Health Service Acceptability Issues
Di McIntyre, Health Economics Unit
University of Cape Town
and
Lucy Gilson, Centre for Health Policy
University of the Witwatersrand
BACKGROUND
A series of articles recently appeared in a national newspaper, highlighting serious problems in terms of the acceptability of health services. There has been heated public debate since these articles were published and the public health sector is under considerable pressure to change the way in which it functions. The Minister of Health has hastily established a Task Team, of which you are all members. The Terms of Reference given to you are to prepare a report within two days based on the information contained in recent press reports (the articles which started the wave of public protests are reprinted below) and drawing on your own expert knowledge of how the health system functions. You are expected:
- To identify the acceptability problems currently facing health services, both from the household and the health worker perspective. These should be categorised into key issues or themes. You should particularly try to identify the underlying causes.
- To propose practical strategies for addressing these problems.
You have been instructed that the Task Team will meet behind ‘closed doors’ and you are not permitted to speak to any person who is not part of the Task Team about these issues.
------------------------------------------------------------------------------------------------------- The National Observer | 15 May OUR HEALTH SERVICES ARE FAILING US For many years, there have been grumblings that our health services are not serving the public in the way they should. This has reached a crisis point with a spate of recent deaths across the country, that are being blamed on uncaring and incompetent health workers – a riot broke out after one funeral where the victim had been turned away from a health facility hours before he died. We sent our reporters wide and far to bring you this exclusive exposé of the state of our health services, recounted in the words of people who have first hand experience. The majority of people we spoke to had nothing good to say about their recent experiences of health services. They recounted many tales of poor treatment at the hands of health workers. “They spend 2 minutes with us. It is like a sausage factory – you walk in, they ask you what is wrong, interrupt you half-way and tell you what to do. They don’t even look at you” The sister of a woman who died after giving birth to a still-born baby told us that while she was in labour, she had seen three different health workers who had all told her that she just had back-pains and to go and wait at home for the baby to come. “She was in terrible pain. We knew something was wrong but they just didn’t believe us.” She was taken to another health worker after the birth because she was bleeding. “The nurse told us it was normal, that this was how my sister would become clean again. We finally found a private doctor who said she needed blood, but we were told to go and get more money. When we got back, she was dead. They are only interested in money, not in saving people’s lives.” A number of people complained about the concern of health workers with making money: “We are not supposed to pay at the local clinic, but if you don’t give them something, they don’t treat you well. They only care about robbing us of our money.” Others complained that health workers do not treat them with any respect. “The nurse thinks she is better than us. I grew up with her, we went to school together. Just because she is now a nurse, she thinks she is something special. She was my friend but now she treats me like dirt.” Sometimes there is insensitivity by health workers, with one woman commenting: “They know at the clinic that in my culture, I am not allowed to show myself to a man. There was a woman doctor and a man doctor, but the nurse made me see the man. I could only try to explain what was wrong, but I was shy, so I am still sick.” There are clearly major problems with communication between staff and patients. In rural areas, we were often told that the foreign doctors employed there “don’t speak our language – they can’t understand us and we can’t understand them”. Some said that “the doctor uses fancy language, so I didn’t know what was wrong with me or how I was supposed to take the medicine”. Others said they were treated like idiots: “He spoke very slowly and loudly – I am not stupid and I am not deaf – he just thinks I am”. For some, they do not even receive treatment. A poor farmer told us his experience of two weeks ago: “I got sick while I was working in the fields. My brother carried me to the clinic. The nurse wouldn’t even let us in. She told us to go away and come back when I had washed. She chased me away like I was a dog.” A sex worker in the capital also told how she had been turned away from her local clinic, being told “we don’t treat people like you and anyway it is your own fault if you are sick”. The situation is so bad that many people don’t trust the health services anymore. “I will never go there [the local clinic] again. The nurse there told everyone in the village that my neighbour had AIDS. Now no one will talk to my neighbour. I don’t want stories to get around about my health problems.” Others felt the staff are incompetent: “These assistants are not properly trained. Nobody gets better when they go there. They send you away without any drugs – how can you get better if they don’t give you drugs?” Others complained that the drugs are not effective: “The drugs they give you in those little plastic packets don’t work – I never get better with those drugs. Only if I go to the drug seller and get the drugs in the proper box will I get better”. Some people did, however, indicate that they would use health services for some illnesses. “I don’t mind going to the clinic, but they cannot cure some things. When my child had fits, I knew that this was because of evil spirits and only the traditional healer could make him better.” We did find a few people who were more positive about the health services. One woman commented: “The doctor doesn’t treat me well, but my husband and my brother say he is a good man who always understands and helps them.” We found one village where many people agreed: “We have no problems here. The nurse at the clinic is always at work on time, she is kind to us, she is one of us.” One person told of how the nurse had helped her: “I was very sick with malaria but there were no more drugs in the clinic. The nurse took me to the drug seller and showed me which drugs I needed. She even asked the drug seller to let me have the drugs and to pay him later when I had the money.” However, everyone said that they knew that this nurse was a “special person” because they had heard about how bad the clinics were in other villages where their families live. Are our health services failing us? We have faithfully reported the views of the public and we leave it to you to decide on the answer to this important question. Next week, we report on the views of health care providers. ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- The National Observer | 22 May HEALTH CARE PROVIDERS HIT BACK In the second of our series on the state of our health services, our reporters spoke to doctors, nurses, medical assistants and other health workers around the country. We exclusively bring you their side of the story. Almost all the health workers we spoke to were angry about the public views on the care they provide and about the pressure that was being applied to “change the way we do things.” Many felt that patients abuse the health service, particularly since free health care was introduced for pregnant women. “Some women just get pregnant so they can get a pair of glasses – the policy is wrong because pregnant women should not get all services free, only the services they need to safely have their baby”. Most agreed that there had been many problems since primary care services were made free: “They come for every little problem now. People don’t appreciate services they don’t pay for – they think they are getting bad care.” Many feel resentful because their workload has increased since fees were removed and that they have not been consulted about changes in policy. “No one came and asked me what I thought about this free care policy. They didn’t ask me when they suddenly decided that we must add outreach services – I now have to walk many miles every day to visit people and then come back to the clinic to see patients; I get so tired. Those people who make the policies must come and see what it means for me.” Health workers also indicated that expectations of them were unrealistic. “They always leave it until it is very late, until they are very sick, before they come to us. It is very difficult to make them well again.” “We are always blamed when a person doesn’t get better but health care is not a ‘perfect science’. We are also given treatment protocols, so we can’t just do what we think would work; we have to follow the guidelines.” Many health workers feel unappreciated and unsupported. “We work very hard but nobody ever says thank you.” Some commented that patients “expect miracles. We are just human and what can we do when we have no drugs. It is not our fault – the district office should take more responsibility. They never come and visit us to see what the problems are and to sort out these problems.” Others had the view that “patients don’t treat us with respect. We are professionals and we have been trained so we know what is wrong with patients and how they can get better. Instead of complaining, people should listen to us and do what we say, then they would get better.” A number of health workers complained about the recent ‘Patients’ Rights Charter: “They are so demanding now, they always talk about their rights, but what about our rights. We have rights too but nobody talks about that. Nobody talks about how hard we have to work, how little we get paid, how we never get a chance to go for extra courses, how all we hear are complaints and never hear anything good about the things we do.” Some health workers complained that managers “think they are better than us. Whenever there is a problem, they come and shout at us and tell us we are to blame for them getting into trouble; they don’t try to understand the problems and help us sort them out.” Female staff seem to have particular problems: A nurse said: “Our clinic manager always demands that I make him tea. Then he talks nicely to the male staff, but won’t listen to our problems. We are always the ones who have to work late if there are lots of patients, we have to do all the admin work.” Managers are not seen as working to help their staff and to improve the services that are provided. Everyone denied that patients in need are turned away. “That man who died – it was just one nurse behaving badly, one rotten apple, but everyone now treats us as if we are all bad.” “We would never turn away someone who is very ill. Sometimes when there are too many patients and we need to close the clinic, we tell people to come back tomorrow but if there is someone who is very sick, we will work late. We have to go home to our families as well.” However, most agreed that there were problems with the health services, but felt that it was not because of what health workers do, but because of how the health services are managed. The Ministry of Health refused to comment when contacted about the issues raised in this and last week’s report. ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Late newsflash Shortly before going to press, the Minister of Health announced the establishment of a task force to investigate the state of health services in our country. -------------------------------------------------------------------------------------------------------
Sources of information for case study:
- George A, Iyer A, Sen G (2005). Gendered health systems biased against maternal survival: preliminary findings from Koppal, Karnataka, India. IDS Working Paper 253. Brighton: Institute of Development Studies.
- Gilson L (2007). Acceptability, trust and equity. In: McIntyre D and Mooney G (eds). The Economics of Health Equity. Cambridge: Cambridge University Press
- McIntyre D, Klugman B (2003). The human face of decentralisation and integration of health services: Experience from South Africa. Reproductive Health Matters; 11(21): 108-119.
