Over the years the Robert Mangaliso Sobukwe Hospital in Kimberley - the Northern Cape's only tertiary hospital - has often made headlines for the wrong reasons.
Last year, two female doctors and a patient were stabbed - allegedly by a patient. There were reports of patients going hungry when kitchen staff (contracted by catering company, Fedics) at the hospital went on strike, earlier this year. During an unannounced visit by Public Protector in February, patients were found lying on the floor. There were also reports of lifts habitually breaking down, water interruptions and healthcare workers having to carry buckets of water to the hospital and then having to heat the water in kettles in order to wash patients.
Democratic Alliance spokesperson for health in the Northern Cape, Dr Isak Fritz said that during a recent oversight visit the hospital was in "a shocking state and hospital staff have shifted into survival mode". "As opposed to the facility budgeting to deliver quality healthcare, the staff are merely trying to prevent death due to limited human and other resources. The hospital is critically understaffed," he said.
And that is not all.
Hospital CEO Dr Alistair Kantani, who was presenting a turnaround plan for the hospital with Health MEC Marupeng Lekwene and acting head of the provincial health department Riaan Strydom earlier this month, also reflected on some of the challenges at the hospital.
"We used to send our oncology cancer patients for radiotherapy to the Free State. That was a frustrating and humiliating experience for patients - not only getting there but also for those that had to travel over 100 km to get to Kimberley and then be driven over to Bloemfontein with no guarantee that treatment was going to be commenced on their arrival," Kantani said.
Kantani said often oncology patients would arrive in the Free State and the bed that was earmarked for admission would be given to another patient and that meant that the patient had to be ferried back to Kimberley, sleep over, and then be ferried back to their original destination without having received help.
"Another serious disadvantage that we had been facing over the years," he said, "is that if you stayed outside of Kimberley and were to suffer end-stage disease which requires you to have dialysis, you were forced to move house and relocate to Kimberley for you to get your dialysis."
Kantani during the briefing referred to an incident when copper cables were stolen from a standby generator for the ICU section in the A block of the hospital. This block also houses the neonatal ICU. "These types of social challenges that we face have an impact on the health system," he said.
The turnaround plan
At the briefing, Lekwene presented a turnaround strategy aimed at "resetting the (province's) health system" and addressing the various challenges at the health facility. Lekwene said that part of this turnaround strategy to improve health services is also to capacitate district hospitals. As the only tertiary hospital in the province, Robert Sobukwe Hospital has to handle referrals of 87% of the province's population (uninsured with no medical aid) of 1.3 million.
The 604-bed hospital employs over 1 600 personnel, of which 195 are medical doctors, 596 are nurses, and 383 are allied health professionals and pharmacists. "Every year there are over 110 000 outpatient appointments recorded and 50 000 accident and emergency attendances," he said. "The hospital records 21 000 patient admissions to wards annually and the average length of stay currently stands at eight days."
According to Strydom, the project will run in batches of three months and the department undertakes to assess and give feedback on tangible progress after three months.
Opposition parties and health activists welcomed the turnaround strategy, saying that it is long overdue. "The list of problems is long at the hospital and we sincerely hope that Lekwene is serious about the numerous promises he has made in respect of fixing what was once an exemplary training hospital," said Fritz.
Philip van Staden, Freedom Front-Plus health spokesperson and MP said any attempt to reverse the current situation is a step in the right direction. "But we see no real plans to eradicate corruption, mismanagement, and maladministration. That should have been priority number one."
Spotlight previously published about issues relating to alleged mismanagement here and here.
Community health activist and deputy chairperson for the Community Care Workers Forum, Thapelo Moncho told Spotlight focusing only on one hospital is not sufficient because the entire health system in the province is suffering.
Both Lekwene and Strydom, however, made it clear the plan for Robert Sobukwe Hospital is only one element of the bigger plan to reset health services across districts.
Below we unpacked the plan in terms of the three biggest challenges - staffing, infrastructure, and oncology services.
1. Staffing
In its latest tabled annual report for 2020/21, the provincial department of health warned that certain services might collapse if the exodus of staff continues. One such vacancy at the time was that of the clinical head at the hospital which put tremendous strain on junior doctors since they did not get the proper guidance and supervision. The post has been filled recently. In the report, the department said the long-term plan is "active recruitment, coupled with training nurses in theatre technique to cover the rest of the province".
But Kantani stressed that it has been very difficult to attract skilled professionals to the province because of its vast geographic landscape and the lack of amenities in the province as opposed to other provinces such as Gauteng. "We have to try our level best to get people here and not only get them in the system but to ensure that we keep them here for a long period of time."
The hospital is accredited as a training facility for young doctors, but the intake and retaining medical interns have been dropping. Last year, a number of medical officers left. According to Kantani, every year there are medical officer appointments done around August and September. "But over the years, every year around this time, we have resignations of 20 or 30 them. Every year."
In a response to a parliamentary question in December last year, Health Minister Dr Joe Phaahla said the hospital has an annual staff turnover of about 30 to 50 community service doctors. "The hospital is currently filling 31 posts, following a resignation of medical officers," Phaahla said at the time. A shortage of nurses, especially theatre nurses, has led to backlogs in ophthalmology, general surgery, and orthopaedics. At the time, Phaahla said the total backlog for general surgery was 492. Phaahla also said in response to a different parliamentary question on the number of critical skills shortages, that the Northern Cape health department's vacancy rate of critical skills is at 2.02%. By May this year, the province had a shortage of critical skills (nurses, medical practitioners, pharmacists, and paramedics) of 562.
The hospital's registrar programme, Kantani said, is among the interventions to help build a pool of specialists in various disciplines and the impact is already visible. The idea is to train these specialists, which will allow the hospital to plan outreach programmes to support services in district hospitals that will reduce the burden on Robert Sobukwe Hospital.
"We developed the registrar programme to train the doctors from within so that we can bind them at least to the period that we supported them in getting their specialist training," Kantani said. He said the programme is running and they've ensured that the hospital maintains its status as a training institution since losing this status was one of the risks they were facing.
Lekwene further explained that as part of this process, the department has an exchange programme where doctors from these (district) hospitals come for training at Robert Sobukwe Hospital in specialties such as anaesthesiology.
In its 2nd Quarter Performance report for 2021/2022, the department flagged 'patient experience of care' that dropped by 11% compared to the same period the previous financial year. Experiences relating to "cleanliness dropped from 72% to 65.8% and values and attitudes (of health personnel) dropped from 74.5% to 68.8%". This was fuelled by staff shortages and overworked staff resulting in low staff morale, the report states. In its annual report for the previous financial year, the department flagged overcrowding as a challenge in the accident and emergency unit due to a lack of health services after 16:00 and on public holidays.
"Unfortunately," said Kantani, "because of all these dynamics, the staff we appoint do not stay long. The general trend of people resigning is still happening, so we have to keep closing the gap. The issue of appointments is a continuous one," he said.
Some relief
In his budget speech earlier this year, Lekwene made several announcements on appointments that are underway.
To support clinical services, he said the department has placed advertisements to recruit "249 permanent support staff ranging from housekeeper supervisors, laundry supervisors, cleaners, porters, general assistants, drivers, registry clerks, food services aids, admin clerks, mortuary assistants, artisans, human resource, and supply chain management staff".
Lekwene also announced that the 99 Post Basic Pharmacy Assistants who were set to qualify in July this year, will be absorbed in primary health facilities across the province, which will help relieve "nursing staff from focusing on dispensing medication and [to rather] focus on patient care".
According to the health MEC, they appointed five specialists in internal medicine, orthopaedics, radiology, and obstetrics and gynaecology. An additional five medical specialists in disciplines ranging from ear, nose, and throat as well as paediatrics and obstetrics, were appointed on contract as "a short-term strategy" while permanent specialists are trained as part of the registrar programme.
During the briefing this month, Lekwene said theatre services will be increased by operationalising an additional theatre in the hospital. This must be done within three months. "Currently, there are nine theatres and only four are functional, so this will increase theatre output and decrease waiting time and backlogs." He said they intend to operationalise the fifth theatre along with appointing three theatre-trained nurses.
2. Infrastructure
There have been several calls to close the hospital due to challenges related to ageing infrastructure. Infrastructure challenges were also flagged in the department's 2nd Quarterly Performance report. It cited the need for continuous repairs to galvanised sewerage pipes bursting and flagged the fact that there was no major maintenance programme. Among the proposals to address this, was to either "propose a new hospital or increase the budget for maintenance".
During the briefing, Strydom (acting HOD) said after facing challenges with water quality in the facility, they started a water project to replace the water tanks, so the problems with water quality at the facility have been addressed.
Strydom also mentioned a maintenance programme but when Spotlight asked for further details, the department said these questions will be answered in a follow-up briefing. No date was given.
Lekwene in his budget speech said the hospital has acquired some "key clinical equipment, including among others, Optical Coherence Tomography (OCT), Endoscope, and plans are underway to procure additional equipment for theatre, radiology, and radiotherapy services". He said new lifts have also been delivered and installation has started on the four lifts that need replacement. The hospital will also receive another generator for Block A that houses the neonatal ICU as part of the electrical backup system.
3. Oncology services
Kantani said the department has outsourced oncology services, which now means patients do not have to travel to other provinces for radiotherapy. He said the department has outsourced the service to a private company - Icon Oncology based at Lenmed Private Hospital in Kimberley. So far, a total of 251 patients had scans and 183 have successfully completed treatment through this arrangement, he said. "To allow for the construction of the new radiotherapy unit in-house, the private partnership with Lenmed Hospital will continue for two years." He said the building will start as soon as a contractor is appointed.
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When Spotlight asked how much the outsourcing is costing the department, the department was not able to provide an answer. In the performance report, however, the department said it secured funding for radiotherapy through the help of the national health department.
The first batch of new medical doctors, who will do their community service in the Northern Cape, has been welcomed at the Robert Mangaliso Sobukwe Hospital in Kimberley.https://t.co/BDcgP5cv4J pic.twitter.com/lWVvrWa2cK
-- SABC News (@SABCNews) January 4, 2022
Money matters
It is not clear how the turnaround plan will be financed amid budget constraints.
According to Lekwene, the budget for hospital services in the province is R443.6 million from the equitable share with an additional amount of R420 514 from the National Treasury grant. "Of this budget," he said, "70% is consumed by employees and 30% is for standing commitments to render health care services. We are working under a tight budget in this financial year," he said.
The department's budget for the 2022/23 financial year is R5.3 billion, which includes the conditional grant of R1.5 billion. "So if you remove the conditional grant, we are remaining with R4 billion, with R3.3 billion that goes for salaries. So, we are literally left with R1 billion for the entire goods and services budget," said Lekwene.
The budget for central hospital services (Robert Sobukwe Hospital) is R1.2 billion. The District Health Services programme is an important element to the success of the intervention plan for Robert Sobukwe Hospital and received a budget of R2.7 billion.
And among these figures, is an important caveat. "The nominal growth in the department's budget," Lekwene said, "will continue to be a challenge, and it does not provide for improvement of capacity in terms of staffing and logistical resources, as well as the expansion of services to match our ever-increasing demand accelerated qualitative and quantitative improvement of health services to communities."
Put simply - there is an ever-increasing demand for health services and not enough money now and in the foreseeable future.
According to Russel Rensburg, director of the Rural Health Advocacy Project, a turnaround strategy is always good, but money, he said, is not always the only solution to problems.
"What is important is the communication method between the clinics and the hospitals, how accessible are services at the hospital for people who are outside of Kimberley, the attitude of staff members as well as the culture and leadership capabilities of the people in charge," he said. "How is their attitude towards this plan, and how much work is everyone willing to put in for this turnaround strategy to be successful? It is not always about the money, but it is the attitude that matters."
