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Would You Seek Medical Care In Africa’s Public Sector?

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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.

READ MORE: ‘Healthcare Has Got To Be Available To Everybody’

“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.

READ MORE: Death, Denial And Fear: What Listeriosis Cost South Africa

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.

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A Country On A Roll

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The tiny country of Rwanda is now producing factory-fresh Volkswagen cars from its rolling hills. Next up are ride-hailing and public car-sharing services by the German carmaker.

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The Heroes Among Us

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Heroes exist in history, on celluloid, in pop culture or in these digital times, at the forefront of technology. These are the mighty who shine on the front pages of newspapers, as the paradigms of victory and virtue. But every day in public life, surrounding us are some of the real stars, the nameless, the faceless we don’t recognize or celebrate. In the pages that follow, we look at some of them, exploring the exemplary work they do, from the war zones to your neighborhood streets. They are not flawless, they are not infallible, but they are heroes.

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The Power, Humour And Anger Of Mandela

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It is a century since Nelson Mandela came kicking and screaming into a world that he would change.

In one hundred years, his name has been spoken with pride from the paddy fields of Vietnam, through the savannahs of Africa to the smoky steak houses of New York. His legacy appears more contested with every passing year.

I was fortunate to have a front row seat in the Mandela years and saw the power, humour and anger of the man. I used to feel 10 feet tall at press conferences when he used to greet my questions with: “Mr Bishop, how are you?” Once I was walking to a TV interview with him, at an African Union summit in Harare, the day after I had ruptured my knee playing football, he noticed I was hobbling far behind – something he was not used to. He turned and inquired of the cause of my pain.

“May I suggest you take up boxing, it’s safer!” says the old man with that million dollar smile. I shall take the warmth of that smile to my grave.

Make it clear, I am no Mandela worshipper. He was no saint and certainly didn’t want to be one: he could be angry and petulant with the best of them; his past was chequered by domestic troubles; a man of the people, yet distant from his own family, according to many close to him. A man who promoted press freedom, yet like many of the lesser politicians who followed him, wanted his picture on every page of the morning newspaper. Mandela drew the line at the sports page – he joked that he didn’t want to risk being associated with losers.

The greatest fear Mandela had was that his ideals – not his name – would be forgotten after his death. Not for Mandela the greed of rule, nor the trappings of power.

Yet it is very fashionable these days to run Mandela down as something akin to a sell-out. Those who claim, erroneously, that Mandela sold out his people. They say he didn’t stop poverty overnight nor right the wrongs of the past with the wave of his wand. They need to talk to those who were there in the negotiations for a new free South Africa.

“People say we gave up too much in negotiations yet we had nothing to start with,” Denis Goldberg, a man who faced death with Mandela at the Rivonia Trial in 1964, once told me.

READ MORE: Mandela Through Their Eyes

The negotiations with an entrenched elite – that held most of the cards and only grudgingly acknowledged Mandela and his comrades – were difficult to say the least. Mandela’s African National Congress (ANC) could not even threaten to go back to war because the depleting arms of its military wing posed little or no threat to the state.

Even so, a deal was hammered together somehow. In the next two years, in the run-up to the 1994 elections, Mandela won his leadership spurs as he steered South Africa away from the civil war that many feared was inevitable. He flew to Durban and told bloody-thirsty faction fighters to throw their weapons into the sea and they listened. When revered freedom fighter Chris Hani was gunned down on his front drive, in 1993, many were ready to take the law into their own hands.

Mandela barged into the SABC studios in Johannesburg that night and made a broadcast to the nation to calm down and put its weapons away. He wasn’t even in Parliament then and I wonder to this day how many lives that broadcast saved with this canny display of leadership.

Then, when into power with a virtually bankrupt Treasury, Mandela steered the National Development Programme that built millions of homes and schools; electrified the homes of legions of poor people and rolled out roads to connect the nation. Yet, the money was never going to stretch far enough and millions still have no roof over their heads and too many schoolchildren attend classes under trees.

It is fashionable these days to say the majority of South Africa must rise in a civil war in which the nation will be cleansed of its past, restored of its land on the path to righteousness. It probably sounds even better after a few drinks.

READ MORE: Celebrating Mandela From Where It All Began; Soweto

I say this is bunkum and anyone who has ever seen or smelt a civil war will agree with me. How a vile, stinking trail of dead fathers, raped women and children, destruction and disorder, can lead a country to the light beats me. Those who scream for war have clearly never seen it.

The first time I clapped eyes on the great man, at the Harare Agricultural Show, on his first foreign visit to Zimbabwe in August 1994, he walked alone, without a security man in sight. I didn’t ask for a selfie – they didn’t exist then, anyway – I was tongue-tied. We merely smiled at each other in passing.

So when people in political circles told me that South Africa’s new president Cyril Ramaphosa didn’t care for wealth and power – he merely wanted to put his name up there with Mandela – I smiled like I did on that August day in Harare.

This does seem feasible as President Ramaphosa – a millionaire in his own right – was the man who stood next to Mandela, holding the microphone, on the town hall steps in Cape Town, on February 11 1990, during his famous address on release from 27 years in prison.

“I stand here before you not as a prophet but as a humble servant of you, the people,” said Mandela to deafening cheers on that bright summer’s day.

Clearly this humility and willingness to serve rubbed off on President Ramaphosa on that fateful day in 1990. In his first 100 days, he has made manful attempts to stop the rot in South Africa by merely enforcing the rule of law. A course of action he made no secret of even before he took power on February 15.

“There are no holy cows. Anyone who is caught doing wrong things will end up behind the bars of a jail,” says Ramaphosa, with microphone in hand and humble service in mind at the World Economic Forum in Davos, Switzerland, in January.

True to his word, Ramaphosa cut swathes through the corruption of the past. Former president Jacob Zuma ended up in the dock on corruption charges something that many – including me – thought they would never see in their lifetime. He removed the rookie finance minister Malusi Gigaba and replaced him with the people’s choice Nhanlha Nene who has staved off more downgrades of the economy. A clean-up of the state-owned enterprises and the institutions is underway and many who thought they were invincible six months ago have been cut down to size.

I am sure the old man, who must have been spinning in his grave over the last few years, would approve.

“Never, never and never again shall it be that this beautiful land will again experience the oppression of one by another,” says Mandela at his inauguration at the Union Buildings in Pretoria.

As we mark 100 years since his birth, it is time for cool heads and clear thinking to make sure this utopian ideal of liberty and tolerance lives on after his death. Our grandchildren will judge us harshly if we don’t.

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