Observations from the Field

Fellows share personal reflections on health professions education, health care, and life around the world.

Vanessa Burch, M.B.Ch.B., M.Med., Ph.D., Gives Inaugural Lecture as Professor and Chair of Clinical Medicine at University of Cape Town

Vanessa Burch, M.B.Ch.B., M.Med., Ph.D.
Professor and Chair of Clinical Medicine
University of Cape Town
Cape Town, South Africa

Vanessa Burch (PHIL 2001) recently gave her inaugural lecture as professor and chair of clinical medicine in the University of Cape Town’s Department of Medicine. Her lecture was entitled Health Care in South Africa Today and focused on the challenges facing South Africa in meeting the United Nations 2015 Millennium Development Goals. Her perspective is that of an educator facing head-on the health care needs of her region. Following are some highlights from her lecture, which began with excerpts from a few recent articles from the South African newspaper Cape Argus on the subject of health care:

Health Care Today

Cape Argus Monday, March 23, 2009
“Birth ordeal outside clinic”
A teenager from Crossroads gave birth on the pavement outside the gates of Gugulethu Maternal Obstetrics Unit just hours after nurses discharged her, telling her she was not yet in labour…
Cape Argus Thursday, March 19, 2009
“A city’s shame”
The granny trudged from clinic to clinic to get help for her sick grandson. After they were turned away 3 times, the toddler died, still strapped to his grandmother’s back…
Cape Argus Saturday, March 21, 2009
“Another clinic baby sent off to die”
One-month old Somila Tshangatsha died just hours after she was turned away from a clinic in Khayelitsha because nurses said “there was nothing wrong with her.”
“Africa is the only world region unlikely to meet the 2015 Millennium Development Goals. At best Africa could hope to do so by 2050!”
– United Nations Secretary-General Kofi Annan, 2006
U.N. Millennium Development Goals
- Eradicate extreme poverty and hunger
- Achieve universal primary education
- Promote gender equality and empower women
- Reduce child mortality
- Improve maternal health
- Combat HIV/AIDS, malaria, and other diseases
- Ensure environmental sustainability
- Develop global partnerships for development
Quadruple epidemic in South Africa
- HIV / AIDS
- Non-communicable chronic diseases, e.g. hypertension, diabetes mellitus, and ischemic heart disease
- Injury
- Other infections, e.g. tuberculosis, diarrhea
Major health care challenges
- Burden of disease
- Funding of health care
- Size and shape of the clinical platform
- Size of health care workforce
- Training of health care professionals
- Health care workforce migration

Epidemics: Disease & Injury

Top causes of mortality in South Africa
- HIV / AIDS (30%)
- Cardiovascular disease (17%)
- Injury (12%)
- Other infections (10%)
- Other (31%)
HIV / AIDS: According to the 2008 U.N. Report on the Global AIDS Epidemic, there were 33 million people in the world with HIV / AIDS, 22 million of whom lived in sub-Saharan Africa and 5.7 million of whom lived in South Africa.
Injury
- Since 2005, South Africa has averaged more than 30 road accident fatalities per 100,000 people (www.hst.org.za/healthstats/224/data)
- Firearm-related homicide rate was 27 per 100,000 people, second only to Colombia (1998 U.N. Survey)
- Approximately 15,000 firearm-related deaths and 127,000 non-fatal firearm injuries in South Africa each year
Other diseases
- Tuberculosis (TB) has been rising steadily. In 2000 the prevalence of TB was 774 per 100,000 population. By 2006 this figure had risen to 998 per 100,000. In real terms this means that the average number of clinic visits for a standard TB clinic in South Africa has risen from about 65,980 visits to 149,409 visits.
- Non-communicable diseases such as diabetes mellitus, hypertension, and ischemic heart disease are also increasing.
Effect on physician caseloads
- Case loads are increasing
- Patients admitted for care are very ill:
  - 53% severely or critically ill
  - 43% advanced HIV infection
  - 70% need specialist opinion
  (Burch & Benatar, 2006: 96: 796-802)

Funding Health Care

Government spending
- Comprises about 40% of the total amount spent on health care
- Comparable to the percentage spent in the United States, but roughly one-half the percentage spent in the United Kingdom
(The World Health Report 2006. WHO)
Per capita spending
- 7 times more in private sector than in public sector (Health Systems Trust, 2008)
- Private sector expenditure continues to rise while public funding remains relatively flat (Health Systems Trust, 2008)
- Per capita spending much lower than developed countries
Health insurance
- 42.7 million people do not have health insurance
- Access to health insurance limited for many

The Health Care Workforce

Balance of disease burden vs. workforce
- Africa makes up approximately 3% of the global workforce, but is responsible for approximately 25% of the global burden of disease. (The World Health Report 2006)
- “An additional 1 million extra workers will be required in sub-Saharan Africa to deliver the health services necessary to meet the Millennium Development Goals by 2015.” (Chen et al. The Lancet. 2004; 364: 1984-90.)
Currently in South Africa
- There are too few public service doctors
- Too few rural doctors
- Much of public service is below the World Health Organization minimum
Rural health care workforce in South Africa
- 1 doctor per 30,000 population
- 21.7 million people live in non-urban areas
(De Vries and Reid. South African Medical Journal. 2003; 93: 789-93.)
Sub-Saharan African medical graduate output
- 72 sub-Saharan African medical schools
- Average graduate class approximately 100
- Fewer than 10,000 graduates per annum
- Sub-Saharan Africa needs 1 million additional health care workers (Longombe, Burch et al. Education for Health. 2007; 20: 1-6.)
The current situation in South Africa
- Need to train more doctors
- Limited facilities to increase training output
- Black African throughput needs to increase
Developed world medical workforce
- Up to 34% of the workforce in the United States, United Kingdom, Canada, Australia, and New Zealand trained elsewhere. Most come from poorly resourced countries. (Forcier et al. Human Resources for Health. 2004; 2:12.)
South African-trained doctors accounted for 34.5% of African-trained doctors in the United States in 2004 (Hagopian et al. Human Resources for Health. 2004; 2:17.)
Currently, South Africa is experiencing a significant loss of South African medical graduates and an enormous financial loss per graduate.

The Way Forward

What options do we have?
- Recruit additional training sites at district service level
- Train in the private sector
- New public medical school
- Private medical school
- Recruit teachers from private sector
- Recruit foreign-trained doctors
Train more health care workers
- Increase health care professionals by 30,000 by 2011
- Train 1,000 emergency service practitioners by 2009
- Double the number of medical graduates from 1,200 to 2,400 by 2014
(National Human Resources Plan for Health, 2006)
Train doctors for rural areas
- Recruit rural origin students
- Recruit students with rural interest
- Develop rural training sites
- Recruit rural role models
- Incentives to work in rural sites
Mosvold Hospital scholarship scheme
- Rural origin students
- Prior rural health care work
- Selected by local residents
- 37 scholarships awarded
- 24 graduates to date
- Success = Rural Origin + Rural Mentor + Mutual Support
Zithulele Hospital: A rural success story
- 100 km from Mthatha
- 146 beds
- 143,000 population
- 7 doctors, 5 Ancillary Health Workers (AHWs)
- CMSA certified
  - Obstetrics and Gynaecology
  - Anaesthetics
  - Child health
  - HIV management
- Success = Rural Interest + Role Models
Need for national health care insurance
- “Universal access to health care is a socioeconomic right and a critical public policy issue. […] There is a critical imperative for health financing reforms in South Africa.” (Sishana et al. South African Medical Journal. 2006; 96:814-8.)
Measures to curtail “brain drain”
- Delay migration
- Promote return
- Improve remuneration
- Public sector tax breaks
- Restrict movement
- Limit recruitment
- Financial compensation
Public perceptions of health care needs
- Of 16,398 South Africans surveyed:
  - 57.2% agreed that medicine prices should be regulated
  - 56.9% agreed in the need for health care coverage for all
  - 47.3% agreed in a need for national health insurance
  (Sishana et al. South African Medical Journal. 2006; 96: 814-8.)
Our health care future in South Africa
- There are no simple solutions
- Multiple strategies are needed
- Feasible options should be explored
- Health care for the greater good of all
- It is going to cost money

David Cameron, M.B.Ch.B., M.Med., M.Phil., Reflects on Providing Care in Rural South Africa

David Cameron, M.B.Ch.B., M.Med., M.Phil.
Associate Professor, Department of Family Medicine
University of Pretoria

Here’s a brief reflection I wrote two years ago following a home visit in a small rural village where I was working:

Home based care? Flies circle like lazy vultures parting the air saturated with the smell of
cervical cancer. Too weak to sit up, she reached out and grasped my hand, 33
degrees outside, it felt like 40 under the low tin roof.
"Hospital?" I suggested.
"No, people die there."
Six pairs of weary eyes watch my every move.

My Experience in Sierra Leone

Elsie Kiguli-Malwadde, M.B.Ch.B., M. Med.
Head, Department of Radiology
Makerere University

At the beginning of this year, I found my self in Sierra Leone. If you had asked me a few years back whether I would ever go there, I would have asked you, “What for?” Here I am in Sierra Leone and enjoying it.

Sierra Leone is a small country of 71,740 sq km with a population of 6 million, in comparison to my country, Uganda, of 236,000 sq km and 26 million people. In many aspects, both countries are similar: they have had civil wars and are developing countries that are on their way to recovery. Uganda has had a relatively longer period of peace, 20 years, compared to Sierra Leone, which has been peaceful for seven years. Both countries became independent around the same time in the early 1960s and were colonized by the British.

The people of Sierra Leone are friendly and very welcoming. They will greet and welcome you to their country in a warm way that makes one feel welcome instantly. They have many languages but the local official language, Krio, is the one that’s widely spoken. Krio is a mixture of English, Portuguese, French, and local African languages. It is distinct from Pidgin English. Most people are fooled into believing at the beginning that English speakers will understand Krio, but they get surprised when they start hearing it. I have started taking classes in Krio and I love it. It is challenging but enjoyable.

The health structure in Sierra Leone, like in so many African countries, is not functioning properly and the hospitals are poorly equipped. Brain drain has not spared it, with most of the professionals working in developed countries. Life expectancy is 46 years. There is one radiologist in the country. They have one medical school and their basic training takes six years. Their curriculum is community-based and teaches radiology in an integrated manner. Both aspects are similar to what is done at Makerere University where I teach; my university has just started this while, in Sierra Leone, they have been doing it for a long time. Unfortunately, most of their doctors don’t stay.

Sierra Leone is a beautiful country; it is green and has tropical forests but what have attracted me most are its beaches. This may be because I am from a landlocked country. They have great beaches with clean sand and ideal conditions for swimming, especially since the temperatures can be quite high — 30 degrees Celsius. Freetown, its capital, is a hilly city and one can see the beach from most places in the city. I learned from Page at FAIMER to look out for the good in life and appreciate it, and that is the attitude that has made my life a lot more enjoyable far away from home.