Why South Africa's health record is poor

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"As a country we spend 8,7% of our GDP on health in both the public and private sectors, yet we have little to show..."

Despite the fact that South Africa spends a higher proportion of its Gross Domestic Product (GDP) on health than any other country in Africa, its health record compares badly against those of many poor African countries.

"As a country we spend 8,7% of our GDP on health in both the public and private sectors, yet we have little to show for it compared with many countries that are a great deal poorer than us and spend much less on health," says Daisy Mafubelu, chairman of the organising committee for the Department of Health's upcoming Nursing Summit in Sandton from 5 to 7 April.

Mafubelu, a former nurse and lecturer, has held senior positions in the South African public health sector and went on to become assistant director of the World Health Organisation (WHO) between 2007 and 2010 -- achieving the distinction of being the first nurse to hold a senior position in the United Nations.

She now runs a management consultancy based in Johannesburg. One of her briefs at the WHO was to gather information about the incidence of child and maternal mortality, including the impact of HIV/Aids, in countries around the world. "We found that 68 out of 193 countries contribute more than 95% of children and maternal deaths -- and South Africa, despite its relatively high expenditure on health, is one of the 68," she remarks.

"In addition, you will also find that there are many other African countries that are not on this list, although they don't have anything like the resources we have. So what are we doing wrong?" Nurses and midwives form the bulk of the health force.

The SA Nursing Council has carried out an investigation to establish the causes of this state of affairs and plans to work with nurses and midwives to address the problems in order to improve the situation. A variety of causes have emerged from its investigations -- ranging from inadequate training of nurses and midwives in basic obstetric and emergency obstetric care; lack of infrastructure in terms of equipment, drugs and medicine; inadequate school and district health services; and faulty organisational and management structures.

"Training needs to be upgraded in terms of basic and emergency obstetric care. More time needs to be spent on midwifery in the training courses, including more clinical practice and dealing with emergencies. "Furthermore, better support systems need to be put in place in the hospitals," Mafubelu stresses.

"Some of our private hospitals can compete with the best in Europe, but in other areas infrastructure is sadly lacking. South Africa has a reputation for paying well compared with other developing countries, but we have found that it is not only the question of money that makes people dissatisfied. In fact, conditions of service and infrastructural support, such as equipment, medicine and transport, are seen as more important than money and frustrate people more when they are lacking or unreliable."

She states that a great deal more could be done on the preventative side, by curbing problems before they start, than is being done at present. "Our present approach is mainly curative, which is more expensive, whereas much could be achieved by nurses visiting schools and communities to promote healthy eating and habits."

Mafubelu cites Costa Rica and Brazil as good examples of countries where such preventative programmes have been taken much further to good effect. "They have divided the country into small manageable health units, in each of which roughly 1000 people are looked after by a dedicated health team.

At government level they assess the needs of various areas and allocate the health teams accordingly. In a rural area for instance, where the people are usually sicker, they allocate a larger team.

"Not only do they achieve better health outcomes in this way, but they do so at less cost." On the score of having more efficient organisational and management structures, she uses Kenya as an example of the kind of workable system that ought to be adopted.

"There the government has an overall manpower plan that includes nurses and midwives. They have a post of chief nursing officer, a government official who is in overall charge of the country's nursing programme and to whom nurses can go with their problems. They also have other officials at a lower level who report to the chief nursing officer and are dedicated to attending to nursing matters," she points out.

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Daisy Mafubelu