.

Appendix:

 

18 hospitals set to collapse

09-Feb-2011 | Anna Majavu

The Eastern Cape's 18 community-run rural hospitals are in danger of collapse, doctors told Parliament yesterday.

The community-run rural hospitals are known as "provincially aided hospitals".

They get a 90percent subsidy from the government, but were built by their communities and are controlled by a board of directors elected by their communities.

There are two doctors at each hospital who are paid to work 40 hours a week each - but in practice are on call 24 hours a day and work when they are called at night.

But now the Eastern Cape health department has decided to slash these doctors' sessions to 20 hours a week, leaving them without enough pay to survive on, Adelaide Provincial Aided Hospital's Dr Susan Christiane told Parliament's health portfolio committee yesterday.

"The proposed plan is an insult," Christiane said, adding that rural doctors would have no choice but to head for cities to find work.

The government will then have to contract doctors from the nearest large towns for 20 hours a week each.

Christiane said it would cost more money to get outside doctors who will only work 20 hours a week - and who will charge the government for transport and accommodation.

"The poor people will suffer. They need committed, compassionate, resident doctors," she said.

Though the provincially aided hospitals are small and lack equipment, many of them perform critical operations like Caesarian sections and appendectomies, and deal with accident and assault victims throughout the night. This will not be possible if their resident doctors leave, the committee heard.

Handing over a hard-hitting dossier detailing the problems in rural areas, Dr Nqabisile Nyushman told the committee that the government also plans to put the provincially aided hospitals under their control.

This will lead to another serious problem - the buying of hospital food and linen will be done through tenders, and a few companies will charge the government a lot more than it is paying now.

"Some provincial hospitals pay their suppliers up to R22,50 for a loaf of bread and R65 for a pocket of oranges. Our average is R5,50 for bread and R15 for oranges," he said.

At Maclear Hospital they used to pay R150 for a load of firewood. After being taken over by the government they now pay R750 for the same quantity" Nyushman said.

Former Eastern Cape health MEC Bevan Goqwana, now chairperson of Parliament's health committee, complained that the government always paid more once a tender was issued.

"It is a national problem that if you get a government tender for a bottle of water it might cost R20, but when you buy it yourself it costs R10," he said.

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