"Bringing health workers into public service on the African continent"
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INTRODUCTION AND INSIGHTS
AHP conducted interviews with four local and foreign-qualified doctors to examine their thoughts on management, team work and perceptions in public healthcare facilities in South Africa.
Some of the main issues raised:
Poor management is one of the main reasons doctors don’t want to work in the public sector. This was again highlighted by the doctors interviewed. Two South African doctors and a European midwife who are working or had worked in Gauteng, the Eastern Cape and KwaZulu-Natal said that the right people are not hired as managers. Frustrations with poor HR and administration were also stressed. Two of these healthcare workers resigned as a result of poor management. Their experiences highlight the serious effect that poor management and a lack of accountability can potentially have on the retention of doctors in rural South Africa.
A Zimbabwean doctor was asked about relationships among doctors to determine whether he had ever experienced xenophobia. He said the attitudes of foreign-qualified doctors play a huge role in whether they are accepted by local doctors. If foreign-qualified doctors learn a bit of the language and culture, they are by and large more easily accepted, he said. Patients, however, didn’t seem to have a problem with foreign-qualified doctors and were overall just happy to see a doctor.
Both local doctors agreed that the idea is a good one in principle, but that the public sector would have to improve the quality of care significantly for the plan to stand any chance of success.
European midwife working in KwaZulu-Natal for more than three years
AHP: What has your general impression been of management?
Midwife: “It’s very poor. A lot of people in management are not really there because they have the right qualifications or skills. They are there because they have many years of experience or because they know the right people.”
AHP: What impact does poor management have on staff?
Midwife: “The staff knows they can get away with anything. They are not too bothered to do their jobs or even to come to work. It doesn’t only have an impact on HR, but also on equipment. Equipment doesn’t get repaired and then you have to go without equipment for a couple of weeks.”
AHP: What impact does poor management have on patient care?
Midwife: “People don’t have to take responsibility for care or the mistakes they make. There’s no accountability in the system and this is reflected in the care. People are not motivated to do their best. Mistakes don’t have consequences.”
AHP: Have you ever experienced good management?
Midwife: “There was a new maternity manager that tried to change things, but she didn’t really get a chance. When the whole system is a big mess, it’s difficult to come and turn it around.”
AHP: What impact does poor management have on new foreign-qualified healthcare professionals?
Midwife: “It’s very frustrating. It’s impossible to understand because it’s a different world. In the beginning you try and fight the fact that nobody cares, but after a while you realise you can’t change it, you can’t win, and then you join them. That’s why I left the hospital.”
AHP: What should be done to ensure better management?
Midwife: “Make sure people with the right qualifications are appointed to the right positions. There has to be accountability so that people know the rules and stick to them. You have to motivate and encourage staff. There are many nurses that want to study and develop themselves, but they are not allowed to. When you don’t see a future for yourself, it’s difficult to do your best.”
AHP: Do you have anything else to add on management issues?
Midwife: “There is often a huge difference between a medical manager and a nursing manager. At one hospital where I worked there were a lot of AHP doctors. The medical manager sent them on courses, but the nursing staff wasn’t allowed. In Europe it is one team and people realise that they can’t do the job without each other. Here it is like the two teams are playing against each other.”
Zimbabwean doctor working in Gauteng. He has been in South Africa for more than four years
AHP: How severe are staff shortages at your hospital?
Doctor: “Staff shortages are real, but it is not as bad as in rural areas. We’re still better off. Our department is doing fairly well. There is a shortage of nurses. They are the backbone of an institution, especially in casualty. You have to be very alert and constantly check patients. If you have too few staff that doesn’t happen. Patients are reviewed every two hours instead of every 30 minutes.”
AHP: What is the relationship like between doctors and nurses?
Doctor: “If a doctor values the team and the importance of working together, then he/she has good relationships. If he doesn’t, it’s the opposite. We are trying to change the organisational culture to make nurses realise we value them and to create a culture of respect. In casualty you have to work as a team. There isn’t the luxury of a hierarchy. When there’s an emergency it’s all hands on deck. The moral was quite low before, people felt their needs weren’t being addressed and they stepped back. Now, we are seeing a change. People are more motivated. We are trying to improve the working conditions and culture.”
AHP: Is there tension between local and foreign-qualified doctors?
Doctor: “I have the benefit of being quite multicultural. I’ve learnt how to fit in. If you learn a bit of the language and make an attempt to break the barriers it helps. I’ve encouraged my colleagues to do so as well and most foreign doctors do. Casualty has a lot of foreign doctors, probably the majority. It depends on your attitude. If you approach locals with humility and learn the culture then you are well-received. If you simply don’t understand the culture or make no attempt to understand it, you will have a rough ride. The country is giving us the benefit of the doubt, but we are also contributing to the development of South Africa.
“A practical tip is to learn a greeting. You are respected for trying and showing that you value the culture. Foreign doctors get a bad rap. Sometimes when working in an environment where there are too many patients the courtesy falls away and doctors treat people as numbers. There must perhaps be a period of re-education on how to treat patients and to be kind and to recognise that a person is in pain.”
AHP: What is the relationship like between foreign-qualified doctors and patients?
Doctor: “On the whole patients are not picky. They appreciate the fact that they are being seen by a doctor. There are some exceptions when language is an issue. If my language doesn’t suffice I get someone to clarify. On the whole, patients are grateful. In some instances, because of the country’s legacy, some patients prefer to be seen by a foreign-trained black doctor instead of a local doctor. I haven’t figured out why this is, perhaps they fear things will be taken out on them. But that’s the minority – maybe 1%. 90% of the time patients are happy to be seen.”
AHP: What impact does working conditions have on team work?
Doctor: “Working conditions do matter. It’s important that you have a place to sit down. It shows management respects you. If the tea room is full of broken chairs, it speaks to the staff by saying this is what we think about you. It does impact on performance. It’s worth the extra money to make staff comfortable. It could go a long way to address the attitudes that people complain about in the public sector.”
South African doctor working in the Eastern Cape for more than six months
AHP: Why do you work in the public sector?
Doctor: “Most doctors that go into private practice after community service go into GP practices. If you want to specialise you must be in public health. It’s the best place to be. In the Eastern Cape there is a huge backlog of patients. You can learn more because there are more patients and less doctors.”
AHP: What kind of perceptions did you have of public health?
Doctor: “When I was studying I knew that I would work in public health, even after specialising. There’s the sense that you are helping people. In private you take orders from patients. Public health is more rewarding.”
AHP: What are the major challenges in public health?
Doctor: “Our department of health in the Eastern Cape is in trouble when it comes to money. We struggle to get our machines and instruments fixed. It takes forever to get done. It’s the most frustrating thing. There’s no foresight in terms of ordering equipment. You will find out today that something is out of stock. There must be five microscopes that are broken before they will get them fixed.
“We haven’t got leaders as managers at hospitals. There is a big lack of compassion from managers, but they are quick to point fingers. The wrong people are in management. At the previous hospital there were lots of renovations being done and there was camaraderie between staff, but the management was pathetic. That’s the reason I left. I couldn’t do anything. It was a waste of time. That’s what chases people away from public health. In the Eastern Cape you don’t get heard. You don’t get help. Some of my colleagues have not been paid for four or five months. The main problem in the Eastern Cape is the local managers of hospitals. Bhisho is trying to deal with it.”
AHP: What is the administration and HR like?
Doctor: “I’ve been quite lucky. My salary has always been paid. Some of my colleagues didn’t receive their salaries for three months. Things get lost and then you have to re-submit it. People are slow. They are not working at the speed that they should be working at. At admin and HR things happen slowly. In our department you have to submit a list of things you need every year. We’ve been submitting the same list for the last five years and have not received anything on the list. When they lose your documents they don’t tell you. You only find out when your salary hasn’t been paid. You are lucky if you get your salary. Admin is very poor. They don’t care and there is no urgency.”
AHP: What is the district management like?
Doctor: “The district is quite accessible. They are visible. You never see hospital management. They hide away. They are scared people will ask them questions. I don’t know where they are. You can’t speak to them directly, you have to speak to their secretaries. They are not very approachable. If you write to Bhisho you are more likely to get a response than from hospital management.”
AHP: Have you had any contact with the PEPFAR partner in your district?
Doctor: “No. Never.”
AHP: What do you think of NHI?
Doctor: “I think it will mean more money so state-of-the-art equipment will be available to everyone. The level of care has to improve to the level of private health. The service has to improve. It will take a long time to get to that high standard. You can’t expect someone that can afford private health to lie in a room with a window that can’t close. They have to lift the care before they can implement it. Private patients will be scared that standards are being lowered. In the long run it will be good. In the interim it’s going to be a rollercoaster.”
South African doctor working in several clinics in Gauteng for less than six months
AHP: Why have you chosen not to work in private health?
Doctor: “The need on the public side is bigger. I work for an NGO and it’s a good in-between. I don’t feel the need is so big in private. If I was working in public health I would have to conform. I wouldn’t have a say or a choice. Because I’m not being paid by them, I can influence them.”
AHP: How important are salaries when healthcare professionals chose whether to work in public or private?
Doctor: “I don’t think it is money. There are other challenges, for example drugs. We don’t want people to miss their ARVs, but we fail to deliver. They come to the clinic, but you fall short. It’s the working conditions. Too many posts are not filled. People are not replaced and the burden becomes heavier. At an NGO the working conditions are better and I’m able to be a more pleasant doctor.”
AHP: What about management?
Doctor: “Management is terrible. There’s no management. People are not held accountable. They don’t answer to anybody. On paper they do. There are the right documents and policies, but nobody holds them accountable by checking if they deliver. People offer management as a reward. You’ve been working for so long so now you qualify to be a manager. They don’t necessarily know how to manage. I’m not sure they are qualified.”
AHP: How important is good district management?
Doctor: “District management is kind of absent. They should play a bigger role. If we could sort out patients earlier we could decrease the burden. Primary healthcare is important. We should practise preventative medicine instead of just focusing on curing people. If we screen people for hypertension we won’t need to admit someone for a stroke. There’s been a lot of attention on hospitals. We’ve forgotten about primary healthcare. It’s a little bit too late now. Clinics have been neglected. Some of them operate without a doctor. There are no pills because they haven’t received stock. We’ve shot ourselves in the foot. If clinics received enough attention then people would go to clinics because it’s closer than hospitals.”
AHP: Do you think things are improving with the reengineering of the primary healthcare system?
Doctor: “It’s not getting better. All the systems are in place. The strategic plans are in place, but nobody is doing anything.”
AHP: What do you think of NHI?
Doctor: “It’s a good idea. There’s no reason why someone who had a stroke shouldn’t get a scan. We should all have access to healthcare. Public health needs to get its house in order and function properly so that people don’t want to go to private health. I don’t think we’re ready. If we implement now it will be chaotic. We first have to fix public health.”