South Africa

South Africa

The Eastern Cape’s broken healthcare system – emergency care required

The Eastern Cape’s broken healthcare system – emergency care required

In 2015, hearings were finally held by the Human Rights Commission to verify the state of emergency care in the Eastern Cape. The outcome was deeply worrying. More worrying, however, is the fact that according to a recent analysis, very little has changed. By MARELISE VAN DER MERWE.

The Eastern Cape is arguably one of the most beautiful places in South Africa. It is home to Addo, Tsitsikamma National Park, and the exquisite Wild Coast.

It’s also home to one of the worst service delivery hotspots in the country. Emergency medical care is no exception.

Nomsa Mbinza, from Nier village, relates an incident that occurred in December 2014. Her neighbour called her, saying her daughter was very ill. The child was evidently in a bad state, says Mbinza.

The child had a swollen tummy and was complaining about excessive pain. The child could not walk and was lying prostrate on the floor of the house. I then called for an ambulance because from what we were witnessing it was clear that the child needed urgent medical attention and we did not have the finances to hire a private vehicle to come and pick up the child. An ambulance was the only option we had.”

Mbinza called the ambulance just after 07:00. She was told the ambulance had gone to get petrol. She phoned several times over a period of hours, but was told the same thing every time. By the time the ambulance arrived, seven hours later, the child was dead.

She had died an awful death,” recalls Mbinza. “We do not know what the cause of death was. We do know that she was in great pain for more than six hours before she gave up and died.”

The right not to be refused emergency medical treatment is enshrined in Section 27(3) of the Constitution. It is absolute; not subject to progressive realisation or resource limitations. But for residents of rural areas across the country, the Constitution’s rules remain out of reach.

Mbinza is one of several people who told her story to the Eastern Cape Health Crisis Coalition, which comprises several organisations including the Black Sash, Sonke Gender Justice, the TAC, Section27 and the South African Medical Association. The Coalition recently released their analysis of what was occurring in the Eastern Cape since the initial hearings were held by the Human Rights Commission in March 2015. In April 2016, the Eastern Cape Department of Health (ECDoH) made their submission.

What the coalition found was disconcerting, to say the least – story after story of patients who were elderly or living with disabilities being unable to get medical care because they could not take the often arduous walk across rough terrain to get to the nearest facility, or because they could not afford to pay private transportation rates to taxis or neighbours. Ambulances are thin on the ground. And where there are ambulances, they can’t always reach the patients.

One of the reasons people are being given [for a lack of transport] is that the roads are so bad that the vehicle can’t get there,” Section27’s Mluleki Marongo told Daily Maverick. “What people are telling us is that even when dispatched, the ambulances get lost. Often, it is that they cannot find the destination or that they cannot cross the terrain.”

How ill, elderly or disabled pedestrians are to cover terrain that cannot be accessed by vehicle remains unclear; one possible solution that has been proposed is 4×4 emergency vehicles. But budget is a problem. In addition to all of the above, not all the existing ambulances are being used and tracked consistently, and mismanagement begins at budget level.

Inconsistent or inadequate planning has negatively impacted on the ECDoH’s achievement of targets and its ability to implement identified priorities,” the analysis reads. “The EMS budget has steadily increased over the past decade, albeit there has been a trend of underspending of the budget. Targets, priorities and budgetary allocations should be aligned to ensure that a clear purpose with appropriate resources has been identified and is capable of being achieved.”

Where is the money going? The coalition isn’t sure.

We don’t know exactly why,” Marongo says. “We have been looking at issues that cripple healthcare. Poor budgeting is one of those issues. There’s just a lack of proper budgeting for healthcare services. Whether it’s a lack of skills or something else, we don’t know. All we can say is that they are not spending or budgeting properly.”

It’s something of a perfect storm. The dire state of emergency medical care in the province is exacerbated by a number of factors, including the poor state of public transport, poor roads, stock-outs and poor service delivery more generally (sanitation and water supply, for example). Emergency care represents just one part of a much bigger problem.

The coalition has focused on emergency medical services and planned patient transport because the failure of these services impacts disproportionally on the most vulnerable,” the authors write.

Those most vulnerable include mothers and babies, Marongo says. The statistical evidence is not yet available, he explains, but anecdotally, the impact on infants and mothers is clear.

All we can say from our standpoint is that with regard to the lack of ambulances, women who are pregnant are some of the hardest hit.”

In the space of a recent three-week period, five women gave birth at home, he says; others have had to give birth on the road on the way to hospital. One resident told the coalition about the birth of her daughter’s child. The ambulance arrived eight hours after the initial call, and when her daughter arrived at the facility, she was told her baby’s heart was beating too slowly and needed to be transferred. The baby did not survive. She cannot help but wonder if the child would have survived under different circumstances.

Also vulnerable are the elderly and chronically ill. Pensioner Mantongomani Nodanga told the coalition that his sole source of income was a pension of R1,200 monthly, which had to support his wife and six dependants. Nodanga must have diabetes treatment at least every month, and sometimes requires emergency treatment.

Throughout the 70 years I have lived in the village, the community has struggled with access to ambulances,” he explains. “There are no ambulances that come to our village. Ambulances are only available for hospital-to-hospital transfers and not for picking us up from our homes when there are emergencies. Over the years, I have witnessed many people die as a result of the unavailability of ambulances. It’s as if we are second-class citizens who are unworthy of the government’s protection and respect.”

On one occasion, transport to hospital cost him R600 – half his month’s income. Other residents speak of having to rely on loan sharks to cover their expenses after the lion’s share of their income has gone to plugging the holes in state medical care. Debt spirals are common.

Unfortunately the desperate situation described above is not restricted to one province; nor are the problems only regarding emergency care. Residents also reported problems with the service provided by emergency call centres, and understaffing was a major problem. This makes it extremely difficult for healthcare workers to provide the level of care they have been trained to give.

A healthcare worker who wished to remain anonymous told the coalition that poor emergency medical services had a knock-on effect that simply burdened the system even more in the long run.

The PPT bus [which transports patients] was scheduled to leave at 3am every morning in order for patients to secure a place in the queues at the hospital in Mthatha. This was the only way to allow for the patients to be seen on the same day. However, in my time at Madwaleni Hospital, there were many mornings in which the PPT bus simply did not arrive,” the worker said. “The patients would then miss appointments and need to be personally rebooked by clinical staff. This would delay access to services for weeks and often months. It could also lead to poorer health outcomes due to delays in receiving treatment. This, in turn, could lead to an increased demand for ambulance services in the future.”

Anecdotally, there are ample media reports speaking of similar struggles elsewhere; Marongo, meanwhile, says that, in the coalition’s work with the TAC in rural KwaZulu-Natal, it has been possible to draw direct parallels.

There is a local component to it,” he says, “[but] there are also parallels, particularly in areas that were formerly homelands [under apartheid]. The break into (a) new dispensation does not seem to have had a radical effect.”

Poor working conditions discourage medical professionals from working in rural areas at all.

We have many complaints of understaffing,” Marongo says. “One has to attend to more patients, which has an impact. We have doctors saying, ‘I have to work all the time’. But then with that overtime, they sometimes face issues of not being paid for their overtime. Human Resources issues are quite big.”

Accommodation for medical staff is an additional problem.

In order for healthcare to improve overall, Marongo told Daily Maverick, it was essential to drive more collaboration between departments, which would improve service delivery in all the areas currently affecting the provision of medical treatment.

Moreover, the HRC found, the ECDoH did not report transparently, consistently, or allow itself to monitor progress. Reporting, it stressed, had to be in line with targets set and maintained consistently.

At this stage, the problems are so widespread – and so interconnected – that it would be foolish to attempt to isolate what is most urgent, says Marongo.

I think it’ll be insincere of me if I were just to pick one intervention,” he explains. “All these issues are connected. One can’t undermine one issue by prioritising the other. They are so intertwined. But a starting point would be looking at who are the most vulnerable individuals.”

Meanwhile, the most vulnerable wait. DM

Photo: Grandfather and subsistence farmer, Selby Hambisa, 79, sits with his wife Nolayani Hambisa, 62, in their family communal mud hut in the hills near Coffee Bay, South Africa, 06 November 2014. EPA/KIM LUDBROOK

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