Over the past two decades Africa has experienced a sharp increase in the mortality rate due to dreadful diseases that have plagued the continent, such as Hepatitis B, Tuberculosis (TB), HIV/Aids, and Malaria, to name a few, some curable and most of which un-curable. This spread of diseases is heavily felt in this third world continent (Africa) and unfortunately a continent where there are less and less solid structures in place to control the spread. South Africa is a prime example of how burdensome this increase has been.
Adding fuel to the fire in South Africa is the lack of human resource in the Health care system, particularly doctors; with or without field experience. South Africa alone has a significant gap in ratio of doctors to patients of 77: 100 000. This lack of or in adequacy thereof is exacerbated in rural hospitals and rural clinics. 'It is largely just that doctors prefer to work in more developed, urban settings than in the rural areas so it is difficult to retain medical doctors in the rural areas after their community service' commented Dr Richard Lessells, a Clinical Research fellow at the London School of Hygiene and Tropical Medicine who is based at the Africa Centre for Health and Population Studies, an infectious diseases specialist and one of the few doctors working in the treatment of TB/HIV at the Hlabisa sub-district in KwaZulu Natal; this sub district with a population size of 220 000 has a high burden of unemployment and a high prevalence of HIV and TB, and most recently noted a high level of prevalence in HIV drug resistance. He added on to say 'Whilst there have been some initiatives and incentives to retain doctors in rural areas, this has not been enough and South Africa is still not training enough doctors to cope with the burden of disease in the country'.
Fairly speaking, this shortage does not only apply to doctors, but also to all healthcare professionals in general (doctors, nurses, etc) 'nurses are forced to take on expanded roles without receiving appropriate training or supervision, and patients often not get seen by a doctor in circumstances where that level of expertise is required', says Dr. Lessells. The victim in this whole shortage scenario is not the patient, as one would feel but the whole health care system. The high burden also puts a strain on doctors who are present which can lead to burn out? thus perpetuating a vicious cycle where doctors do not want to stay and thus the shortage continues and puts strain on the next group of doctors. 'This causes high attrition rates, the inability to attract and retain staff in the public sector, which results in chronic understaffing' added Dr. Cloete van Vuuren, a physician and an HIV specialist working at the University of the Free State. According to Dr. van Vuuren, the implication of this to the patient is long queues and waiting times.
Most of the articles published concerning this topic have focused on exposing how little government is doing to limit the shortage of doctors, however this blog do not want to do this as we have experienced (in the past 13 years working in South Africa) that the government has been trying very hard and achieving very good results on the expantion of HIV and TB treatment. Although longitudinally these articles tackle important points that have to be looked in to, however they fail to look at current state of the country and what is or not possible during this HIV/TB national emergency. Looking at the threat of TB/HIV drug resistance, and with limited doctors with or without experience in infectious diseases, one approach would be to look at this in a South African context, if not Africa as a whole; at the moment the closest person to the patient in clinical care is a nurse, and in one way or the other a patient will meet or be in contact with in a nurse in any/every clinic visit. If there is not a good supply of doctors, then they will be no choice but to use nurses to treat complex illnesses, to have confidence in implementing this approach the focus should also be on equipping and capacitating nurses to handle complex clinical cases. 'We need to limit unnecessary expenditure, create an environment where people feel valued (resources for junior staff to attend conferences and courses), senior support at all levels for junior doctors etc' (Dr Cloete van Vuuren).
Dr. Lessells added on to say 'We need to rapidly capacitate the health system to be able to manage drug-resistant HIV and TB cases, as specialist physicians will not be accessible to all patients. This means educating doctors, nurses, and allied health workers in drug resistance and cascading that knowledge through the health system. It also means a key role for surveillance and research so that we develop evidence-based treatment policies and work out the best way to implement these in the real world'.
In conclusion, it is easy to pin point loopholes in the system, and not provide substantial solutions or suggestions to fill in the loopholes. While the South African heath ministry continuously strive to find better treatment of quality for all to treat its patients, it can never overlook the fact that the health care system itself needs to be treated, so in essence treat the health care system in order to treat patients. Recently, Dr. Tulio de Oliveira has been participating in discussions with the government (e.g. HIV and TB Research Summit) and believes that the public health system is advancing and that we are likely to see much better results in the near future!