The initial 'tourist phase' over, having already marvelled at the disparities between 'my' life and 'theirs', the reality of community hit me right in the chest this week like a foam-covered morning star. Hard enough to jolt me into the harsh reality of the community, but soft enough that I know I will be able to get my breath back in time and keep moving forward. So many stories, so many wounds, but too few ears and too few Band-Aids.
The shortcomings of the public healthcare system were made visible this week with my home visit clients, when the realities of healthcare provision in lower socio-economic sectors of society became glaringly obvious.
In the first week, I had accepted the situations these people had found themselves in as an inescapable part of the 'rural' experience. This week I started to question:
Why did the mother of the little child we had been visiting not even know the diagnosis of her child? Had no healthcare professional explained the diagnosis to her or indicated what the medication she gave the child was for, let alone given her a home programme to follow for the past few years?
If Mr J, my elderly CVA client, had been born into a different family just a few kilometres east, would he have been left to lie in bed for 6 months, in a dark, unventilated room, with flies buzzing around his necrotic pressure sores, attracted by the overpowering smell of dying flesh?
It's easy to write off these situations as a direct result of poverty. However, given that every person in the country- no matter their financial status- has the fundamental right to quality healthcare, I have to ask myself the question, 'How and why has the healthcare system failed this city?' (And yes, I've probably watched one too many episodes of Arrow...)
Moving into the glorious age of democracy in 1994, reform of the healthcare system was put into motion. The Reconstruction and Development Programme and the National Health Act were put in place to equalise healthcare and combine fragmented health services into a more comprehensive care model (Venturino, 2013). The focus of health intervention shifted from a curative model, which was often more expensive and time-consuming, to a preventative model, also prioritising community-based healthcare, in an effort to make healthcare more accessible to people living away from the city ( Venturino, 2013).
However, although access to healthcare and equitable health expenditure has been accomplished, the overall health outcomes in the country still remain poor (Harrison, 2009). In terms of the Millennium Development Goals, South Africa still falls short of many MDG targets (Centre for Rural Health, 2013). This may be due to a variety of reasons, amongst them being financial constraints of the government, as well as the quadruple disease burden prevalent in the country, resulting from having one of the highest HIV/AIDS rates globally, predisposing HIV + patients to a range of opportunistic infections and disabling conditions, running parallel with the cycle of poverty that many South Africans remain trapped in (Venturino, 2013). Engelbrecht and Crisp (2010: pg.196) state,
It must be stated that, in theory, the current health system provides universal coverage. Yet, from a service delivery, resourcing and quality perspective, the distribution and level of services is inequitable with many communities and patients experiencing great difficulty in accessing the public health system. Furthermore, both the public and private health sectors of the South African health system are unsustainable and fail the challenges of coverage, quality and cost.
The gaping divide between private healthcare, accessible to the rich, and public healthcare, available to those who cannot afford private care, has become more significant, with the quality of public healthcare provided below that anticipated (Englebrecht and Crisp, 2010).
As part of the Government's plan to provide community-centred healthcare, one of the mechanisms that has been put into place to cope with the heavy patient burden is the provision of community caregivers (CCGs), health workers from within the community who are responsible for ensuring that adequate care is provided to individuals upon their return to the community from the clinic or hospital (Centre for Rural Health, 2013).
Ideally, the role of the CCG would be to carry over treatment into the home setting, to ensure that the health of the individual is maintained. However, when I consider that the caregiver assigned to Mr J had not even picked up that he was developing pressure ulcers, meaning that she had not checked that he had been turned regularly, let alone engaged him in a home rehabilitation programme, it raises the question, 'How well are the community caregivers trained?' More specifically to us as healthcare professionals (in training), how have we role-released to the CCGs so that they can carry over the correct therapy in our absence?
In an ideal world, when Mr J received his diagnosis (and was properly explained the implications of this diagnosis, in the presence of his caregiver), he would have been assigned to an occupational therapist, physiotherapist, speech therapist, and perhaps a dietician. Prior to his return home, the team would have been informed of his discharge, and of the CCG assigned to Mr J, allowing them to put together a home programme, provide the relevant training and role release to the CCG, as well as schedule intermittent follow up visits to the client, to ensure his care was proceeding optimally. Mr J would be taking life easy, enjoying his retirement.
However, Mr J is now in hospital, malnourished, weak and unmotivated, being treated for conditions that were preventable, had the healthcare team, including Mr J's primary caregiver, all been on the same page.
As occupational therapists, we are a finite human resource. We don't have the capacity to see every person that requires our care, and this week's mad dash to fit all our home visit clients into our schedules was testament to this. There was the dilemma of wanting to provide as much care as possible to as many people, while knowing that we cannot approach new clients without knowing that we have the capacity to follow up with them. It is for this reason that carry-over and caregiver role-release is so important.
According to Uren (2009: p 116),
"knowledge provided an integral component of the caregivers’ competence and informed their perception of their professional identity as a formal caregiver. Their ‘ownership’ of this knowledge created the perception of caregiving as a privileged or restricted profession, in this manner attaching prestige to the professional identity. This provides the individual with sense of importance and increases the significance of his/her role"
If we can provide the primary caregiver with sufficient skills, support and motivation, we can lessen our burden and still ensure the client is receiving appropriate and relevant carry-over care in our absence.
When working in the community, and seeing the vast needs of the people in relation to our ability to satisfy these needs as healthcare professionals, it is difficult to prevent a sense of frustration and perhaps despondency from developing.
The reality we are faced with is that there are multiple issues, at a political, social, financial and organisational level, that prevent the provision of efficient and effective healthcare. When we see qualified OTs who spend a significant amount of time doing nothing of consequence, even though there's a mountain of work waiting outside the door of the hospital or clinic, we often become angry or indignant in the knowledge that they are doing an injustice not just to our profession, but to the people we serve. However, perhaps they have looked into the abyss that is the over-burdened health system, and that view has snuffed out the flame that once fuelled their passion for their profession.
For us, emerging into the same world, with the same problems, it is imperative that we learn to draw our gaze back to the small accomplishments we make every day, to continuously rekindle the enthusiasm within us and make sure that we remain burning steadily bright, carrying the torch for our profession.
Venturino, M. (2013). Health Care Reform in the US and in South Africa: Does New Policy Cure the Disease or Merely Alleviate the Symptoms? Africa Institute of South Africa. Policy Brief no. 90. Electronic copy retrieved from http://www.ai.org.za/wp-content/uploads/downloads/2013/07/Health-Care-Reform-in-the-US-and-in-South-Africa.pdf
Centre for Rural Health (2013). The perceived roles of CCGs and acceptability of implementing a community-based maternal, neonatal, child and women's health intervention in KZN, South Africa. Retrieved from crh.ukzn.ac.za/.../cframewrok_report_1March_final_AP_14_45.sflb. on 27 April 2016.
Harrison, D. (2009). An Overview of Health and Healthcare in South Africa 1994-2010: Priorities, Progress and Prospects for New Gains. National Health Leaders' Retreat: Muldersdrift.
Engebrecht, B., Crisp, N (2010). Improving the Performance of the Health System. South African Health Review 2010. pp. 194-205
Uren, S (2009). An Investigation into the Emotional Experience of Caregiving. University of the Witwatersrand: Johannesburg.
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