It's a tough time to be both poor and sick in Africa as governments continue to reduce their support for public services. Even among the more affluent countries on the continent, it is pretty rough as the following report on health services in the Gauteng province in South Africa, shows.

By Pumla Tshego

November 1999

South Africa's public hospitals, particularly in Gauteng, the country's richest province, are in crisis. On the edge of Soweto is Africa's largest hospital, the Chris Hani Baragwanath Hospital, always known as 'Bara'.

It has more than 3,000 beds and caters for more than two million people from Soweto and surrounding areas. It has neither enough doctors nor nurses to cope with demands.

The same grim picture can be seen at the other great South African hospital, Johannesburg General, fondly known as the 'Gen', an ugly conglomeration of squat concrete buildings high on a leafy ridge overlooking South Africa's main highway to the north.

Before democratic elections in 1994 the 'Gen' mostly catered for whites, and Soweto's 'Bara' was the main hospital for blacks. That has all changed with the end of apartheid.

Poor people of all races are now admitted to both hospitals. Budgets have been slashed in real terms, doctors and nurses have departed for the more lucrative private sector, and both hospitals have been forced to limit their services.

Senior staff at these and other Johannesburg hospitals recently took the unprecedented step of issuing public statements warning that patients were going to die unnecessarily, some wards would be closed, and casualty admissions would be stopped after 5 p.m.

The health professionals who set off the alarm bells were not old apartheid dinosaurs. They were doctors who had fought for democracy against incredible odds, dedicated themselves to the public service and had refused lucrative offers of jobs in the private sector. They are the heart, soul and energy of public health in South Africa. Their press conferences reverberated around the country, and caused a huge uproar.

Johannesburg's main newspapers carried banner headlines: 'Wards of Death', 'Condemned to Die'. There were pictures of babies in incubators who would stop breathing because they didn't have ventilators, reports of badly injured people admitted many hours after arriving at casualty, shortages of equipment, drugs and dressings.

Saddest of all, perhaps, was the despair of doctors asked to play God, to decide which baby would get a ventilator and which would die.

These are familiar stories from most of Africa's public hospitals, but South Africans have been deeply shocked to discover that democracy did not coincide with better hospital care. On the contrary, the new government's mantra, 'fiscal discipline', meant a gross deterioration in most public hospitals.

The Gauteng Health Department had little ammunition with which to defend its record. It said huge salary increases three years ago had undermined its budget, reforms in deploying existing resources more effectively had not yet matured and inherited staffing patterns were skewed.

In addition, said the head of public relations of the Gauteng Health Department, Joanne Collinge, the disproportionately high number of general workers in hospitals had not been reduced.

She said that under the old regime, scab labourers hired to replace striking workers were given permanent posts, and legislation from that time prevented retrenchments.

Collinge also said previous administrations were not forced to stick to budgets, and overspending became part of public hospital culture.

Burgeoning crime has also placed an enormous burden on hospitals.

Previously most crime-related injuries were stab wounds, which affected one bodily organ. Now, it's gun shots, which often can affect four or more organs, putting a greater demand on surgeons in Johannesburg, Africa's most dangerous city.

Another growing problem is AIDS. More than 40% of people admitted to public hospitals were now more seriously ill than ever before and, inexplicably, the epidemic proportions of the illness had not been anticipated and therefore was not budgeted for.

No one can satisfactorily explain why the first post-apartheid government did not anticipate the AIDS pandemic when it came to power five years ago.

South Africa's health statistics are staggering. There are 100,000 nurses in the public health sector alone. Africans from outside of South Africa clamour to get training in Johannesburg, the best on the continent.

But now a lack of resources has undermined these standards. One out of many poignant stories on hospital crises came from Cape Town, where Dr Peter Bants, head of the trauma unit at Groot Schuur Hospital, had quit in despair. He was five years in his job, and has now left the country and public service to which he was dedicated because he said his working conditions were 'intolerable' in what he called the 'Siberia of surgery', where gun shot wounds account for 80% of all surgery.

'We are looking at the total destruction of medical standards in South Africa. We have lost our best theatre nursing staff, and our teaching and training is also under threat because of diminished resources.'

The new health minister Dr Manto Tshabala-Msimang had few words of comfort, however. 'There's inflexibility in health management and staff are unfamiliar with how to spend money effectively and's common knowledge that some health workers sit on the phone chatting. There's scope for creativity, not just complaining. We need to develop a work ethic.'

No one doubts her own work ethic, but the crisis in South Africa's public hospitals is far more serious than nurses gossiping on the phone. - Third World Network Features

About the writer: Pumla Tshego writes from South Africa for the Africa Information Afrique, AIA.