Contextual challenges amidst the provision of healthcare in rural South Africa: a personal view.
“To strive, to seek, to find, and not to yield”
General background information:
Being a Dutch medical graduate from the University of Maastricht, I worked both in the Netherlands, Venda (Limpopo/ South Africa), England, Scotland and Australia. I have my qualification from the Netherlands, the UK and Australia.
In Australia, I worked in both Pinnaroo (SA), Laurieton (NSW) and Tailem Bend (SA).
Currently I am working in Aldinga – close to Adelaide – and in Cairns ( northern Queensland).
The main stream of my work experience in Australia has been in (remote) Rural General Medical Practice, – the last including Hospital Care and Accident & Emergency (ED), and often under very challenging circumstances.
In those years I did various RFDS & Rural Doctors Work Force initiated “update courses” – in both BLS, ALS and emergency medicine. Very helpful in those days!
Since the end of December 2016, I work at “Aldinga Day & Night Surgery”(SA) as a GP Family Physician – along with 4 -5 other General Practitioner’s.
I am actively & enthusiastically involved in both GP and Medical student training ( mentoring &
From the end of 2022 I divided my medical work in Australia between Aldinga (SA) and Cairns, in
northern Queensland. The last in a well set up (international) practice – with great staff, working in operational teams from 7am until 11 pm, and with plenty of interesting variety.
From the 1st of April 2023 until the 31st of May, I have been privileged working via the Tshemba Foundation in South Africa – in the Limpopo area, for Tintswalo Hospital, a District Hospital. Tintswalo Hospital has 15 or 16 outer clinics and I had the opportunity to visit 3 of them. Both the Dwarsloop, Cottondale and Hlokomela clinic. Very pleasant but different experiences.
Tshemba Foundation was founded in 2014 by Neil Tabatznik – with Godfrey Phillips. Now living in
Canada, South African-born Neil Tabatznik practiced as a Barrister at the Bar of England and Wales for some 19 years and was formerly director of the Arrow Group of Companies. I am not sure whether he is currently still chairman of Blue Ice Capital and Blue Ice Pictures, founder of the Blue Ice Hot Docs Documentary Film Fund. He has served as executive producer on the films Shake Hands with the Devil, The Bang Bang Club, Fanie Fourie’s Lobola, Romeo and Juliet and Nebraska. In other words a very successful and colourful person, who had a very specific reason to “give back to South Africa”, the country he once left and did not want to see anymore. Godfrey Phillips lives at the Tshemba plot close to all international volunteers and it was an honour to meet him in person and listen to many of his entertaining stories. He has a diverse background and was living in the US a significant part of his life. The broader Tshemba Foundation team has a colourful background as well and needless to say they all have a big commitment towards their common purpose.
As a way to improve access to healthcare in under-resourced communities in rural South Africa, the Tshemba Foundation is pioneering a new era of medical volunteering. Based in a purpose-built Volunteer Centre near Hoedspruit and currently serving communities in Limpopo and Mpumalanga, the initiative is built around a vigorously managed healthcare delivery system – based on volunteer input supporting local capacity through service training and skills development. However (!), not having any formal responsibility in the leadership and management of (in this case) Tinstwalo Hospital itself.
Tintswalo Hospital is a 350-bed level 1 district hospital with Emergency, Medical (FM&MM), Surgical, Pediatric, Obstetric and Psychiatric wards. There is a busy outpatient department as well as HIV, TB and eye clinics on hospital grounds. The hospital currently serves communities in Limpopo and Mpumulanga. Many of the around 10,000 patients visiting the hospital each month present with life threatening diseases such as malnutrition, malaria, diarrhea, HIV/AIDS, tuberculosis, diabetes & hypertension – in really epidemic proportions.
Tintswalo Hospital is at large staffed by employed “community service” doctors in their third-year post-qualification. They undertake nearly anything, definitely within their limitations, from manipulating a fracture under sedation, performing emergency C sections, leading pediatric resuscitation’s, and providing anesthetics cover for theaters etc.
The rules by the HPCSA (The Medical Board) are strict – and overstepping boundaries with ramifications. for patients may have serious implications. On a side note, there are various obstacles in the retention of doctors as well. The reasons for this will be in part further reflected on.
At Tintswalo I worked at large in OPD and (foremost) at 3 clinics for almost 9 weeks.
The experience with the Tshemba Foundation has been both amazing and interesting in different ways. It offered me an opportunity to visit the huts and villages of the most poverty-stricken areas,and make very meaningful connections, apart from the interesting medical work in remote South Africa. Different again than my experience long ago at Siloam Hospital, northern Limpopo area (Venda).
The Tshemba management has certainly challenges of different nature – but is growing in strength. They are focused on getting as many useful volunteers as possible, which gives at times the impression that volunteers are coming and going on an increasing larger scale at a cost perhaps of more personable interactions between staff members and volunteers.
The RACGP requirement for my profession is to provide an evaluation (with a view to CPD points) on my experience at Tintswalo Hospital, hence this article with an effort to picture Tintswalo Hospital in the wider context of the South African health care environment. An audacious endeavour, actually, after only 9 weeks medical volunteering, – let that be said.
South Africa background:
There is overwhelming evidence that the quality of health care in South Africa has been
compromised by various challenges that impact negatively on healthcare quality. Improvement in
quality of care would definitely mean less errors, reduced delays in care delivery, improvement in
efficiency, increasing market share and lower cost. Organizations can increase market share by more closely aligning providers, administrators, and the data they rely, on to make decisions. The last being very important. A health system’s leadership team should be committed to improving the quality of healthcare delivery, employee engagement, provider recruitment, and financial gains – while also finding a way to scale the process, apply it to other clinical domains, re-monetize the platform, and ensure sustainability. All this in an ideal world. But …the world in South Africa is not ideal.
If any healthcare environment is willing to survive the modern demands, it is critical that health systems have a clear objective, strong leadership dyads (composed of one administrator and one clinician) supporting the objectives, and easy access to keep team members on track. The “dyad model” allows leaders to make quick decisions alongside each other – and expand those decisions to their broader teams and community. Implementing a strong dyad model before a crisis hit is crucial. I haven’t seen this in Tintwalo Hspital, but this really needs to be seen in a “contextual way” because where actually can this be seen in the rural healthcare environment in South Africa?
Decline in quality health care, however, has caused the public to lose trust in the public healthcare system in South Africa. My impression is that this is widespread and based, in part, on cultural aspects, – but at large on poor funding from the SA Government and lack of real leadership in public hospitals, despite very willing efforts in the positive from some very dedicated people. Often medical work in South Africa is like swimming with the tide against you.
Cultural aspects of organisations are hard to change. Improvement in quality care is a nice phrase when the medical infrastructure has so many shortcomings. It’s like cleaning the floor with the tap running. There you see the challenges.
The purpose of this evaluation on my stay at Tintwalo Hospital (and at large in some of the outer clinics), is to identify those challenges that are being incurred in practice – that compromise quality in the healthcare sector, including strategies employed by government to improve the quality of health delivery. All this is relevant at Tintswalo Hospital and Tintswalo Hospital is only to be seen as a symptom of “ The South African Health Care Disease” – which is at least complex – certainly crippling the whole public hospital sector, in rural communities, at large. Lacking leadership and effective management based on poor government support and funding are the key components. “Load shedding/ intermittently no electricity – made matters only worse recently, in particular where hospitals had insufficient functioning generators, like Tintswalo Hospital. An accumulation of preventable problems. Mind blowing complications at times.
Not typical scientific, definitely. My observations in April and May 2023 are of a personal nature and are restricted to general impressions in Tinstwalo Hospital, and 3 outer clinics only: Cottondale, Dwarsloop and Hlokomela. I was a volunteer doctor , working for the Tshemba Foundation at this time frame. Only Hlokomela clinic scored higher on the criteria of leadership and team involvement, because it became a private managed entity after the government suddenly ceased all funding for incomprehensible reasons. This however is not a reason to cease funding in other clinics, because they might be less privileged to survive against all odds. Hlokomela did do an amazing job!
The Tshemba Foundation’s medical volunteer program brings healthcare professionals in
partnership on most parts of medical disciplines with knowledge, skills, experience and a deep desire to give back to rural communities in need. The management and leadership of Tshemba has (again) no responsibility with the way Tintwalo Hospital is structured or managed, including the outer clinics. Their website and presentation is cleverly designed but it would seem there is some discrepancy in what is presented and actually happening. The quality of management could be a potential concern when the the leadership of Professor John Gear falls away. Like many organisations there is an increasing shift on numbers whilst often applies “small is beautiful”, with an optimal personal touch with volunteers who spend their free time on medical volunteering. The management and leadership training of the Tshemba team needs attention with a view to the future.
I encountered myself a somewhat unprofessional interim assessment, based on a baseless complaint from a nurse – and non principal centered bias from a staff member – which could only be corrected by a positive feedback from an outer clinic, which valued me as a volunteer (team member) based on efforts to get each other to know, and accept cultural differences. Staff members of the Tshemba Foundation are not always in the best position to get to know their fellow volunteer members on a more personal base. And applying valued based management criteria, should never be sacrificed for the sake of a good relationship with Tintwalo Hospital. Honesty with respectful diplomacy is always the key. And personal bias needs to be avoided, for the sake of professionalism in both management and leadership. The challenge is ongoing, for everybody.
Tintswalo Hospital is a typical South African rural hospital. Tshemba only assist, where needed, by a
dedicated team of staff members and volunteers. They have however to balance wisely with a large
rural medical entity – bearing the typical South African colors of imperfections in various domains. The last caused by the never-ending status quo on stagnant progress at different federal and provincial government levels, – and then not to speak at some personal levels as well.
CLINICAL TRAINING AND EDUCATION FOR HEALTHCARE PROFESSIONALS:
Tshemba Foundation offers formal clinical education to local healthcare professionals through ongoing professional development sessions – and informal clinical teaching, ensuring they make an justifiable impact. However, the long-lasting impact might be overshadowed by the dormant state of affairs at various government departments. Besides this, some cultural aspects are being hard to change because of South Africa itself, – with all respect.
Women in rural and outlying communities do not have access to essential medical check-ups. The
Tshemba Foundation recruits medical volunteers so these women can get the treatment they
deserve. And the list is by far not complete. Beneficial, though, for International volunteers is to work as much as possible in team entities because working e.g at different outer clinics and OPD does not always provide the required structural entity to add in valuable ways because you only “fill the gaps”. This is different for surgeons, gynaecologists and ED specialists.
COMMUNITY OUTREACH, HEALTH PROMOTION AND EDUCATION:
Tshemba Foundation partners with local schools and clinics to provide screening and health
prevention education, and work with a community radio station on health promotion programming.
SPECIALIZED SERVICES AND PROGRAMS:
The Tshemba Foundation is constantly exploring opportunities to improve and strengthen local
healthcare delivery, as with quality improvement programs for both women’s and eye health. In
this domain progress is made but without Tshemba it’s questionable how progress lasts. However, the regular specialist cataract camps at the Tintswalo eye clinic – one of the flagship projects, in which great eye specialist volunteers help return vision to the blind,- will definitely last through its impact.
In e.g., the domain of the unrecognized largest public health care risk (the last associated with both domestic and sexual violence), the activities of Tshemba may have a very restricted impact when rural hospitals have only very limited resources available to fund and provide adequate staff for essential outreach support activities in this domain.
There have been many quality improvement programs initiated, adapted, modified and then
tested but they did not produce the required level of quality service delivery as desired. As a result,
the Government of South Africa has a challenge to ensure that the implementation of National Core Standards will deliver the desired health outcomes, however it does not happen because achieving a long lasting quality improvement system in health care – seems hard to accomplish due, to inactivity and stagnancy at various levels, including both poor leadership and management at almost all levels.
Despite a number of commendable goals having been set by government for improved quality of
service delivery in healthcare settings, reports by media and communities (in 2009 already) showed that services in public health institutions were nevertheless failing to meet basic standards of care and patient expectations. The warnings were verbalized long ago. Nothing happening in terms of effective action, negligent as it is, and this has understandably caused the public to lose trust in the healthcare system. Some people describe the healthcare system in South Africa as ruined and in serious need of repair. This is affecting the whole rural public hospital system with clinics supposed to be adequate buffers to prevent an overload on the hospitals. It simply does not happen in ways being called sufficiently effective. None of this. People get used to the unacceptable.
Tshemba Foundation has the task as well to deal with various cultural sensitivities – because speaking from the heart on this situation is not typical South African, and can be considered as offensive (and not effective).
Some significant problems in the South African healthcare system can be traced back to the
apartheid period (1948–1993) in which the healthcare system was much fragmented, with a
discriminatory effect, between four different racial groups (black, mixed race, Indian and white). To worsen the situation, the apartheid government developed 10 Bantustans (the so-called ethnic homelands) into which Africans were unwillingly segregated, and each of which had their own departments of health with their professional bodies. This, in part, led to deterioration in health system delivery because of lack of resources, and poor communities were especially affected.
Having said this, there have been examples of rural hospitals with Medical Superintendent’s with good leadership skills and a good oversight in an imperfect system. it seems, however, that the quality of health care has been going further down the hill and not everything can be blamed on the apartheid period anymore. History can’t be reversed but the future can only be made on the combined efforts of various ripples of hope within all levels of government. But we don’t see those ripples of hope very often for various reasons. As a matter of note, the “Dr Pierre Jacqes Award” award, annual presented by the Department of Family Medicine in South Africa is in honour of an eminent Medical Superintendent who served the medical profession with exceptional leadership during the Apartheid. Many good people seem to be forgotten. I can mention as well the late Dr Evert Helms, a very remarkable medical doctor, who for many years worked at Siloam Missionary Hospital in the northern Limpopo area, Venda. And there are many others. Most of them where not politically involved which was not liked at the time, but definitely they were against the oppressive systems at the time and looked after the people in the poorest areas. In some occasions the health care was better organised than now. An inconvenient truth personal, which has nothing to do with the evil of apartheid. Wherever Médecins Sans Frontières is working, they make sure that local people understand that Médecins Sans Frontières is politically neutral and will provide assistance to anyone who needs it. It’s the same, but this has been always more accepted.
Huge efforts have been made to improve the quality of healthcare delivery in South Africa since 1994 elections, but several issues have been raised by the public regarding public institutions. Among the many, the following seven issues are discussed in this evaluation: prolonged waiting time because of shortage of human resources, adverse events, poor hygiene and poor infection control, increased litigation because of avoidable errors, shortage of resources in medications and equipment, including poor record-keeping, files being lost and often in serious disarray. Besides this the difficulty to retain doctors in the rural areas in ways satisfactory for them.
Prolonged waiting time because of shortage of Human Resources
A major weakness in African health systems is inadequate human resources. Africa is said to have less than one health worker per 1000 population compared to 10 per 1000 in Europe. Health problems in South Africa are worsened by unequal distribution of health professionals between the private and public sectors, coupled with unequal distribution of public sector health professionals among the provinces. Exhaustion is often the result in an overstretched health system, both physical and mental exhaustion, – and in some of such cases this leads to further deterioration of the medical condition of people with in the domain of their care.
To provide an additional dimension:
The HRH Action Framework diagram includes six clickable action fields (HR Management Systems,
Leadership, Partnership, Finance, Education and Policy) and four clickable phases (Situational Analysis, Planning, Implementation and Monitoring & Evaluation). Based on the key elements of HRH governance outlined in the conceptual framework, it is clear that there are profound weaknesses in (1) the structure and stature of the HRH unit at NDoH; (2) alignment the regulatory bodies with national policy; (3) the relationships and coalitions between the diverse stakeholders and (4) the availability of the right kind of information for planning and decision-making. It has been suggested that strong HRH governance, as well as explicit stewardship of that function, is a key attribute in tackling this and, in the case of SA, requires renewal and clarification of the HRH governance priorities at national level.
Firstly, the HRH unit at the Department of Health needs to be enabled to perform its governance
function at the required level. It should be observed that this is easier said than done. The Health Dep of South Africa has many links at provincial levels, public entities, health professional councils and various service links. While good HRH strategic plans are an important part of this function, they should aim to support the development of further HRH planning at the lower levels of government in particular, rather than lock sub-national departments into fulfilling plans they cannot realistically fulfil. This requires that strong information and monitoring and evaluation systems are in place to facilitate decision-making close to the front-line. I reflected earlier on the “leadership dyads”.
FHIR is the Future of Interoperability and Application Development in Healthcare. On top of this Medical Practice Software needs to be widely recognized. Secondly, there is a need to understand what else can improve the organisational capacity for HRH governance at national level, in particular within the domain of values, norms, informal rules and relationships—that are fundamental to effectively improve management and establishing a shared vision, in particular in local public hospitals as well. This requires good governance, an appropriate mix of skills and explicit political support—which is not a purely a technical and administrative role. Finally, HRH governance is an area in dire need of more research and more attention. Strong leadership and effective management are required. And it would seem this is the crux of the matter in a fairly chaotic social and medical culture. Again, “leadership dyads”
SA has made some progress in addressing its HRH challenges and has been able to produce fairly -consistent national-level strategic plans that offer some form of strategic vision. Nevertheless, the landscape of HRH policy and planning is also marked by systemic breakdowns, crisis management,and plugging holes, all of which requires a concerted effort to reverse. Much of this is symptomatic of a lack of continuity between HRH strategic plans, a lack of capacity for stewardship of HRH policy at national level, and major issues with inter-sectoral and multi-stakeholder collaboration. The findings of this review at Tintswalo Hospital and outer clinic level shows that without strong political support for, and stewardship of, the HRH governance function at the national level, will continue to
be undermined with clear ramifications for rural public hospitals in South Africa, like Tintswalo
Hospital. Tinstwalo hospital and the level of organisation of outer clinics within the public domain is only symptomatic for the healthcare in South Africa actually being in crisis
Various incidents being reported are e.g., patients who developed complications, and in some cases died, because they were turned away from the public healthcare facility or denied access to healthcare service. Hospital doctors in Tintswalo Hospital are faced with the problem of transferring patients to better equipped hospitals elsewhere. Sometimes people are turned away elsewhere because the system is overloaded and struggling with efficiency matters in various domains.
Poor hygiene and poor infection control measures
Public healthcare facilities show numerous shortcomings such as long waiting times, poor-quality healthcare delivery, old and poorly maintained infrastructure, and poor disease control and prevention practices. Tintwalo Hospital and the outer clinics are no exception in this domain. Far too many facilities have problems with poor waste management, lack of cleanliness and poor maintenance of grounds and equipment. Dirty toilets, intermittent no water, intermittent no electricity, a systemic lack of towels to dry your hands, a lack of personal protective equipment (PPE) etc.
Increased litigation because of avoidable errors
Medico-legal claims – claims based on medical negligence or malpractice – have escalated in South Africa. Recent figures indicate a growth rate of 23% for medico-legal claims in the public sector since 2014
In the past financial 2022 year, more than R6.5 billion (over US$390 million) was awarded in
medico-legal claims. This is not just a South African issue but a global and regional one. I am not sure how this affects Tintswalo Hospital at the moment. The cause of the sharp increase in claims in general – and how to address it – has been examined and discussed by various academics in various jurisdictions in South Africa. Money spent on these claims from the health budget is money not being spent on essential healthcare priorities, and the costs of claims are staggering. The 2023/24 budget allocation for National Department of Health shows a decline of R4,4 billion from R64. 5 billion in 22/23 to R60. 1 billion in 2023/24.
The South Africa Nursing Council likewise reported a rise in misconduct cases against nurses, which indicates that the rights of both patients and families were violated. On the other hand, the urgent action agenda for 2023 and beyond highlights the increasing evidence of the stress, burnout, absence and associated symptoms of a health system being on the verge of burn out.
Shortage of resources in medicine and equipment
TIMESLIVE reported on 2018 that “Public hospitals have become a death-trap for the poor‚ says Refiloe Nt’sekhe of the Democratic Alliance.”The party has produced a checklist of the top eight problems that it says require urgent intervention‚ following inspection visits to hospitals and clinics by DA provincial health spokespersons Jack Bloom MPL (Gauteng)‚ Dr Imran Keeka MPL (KwaZulu-Natal)‚ Dr Tutu Faleni MPL (North West) and Langa Bodlani MPL (Limpopo) that year. It’s an indication how bad the situation already was 5 years ago.
Shortage of equipment in hospitals that leads to fatal delays in urgent surgery. Work backlog causes extended delay for some patients awaiting treatment, such as cancer patients who are affected by the lack of oncology doctors and of equipment, and long waiting lists for surgery or diagnosis, also because of the lack of equipment. According to the report, the long waiting times for medical intervention potentially exposed patients to development of complications or even loss of life. Also, the lack of material resources, equipment and supplies (e.g., glucometers for monitoring blood glucose and needles for lumbar puncture in investigating or diagnosing meningitis), resulting in prolonged patient stay in the hospital. Not to speak of medication shortages.
Tintswalo Hospital is lucky enough to have intermittent specialist services available via the Tshemba volunteering system, but not every rural hospital has this privilege.
Poor record-keeping causes unnecessary delays for patients. Sometimes, patients’ folders are missing or lost, and instead of healthcare workers explaining this to the patient, they simply let the patient wait. In worst scenarios, the medical history of the patient is lost, which can create further complications leading to incorrect diagnosis and in some cases death of the patient. In Tinswalo hospital “lost and incomplete files often being in disarray” (also in most phc clinics) proved to be a reoccurring issue as well, apart from serious waiting times people getting their files – and the frustrations e.g. when the OPD was closed at about 4 pm, whilst still patients have been waiting the whole day – and being sent away. Needless to say, this has been leading to frustration and not rarely to aggression. The OPD windows in Tintswalo Hospital are bearing “the scars” of this. The Tshemba Foundation tried to improve matters on follow up appointments for people who have to come back in OPD, but also the imperfections on the filing systems. Files being in disarray is a very common occurrence in the outer clinics – where Hlokomela is doing better than other clinics.
The Emergency Department:
At Tintswalo hospital there are various ED limitations, which creates fatal inefficiencies, compromise decency, and erodes community trust. This is the environment where dedicated staff tries to do their work, without much grace. There is e.g., no bodily and mental integrity for intimate exams. There are issues like plumbing being clogged, roofing leaking directly onto critical patients during rain, apart from the problems with intermittent “load shedding” resulting in electrical equipment breakdowns. Besides this frequently missing equipment makes monitoring very difficult for the sickest infants with breathing difficulties and the absence of storage space (probably the most essential issue of all), means that essential stock is lost and e.g., wounds keep bleeding whilst staff tries to find gauze and a drip. Resuscitation equipment or monitoring systems are insufficient, parts missing besides faulty equipment, resulting not rarely in permanent brain damage if a patient survives in such a context. It’s a problem for many rural hospitals and a symptom of highly inadequate funding and decision making with very tragic implications. The demand on services has increased whilst the level and quality of the infrastructure decreased as a result largely of systematic deficiencies at all.
What can we say about this: “And if by grace, then it is no longer of works; otherwise grace is no longer grace. But if it is of works, it is no longer grace; otherwise, work is no longer work.”
The positive is that people keep working within all those imperfections, not self inflicted, but by failure of health service delivery in parts of South Africa is often due to an ineffective Provincial Department of Health. The provincial departments of health are responsible for delivering the health services in the province they govern. And I am not sure how they speak out to the Government of SA who is in the end responsible for this.
The outer clinic’s
Tintswalo Hospital has some 16 outer clinics and I had the privilege to visit 3 of them. Both
Dwarsloop, Cottondale and Hlokomela clinic. Above observations apply at large to the outer clinics as well. The staff is friendly but poorly supported and governed and working in a fair degree of disarray seems the norm people get used to within the context of setting staff expectations. Hlokomela is within the context of South Africa well organised.
My recommendation to the Tshemba Foundation is to increasingly focus on the needs of primary care in those clinics – because those clinics are in general poorly organised, and primary care at the centre and being the main focus for improvement prevents an overload in OPD and in the hospital.
Retention problems doctors
1.Improving the financial situation of rural doctors
2.Improving the physical hospital infrastructure
3.Often there is poor hospital accommodation
4.Often there is scope to improve the working conditions in rural hospitals
5.Often improvements are required in continuing medical education
(Thsemba Foundation facilitates this at Tinswalo Hospital but not rarely there is nothing of this
nature in other hospitals)
6.Provide specialist support in rural hospitals.
Fortunately, there is intermittent specialist support via Tshemba volunteers. However, for the ED, sustained leadership is required with inconsistent and frequent changing teams – and challenging material conditions.
6.Ensure career progression for rural doctors
7.Needless to say the improving of rural hospital management.
8.Proper leave conditions
Factors that make doctors want to leave rural hospital practice:
Factors that made doctors want to leave rural hospital practice included the factors already
mentioned, such as insufficient salary, heavy work load and under-staffing, poor housing, poor
hospital management, lack of basic medical equipment, personal relationships, no recreational facilities and specialization.
Discussion retention problems medical staff and final conclusions.
A shortage of Australian doctors in rural communities continues to be a serious problem as well. It’s hard to compare South Africa with Australia. However, recruitment and retention of GP’s are almost everywhere and anywhere in the larger country areas. In Australia GP’s need to obtain their FRACGP qualifications before being able to work. Working in the countryside requires additional skills and the Rural Doctors Work Force is actively involved in supporting programs and assisting doctors in educational and recreational needs. This could apply to South African doctors for Family Medicine training to link them up with rural clinics and add value whilst in training, however in one team entity. Tshemba could by principle support this because an effective primary care with optimal chronic and acute disease management adds to the improvement of care in rural communities.
Researchers at the University of Melbourne and Monash University have recommended several key steps to reduce the persistent reliance of regional centers and small towns on international medical graduates. The last is different in South Africa because some doctors would wish to work in Australia and not in South Africa for various reasons. However the South African Government could put incentives in place for Family Physicians to work on a contract base for 3 years in primary health care settings, with training in place to support and improve team dynamics.
Attracting e.g. doctors to rural areas with a view to increasingly meet the healthcare needs of Australians living outside metropolitan areas, is a similar need for South Africa. Supporting employed “community service” doctors in their third-year post-qualification to get distance learning opportunities via e.g. MedunSa – in let’s say Career Paths for Public Health Medicine Specialists in South Africa, Postgraduate Education in Family Medicine – which can be studied at various universities in South Africa (including Limpopo), could be very helpful. The point is when you obtain a baseline qualification you can continue in different ways and it may provide a degree of job satisfaction as well, when the living conditions are good. A Masters e.g., in Medicine (Family Medicine) is helpful in rural settings because it enables to look at your own work in a different dimension and improve existing dynamics. Various opportunities amidst increasing skill set in rural SA hospitals, should be considered as part of formal training courses and assessments.
Selection of medical students with rural backgrounds and provide rural immersion options, could double the supply of rural general practitioners in South Africa where money is not the major incentive to study medicine, rather than the fun to improve a medical environment with various short comings.
Increase the number of trainees in general practice and other generalist specialties would boost the uptake of rural practice as a career, perhaps.
Ensuring more vocational training is available in rural areas, particularly for GPs and specialties most needed in these locations.
“Improved rural recruitment could be achieved by more widely disseminating evidence showing that a career in a rural area, whether as a GP or a specialist, is rewarding and satisfying despite the
challenges,” Professor Scott said – in Australia.
“Food for thought” – this article, not an answer on many questions. Perhaps it raises more questions.
But more questions being answered and materialized in the physical world of South Africa’s health care drama – and an increasing adequate healthcare provision – and regaining public trust – would be progress.
Regarding the Tshemba Foundation I would suggest to shift the focus increasingly and slowly to enhancing the quality of primary care. Likewise to shift the emphasis from individual efforts to team efforts for any longer stay doctors in PHC. Dedicated teams achieve far more than dedicated individuals.
In general (on top of earlier reflections on leadership dyads a/o), bolstering primary care into the most optimal condition and entity – in rural South Africa, will definitely reduce the overload on overstretched public hospital services. A future PHC situation, as mentioned, with an increasing focus & investment on enhancing team dynamics, cultural aspects and leadership, will pay long term dividend.
Working on >”teams<” should be the general future emphasis in the health care system because: communication is the cornerstone for progress in various dimensions, and needs to be cultivated in all possible avenues.
Team work involves brainstorming, goal setting and improves problem solving skills. Teams rely on mutual trust and enhance the wider culture of an organisation in the positive when people buy into the principle of effective cooperation through (!) >involvement<(!)
The crux of effective team communication, brainstorming and goal setting is that it creates efficiency through cooperation. It’s not a quick fix process but an endeavour with different hurdles where people slowly need to “buy into” effective change for the better as a team, rather than “dying” as individuals on a “ South African health care Titanic” – which, likely, has no lasting future anymore. The health care situation in South Africa has so many “hole’s” that individual efforts only ( though helpful) don’t bring enduring change currently in a slowly “dying situation”.
Shifting focus therefore towards an increasing functionality as teams, within the different entities of the current health care situation, – is the final “rescue remedy” perhaps. The last so much needed in both Tintswalo Hospital, the clinics and the wider context of the health service in the existing health care climate of South Africa. However, this requires a different mindset, focus and goal setting, which could be really a starting stumbling block for those who resist change. But that’s a problem which can be solved because “resisting change” is anyway an ongoing issue.
But when it becomes clear it’s for the better, in the simplicity of a different way of thinking, it’s all worth the efforts. Including all the headaches and frustrations to start to change the emphasis is more sustainable ways than before.
“Old ways” proved (!) not the be the driving motor for much needed change in nowadays cultural climate – because they have been driven by an at large inflated paradigm of “individual efforts” being the driving force and hospitals being the central entities in rural South Africa . It worked at times, indeed (!) – but it will never create lasting change because individuals can’t change a culture long term, – but slowly changing organisational & political cultures, however, CAN change individuals in (currently) a slowly”dying” healthcare culture, – where dysfunctionality and apathy are at large becoming the accepted norm.
And long term change for the better in the wider spectrum of health care teams, with a clear and shifting focus on primary health care, is better than “dying for the bitter” – in overstretched public hospitals (as dedicated and often lonely health care professionals, all staff included).
Problems created by people can be solved by people, interdependent as we are. It’s like the late former US President John F Kennedy once said:
And mind you 🆘 🇿🇦, the animals below agree.👌Because giraffe mythology in sub – Saharan Africa carry distinguished wisdom, uniqueness, aspiration and prophecy: >>…South Africa has a future, when the combined efforts are there.
Dr Paul Alexander Wolf FRACGP June 2023.
The challenge endures and the dream will never die.