On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.9 Cape Town Sep. 2011
Re-invigorating long-neglected rural health workers
It took the deaths of 121 babies after an outbreak of diarrhoeal disease in the poorly served Ukhahlamba District of the Eastern Cape to highlight how disillusioned and unsupported its health care management really was.
Managers and staff at various admitting facilities were overwhelmed by a sudden surge of dehydrated babies for nearly four months from January 2008, triggered by terminally decayed township water reticulation and purification systems.1 To aggravate matters, grossly understaffed clinics and district hospitals and dismal infrastructure with a shortage of mobile clinics and medication meant that those on duty took the brunt of the stress and burnout induced by the crisis. (Empilisweni Hospital saw 107 admissions of severely dehydrated babies in January alone, of whom 28 died.) Some five months later, after much debilitating finger pointing up and down the chain of command during multiple official probes, a veteran rural public health clinician, Dr Tim Wilson, was sent in by Pretoria to come up with ways to prevent a repeat.
The core problem as he saw it (the water reticulation and purification woes were finally addressed after years of total system neglect), was stress and burnout among the local health care leadership - so he introduced a pilot workshop to deal with these. The 12-day course (over six months) proved so
successful that it is now being requested by colleagues of participants across the province. Outcomes include rejuvenated team spirit and organisational communication, boosted morale, more holistic views, and deeper understanding of colleagues. Wilson told a conference 'Celebrating Innovative Health Management in the Public Sector' (organised by the University of Cape Town and the Oliver Tambo Fellowship Programme) this June, that devil-may-care attitudes were so entrenched that Ukhahlamba's acting district health manager only saw the official baby death report four months after it was completed.
Wilson first met with 22 local health care managers from the area in November 2008, discovering that many had been in the same job for years. He asked what support they needed. 'I got a long list of very reasonable suggestions and requests, but my overwhelming impression was of people feeling guilty and depressed, traumatised, stressed, burnt out and totally disempowered,' he said. Acting on this and as part of an overall strategy put together last year, he called in Tanya Jacobs, an East London-based social scientist with a Masters in Public Health. She tackled the cynicism, demotivation and lack of caring with an interactive workshop.
Breakdown in caring capacity
Jacobs reported that the impact of burnout on service delivery included a near-total breakdown in communication, lack of co-operation, demotivated teams, no implementation of decisions, plans or projects, little cohesion or participation, no trust and a 'silo' approach to doing things, plus the concomitant poor productivity. Describing her workshop as creating 'effective management and leadership in resource poor settings', she describes it as a platform where 'we perceive ourselves as a complex whole consisting of the health professions and the support professions (human resources, finance, supply management), all working towards a common goal of service delivery'. She set herself the task of making people feel acknowledged and working with the ensuing material to respond to local needs through games and adult learning techniques, enabling self-growth grounded in each others' experiences. 'I was truly humbled and excited by the process,' she told the conference.
Conference delegates described how one of their colleagues, a primary health district manager, was ordered by his executive manager in Bhisho to intervene in a wildcat nurses' strike while attending the workshop. Nozipiwo Gysman, a director of Transversal Services in the Eastern Cape Health Department, said the top executive wanted the names of all the toy-toying nurses and/ or 'have us bring them to him'. Instead of instantly obeying, the district manager took along several of her course participants to test their new-found empathic skills. They courageously identified themselves to the striking nurses, calmly telling them, 'We're here to listen and help'. The nurses obliged by listing their grievances which revealed gaps both locally and at head office. 'Everybody went back to work and was happy. When the executive manager wanted to know if we got the names we said no, but a lasting solution was found,' Gysman grinned.
Problem district no longer
Wilson said two quotes from participants neatly summed up the difference the intervention made. One district manager said he used to blame the government, 'but now I have a different perspective and know that there is something I can do'. Another said she used to say, 'Bhisho must do this and national government must do that, but now we ask what we can do ourselves'. Chief directors of health had also reported to him that what used to be considered as 'problem districts' no longer were, while applications for sick leave had dropped dramatically.
Challenged by Professor Hugh Philpott, a former director of the University of KwaZuluNatal's Centre for Rural Health, as to why Jacobs' type of workshop was not included as part of undergraduate preparation, Wilson said its efficacy was premised on participants being able to 'internalise' material that was grounded in their own experience. 'Health science students might find it interesting but they're in a very different place - there's a place for such interventions at different points in people's lives ... and if you talk about Batho Phele (People First), this applies equally to patients and staff members.'
Jacobs warned that while the working environment was the best training ground, she still had 'a lurking concern around sustainability'. 'You need the ability and the opportunity to get together and reflect on how you've dealt with problems and create the spaces for that community of learning.' While celebrating the short-term gains, one had to identify what 'basket' of interventions was needed to sustain them. She emphasised that each workshop was tailored to specific contextual needs.
Dr Carol Marshal, the national chief of the Office of Standards Compliance (setting up hospital service delivery measurement standards in advance of National Health Insurance (NHI)), described the stress management course as 'absolutely marvellous'. 'I said to myself I must keep some degree of skepticism because it cannot possibly be that good. There's the old saying that if not us then who, if not now, then when? - it's all about individuals stepping forward and saying I'll do this', she added. Marshal said she believed that it was 'all about accountability but no blame, personal responsibility versus the system. Do we enable or disable our people? To me we have to accept that if we're not implementing change then we've made a conscious choice to carry on as always.'
Health DG shares her NHI insights
Precious Matsoso, National Director-General of Health, told the conference that improving management capacity was fundamental to the success of an equitable NHI 'otherwise, to quote a fellow delegate (Dr Craig Househam, DG Western Cape Health), we'll have to start the NHI in the Western Cape'. She was alluding to the NHI pre-funding requirement that all health care facilities meet a set of minimum standards set by Dr Marshal's department plus the policy decision to upgrade historically underserved areas first, so they can be prioritised for NHI funding. Househam told the conference earlier that if the NHI was to be 'implemented tomorrow' it would have to start in the Western Cape (because his province had the country's highest standards of health care with a solid infrastructure) - thus perpetuating inequities.
Matsoso said it was 'insufficient to respond clinically only - you have to look at the social determinants of health, the drivers and socioeconomic indicators. You can ask how much each of the 4 300 health care facilities spend, how they're performing and what their profile is, but that's not enough.' Audits revealed that government had built many facilities and invested in infrastructure but, alarmingly, 'we're not doing health facility planning'. In Mpumalanga some facilities were running at half capacity because they were so badly under-equipped and under-staffed.
'So we have to take a deep breath and make all our existing facilities work, equip and staff them properly to ensure they meet Carol's (Marshal's) standards.' Matsoso added that accessible-to-all, accurate health indicators and mortality rates were essential for every province, 'so we can tell at any time where we are'. What was currently needed was 'five years of planning and delivery', with a critical mass of appropriate skills to enable NHI delivery in the longer term. 'We need to demonstrate our level of readiness to build confidence in the health system so that we can rebut anybody with medical aid (who will be paying more to help fund the NHI) who legitimately asks, 'how much am I buying and what will I get for it?'
1. Bateman C. Incompetent maintenance/inept response; 80 more Eastern Cape babies die. S Afr Med J 2008;98(6):429-430. [ Links ]