On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.5 Cape Town May. 2008
FROM THE EDITOR
J P de V van Niekerk
We have become accustomed to darkness. Power failures have become so routine that there is a danger of regarding them as quite normal. The electricity crisis causing the blackouts is a concentrated and striking symptom of widespread declines in many public services in South Africa. The shortage and decline in quality of our water supplies has been cited as the next crisis. The chaos in our rail services has prompted the appointment of the respected Maria Ramos to prevent derailment. But many public services, including education, roads and prisons, are also ailing. One of the worst affected services is health care in the public sector. What is certain is that the optimism of the past few years over global improvements in living conditions for the world's poorest people is being sorely tested. Predictably, production of biofuels to replace coal and oil as a major energy source has contributed to worldwide rising food prices as crops for burning replace planting for food. Most of the world's peoples spend the bulk of their income on food, and this applies to about 70% of South Africa's population. Shortages and huge cost increases in staple foods can result in riots and even wars over scarce resources.
Now starts the blaming game. Apartheid was evil and caused untold damage to our country and its people. But other factors now also contribute to public service decline. Scoring points for promotion and bonuses based on the degree of transformation is cited as one reason for the sorry situation our electric power supplier now finds itself in. Prolonged political power breeds nepotism, and there is evidence that many appointments are influenced by ideology and politics rather than competence.
A major factor in our health care crisis is the shortage of available health care professionals, and the public sector is finding it increasingly difficult to recruit those who remain to work in its deteriorating facilities. South Africa is not alone in facing this problem. The First Global Forum on Human Resources for Health held in Kampala, Uganda, in March 2008 provided ample evidence that it is a worldwide phenomenon. A major theme was the problem of emigration of health care professionals from the countries in which they trained. Invariably this is from the poorer to the richer countries, a phenomenon a colleague called 'the transfusion from the anaemic to the plethoric'. Such migrations are recognised as being due to push factors (those driving one away) and pull factors (those alluring promises from the greener other side of the fence).
Cures are much more difficult and require expertise, commitment, hard work and time. Mere political pronouncements are certainly not cures. A critical requirement is wisdom and support from the highest levels. Scientists and health care professionals have felt unappreciated and alienated for many reasons, including the 'virodene' scandal and dumping of the Medicines Control Council chairman; the political sidelining of their expertise while favouring AIDS dissidents; and the persecution of those who exposed the poor state of health facilities in East London (and all over the country) and others who provided antiretroviral treatment to patients. The Biko case in which the then Medical and Dental Council initially refused to take action against the implicated doctors, but was later forced to by the courts, is a salutary lesson on the importance of having regulatory bodies independent of political influence. This is in stark contrast to the political control that the Minister of Health has forced on South Africa's health professions councils.
One method of rapidly strengthening and expanding the health workforce and rapidly increasing access to HIV and other health services is 'task shifting'.1 This involves the rational redistribution of tasks among the health workforce, moving tasks from highly qualified workers to workers with shorter training. The Hospice Association of South Africa has developed training programmes for community caregivers who undergo short but intensive training in managing patients with AIDS. Each community caregiver can attend to about ten AIDS patients. In turn a qualified nurse can supervise about ten community caregivers. Such proven progammes can be applied to many other health care services. Teamwork is critical to such programmes, and resistance from health care professionals who fear loss of their defined professional activities is sometimes difficult to overcome. Elsewhere in Africa 'mid-level' workers are trained for specific tasks such as obstetrics (including caesarean sections) or orthopaedics. In South Africa training is aimed at producing a multi-skilled practitioner, and the Department of Health also considers that the training of community caregivers should be broad rather than specialised, e.g. the hospice workers.
South Africa's power crisis provides lessons in addressing our health care problems, including: acknowledge rather than deny the presence of the problem; each should take our appropriate share of responsibility; and value each other and all pull together. Failure to do so will result in further health care power shedding.
1. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. World Health Organization, 2008. [ Links ]