It’s the worst thing to happen – to anyone.
We meet Natasha Sibanda in Johannesburg’s bustling Central Business District. On the street, the cantankerous crowd has a life of its own, their colorful clothes distinct in the morning light as they move in unison like shoals of fish.
Adjacent to this street is a tiny one-bedroom apartment the size of a matchbox and in grimy grey.
As we enter, a pall of gloom. Sibanda, only 22, lost her husband Samuel four weeks ago in Zimbabwe, his country of birth. Their only son is a year old.
“My husband was 25 years old… We were in Zimbabwe visiting family when he suddenly fell ill. We went to the hospital where they gave us a list of all the items they needed in order to help him. We had to buy all of them [with] cash at a pharmacy before they could treat him,” she says, as a lone tear rolls down her cheek.
The items totaled a bill of $300, which they didn’t have. Her sister, working in South Africa, promised to send the money the following day.
“I pleaded with the hospital to help him while we looked for the money because we both lived in Zimbabwe and had no jobs but they said his condition wasn’t serious and we had to come back when we have money because the hospital didn’t have any of the medicines needed.”
Heartbroken and worried, Sibanda took her husband home.
The night was going to be long.
At about 2AM, Samuel started vomiting. She took him back to the hospital where he was declared dead on arrival.
“I’m still not sure what killed him but I’m hurting because doctors wanted to help him but couldn’t because they didn’t have medicines and now he is dead and my son has no father,” sobs Sibanda.
Her story is only one of many painful parallels in some of Africa’s developing economies with poor – and crippling – healthcare systems.
“You don’t want to fall ill in Zimbabwe. It’s like a backyard garage where you bring all your car parts for your vehicle to be fixed. If you have no cash, you can’t be treated,” says Mthokozisi Khuphe, a former government nurse.
Khuphe worked for government for eight years before moving to the private sector and then migrating to work in Namibia.
“When I started, there was already a crisis. I remember there was a big strike and a lot of people resigned. We, the new junior staff, had to work on everything even though we were just starting out. I would have 120 to 150 patients in a day [who] I had to help by myself,” says Khuphe.
He says Zimbabwe’s healthcare system was and still is putting patients’ lives at risk.
“Many patients lost their lives. I remember sometimes there would be no syringes, and needles were in shortage. We would reuse them repeatedly on the same patient when in fact you are supposed to use one and dispose it off immediately… There was even a time the whole hospital had one ventilator… As a nurse, it is difficult to know what can help the patient but you don’t have the equipment and the patient dies.”
Zimbabwe is not alone. Africa’s public healthcare sector is in the intensive care unit.
Although the situation is not as terrible as in Zimbabwe, the World Bank and World Health Organisation issued a report on universal healthcare in the world in December, where South Africa received a score of 70 out of 100 for Universal Health Coverage. (The National Health Service (NHS) in the United Kingdom (UK) scored 90.)
The report stated that the poor quality of healthcare in the public sector was concerning.
Jasson Urbach, a director of the Free Market Foundation and head of its Health Policy Unit says the situation is dire. There are pervasive problems with the quality of healthcare in the public sector.
“The healthcare system is a sea of mediocrity in the government-run healthcare sector, punctuated by islands of excellence in the private healthcare sector. Currently all political will is aimed at implementing National Health Insurance (NHI) [free health for all] and nothing is being done to address the current issues of pervasive poor quality in the public sector,” he says.
According to Urbach, the NHS in the UK employs 1.3 million people to service 55 million UK residents, yet the entire South African civil service employs 1.3 million people.
“To think that South Africa can run a government administered Universal Health Coverage system such as the National Health Service is unrealistic.”
He says the poor quality of services in the public sector is the single greatest challenge in South African healthcare.
“If the quality is not addressed, 70 percent of public facilities will not qualify to contract with the NHI, if it gets implemented, which will collapse service provision in the healthcare system altogether. Poor quality is not the result of shortages of funding; it is the result of poor management,” he says.
It is true.
According to inspection records published by the Office of Health Standards Compliance, a government agency in South Africa, hospitals and clinics in the government’s flagship NHI pilot program are failing to improve any faster than those in the rest of the country.
Among the 1,427 facilities inspected, only 89 scored a pass mark of 70% or more. Facilities fell short on matters ranging from the availability of medicines to infection control.
“As an example, there are contracts with cleaning services in place in all public facilities, or cleaners are employed. If a facility is not considered clean, that is a management failure. Poor systems and processes lead to undue delays in treatment. Incompetent political managers at the provincial level, leads to incompetent appointments at hospital levels, which leads to failure of the system,” says Urbach.
Patients in South Africa’s public hospitals are dejected.
Results cited in the General Household Survey 2015 suggest healthcare received from the private sector is significantly preferred to that from the public sector, and states that users of private healthcare facilities seem to be more satisfied with those facilities than users of public healthcare facilities, across all provinces.
“Whereas 97.7 percent of users were satisfied with private facilities (91.9 percent were very satisfied), only 81.1 percent of users of public healthcare facilities were somewhat satisfied or very satisfied. Only 57.6 percent of individuals that used public healthcare facilities were very satisfied,” states the report.
According to Urbach, another problem is that the government does not have the same incentives as the private sector. It partly explains why there are poor healthcare outcomes in the public sector.
Dr Matthew Adams, a surgeon at one of the big public hospitals in South Africa, agrees with Urbach.
“Private hospitals pay two to three times more than government and they have better working conditions compared to us… essential machine breakdown and fixing them is delayed, and tenders to supply certain things are given to people who can’t deliver on time which always sets us back,” he says.
That’s not all.
Adams says hospitals are understaffed and they have to work long hours and there is misadministration by hospital management.
“[The] department says there is no more money for new doctors but not enough monitoring is done on how much is spent per patient and measures aren’t taken to see how we can save the hospital money… Hospitals are actually set up in a hierarchy, so that the first place a patient goes to is a clinic before a hospital for day-to-day assistance, but because of low quality, patients overlook lower level health centers to go to hospitals and doctors see cases they are not supposed to see adding to doctor frustration,” he says.
Frustration leads to doctors leaving the public sector for the private sector, or leaving the country altogether.
“The last time I saw statistics [about the number of doctors leaving] was in 2005 when the Health Professions Council of South Africa reported that despite the fact that medical schools produced approximately 19,500 graduates between 1990 and 2005, their records show only 9,304 new registrations during this period. This implies that a significant number of individuals, after graduating, instead of practising in South Africa, are leaving the country,” says Urbach.
Among the common reasons cited for the mass exodus of skilled healthcare personnel from the public sector are poor salaries, high workloads, poor work environments and few opportunities for advancement.
According to Liz Still, who compiles the annual Health Care in South Africa publication, the public sector does not have enough posts available to employ South Africa’s health professionals. For example, over the period 2002-2010, approximately 11,700 doctors graduated but only 4,403 posts were created in the public sector. In the field of dentistry, there were 2,140 graduates but only 248 public posts were concurrently created.
These conditions impact the quality of care.
According to various reports, last year, South Africa’s Health Minister, Aaron Motsoaledi, said more than 5‚500 medical negligence claims have been made against the health department since 2014. The number of claims grows every year. There were 1‚562 claims made in 2014/15‚ 1‚732 in 2015/16 and 1‚934 in 2016/17.
And it hurts the tax payer.
The department paid R391.32 million ($32.4 million) in medico-legal claims in 2014/15 alone and a whopping R730.87 million ($60.6 million) in 2015/16.
It is so bad that in 2016/17‚ the total value of claims rose to R1.2 billion ($99.5 million)‚ with Gauteng’s 521 claims accounting for almost half of this at R566 million ($47 million).
Romany Sutherland, an attorney at LLA INC. Law, says the majority of these cases are due to obstetric damages.
“These are children who suffer brain injury as a result of complications during birth… South Africa has a 10 percent higher cerebral palsy rate than anywhere in the world and we don’t know why this might be… To me, as an attorney, it comes down to perhaps people not being trained properly. Nurses are not involving the obstetricians soon enough,” she says.
Cerebral palsy cases cost the government about R17 million ($1.4 million) on average per case.
“Each province deals with the issues differently. I’m in the Western Cape and here; we try and negotiate or mediate these cases as soon as possible so that reasonable pay-outs are made without undue delay. I believe the best way to go with the negligence cases is to take the initiative to open discussion with your opponent,” says Sutherland.
The problem is, some health departments don’t have any decision-makers who have settlement authority. It means all negligence cases have to go before a judge in the court of law before the department can pay out. It takes longer and costs the state more money.
“The litigation process is extremely expensive. The amounts you see reported in the media don’t include costs. It is a big worry because I haven’t gone to court in nine years because I like to negotiate cases and come to reasonable settlement and the Gauteng government doesn’t allow for that to happen,” she says.
According to Sutherland, some costs to take the case through trial can be four times the amount of settlement.
The amount of money that attorneys stand to make on such cases has caused a boom in the medical negligence industry.
“There are attorneys who are touting for clients and some even paying midwives up to R30,000 ($2,500) for a file. There are also some frivolous cases where the negligence did not cause damages… yet they carry on… If such cases are settled, it is not the touting attorney’s fault but the department that is not defending those cases properly,” she says.
The rise in lawsuits is also causing medical insurance for obstetricians to rise.
“An obstetrician is currently paying R1 million ($82,830) in insurance. I think the price has gone up by approximately R100,000 ($8,283) if not more every year for the past couple of years… This is also cause for some medical students to not consider this field because insurance is just too expensive.”
Back in Johannesburg, as we part with Sibanda, she tells us she wants to go back to school to study public healthcare administration so she can help the very hospitals that didn’t give her husband timely treatment. She wants to save lives.
If only government authorities sitting in their airconditioned offices and seeking treatment in plush private hospitals knew her pain and predicament.