Tolerance of incompetence is key to SA’s poor healthcare – HST report

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A tolerance of incompetent staff Is a key reason for the poor performance of SA’s health service, according to the Health Systems Trust‘s annual report.  Meanwhile, an alarming number of state health workers in KwaZulu-Natal are reporting in “too sick to work””– with absenteeism costing the province’s Health Department R452m in one year alone.

The Health Systems Trust’s annual publication on health trends and topics in South Africa includes chapters on water and sanitation, eHealth, and sexual and reproductive health, reports Health-e News. In a forward by authors, the review notes that its 20 chapters largely reflect current trends in the global health and development agenda, including focuses on universal healthcare as well as good governance.

The 369-page report is divided into four themes, namely leadership and governance, human resources for health, service delivery and information.

Now in its 19th edition, the review begins with an overview by University of KwaZulu-Natal’s Andy Gray and Yousuf Vawda of new heath policy and legislation. The pair notes that while the long-awaited National Health Insurance White Paper was released, related funding and policy issues have yet to be finalised.

The book then goes on to discuss topics including the impact of climate change on water, sanitation and health before looking at the state of nutrition and non-communicable diseases. Chapters on breastfeeding, the eHealth MomConnect programme and the intersection between biomedical and traditional sectors all follow.

Notable chapters focus on the rights and health issues of sex workers in the wake of the South African National AIDS Council’s national sex work plan and financing South Africa’s HIV response.


There is a human resource crisis in healthcare that is driven partly by government tolerance of incompetent staff, Health-e News reports that the review found. It paints a picture of massive differences in the quality of health services between provinces.

You are least likely to see a dentist or a doctor in the 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 around 1,100 practicing 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 the North West, which has 21.3 doctors per 100,000 people (nine below the national average).

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 that has fewer doctors in 2015 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 per 100,000 people), while if you need counselling it’s best if you don’t live in Mpumalanga, which only has one psychologist for every 100,000 residents.

Between 2010 and 2015, the infant mortality rate increased in the Eastern Cape, where there are now 43 deaths per 1,000 babies – almost three times the rate of 16.5 deaths per 1,000 in the Western Cape.

Meanwhile, 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 government’s tolerance of incompetent staff as a key reason for the poor performance of South Africa’s health service. Over a period of four years, there was R24bn 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% of provincial budgets.

She blames 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, government spent R1.5bn in the 2009/10 financial year to hire temporary agency nurses for public sector hospitals. Meanwhile, 40% 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 around the same number of obese girls and boys under the age of 15 (13.6%), in adulthood women tend to balloon – almost 40% of adult women are obese in comparison to around 10% of men. In men and women over 65, hypertension is the norm, affecting almost 80% of women and 70% 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%,” 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,” she adds.


Increasing the HIV/Aids budget in the current fiscal climate will be tough, Business Day reports that the review found.

South Africa has the world’s largest HIV burden, with between 6.4m and 6.8m people infected with the disease. By December last year, 3.26m of those with the disease were on treatment.

The expansion of this treatment programme by about half a million people a year has required an extra R1bn-R1.5bn a year. And, the report says, this has put increasing pressure on other aspects of health-care spending and raised tough questions for the government about how best to allocate its limited resources.

Healthcare spending is constrained by a long-standing government expenditure ceiling put in place because of low economic growth, the weak rand, a high fiscal deficit and a lower credit ratings cloud that have increased debt-servicing costs. At the same time, the report says, the government has committed to expand its HIV/Aids prevention and treatment programmes, the costs of which have grown 14-fold in nominal terms since 2004-05. Its HIV/Aids allocations have grown from R1.2bn in 2004-05 to R17.5bn in 2016-17.

Modelling the costs of various responses to the country’s HIV/Aids epidemic, the report says the authors concluded that a more aggressive, earlier intervention would have a greater effect on health outcomes in the next 20 years and that this would lead to reductions in total spending in the long run.

A scenario that provided for condoms, medical male circumcision, antiretrovirals at current guidelines, prevention of mother-to-child transmission of HIV and infant-testing at six weeks would take South Africa close to the United Nations 90:90:90 targets to which the country has committed.

However, this would require significant additional funding in the medium term – an extra R6.95bn in the next 10 years, said Yogan Pillay – the Department of Health’s deputy director-general for HIV/Aids, TB and maternal, child and women’s health – who is one of the health study’s authors.

Pillay said in the report that South Africa’s HIV/Aids programmes had scope to be more efficient, for example, by providing medication to stable patients via courier pharmacy services or adherence clubs, rather than at hospitals.


Injuries transport accidents and violence account for over a quarter of all emergency department visits, yet many hospitals are ill-equipped to deal with them. Health-e News reports that this is the conclusion of a 2010 study of trauma in KwaZulu-Natal, which estimated that the cost of trauma care in the province that year was almost R5.4bn, according to Dr Timothy Hardcastle and colleagues in the review. At one large trauma referral centre serving most of rural KZN, the cost of treating victims of interpersonal violence alone (38% of the trauma burden) amounted to over R32m per year.

There were 197,219 emergency department visits for trauma in 2010 (27% of all emergency department visits) and almost 102,000 trauma-related emergency medical services (EMS) call-outs. Almost 80% of patients were considered serious or critical, yet only 40% were admitted directly to the correct level of care. The others went first to primary healthcare facilities. “Less than half of the province’s district facilities had adequate resuscitation-area facilities, none had CT-scanners, only 62.5% had emergency mobile X-ray units, and 58% did not having access to an emergency operating room,” according to the review.

Nationally, South Africa recorded over 50,000 trauma-related deaths in 2009, the majority related to transport and violence. For every death, it is estimated that there are between 10 and 50 injured survivors, half of whom will have a permanent disability.

Young, healthy men of low socio-economic status influenced by alcohol and drugs are worst affected by trauma. Three Pietermaritzburg hospitals, which treated over 5,000 trauma cases in 2010, recorded four times as many male patients as females.

Hard castle, from the trauma unit at Inkosi Albert Luthuli Hospital, and co-authors George Oosthuizen and Damian Clarke from the Pietermaritzburg Metropolitan trauma, along with Dr Elizabeth Lutge from the provincial health department, conclude that the health department cannot address trauma alone. They call for inter-ministerial units to work together to address the injury burden, most of which should be preventable, including law-enforcement (Justice and Police), road safety (Transport) and social change (Social Development/ Home Affairs).

There should be a “coherent functional trauma system, from pre-hospital to hospital level” to “deliver the right patient to the right facility in the right timeframe, and reduce morbidity and mortality through provision of quality care”. In addition, injured patients should have access to rehabilitation services to ensure that they “are restored as economically viable members of society, through a well-orchestrated, continuous care pathway,” conclude the authors.


Meanwhile, an alarming number of state health workers in KwaZulu-Natal are reporting in “too sick to work””– with absenteeism costing the province’s Health Department R452m in one year alone.

A Daily News report says the review spoke of a crisis of ineffective health management in South Africa, painted a dismal picture of a lack of organisational support, and psycho-social stress among public health workers, resulting in high levels of absenteeism across all public health care facilities. According to the HST, this province (KZN) is the worst affected.

Despite there being a national guideline on the medical surveillance of health workers, researchers found this was not being implemented. “In some KZN institutions, medical surveillance programmes are managed by sessional doctors, mostly without any specific training in occupational health, and in others there is no medical doctor. Doctors without the necessary training are not able to assess hazards, nor are they able to recommend interventions to control these hazards or to implement medical surveillance to detect workers who are likely to acquire work-related diseases,” the review said.

The report said the result was employees taking time off, leaving a huge hole in KZN Health coffers: R452m in 2014, compared with R15m the same year in the national Department of Health.

Health-e News material
South African Health Review 2016
Health-e News material
Full Business Day report
Health-e News material
Full Daily News report

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