The author, a public servant in the Department of Health of South Africa, offers an analytical view of the country's current state of the health sector, especially in rural areas of South Africa.
The National Department of Health has become one of the distressed departments in both the Zuma and Ramophosa’s cabinets. Way too many complaints, allegations and challenges have been levelled against the Department. These complaints come from both the community and the employees alike.
At the helm of it all is a challenge regarding the condition of our Primary Health Centres (PHC) in general. The Department is facing lawsuit cases and this has become another problem, as the funds that are allocated for the provision of the services have to be redirected to resolving these issues. As the result, the Ministry of Health has been on the spotlight and as unfortunate as it is, it is mainly for the wrong reasons.
This article takes an analytical look inside the PHCs mainly focusing on the challenges endured by the employees as they feel that they are not appreciated enough. The truth of the matter is that the media is mainly highlighting the problem from the point view of the patients not the staff’s.
It is a known fact that some of the country’s health facilities are old and dilapidated. As you walk to most of them what you see first is the dirty surroundings of the buildings. Most of the facilities are old buildings made up of cracked walls, dirty and patched up painting with grass and litters around the buildings. If you are a visitor or a new person to the place, the look does inspire confidence and hope that this is a place one would get help and satisfaction. The environment is just not welcoming or promising.
As you enter the door, you are greeted by desperate and frustrated eyes of people who have been on the waiting area for a long time. There are those who wake up in the early hours of the morning to try and shorten the time they spend in the queues. For a clinic that opens at 7:30am you find a person who was at the door since 6-6:30am. This waiting is frustrating and inconveniencing for many, but it is seen as the only option to avoid the long waiting.
The attitude of some employees is another urgent matter that must be attended to. These people have a serious behavioural problem. It is like they are trained to be thick skinned, cold-hearted individuals who don’t appreciate the circumstances of the patients. The tone some of them use to the patients is not desirable. These I believe contribute massively to the rising numbers of defaulters. People who cannot take the bullying of the nurses resort to rather stay without medication.
In one facility, I witnessed an incident where the home based care givers were tasked with tracking down defaulters and referring them back to the facility. Upon the defaulters arrival, the nurse refused to help the patient citing that she doesn’t have time for her and she will have to wait until she finishes her administration work. In another incident the defaulter came back on her own will, but did not get attended to because the nurse who advised her to get medication was not on duty. On both occasions, the patients stormed out of the facility and highlighted that it is this ups and downs they encounter when they want their medication that keep them away from the clinics. They left the clinic without medication and vowed not to come back again.
In some other facilities there is no or not enough medication. The patients have to go to the clinics every day or week to check whether their medications have been delivered. The facility managers argue that they follow proper procurement procedures and are ordering enough and much needed medication, saying that it is the Department that doesn’t deliver. The delays in the delivery of the medication can mess up the medical progress of some patients. For example, you find a patient who has been on a particular medication for years having to stay for a while without it; this has the potential to have them relapse or react negatively, putting their lives at risk.
The availability of other medication like contraceptives is not consistent, for example, one day you find Depo-Provera, the other day you only find Nur-Isterate, it is a miracle to be able to find them all available at once. So people are given what is there, not what their bodies or systems are used to. This concerns many who believe that their hormones are messed up and resolve to stop taking contraceptives. Whether this is a factor in the rising numbers of teenage pregnancy or pregnancies in general is a subject worth exploring on its own.
In one community health centre that I visited there is no enough beds for patients. Sometimes when a patient has to be admitted, the admission gets postponed until there is space to accommodate them. In this very facility it is a known fact, even around the community, that there is no enough food for admitted patients so it is up to the family to see to it that their patient has enough to eat. It is for these reasons that patients are unable to be kept for a long time in a hospital even if their conditions require so. So an alternative is to discharge them and have them follow up at a local clinic or even at the very same hospital but as out patients.
Those in charge of the facilities posit that their problems lie with the Department. They allege that the decisions are made for them by their seniors who stay in the offices and do not have a clue of the challenges on the ground. They also highlight that the policies are made and adopted without their input. Some argue that should the managers spend just a day in the facilities they will sing different tunes, having been exposed to and understood the trials and tribulations they deal with on a daily basis. It is the nurses who believe that the challenge is that the policies and procedures are imposed on them. In investigating the staff’s grievances these came to the fore:
The exact allocated funds for most of the facilities are never disclosed to the managers. The operational managers are required to submit procurement plans every financial year to their area managers. What these managers do is to submit the list of their facilities’ requirements, and then it is their seniors who decide when, what and how much money they get.
The challenge is that the facilities never get what they are asking for; it is either they get too little or the opposite of what they ordered. In addition, the necessities like cleaning materials are never enough because the budget is claimed to be finished even before the financial year elapses. The money gets exhausted even when the clinics did not get all their ordered requirements. One operational manager claims that at times she was forced to use her own money to cover the necessities the clinic can’t operate without such as stationery, disinfectants, cleaning materials, toilet rolls etc. The operational manager posits that it is hard to adhere to a budget that you don’t know how much you are working with. “If you send an order, you have to pray that you get them [materials], ordering is not a guarantee that we will get them all”, she said.
Shortage of staff
The problem of shortage of staff starts from a gardener, to reception right through to the consulting rooms. Because of this shortage people find themselves performing the duties they are not hired for. For instance, in one facility that is known to be very dirty I found that the cleaner is performing the driver’s duties because the facility has no designated driver. The staff alleges that mismanagement occurs because people are performing the duties they are not trained to do. The nurses also complain of being overworked. They assert that patients wait for a long time to be attended to simply because there is no enough staff to attend them.
In majority of PHCs, there are never enough nurses on duty. Those on duty become so stretched that sometimes they do not get time to eat and they argue that this affect their productiveness. Others add that the bad attitude and short-temperedness emanates from fatigue and tiredness. One nurse assets that, “How do I give a happy and welcoming face when I am too exhausted to even stand? Yes I get agitated when yet another patient on top of the 100 I have attended to alone walks into the clinic”. In one facility a cleaner who works as an administrative clerk said that, “I can’t run around looking for a file, if I don’t find it where it should be I just open another one”. Who can blame him? This is a person who doesn’t understand the importance of record management, he never had training, therefore doesn’t understand the sensitiveness of the matter.
Lack of communication
There is no communication between the decision makers and the implementers. The Department’s administrators who are responsible for managing and supervising those in the facility rarely go to these facilities. For those who happen to “drop by” it is either a mere in and out trip delivering something, giving more work or introducing many projects to be implemented or a five-ten minutes “support visit” and making empty promises about improved working conditions.
There is no security to protect the staff. The safety of the staff is taken for granted. Their lives are at risk, as they sometimes work with unstable, violent, abusive and angry patients. Some patients do not have the patience to follow orders and procedures, when they are kept in line they revolt, threatening the very lives of those who are expected to attend to them.
Not all health facilities have security guards. In Warrenton, Northern Cape, for instance, out of four health facilities only one has security guards who are only placed at the gate and are nowhere inside the facility. It is my observation that the security guards are mainly placed in the hospitals not the clinics, however the dangers are the same. In some facilities the security guards are only hired to patrol at night, looking after the empty buildings. This might suggest that the Department only cares about the materials and equipment but not the lives of its employees.
Within the Department the reality is that there is low staff satisfaction; (1) after the nurses upgrade their qualifications, it takes a while before their salaries are adjusted to the new level (2) people stay in probation for more than 12 months (3) volunteers provide services for a long time and are even ordered around without being compensated or absorbed into the Department.
All these add to frustrations of staff resulting in the feelings of unappreciated and used and as a result some end up not giving their job the love and dedication it deserves. For example, in one facility an acting facility manager has been doing her duties and even going extra miles to ensure that the facility becomes one of the best in the district. Well, the facility is number one in the district, but the poor lady has not been paid the salary for her duties as the acting facility manager, the post she has been in for over ten months.
The Department is killing the passion its employees have for their jobs by overworking them, not giving what is due to them and not giving the necessary support to make their jobs easier. The staff in the facilities are expected to do so much with so little. The problem within the Department of Health starts with the head, which are the administrators who are unable to supply the basic necessities required to make facilities effectively functional.
In trying to resolve the challenges, the Department adopted an Ideal Clinic programme. The programme is aimed at improving and correcting the state of the health care in PHCs. As unpacked in the Ideal Clinic Manual (2013) “an Ideal Clinic is a clinic with good infrastructure, adequate staff, adequate medicine and supplies, good administrative processes and adequate bulk supplies that use applicable clinical policies, protocols, guidelines as well as partner and stakeholder support, to ensure the provision of quality healthcare services to the community”.
The programme clearly stipulates how the services should be provided. The Ideal Clinic initiative addresses the issues ranging from administration, staff and dress code, management of patient records, clinical services provisions, clinical guidelines and protocols, professional standards and performance management development, finance and supply chain management to hygiene and cleanliness.
The Department has taken a progressive step to audit the facilities regularly (at least once or twice a year) to evaluate whether the Ideal Clinic status is achieved or not. The standard is very high and there is a certain percentage in different elements to get to qualify. A lot is being done to address the challenges plaguing the Department. In principle, the programme is “ideal” however sufficient man power is required to see it through.
I argue that unless the grievances of the staff are adequately addressed, the Ideal Clinic Programme of 2013 that is still not fully implemented in the majority of the PHC in 2018 will remain one of many great African National Congress government policies that never see the light of the day. As things stand, efforts to adhere to the Ideal Clinic Manual are merely putting up a “show” and an “act” because changes are made just to pass the audit, after that it is back to square one where there is no improvement in services or conditions.
The Department of Health needs to attend to its staff’s grievances, only then we will have outstanding PHCs with committed and passionate staff under working conditions that inspire productivity.
* Bonolo Lovedelia Pelompe is a public servant within the Department of Health, South Africa.