Owing to a shortage of doctors, patients wait long hours to be treated at Madwaleni Hospital. (Thembinkosi Dwayisa, Sunday Times)

Rural hospitals in terminal crisis

Mia Malan
Rural hospitals are struggling across South Africa - that they function at all is too often not thanks to the state, but the work of Good Samaritans.

For the third year, Dr Richard Cooke and other health professionals will retrace Nelson Mandela's footsteps as a seven-year-old boy.

Next weekend, he and other health professionals will run until their sweat mixes with the dust hanging over a long and lonely dirt track in the former Transkei, where the famous South African and his mother had to walk 34km from their home to Soga clinic at Miller Mission, their closest point of healthcare.

The goal of the Miller Mission Challenge – to highlight the hardship that rural South Africans endure because of poor access to medical facilities – is close to Cooke's heart. For six years, between 2004 and 2010, the doctor toiled at trying to end the complete dysfunction that reigned at the isolated Madwaleni Hospital, Soga clinic's "mother" hospital. When he left his post as clinical manager at Madwaleni at the end of 2010, the facility, which is about 100km from Mthatha, boasted seven doctors – a nearly full staff complement.

The hospital had become renowned in the region for an extraordinary antiretroviral programme for HIV patients, a round-the-clock caesarean section service, an inspiring rehabilitation department and, uniquely in the area, for providing home-based care to chronically ill patients.  

Madwaleni's well-crafted website advertised: "Joining us will provide you with an opportunity to belong to a multidisciplinary team of hard-working dedicated professionals who passionately believe that each member of our community has an equal right to quality healthcare." The website still beams this statement but it is now an illusion, because there is almost no medical team left to join.

Less than two years after Cooke's departure, there is a single physician at Madwaleni: a Dutch doctor who must serve the needs of a community of more than 260000 people. Just two clinical associates help her. These are health professionals trained at a higher level than nurses, but ranked lower than doctors. They  are not permitted to work without a doctor's supervision.

The hospital's theatre is no longer active. No emergency caesarean sections can be performed. Patients who need them are referred to the Nelson Mandela Academic Hospital in Mthatha, an hour-and-a-half's drive away. "I can't say what happens to those who don't make it there in time," said a Madwaleni staff member, who asked not to be identified.

The hospital has also ceased to perform x-rays. According to the health worker, the facility has tried to procure a new x-ray machine for the past two years after the original one broke, but the health department has refused every request. Now, every Friday, patients requiring x-rays are transported to Nelson Mandela Academic Hospital with the hospital's two radiographers to use the Mthatha hospital's x-ray machine.

Said the health worker: "They return to Madwaleni only late on Friday afternoon and, because there is hardly ever a doctor on call at Madwaleni, they are sent home. They are supposed to return on Monday so that the doctor can look at the X-ray. But if the patient lives far away, he or she is unlikely to return after the weekend and often gets lost in the system. Such patients often turn up months later with chronic disabilities due to complications that were completely preventable."

Unwilling celebrity
Madwaleni has, over the past year, become something of an unwilling media celebrity, a prominent side of the blemished face of South Africa's crippled public healthcare system.

Yet Cooke refuses to stop hoping that things will change at the facility. "There is not a day that goes by that I don't think about Madwaleni and I'm still very much in contact with it. I'm going there a few days before the race so I can spend time with some of the people there," he said.

"The clinical staff are extremely dedicated. They just work within a system that makes it impossible to survive. Every time someone leaves, it becomes harder for those staying behind and easier for the next person to leave."

As the hospital's clinical manager, Cooke was the individual constantly fighting a broken system to ensure that health professionals' salaries were paid, equipment was fixed, masks and gloves were delivered and life-saving drugs arrived on time.

He was often unsuccessful, but that there was someone in their corner made it more bearable for his colleagues to operate within the realms of a dysfunctional provincial health department.

Cooke also recruited clinical staff and regularly bused in medical students to encourage them to apply for community service vacancies at Madwaleni. He forged relationships with South African and international universities so that they would send students and qualified doctors to his hospital to gain experience in treating infectious diseases. He personally followed up on job applications to speed up their processing.

But, as is the case in most of South Africa's rural hospitals, where extreme stress and the lack of a quality family life take a heavy toll on staff, Cooke reached "saturation point."

Isolation
"On a personal and professional level I had to move on, away from the isolation and burn-out I experienced at Madwaleni," he said.

"I wanted to get married and the woman I loved lived in Johannesburg. I needed a normal life again."

For months after Cooke's departure, his position remained unfilled. Eventually, someone was appointed in his place, but the person was eventually dismissed for extreme absenteeism.  Madwaleni again slid rapidly towards the precipice on which it is now teetering.   

Said Cooke, who now works as a rural-health consultant: "In rural-health circles, if you don't have a Doberman or Rottweiler [type of person] in place to make things happen, everything soon falls apart because the entire health system is unsupportive."

Cooke does not believe that he was Madwaleni's saviour, but he did lead the facility from the front and his leadership ensured that it never sank to its present low level.

'I must emphasise that I was no more committed than any of my colleagues – it's just that they now have no one to help them fight their battles," he said.

At the receiving end of Madwaleni's decline is the hospital's chief occupational therapist, Emily Currie. She was appointed in April last year and has a deep passion for rural healthcare. Currie is committed to staying for three years to rebuild its rehabilitation department.

Low morale
With assistance from colleagues, she recruited enough therapists to fill the posts at her unit. But low morale now permeates Currie's department. She herself has reached the point where she is preparing to leave at the end of the year, after constant administrative battles.

Currie said there has not been a single month since her appointment that she has been paid a full salary. She has made countless inquiries to administrative staff at the provincial health department and launched several grievance procedures, to no avail.  

"I thought I had been appointed at staff level nine, but after my appointment the health department said that, even though I had signed a level nine appointment letter, they had mistakenly appointed me at level eight. This means I get significantly less money than I signed up for," Currie said.

In addition, as a district health office appointee, the therapist receives a rural health allowance of only 12% of her salary, whereas her far more junior colleagues, who have been appointed by the provincial department, get 17%.

"The district office has told me that Madwaleni is not classified as 'deeply rural', yet the provincial department recognises the hospital as exactly that. Honestly, you don't get more rural than Madwaleni and how does it happen that different sections within the same department have different classification systems?"

Eastern Cape health director general Dr Siva Pillay acknowledged that "the whole rural allowance thing is nonsensical and is going to be reviewed".

However, until that happens, employees like Currie have to suffer the consequences.  

Helples and voiceless
"Because my basic salary is much less than it should be, it follows that annual increases and rural allowances are smaller because they are calculated as a percentage of my basic salary. It has left me in a terrible financial position. I am really drained, sad and angry," Currie told the Mail & Guardian.

But the salary issue is just one of many counting against hospitals like Madwaleni.

Owing to the shortage of doctors, Currie and her colleagues are often unable to treat in-patients in time. "We can't function without doctors. We need to know that patients are medically stable and ready to start rehabilitation. But the one doctor we have has so little time to do rounds that we frequently have to wait for up to a week, when it is sometimes too late, to know if we can start or adjust therapy.

 "I feel abused, because we are the ones on the ground having to explain to patients why there are no services and why we can't help them. They get angry at us, yet we're not the cause of their problems."

She said staff members felt ­"helpless" and "voiceless".

"Whenever people try to speak up about the problems, they are silenced. We've been told that no one is allowed to speak to the media and that there will be strong consequences if we do. But I have decided to speak up, because I feel I just can't fight these battles on my own any longer. I see the lack of service and support every day and feel it's my responsibility to make the rest of South Africa aware of what is happening and that what used to be a really good hospital is now disintegrating. And there doesn't seem to be any plan to prevent its total collapse."

Pillay said he was doing his best to improve conditions at facilities such as Madwaleni. But he is clearly frustrated. In June, his department was stripped of its supply chain and human resources management responsibilities after it failed to pay service providers and the salaries of thousands of nurses and doctors.

Signed off
In an effort to avoid the department being placed under the administration of the national government, health MEC Sicelo Gqobana tasked the provincial treasury with running health services and managing materials and equipment, and the premier's office with staff management.  

According to the medical recruitment agency Africa Health Placements, two foreign doctors – a Dutch couple – are set to begin work at Madwaleni in November and five more doctors from England, the United States and the Netherlands are interested in working at the facility pending job offers from the Eastern Cape health department.

Pillay said he had "signed off" on the appointment of six of these doctors, but he had "no idea" if and when this would be approved by the treasury. "I've done everything I can. I have even personally assisted with the processing of their work permits and foreign registration papers. Now all we can do is wait and see," he said.

Pillay said when he took over the provincial health department in 2009, he did so on condition that a "financial injection" would "manage" the R2.8-billion deficit that he inherited  and he would be given a sufficient budget to run his department.

Although this did happen initially, said Pillay, the situation changed earlier this year when "bean counters" told his department the deficit had to again be absorbed by his budget.

"When you have 47 000 employees and you need R9.7-billion to pay them and you are suddenly told you have to find more than R2-billion because your budget is short, what do you do?" he asked. "Before you even start to pay salaries, you have a budget deficit!"

Pillay said he was also confused about what was funded in his department and what was not.

Budget shortfall
"On paper, staff positions are funded, but if you have a budget shortfall every post is unfunded. Therefore, there is effectively no funded post. That is what treasury has created," he said.  

Pillay, a former medical doctor, has become so despondent that he told the M&G he thought he "made a mistake" in accepting his position. "I thought I could come and clean up the department, but the level of corruption is just so endemic – it's unbelievable," he said.

Zithulele Hospital, near Madwaleni, stands in stark contrast to its neighbour. There, clinical manager Dr Ben Gaunt is leading a health team that has managed to reduce maternal and infant mortality rates drastically over the past six years. Seven out of Zithulele's nine doctors are South Africans, whereas Madwaleni has not managed to employ a single local doctor this year.

But Gaunt and his wife – also a doctor at Zithulele – find themselves under immense pressure. He acknowledged that a "slow exodus" of clinical staff could easily begin at the facility if steps were not taken to avoid it.   

Gaunt said: "One of the key things about rural hospitals is that you need somebody pulling the train a bit and creating an environment for other people to work in. If my wife and I had to leave, it would be hard to retain staff members. Not because I think we're amazing, but because there would be a lack of support within the current health system."

Just as Dr Richard Cooke did at Madwaleni, Gaunt personally recruits most of Zithulele's staff.

"Sometimes it's through friends, sometimes it's people we know, sometimes it's people who have heard about us. But nobody we've employed got here by waking up on a Monday morning, reading a government newspaper and thinking: 'Wow! Zithulele is looking for a doctor, let me apply!'" he said.

A lack of decent accommodation, roads, infrastructure and schools all contribute to doctors being reluctant to take up positions at isolated Eastern Cape hospitals. According to Gaunt, the situation is worsened by government officials who delay the processing of appointments.

Lack of transparency
"They don't appear to understand that doctors aren't prepared to indefinitely wait for government appointment letters. This means rural hospitals lose some of the people they recruit, because they accept other positions."

Even at a well-managed hospital such as Zithulele, said Gaunt, staff were often not paid, or paid incorrectly.

Moreover, he said, the health department's "lack of transparency" with regard to the appointment of community service doctors was cause for concern. "Sometimes, students who put us down as their first choice don't get allocated to us and we have no idea why," said Gaunt.  

Madwaleni did not receive any community service doctors this year. Pillay said this was owing to the inefficient administration of government bursary holders, who are required to work in rural areas, which the department was trying to rectify. "Madwaleni had an allocation, but somehow students who were supposed to go there didn't turn up there. Next year, we're going to make sure that some scholarship students go there," he said.  

Gaunt said although foreign doctors were of great assistance, it was essential to attract South African physicians to rural hospitals as a long-term solution. "We need to specifically accommodate families and therefore make it possible for mothers to work in these places," he said.

Gaunt has split one of Zithulele's doctor posts between his wife, Taryn, and another female doctor to enable both to work but also continue to be mothers. "It's great for them, but also for the hospital, because we don't end up with people with skills sitting at home," he said.  

The Gaunts plan to stay at Zithulele for as long as possible, mainly because of their faith and a strong sense that they have been called to serve the local community. They have built a house at their own cost and Taryn home-schools their children because there are no suitable schools nearby.

Good Samaritans
But, sighed Pillay, the Gaunts were "the exception to the rule" and few doctors had the "same outlook" as they do.

Health professionals agree that relying on more Good Samaritans to turn up periodically is not going to fix the Eastern Cape's – and South Africa's – broken rural health care system; neither is the intermittent flow of foreign doctors who generally work at hospitals for short periods.

With the lack of administrative and management support, many are convinced that provincial health departments such as the Eastern Cape need a complete overhaul. But until that happens and hospitals like Madwaleni receive the support they deserve, staff voids will continue.

Said Currie: "Who in their right mind would want to come to a hospital that doesn't have a human resources manager, that is understaffed and where you don't get paid properly?

"It's all fine and good to be noble and to want to make a difference, but if you aren't given the means to do that, then what's the point?"

Mia Malan works for the Discovery Health Journalism Centre at  Rhodes University

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