Honourable Minister, members, fellow South Africans,
Juanita Becker’s published paper titled ‘Reasons why patients with primary health care problems access a secondary hospital emergency centre’ in the South African Medical Journal in 2012.
The researcher wanted to understand why patients went directly to a secondary care hospital in George when they had primary health care problems.
It is a not a trivial question.
If community-based primary care prevents preventable diseases, the trauma and opportunity costs of hospital care can be avoided and physicians are able to focus on patients with emergency complaints.
More broadly, if Primary Health Care (PHC) worked well to prevent disease our country could spend billions more Rands on treating disease and conducting clinical and discovery research to find new cures in the light of our changing demography and shifting complex health burden.
So, what does the research say about PHC in our country?
The researchers found that 88.2% of the patients who came for emergency care at the George Hospital were self-referred and that 30.2% had complaints that lasted for more than a month.
They established that a mere 4.7% of the self-referred cases were for emergency care.
The reasons why patients came for hospital emergency care were:
- 27.5 per cent of the respondents claimed that the prescribed clinic medicine was not helping;
- 23.7 per cent believed that the treatment at the hospital is superior; and
- Everyone complained that no after-hours primary health care services were available.
Health Minister Aaron Motsoaledi is therefore entirely correct in his desire to re-engineer PMC as described of the 2014/15 – 2016/17 Annual Performance Plan.
So, what is the plan?
The George study researchers made some evidence-based recommendations:
- Introduce education campaigns on (i) the primary health care services that are available and (ii) the appropriate use of emergency services;
- Make clinics available 24/7 which will reduce the number of patients inappropriately ending up in emergency care (alternatively, specially appointed clinical nurse practitioners could provide after-hours primary health services at hospitals); and
- Channel patients using the triage system to the appropriate level of care by ramping up the quality of the health information and communication technology and introducing a standard referral letter.
Equally important to consider is the Tshwane Health Post Model.
In a paper published in the African Journal of Primary Health Care & Family Medicine in 2014, Nomonde Bam et al recommend that primary health-care teams with the following qualities be established:
- A health post manager (a professional nurse) and between 20-30 community health workers (recruited from the communities surrounding the health post);
- Each health post serves between 2,000 and 3,000 households in a defined area within a municipal ward;
- The Health Post is hosted by an existing community-based nonprofit organisation (NPO) rooted in the community; and
- That teams collect digitized records using cellular and other modern information technology for the entire community.
Honourable Members, I share this sample of work with you because they come from medical doctors, health professionals and researchers working in the field.
These are people who know how to get the job done.
They know how to apply expert knowledge to the task at hand.
They know what it is like to spend your life devoted to promoting health.
We have a large community of medical and nursing professionals with a wealth of experience, insight and commitment.
It is government’s responsibility to take up the recommendations of health professionals and I believe that Minister Motsoaledi has begun to do so.
The most recent annual performance plan sets as a short term goal improving ‘access to community based PMC services and quality of services at health care facilities. This will be achieved by having 1500 functional ward based primary health care outreach teams by 2014/15 and 3500 by 2018/19.’
But for the life of me, I simply fail to find the budget to support success in PHC.
The budget seems to be inadequate to the task.
Not only is the 2013/14 allocation of R102.6 million small for such a high priority item but it faces a budgeted decline to R93.5m for 2014/15 only to recover with an inflation level increase to reach R98m by 2015/16.
The Portfolio Committee was alarmed by this: ‘PHC services again declines in both nominal and real terms in 2014/15’ its report reads. ‘Less than 1 per cent is allocated to this programme (R93.5m), which is less than it received in the previous year, both as a percentage and in Rand value.’
It is certain that some funds from other programmes such as the R13.049 billion HIV and AIDS, TB and Maternal and Child Health (Programme 3) or the R18.925 billion Hospitals, Tertiary Services and Human Resource Development (Programme 5) are spent through the PHC system.
But I have no idea how much and where.
Similarly, I am certain that some of the modest R621.3m National Health Insurance (NHI), Health Planning and Systems Enablement (Programme 3) must be spent on PHC infrastructure and planning to progressively advance universal access, something the Democratic Alliance wholeheartedly supports (the Western Cape MEC for Health Mr. Theuns Botha for example asked me to convey to the House his willingness to host more NHI pilot projects that advance universal access).
But, again, I have no idea how much and where.
I would therefore like to recommend that Minister Motsoaledi present to the Portfolio Committee (1) a consolidated budget for all PHC activities that form part of his re-engineering intention; (2) some ideas about how he would propose to ring-fence PHC related spending on a provincial level; and (3) explain the paradox that so little is spent on such a high priority item essential to achieving his department’s strategic goals.
Honourable Members, my deputy Dr. Heinrich Volmink and I spent this past Sunday and Monday speaking to medical doctors, nurses and administrators at Pelonomi Regional Hospital and National Hospitals in Mangaung.
We were confronted with the stark reality of the scale of collapse of health services there:
- Patients with bone fractures are accommodated within the referral ward on stretchers due to a shortage of bed space;
- The hospital does not have hot water. Nursing staff and patients boil water in coffee urns;
- Patients bring their own blankets and pillows to hospital due to medical linen shortages;
- The hospital regularly runs out of medical consumables;
- According to hospital staff there are three fully equipped operating theatres on the seventh floor out of operation due to a shortage of anaesthetic machines;
- Some patients in the orthopaedic ward have been waiting for surgery for more than three months;
- According to medical staff at the hospital, only four operating theatres are functional and a fifth is out of commission because it is not equipped with an anaesthetic machine.
This is a moral and constitutional failure that goes beyond the Free State. It is for this reason that we called on Minister Motsoaledi to intervene.
We will spare nothing to compel provincial governments to uphold the Constitutional requirement to make health care progressively available so that there is life in the better life for all.
The Free State hospitals are examples of health institutions that suffer from a double whammy: they receive many patients with primary health care problems because, with some notable exceptions, PHC does not exist in the broad swathes of a large province geographically-speaking and, their own hospital facilities are grossly dysfunctional.
It is government’s responsibility and duty to support the nation’s health community of professionals by ensuring that there is adequate infrastructure, a functional work environment, future oriented human resource development, sympathetic, responsive and professionally organized support services and properly calibrated budgets to make it work.
Honourable Members, I believe that Minister Motsoaledi and his Ministry are a strength in the system.
But the fact is that close to 90% of the health budget consists of transfers and subsidies to provinces and municipalities.
If there is a weak link in the healthcare chain, then it is here.
It is the failure of Municipalities to proactively and regularly test for pathogenic bacterial, viral and parasitic water contamination that led to the wholly preventable and heart-breaking deaths of infants from dysentery in Bloemhof and elsewhere.
It is the failure of most Provincial governments to spend their health funds properly, efficiently and strategically that result in the chaos we have in Limpopo, Free State, Mpumalanga, Eastern Cape and elsewhere.
Judged from auditing outcomes, here are the seemingly intractable problems associated with the worst governed provinces as framed by the Auditor-General:
- Limpopo: 2012-13: Disclaimed with findings. Root causes to be addressed: slow response by political leadership. Lack of consequences for poor performance and transgressions. Key officials lack appropriate competencies;
- Free State: 2012-13: Qualified with findings. Root causes to be addressed: Instability or vacancies in key positions. Vacancies in the districts. Slow response by leadership. Lack of consequences for poor performance and transgressions.
- Eastern Cape: 2012-13: Qualified. Root causes to be addressed: lack of consequences for poor performance and transgressions. Key officials lack appropriate competencies. Slow response of leadership.
- Northern Cape: 2012-2013. Qualified with findings.: Root causes to be addressed: Slow response by political leadership. Slow response by management. Instability or vacancies at key positions in all areas. Key officials lack appropriate competency. Lack of consequences for poor performance and transgressions.
- Mpumalanga: 2012-13: Qualified with findings. Root causes to be addressed: slow response by political leadership. Slow response by management. Lack of consequences for poor performance and transgressions.
- Kwazulu-Natal: 2012-13. Qualified with findings. Root causes to be addressed. Vacancies in key positions. Slow response by management and key officials lack appropriate competencies.
- Gauteng: 2012-13. Qualified with findings. Qualified with findings. Root causes to be addressed. Instability of vacancies in key positions. Key officials lack appropriate competencies/ineffective administrative leadership. Lack of consequences for poor performance and transgressions.
What is to be done?
- Appoint qualified and capable individuals for the job.
- Support them fully, but have real consequences for failure.
- Hold them accountable.
- Ring-fence key provincial budgets.
- Be responsive to problems.
- Support and value our health-care professional community.
I wish I had the time to develop the point properly, but I wish to point out that the National Institute for Communicable Diseases (NICD) – a surveillance body – and its parent the National Health Laboratory Services – a pathology testing body – are bankrupt, have frozen all posts and no longer have a critical mass of epidemiologists working there.
The system of notifiable diseases is spotty and unreliable.
Relying on the Human Sciences Research Council (HSRC) for survey based data on HIV, valuable certainly, is not good enough given that the population of young women presently experiencing a rise in HIV and STD infections cannot be included in the samples because they are under-age.
Add the fact that municipalities are also not testing for pathogens in our water supplies, as a country we are unable to anticipate what will hit us and therefore we cannot prepare.
We recommend therefore the Department create a proactive national surveillance system based on the current strengths in the system as a fully funded programme.
It is my hope that this Department will prioritise the above-mentioned recommendations as we cannot allow a single life to be lost due to the failure of this administration to act.