On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.100 n.7 Cape Town Jul. 2010
Crowded wards, lousy admin contribute to death and suffering
Unpaid debts, poor infection control and slack administration cost at least half a dozen babies their lives and caused unnecessary suffering for thousands of patients at several public sector hospitals and clinics in Gauteng and KwaZulu-Natal in May.
It also emerged that between January and May this year 181 infants died at the Nelson Mandela Academic Hospital in the Eastern Cape, a dysfunctional referral system and dismal ambulance service among the primary contributory factors. The Eastern Cape has the country's highest poverty levels, lowest public health spending and one public sector doctor to every 5 882 people, the country's second lowest ratio.
Eastern Cape Health MEC, Phumulo Masualle, promised a basket of reforms at district health level, including the appointment of more doctors, basic equipment, and a skills upgrade to cut down on the high referral rate to Nelson Mandela Hospital. The travel distances for patients in the largely rural province remain an intrinsic problem.
A provincial probe showed that 54 babies died at the hospital in January, 31 in February, 46 in March and 50 in April. 'This was the equivalent of 45 deaths per 1 000 births, way above the national average, which stands at 36 per 1 000 live births,' Masualle confirmed.
He said 40% of the babies had died as a result of a lack of oxygen during the birth process while another 40% were born prematurely, which 'dramatically lowered' their chances of survival.
Nurses unsurprised by baby deaths
Nurses were unsurprised by the deaths, blaming poor conditions in the tertiary hospital's neonatal ward. They claimed it was 'grossly understaffed' - with one nurse caring for about 40 babies instead of the required three. Ventilators were allegedly shared by two or three babies.
Another nurse, who claimed to have worked at the hospital for more than 5 years, said she had never come across babies dying at such an alarming rate. 'Another factor is that there has been an outbreak of diarrhoea, which could have contributed to the deaths. Most of them (babies who died) ... (were) also very premature.'
However, Masualle, who was accompanied on a hospital tour by a team of senior departmental officials, blamed the ongoing tragedy largely on the failure of pregnant mothers to go to antenatal clinics, thus preventing the early identification of complications, including HIV. 'Young mothers, in particular, often hide their pregnancies from their parents, and are unwilling to go to the clinic,' he said.
These all too familiar bugbears of public health care delivery again highlighted the urgent need for acceleration of a major quality assurance push in advance of State hospital accreditation for the National Health Insurance system due later this year.
Urban hospitals anything but immune
In Gauteng, cable theft near Chris Hani Baragwanath blacked out the hospital for 2 days in mid-May, exposing slack monitoring and inept maintenance of back-up generators (failure due to lack of diesel). The generators were in working order but, to quote Gauteng Health Department's Mandla Sidu 'there was not enough money' to pay for fuel.
As it turned out, the diesel provider suspended services because the province repeatedly failed to pay them, part of a much wider ongoing bad debt problem for the administration whose day-to-day running of practical finances creates equipment and provisioning nightmares for caregivers.
Who to pay, who not to pay...
Gauteng Health MEC, Quedani Mahlangu, said that the chief financial officer of her province's Shared Service Centre (which processes every department's invoices) had told her that the diesel provider, based in KwaZulu-Natal, was 'cut' during a high-volume invoice processing day. They had agreed that in future they would go through all health department invoices every Friday to prioritise and ensure no critical service provider payment was missed.
'It was more a question of cash flow - some invoices are left out in order to get others paid on time,' the economist-turned health minister explained. She said individual financial managers of hospitals also needed to take greater care and responsibility and 'do their jobs properly', and admitted that some service providers to her department had not been paid since December.
Chris Hani Baragwanath Hospital rescheduled several elective surgeries and ambulances were diverted to other hospitals while diesel was sourced and power restoration prioritised to neonatal wards, incubators, labour and ICU wards. Miraculously, there was no reported loss of life.
There were no miracles at Johannesburg's Charlotte Maxeke Hospital in mid-May however. Here 6 premature babies died after being infected with the diarrhoea-causing norovirus. They were among 24 infants infected in a group of 50 crowding out a high-care ward designed to handle 35 premature babies, and which was then closed for proper infection control.
Mahlangu vowed to discipline anyone found guilty of negligence and set up an 8-person panel led by some of the country's top perinatal mortality experts to identify what went wrong, offering her condolences to the families. She remarked that the high-profile incident was the kind of thing that 'sets the entire country back' in its bid to meet the UN Millennium Development Goals of curbing the infant mortality rate.
Study after study has shown that the quality of maternal and infant care is responsible for South Africa's woeful outcomes in spite of the relatively large amount of public money allocated, with national health minister Dr Aaron Motsoaledi vowing to fight what he sees as the biggest evil - the 'neglect of basic protocols' - by existing staff.
Give us resources and we'll save more lives
Staff, however, blamed the ongoing crisis on a lack of resources, complaining, for example, that autoclaves at Charlotte Maxeke had not worked properly 'for months'.
Said one nursing sister, who asked not to be identified: 'We've been asking for months for materials for our autoclaves so we can test them to see if they're working properly, but we're told there is no money.'
Mahlangu said any doctor or nurse frustrated by service provider-related problems should call her directly and promised to 'resolve the matter that same day, if possible'.
The National Education, Health and Allied Workers Union (NEHAWU) said hospitals were understaffed, poorly equipped, under-resourced and over-burdened while the Democratic Nursing Organisation of SA (DENOSA) took 'exception' to nurses 'being depicted as murderers' whenever infant deaths took place.
Charlotte Maxeke Hospital chief executive Barney Selebano said the mothers of the surviving children had been advised that it was in their children's best interests not to have contact with them 'while we deal with the situation'. He said all staff had been advised to take necessary precautions when they entered the hastily replaced high-care ward in future.
Asked about the implications for Chris Hani Baragwanath Hospital being able to cope with any World Cup emergency patient 'surge', Mahlangu said the affected generators were in a 'separate section' from those accredited to the soccer bonanza.
Natalspruit escapes blame for its baby deaths
Commenting on the deaths of 11 other babies at the Natalspruit Hospital in Katlehong within days of the Charlotte Maxeke tragedy, Mahlangu said most had died in utero before arriving at Natalspruit, while two were born live but very underweight (500 g).
'We need to ask ourselves why we see so much low birth weight. The answers seem to be teenage pregnancies, HIV/AIDS and the environment at societal level,' she said.
Mahlangu said she was 'personally' attending to ward overcrowding in neonatal wards, admitting that Natalspruit Hospital's neonatal ward was designed to take 40 infants but held 71.
'By early July we'll have 26 extra beds and incubators there and we're adding 20 beds at Maxeke. The only reason we could move those babies so quickly during the infection crisis was that Carte Blanche's 'Making a Difference' campaign had already renovated a new ward,' she revealed. She promised expanded public/private partnerships in future.
Motsoaledi confirmed that countrywide annually 23 000 babies are stillborn, 22 000 babies die as newborns and between 1 400 and 1 600 mothers die shortly after giving birth. Fortythree per cent of these deaths were linked to HIV/AIDS. To reduce this number every HIV-positive child under 1 year old was now being put on ART, regardless of their CD4 counts.
A tender tale to writhe by...
In KwaZulu-Natal, hospitals in the Umgungundlovu (Pietermaritzburg) and Ugu (Port Shepstone) districts ran out of a high-nutrient porridge supplement handed out to thousands of TB and HIV/AIDS sufferers to boost their immune systems.
What turned out to be a near 5-month supply lapse was 'restricted to these two (large) districts', according to Chris Maxon, spokesman for the KwaZulu-Natal Health Department. He denied newspaper reports that a provincial lapse in tender renewal accounted for province-wide shortages.
District nutritionists had been advised and had informed his department which institutions in their districts were more critical. In the Umgungundlovu District these were the Imbalenhle Clinic, East Boom CHC, Grey's Hospital, Northdale Hospital, Edendale Hospital, Appelsbosch Hospital and Doris Goodwin Hospital. In the Ugu district it was 'mostly hospitals' that required stock.
The vital multi-million rand programme has since last December benefited over 100 000 ART patients in the province, many of whose CD 4 cell counts are so low that without good nutrition their conditions either fail to improve or deteriorate. At worst, they simply die, unable to pay for basic life-giving nutrition, all resources having been spent on transport to health facilities or helping keep dependants fed.
The former service provider said she was overwhelmed with calls by desperate patients whom she was powerless to help.
Dawnfeeds director Dawn Schneederger said: 'Patients call us daily but there is nothing we can do because our contract ended in January. We were told that it would be extended.'
Maxon explained that the programme was 'taken over' by National Treasury, which had since awarded a new tender. Supply distribution had resumed on 27 May. His initial comment on the controversy was: 'I think the whole province was affected but some facilities may still have had some left, so they could continue.'
However, he later said only two districts were affected and that the lapse was due to individual hospital supply chain managers not responding proactively to a January provincial advisory note about the tender contract change. 'It was just the facilities in two of our 11 health districts and they could have made arrangements to supplement stocks via other well-stocked hospitals,' he asserted.
Not our fault, or responsibility - National Treasury
A national treasury spokesperson, Lindani Mbunyuza, said the province was solely responsible for any lapses due to tender changes. She confirmed that a supplementary national tender (to include the porridge) to an umbrella national 'RT9' tender was approved on 18 February this year, for initiation on 15 May this year, at the specific request of the KwaZulu-Natal Department of Health. She said 15 May was chosen because the KwaZulu-Natal Department of Health told them their existing porridge contract expired on 14 May. However, Maxon said all KwaZulu-Natal nutritional porridge contracts expired at the end of January.
According to national transversal (RT9) tender rules, the placing of orders, deliveries, distribution, payment of supplies, stock and inventory management and supply and performance management are the sole responsibility of provincial management.
KwaZulu-Natal's health department is buckling under a R2 billion budget over-run. Its entire top management has been progressively replaced over the past 6 months. A top official from the province's treasury has been seconded to the health department to untangle numerous inflated or otherwise flawed tender contracts plus probe suspect black economic empowerment deals.