Addressing South Africa’s health system dilemmas, one entrepreneur at a time

A successful economy is dependent on a population that is healthy enough to work.  The health system in South Africa is responsible for supporting and promoting health, whilst treating and preventing illness, but it is unable to meet the growing burden of disease.

In the Western Cape the public health system provides chronic medication to 200 000 patients each month.  Queues to collect medication start at five in the morning and people are frequently known to queue for eight or more hours.  The people queuing for medication may be elderly, disabled, sick, or they may have to bring their children with them because they do not have childcare.  Patients are forced to take time off work. This means they sacrifice their wages, spend money on transport and lose out on productive time due to long waiting times.

The failure to meet health outcomes is apparent in informal settlements such as Khayelitsha where the population that is reliant on the public health sector is large, dense and they are mainly from low-income households.

Khayelitsha is reputed to be the largest and fastest growing township in South Africa.  It is one of the poorest areas in Cape Town with a median family income of R20 000 per year.  The most common forms of employment for residents include domestic work, service work, skilled and unskilled manual labour.  With high levels of unemployment, it is estimated that 89% of Khayelitsha households are either moderately or severely food insecure.  Khayelitsha has the highest rate of murder, aggravated robbery, assault with intent to do grievous bodily harm and sexual offences in South Africa.  And surprisingly, it has the lowest police to population ratio in the Western Cape.

Enter Sizwe Nzima

After matriculating in 2009, Sizwe Nzima completed a course as a legal secretary, only to join the large number of South Africa’s unemployed youth.   ’Youth’ (aged 14 – 35 years, as categorised by the National Youth Policy) represent 55% of South Africa’s population, and 60% of them are unemployed.

Sizwe Nzima was not prepared to give up his dreams of having a job and being successful. In 2012 he was accepted as a student at the Raymond Ackerman Academy of Entrepreneurial Development, based at the Graduate School of Business.  Scavenging newspapers for ideas at the Academy, he read about the difficulty that patients face collecting their medication from public health facilities and the difficulty the health facilities have in meeting the needs of their patients.  He was reminded of his own experience collecting medication for his grandparents, with whom he grew up, and so a business idea was born.

Iyeza Express, a bicycle courier service collects medication from the day hospitals in Khayelitsha Site B and Harare delivering it to the patients’ doors.  No more waiting in long queues for the day. Initially Sizwe Nzima worked by word-of-mouth referrals, charging R10 a delivery.  R10 is a lot of money for some residents and the profit margin for Iyeza Express is tiny. Fortunately Sizwe Nzima has managed to secure financial sponsorships.

Mr Nzima is currently in negotiations with Western Cape Department of Health to assist his work through funding from the budget for the Chronic Dispensing Unit (CDU).  The CDU’s goal is to alleviate the crowding of approximately 47 000 patients per month by delivering medication to patient homes.  And Iyeza Express has an advantage over the CDU in Khayelitsha: Local knowledge. Informal settlements have limited street name signs, house numbers, and maps of the area are incomplete, certain areas are difficult to access and local knowledge of potential dangers is important.  The large geographic area that CDU needs to service creates new challenges of timeous deliveries, fuel costs and distances covered over many areas within the Western Cape.

Improved ways to serve resource-poor communities are receiving attention globally. One solution is to involve community members.  Local examples includes the emergency first aid response (EFAR) system first implemented in Manenberg, where community members are trained as first aid responders, or the City of Cape Town’s treatment support system for Tuberculosis (TB) management.  These initiatives, and Iyeza Express, demonstrate that task shifting in healthcare creates new leverage, and it challenges the tradition of exclusive reliance on trained professionals for healthcare delivery.

Iyeza Express addresses one of the biggest frustrations to both patients and healthcare workers: waiting time.  Iyeza Express has increased patients’ accessibility to healthcare and arguably affordability (by taking out their transport costs, and removing the need to lose wages through hours spent waiting in queues).

Why it matters on a macro-economic level

Brain drain, staff shortages, burn out, low attrition rates after studying are common factors hindering the public health sector’s ability to serve community health needs.  Doctors and nurses are expensive to train and it takes several years before they are competently trained. Waiting for enough qualified health professionals to save the day is simply not a viable option. Thus, investing in training more health workers is only part of the solution.   Supporting and using innovative local community members must be another part of the solution.

There is an association between a country’s stage of economic development and its level of entrepreneurial activity.  According to the Global Entrepreneurship Monitor (GEM) high levels of entrepreneurial activity are predicted for South Africa.  However the rate of entrepreneurship has been steadily decreasing and is far below the average for efficiency-driven economies such as South Africa.  The link between entrepreneurs and economic prosperity is particularly true and important in developing countries.

In May 2014 a new ministry for Small Business Development was established and in November 2014 its Minister, Lindiwe Zulu, unveiled a target for raising the GDP contribution of small, medium and micro enterprises (SMME’s) to between 60 – 80% over the next 15 years.  Current contribution to GDP is 35% and the global average is 45%. She has also set goals to reduce some limiting factors in this sector such as reducing red tape and regulations.  This makes it easier for people such as Mr Nzima to develop ideas and grow enterprises within the economy.

The government does not have the capacity to resolve unemployment on their own.  South Africa needs innovators in the informal settlements that can create hope and set an example to the youth.  Sizwe Nzima is such a person: an inspiration and mentor. He has employed people to assist him in his social enterprise, thus directly impacting on unemployment.

Final thoughts

I’m inspired by Sizwe Nzima’s story and it shows us that where there is a will there is a way. I think that he is courageous and I’ve enjoyed learning and reading about him.  I’ve included a link to an interview with him by ‘Kaelo Stories of Hope’.  I would recommend watching it for a good dose of inspiration.  https://www.youtube.com/watch?v=Z-_1qXbZ4x8

Healthcare is a dominant economic and political issue.  In South Africa healthcare is a constitutional right, however inequity remains rife.  This inequity creates opportunities that only emerge when a current system is failing.  We need more grassroots entrepreneurs such as Sizwe to help our health sector become more efficient and effective in rendering care.

Read more about Sizwe Nzima and Iyeza Express at www.iyezaexpress.co.za

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Community Innovation… Volunteer Ambulance turns 21!!!!

Twenty One and still going strong! The Houtbay Volunteer Ambulance Service (HBVEMS) is a community based volunteer service working mostly within the indigent communities of Houtbay and immediate surrounds.

Niche volunteer group

What sets the paramedic volunteers apart is the nature of the volunteer. Qualified and registered people who can perform exactly the same work for monetary gain yet choose to perform it for free.  Just to reiterate….HBVEMS performs unpaid, non-compulsory work in their leisure time using some of their own resources within the organizational setting of a volunteer ambulance service that is a registered legal entity.  Some members are full-time paramedics and yet they spend leisure time working for-free shifts.

Volunteer paramedics are exposed to same occupational risks as fulltime paramedics, including but not limited to ambulance crash whilst responding, working in high conflict areas, exposure to Tuberculosis, HIV and other infectious disease.

It takes a fair amount of courage for volunteers that are from non-healthcare environments to expose themselves to the above risks and commit to emergency services. Volunteers who does a 8-5 job followed by a Friday night shift on an ambulance, that live an hour away and happily drive through to work a 12 hour shift, the students that could be partying but are working a shift, there are sacrifices to volunteer!  These volunteers allow the service to exist and they create a strong foundation for future growth.

HBVEMS provides a testing ground into the system and a few volunteers have given up on their previous occupations to become full-time paramedics or pursue careers in health care including nursing and medicine.

In the beginning

The ambulance service was founded by local community members out of a perceived need for expedient emergency care.   Prior to the HBVEMS, the ambulance response time for a priority one case (life threatening emergencies) measured 35 minutes from the Retreat Area where the closest ambulance was stationed.

A group of community members proactively tackled the problem. They searched for ideas and the framework for the organizational structure was adapted from a volunteer student ambulance service, Harpurs Ferry at Binghampton University, New York.  The first volunteers took eight months to complete their basic training and in January 1994 eleven persons qualified as Basic Ambulance Assistants.

Response times prior to HBVEMS

Due to mountains surrounding Houtbay, it is relatively isolated from the rest of Cape Town. Access and egress is restricted; roads are congested with little space to manoeuvre to make way for an ambulance especially when coming over the mountain necks. This impedes on the ability of ambulances outside of Houtbay to respond in time.

The principle indicator of service performance for the Emergency Medical Services (EMS) is response times. This creates a strong case for community volunteer ambulance services in specific areas that can assist over peak times notably for priority calls.  Obviously boundaries need to be set and since 2004 this has been contractually formalised between the HBVEMS and parent body Western Cape EMS and are renegotiated annually.

The typical HBVEMS volunteer

In 2013 the underlying motivation of HBVEMS to volunteer was studied. The Volunteer Functional Inventory was used.  The inventory is based on the theory of functional analysis and has been used in various volunteer settings.  It is based on the hypothesis that although volunteers perform the same functions, they have different underlying motivations to perform the functions.  Two main motives emerged for the HBVEMS: Practising knowledge, skill and abilities that may otherwise not be applied and to express important humanitarian values and concern for others.

The typical member is 29 years old and more likely to be male. Most volunteers are full-time employed and have a degree. The majority does not live in Houtbay.

57% of the HBVEMS also volunteer at other organizations including Volunteer Fire Fighting, NSRI, Life Saving and other volunteer ambulance services. These organizations share a few characteristics:  They all require specialised skill training, a high time commitment, physical fitness, set criteria to volunteer and all carry high personal risk.

The importance of services such as HBVEMS in the South African health sector

According to the Ministry of Health (2012) the South African health care system is on the verge of collapse and in desperate need for innovative action.   The growing demand for health services as result of population growth and the burden of disease are central to this message of impending doom.  The state contributes approximately 40% of all expenditure on health with the public sector delivering services to 80% of the population.

Volunteer Ambulance services can fill a gap and be part of the solution within the EMS system. As mentioned earlier, the principle indicator of performance is response times.  The challenge for operational efficiency is to maximise the fleet over peak periods. The peak periods coincides with times when the volunteers are typically operating.  In 2004 it was estimate that volunteers in the Western Cape made up approximately 30% of any shift in the metropolitan district of Cape Town.  This increases fleet and reduces response times over peak periods.

Response times are prolonged by travel distances, inadequate roads and street markings. Although it may sound trivial, after years of responding within Houtbay’s informal settlements most volunteers don’t need maps and have a good idea of where and how to approach the trickier areas.  Maps and GPS do not show potholes and obstructed routes.

Houtbay and its informal settlements Imizamo Yethu and Hangberg geographically represent a microcosm with its unique socio economic representation of the diversity in South Africa. The informal settlements are a result of urbanization; most residents living in corrugated iron shacks and self-constructed shelters; the majority of HBVEMS calls originate here.  It is estimated that Imizamu Yethu has a population of 20 000 people living within 18 hectares and the 2011 census demonstrated a 51% growth in Houtbay since 2001.

Within the informal settlements there are complex social problems, community conflict is rife and there are high levels of violence. Injuries account for 18.1% of the burden of disease in the province with injury related mortality in men ten times the global average.  (Women: seven times the global average).

Since the inception of the HBVEMS the level of acuity of patients in the Western Cape has risen sharply. This has not been met with an increase in capacity and the demand completely outstrips the capacity.

I sourced some data from the annual report of the Western Cape DOH to demonstrate the capacity and demand mismatch. Note that this is by no means a complete representation of all their performance indicators!

2009 2011 Demand/Capacity
Total population Western Cape 5391765 5634323 Demand
Percentage of Health budget allocated 5% 5% Capacity
Performance indicator  
Rostered Ambulances 230 132 Capacity
Patients transported 404134 446566 Demand
Total ambulance responses 373940 519228 Demand

I excluded the response times for priority calls, an achievement worth mentioning is that the EMS response times for priority calls has dramatically improved possibly due to the implementation of the CAD system.

Capacity concerns

The rostered ambulances are calculated as hours by ambulance personnel worked x hours in a day x two personnel.  It takes into account average number of ambulances available per hour and absenteeism due to sick leave, leave or training.   It is concerning that the number of ambulances has decreased and a contributing factor could be the vacancy rate.  EMS has the highest vacancy rate in the Western Cape DOH.  According to the annual report 32% of the operational posts in EMS are vacant.

It also appears that the funding is insufficient to meet rising demand; this is unlikely to change soon.

The conclusion is that the provincial services have a problem supplying sufficient ambulances per shift to match the demand.

A solution

When operational HBVEMS reduce response times in Houtbay and provides EMS with trained volunteers. This immediately increases the capacity at no cost to EMS.

The volunteers carry their own expenses for annual individual registration, annual public driver permit, indemnity and insurance cover. Most volunteers use their own jump bags containing equipment purchased by the volunteer.

The solution that services such as HBVEMS provide to the bigger health sector is that they provide a basis to develop and recruit future paramedics for the health sector whilst simultaneously increasing the capacity of an overstretched public health sector.

The above is the by-product, HBVEMS exists is to offer patients better care with quicker response times. Having responders within Houtbay allows for faster response times especially during life-threatening emergencies where every minute counts.

Ultimately HBVEMS saves lives.

Congratulations on your 21st HBVEMS, hopefully the first 21 years was only the beginning!

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Access to Care: Imizamo Yethu 2004 – 2014

As member of the Hout Bay Volunteer Ambulance Service (HBVEMS), I’ve witnessed a shift in the access to (emergency) care within the informal settlement Imizamo Yetu (IY). Most of our calls originate within IY and by applying the 5A’s (Pechansky and Thomas, 1981) the improvement in each dimension of access to care can be highlighted. Same theory, different case scenario to last time.

Background into the Hout Bay and IY community
Hout Bay; a suburb of Cape Town lies 20km south from the central business district on the western coast line of the Cape Peninsula. Despite apparent close proximity to emergency medical services, Hout Bay is relatively isolated from the rest of Cape Town due to mountains surrounding it to the north, east and south. Access and egress is restricted to three two lane roads via the mountains.

The majority of the emergency response calls originate from the informal settlements Imizamo Yetho and Hangberg. Here most residents live in corrugated iron shacks and other self-constructed shelters with limited infrastructure such as plumbing, roads, water, sanitation, health care and electricity. Imizamo Yethu is a particularly dense settlement with approximately 20 000 people living within 18 hectares. The 2011 census estimated that the population of Hout Bay has increased 51% since 2001.

Health care in South Africa
The South African constitution is a human rights-based constitution and is one of few global constitutions that include socioeconomic rights within the constitution. It makes the right to health care in South Africa a constitutional right. Despite the progressive constitution South Africa remains a highly unequal society with informal settlements like IY making up approximately a fifth of all urban population.
The health system is divided into private and public health sectors with the public health sector serving the majority of the population. South Africa’s public health spending is approximately 3.5% of the GDP.

There are various indicators to determine a countries wealth, one indicator are quality of life; this is diminished within informal settlements due to susceptibility to environmental health issues, complex social problems, community conflicts with increased levels of violence and poor access to health care to name only a few.

Changes in the 5A’s in IY 2004 – 2014
Availability
The change in Police Station location now on the doorstep of IY has provided IY residents with improved means to call for help and shelter whilst awaiting the arrival of an ambulance. Ambulances can access the patient easier without barriers like lack of roads, road maps, marked roads and house numbers that impacts on response times from call out until arrival on scene. It is appreciated that this is not a core function of the Police however it has improved access to emergency care for the community.

Hout Bay Fire Station (2006) that literally neighbors both the Police station and IY. The Fire Services in Hout Bay has played a substantial role to increase accessibility to care. The Fire Services provides 24hour access with trained staff that can render care, stabilize and “hold” patients until an ambulance become available. The fire services has responded to medical calls within IY and has on numerous occasions assisted HBVEMS to render care, access difficult locations and help in multiple patient scenarios. Yet again access to medical care is not the core function of the Fire Services.

According to the Western Cape Department of Health statistics there are predictable peaks in emergency response calls over weekends and public holidays. The department has acknowledged that there are resource restrictions in meeting the increased demand during peaks periods. Resource restrictions include vehicle; fleet availability and the highest vacancy rate in the department. In 2012 an aggressive overtime strategy in attempt to meet key response times targets failed when funding was exhausted within the first quarter of the financial year and the challenges in meeting the demand remains.
How can this be good news for IY? The good news for IY residents is that these are typically the times that HBVEMS are operational and as such the supply and demand issues experienced by the rest of Cape Town over the peak periods has little/less impact on the response and waiting times for the IY community.

Area for growth
There are limited taxis from Wynberg and Retreat to IY at night and if patients are discharged after hours; they wait at hospital until the following day. More accessible and affordable means to travel to hospital for routine cases and to travel back from hospital after discharge can decrease pressure on the overstretched ambulance services allowing them to focus exclusively on priority calls and not patient transport calls. It would be exciting to see the mycitibus covering the Wynberg route.

Taking into account the population growth and relative isolation, perhaps the time has come to consider a 24hour day clinic in Hout Bay.

Accessibility
The South African Triage Scale has increased accessibility to care. Prior to 2004 there was no accepted triage scale in the country. The aim of any triage scale is twofold; firstly to expedite emergency treatment for patients with life-threatening conditions and secondly to ensure that persons requiring emergency treatment are categorized according to severity which allows for time-critical intervention. Triage has increased access to care for the IY community by allowing for seriously injured or ill persons to be transported to the appropriate facility. Depending on the triage score and discriminators it allows the bypassing of smaller facilities to more appropriate facilities. Triage impacts on the utilization and dispatch of secondary resources.

Technology; the mobile phone industry has grown dramatically over the past 10 years and it is estimated that approximately 75% of low- income groups in South Africa owns a mobile phone. This enhances the ability of IY residents to call for help from home. Western Cape EMS and Dimension Data are in the process of rolling out a sophisticated data-capturing technology that will rely on mobile phone technology to locate patient address.

Area for growth
Geographic accessibility remains an issue. Hout Bay’s relative isolation from the rest of Cape Town due to mountains and access and egress issues are even more pronounced in IY with complicated access due to narrow roads, poor infrastructure, unmarked streets, and houses are not numbered, temporary houses/ shacks, no streetlights. As such any improvement in the infrastructure of IY would increase accessibility to care.

Accommodation
Most serious cases originating in IY are taken to the district hospital in Wynberg (Victoria hospital). The peadiatric wing of Victoria hospital was reopened in January 2014 after receiving a R10 million upgrade and extensions that allow the facility to now care for and stabilize critically ill and injured children. There is now overnight facilities for parents with their child and other than the obvious benefit in patient care; from a transport perspective for parents this implies substantial cost –saving and time. They need not travel as far to Red Cross Children’s hospital, nor consider the cost of transport after hours from Victoria (or Red Cross) back to IY.

2006 demonstrated a milestone for the region’s paramedic profession with the graduation of the first group of National Diploma Paramedics in the Western Cape and since then the amount of Advanced Life Paramedics has grown. The course remains a contentious issue amongst many within field and the advantages and disadvantages are not for discussion here. My focus is on how this impacts and improves access to care for the typical IY patient. HBVEMS membership has grown with paramedic students wanting more hands-on experience prior to qualifying. Once qualified some of these practitioners has remained members and has continued contributing to HBVEMS. This benefits the IY community as they have access without delay to an advanced qualification which impacts the available level of care rendered. IY and Hout Bay are exceptionally fortunate in this regard. In addition the influx of students provides HBVEMS with access to the newest guidelines, standards of care and practice fresh from the tertiary institutions, which again has an impact on quality and level of care rendered.

Area for improvement
The operating hours of HBVEMS creates a gap within off peak times and times when there is no staffing for the Ambulance; fortunately there is the Fire Services and Western Cape EMS. At times when HBVEMS is non-operational EMS has placed an ambulance within Hout Bay. 10 Years ago there was no Ambulances standing by from Hout Bay. 

As mentioned previously the hours of the clinic is a constraint in accessing care; as is the capacity of the clinic to manage emergencies.

Affordability
The Public Health Sector provides care for free thus the IY community has access to free services.

An indicator of affordability to access care is the cost to call for help. 10177 are a toll free number. There has been pressure to roll out a single toll-free emergency number for South Africa which integrates Police, Fire and Ambulance. Consistent progress has been made to establish a regional interdisciplinary call taking center within the Western Cape. This will enhance communication between services and result in resources distribution as needed, increasing capacity for all involved. This will impact on access to care for IY in 2014.

Acceptability
Acceptability indicators are not typically measured or reported and I’m not sure if it has improved for IY residents.  Beyond IY; the right to health care in South Africa is a constitutional right. The two tiered private and public system are inequitable and private health care remains inaccessible to the majority of the population. It has been mentioned in some sources that whilst access to public facilities has increased, the quality of care within the facilities has continued to fall.

According to Penchanksy and Thomas the five dimensions are only as strong as the weakest link; it implies that access cannot be improved if it is not across all dimensions including equity under the heading of acceptability.

In summary
I think it’s fair to say that access to care for the IY community has improved over the past ten years. Some of the improvements were probably unintentional such as moving the Police Station and the commissioning of the Fire Station.
I’ve been involved in some access to care studies and in retrospect a quick analysis using these headings during those studies would’ve provided value and possibly different insights. I’m eager to refine and apply these dimensions in future.

Due to the interrelations of the dimension my attempts at separating some factors was a mission. Any comment on how you would’ve classified it differently or points that I may have missed would be much appreciated.

Note
Please note that the Western Cape Department of Health and EMS Operational Management have implemented highly successful strategies other than the overtime strategy mentioned. Some of these strategies include changes to shift system, changes to dispatch systems, appointment of fleet managers. The Department met their response time target of 15 minutes for priority calls within urban areas in 2012. There has been changes to the procurement process of vehicles in attempt to reduce turnaround time when vehicles are serviced and the knock on effect that longer servicing times has on fleet size. All of these impact and improve access to care. Mentioning the failed strategy is to highlight human resource restrictions in meeting demand and how HBVEMS assist and not a criticism of the strategy.