UNIVERSITY OF CAPE TOWN

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UNIVERSITY OF CAPE TOWN
Submission to SAHRC
Faculty of Health Sciences
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HEALTH AS A HUMAN RIGHT
PHC as social justice
SOUTH AFRICA Health as a right social
justice health equity Constitution Health Law
and Policy
PGWC HEALTH Service
Statutory Councils MRC Research
Health Regulatory Bodies DoE, DoH, HPCSA Teaching
and training
UCT FACULTY OF HEALTH SCIENCES Activities,
operations, resources
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Quality of Health Care

• Black people in this country did not strive for
  equal access to mediocrity, they strove for equal
  access to excellence
• Mamphele RampheleFormer VC UCT
• membership of the health care profession
  includes the responsibility for dealing with
  people who are in a dependent, vulnerable,
  exploitable state of weakened humanity
• Desmond Tutu, 1977
• We have appeared too tolerant of mediocrity
• Affirming excellence and challenging mediocrity
  Naledi Pandor 2007

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Quality of Health Care

• We owe our population an excellent health service
• Quality health care is a human right

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Excellence in Health Care

• High degree of expertise at all levels of care
• Primary care clinical staff
• Specialist clinical staff
• Super and sub-specialist staff
• Appropriate facilities at all levels
• Excellent training to provide the service
  personnel
• Excellent research to maintain clinical services
  at the cutting edge

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Health Care in the Western Cape

• Currently a true centre of excellence
• Three academic hospitals providing high standards
  of health care at all levels
• One of the few areas in the country where a full
  spectrum of sub-specialist care and training is
  available to indigent patients
• One of the few areas in the country where
  sub-specialist training is available across the
  spectrum
• Accounts for the production of 30 of all medical
  graduates and over 30 of all specialists in SA
  as well as other African students
• Critical national resource
• Excellent health care in South Africa depends on
  excellent health services in the Western Cape

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PHC - The Facultys lead theme

• Philosophy of health equity
• Directed at comprehensive health care which is
• Universally accessible
• Affordable by state and communities
• Demands full community participation
• Includes promotion, prevention, cure and
  rehabilitation
• Delivery through multidisciplinary teams
• Seamless connection between all levels of care

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This means that .

• Our academic service platform for teaching and
  research must include all levels of care
• Primary (first contact), e.g. Vanguard,
  Khayelitsha
• Secondary, e.g Somerset, Victoria, GF Jooste,
  Vredendal
• Tertiary, e.g Sub-specialist services at GSH and
  RXH
• Nationally Unique Quaternary, e.g. liver
  transplantation (GSH and RXH national referral
  centres)
• All of these levels of care must be maintained in
  a productive and sustainable condition

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Our relationship with PGWC

• Aligned with goal of health equity
• Based on the principle of the indivisibility of
  teaching, research and service
• Governed by Joint Agreement (1966) which
  determines
• Academic service platform for teaching, training,
  research and service delivery
• Conditions of service for staff
• Managed through
• Joint Standing Advisory Committee (JSAC)
• Joint Management Teams (JMT) for central
  hospitals, psychiatric hospitals and district
• Operating principle
• Agree to share plans, strategies and budgets that
  influence academic health sciences

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Factors impacting on our relationship

• National recognition that tertiary care is an
  essential component of health equity expressed
  through
• Modernisation of Tertiary Services plan
• Financing of tertiary care at central hospitals
  through conditional grants
• National human resource policy and plan for
  academic health sciences
• Requires provision for training of increased
  numbers of health personnel
• Budgetary pressures

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Desirable position

• MTS implemented with appropriate funding for
  tertiary and quaternary services from national
  government
• Conditional grants sufficient for delivery of
  tertiary and quaternary care, taking into a/c
  increased pressure on service (HIV/AIDS, urban
  migration, etc)
• National human resource policy (doubling of
  numbers) linked to adequate funding
• National plan for academic health sciences and
  provincial joint agreement both acknowledge the
  importance of a joint staff
• Provincial Comprehensive Services Plan and budget
  based on full participation

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The reality

• Modernisation of Tertiary Services plan
• Financing of tertiary care at central hospitals
  through conditional grants
• National human resource policy
• Plan for academic health sciences
• Provincial Comprehensive Services Plan
• The provincial budget
• Joint agreement

• Policy suspended
• Not sufficient
• No additional budget
• Some hope for funding from DoE
• Limited participation by HEIs
• Insufficient for health equity
• Stalemate

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The Reality

• Economic migration to the Western Cape
• Health migration
• Massive and unfunded burden on health services
• Increased logistical teaching and training
  problems
• PHC requires far more extensive teaching and
  service sites
• Increasing costs of care also lead to increased
  training costs (unfunded)
• Shrinking budgets in real terms
• Decreasing health service platform

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Budget problems

• Three sources of health funding for academic
  complexes
• Provincial equitable share
• Health Professions training and development grant
  (HPTDG)
• National tertiary services grant (NTSG)
• Provincial equitable share takes no account of
  health migration
• Western Cape provides approximately 34 of budget
  to health in 2007
• HPTDG does not compensate for the heavy training
  burden of the Western Cape
• NTSG has decreased in real terms despite
  increasing demand

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The Challenge

• Provision of adequate primary and secondary level
  care
• Western Cape is particularly deficient in
  secondary level services
• Maintenance of tertiary and quaternary services
• Maintenance of teaching and research at adequate
  levels

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• Reduction in all service posts since 1995

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Service teaching posts have been falling since
1990
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Major pressures on teaching services

• Compliance with HPCSA means we must develop and
  resource off-campus teaching sites, and get our
  students there
• Increased demand on the health service means
  clinical teachers have less time for teaching
  (and research)
• Decrease in budget means
• Decrease in beds and in quality of care (patient
  delays)
• Fewer nurses and less theatre time means fewer
  procedures meet requirements of specialist
  training

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Comprehensive Service Plan (2010) Tertiary Beds
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Current Demand

• PGWC figures indicated that there were 15 million
  primary care contacts last year
• On the basis of the proposed ratios of 90 1º, 8
  2º and 2 3º this would require approximately
  2000 beds at tertiary level
• At present there insufficient beds to meet the
  demand, supporting this figure
• The CSP is budget driven, not needs driven
• Health in the Western Cape is massively
  underfunded

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Average waiting times for surgery

• Cardiac bypass surgery (gt 6 weeks)
• Cataracts (gt 1 year, gt 1000 cataracts)
• Joint replacements (gt3 ½ years, gt700 patients)
• Colon cancer (gt 2months)
• Breast cancer (gt 6 weeks)

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2010 Health Care Plan proposes further staff
reductions
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Further budget problems in 2007

• R30 million from budget of two academic hospitals
  GSH TBH
• Revenue generated from fee paying patients
  absorbed by centre (further R19mill removed from
  GSH budget)
• Closure of 60 beds
• Ability to train UG and particularly PG students
  further hampered

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Healthcare 2010

• The Faculty supports the philosophy underlying
  Healthcare 2010 and the Comprehensive Service
  Plan
• A milestone in re-shaping the provincial health
  service to promote equity and allow greater
  access to healthcare within the context of
  affordability and sustainability
• However, the service reductions envisaged in the
  current budget and the CSP will have a
  significant effect on services at a secondary and
  tertiary level and on research, teaching and
  training, the mandate of the Faculty

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Comments 2010

• Consequences of implementation not calculated or
  explicitly stated
• Reduction of level 3 without corresponding
  building of other levels
• Rigid separation of levels of care need
  continuum of service
• Patients and illnesses not readily classifiable
  into levels (HIV)
• Support strengthening of service across platform
  not at expense of tertiary

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The dilemma

• Inadequate budget for the province
• Equitable share
• HPTDG
• NTSG
• Need to develop and support primary and secondary
  services
• Need to maintain existing scarce resources in the
  tertiary and quaternary services

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Impact on tertiary services

• Good PHC System requires strong primary,
  secondary and tertiary level services components
• More patients seen at primary level means more
  referrals up to, secondary tertiary care
• Unethical to have patients referred upwards and
  not have personnel, resources to be able to treat
  them
• More pap smears at primary level more women
  requiring surgery
• Earlier surgery means cheaper, more effective care

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Impact on teaching

• Teaching and training dependent on adequate
  clinical platform
• Access to real patients in clinical settings
  backbone of clinical training in UG and PG
  contexts (apprenticeship)
• Clinical training begins in third year of MBChB
• 800 undergraduate students from UCT need to be
  accommodated on platform
• Total number of beds required 1480 and 400
  anaesthetic events
• Many patients too ill to have students examine
  them

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Training of Registrars in Surgical disciplines

• Based on apprenticeship need to enhance skills
  in theatre
• Reduction in theatre time less time for
  training
• Reduction in numbers of registrars impact on
  services (patients with life-threatening
  illnesses cannot be treated in time) impact on
  numbers of specialist trained impact on medical
  students training
• High levels of trauma beds not available
  (specialists and registrars spend time looking
  for beds)

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The education budgetFunding of Health Sciences
Education

• Two funding streams
• DoE higher education subsidy (all students at
  HEIs)
• DoH Health Professions Training and Development
  Grant (HPTDG) channelled through the provincial
  health departments and
• DoH National tertiary Services Grant
• Not enough!
• Conference May 2004 on funding of Health Sciences
  Education
• FFC research, HESA intervention with Minister of
  Education
• Agreement from DOE that R8m be set aside to
  investigate special grant through DOE to
  universities for health sciences education
• Further funds to be announced

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To be effective, we need reassurance that

• The health budget will provide for an adequate
  academic health service platform
• The education budget will provide for adequate
  health sciences education
• Our inputs into health service planning will be
  taken seriously
• There will be effective governance of academic
  health sciences
• The joint agreement will acknowledge the
  importance of a joint staff

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Health service planning

• Submissions on health plan 2010
• Request for further involvement
• National intervention?

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The Faculty of Health Sciences at UCT commitments

• Equity in health (adoption of PHC philosophy as
  Lead Theme)
• Training health professionals responsive to needs
  of country
• Human rights (adoption of Faculty Charter,
  curricula transformation, sites of teaching)
• Partnerships with others (PGWC, other HEIs, NGOs
  and other sectors)
• Provision of healthcare at most appropriate level
  of care

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About the Faculty

• Educate and develop quality health care personnel
• Trains UG and PG students in audiology, dietetics
  and nutrition, OT, physiotherapy, medical
  sciences, speech language pathology and medicine
• 1742 UG students (1145 in medicine) and 1173 PG
  students (353 registrars)
• Striving to ensure demographic profile
  approximates that of population
• In 2006 the MBChB student population comprised
  34 African, 31.6 white, 18.7 Coloured and 15
  Indian with 38 male and 62 female

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Transformation of our Student Body (UG)
2003
1994
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Primary Health Care Systems

• Take account of broader issues, income, housing
  etc
• Create conditions for effective provision of
  services to poor
• Organise integrated and seamless care from
  primary to tertiary levels of care with
  patients treated at most effective level of care
  eg Obstetrics and neonatal services
• Link promotion, prevention, acute and chronic
  care and rehabilitation across all components of
  the health system
• Continuously evaluate and strive to improve
  performance

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The Threats

• Progressive erosion of services at secondary and
  tertiary levels has impaired ability to provide
  adequate service to people of Western Cape
• Right of access to healthcare impacted
• Potentially irreversible destruction of major
  healthcare assets

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Possible solutions

• Urgent national review of health funding policies
• Education
• Tertiary and quaternary services funding
• National policy on the status of Joint staff
• National policy on centralising and equitable
  funding of advanced health care training

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Conclusions

• Access to quality health care is a human right
• Primary
• Secondary
• Tertiary
• Health in the Western Cape is underfunded
• National government must urgently reconsider
  health funding in a broad context