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Doctors, Hippocrates And Hypocrisy (Cont.)

The cacophony surrounding the wage negotiations in the public health sector has generated more heat than light. The sight of highly qualified professionals engaged in picket line protests complete with toyi toying is novel. Their placards prescribing a “cash injection” for the sector are plaintive, pointed and unlikely to be heeded. Some of the criticism of the unfolding power play between employer and employees is a little misplaced, if not hypocritical.
The ancient Greek who was the father of modern medicine and devised the code of ethics for doctors which still bears his name would no doubt be surprised to hear that his name is invoked by those who feel that doctors have no business protesting the state of affairs in the public health sector of South Africa’s civil service. The oath devised by Hippocrates forbad abortion and euthanasia as well as surgery for kidney and gallstones. In its modern incarnation it is barely recognizable as his handiwork, but it does still require doctors always to act in the best interests of their patients.
The question ought then to be: is it in the best interests of patients that the incidents of protest and industrial relations strife experienced in recent weeks have occurred? The answer is the subject of some contention. Any strike in the essential services arena is illegal. It is generally regarded to be in the public interest that essential services for the nation continue irrespective of disputes in negotiations over the conditions of service of those who provide the essential services. Other mechanisms exist when negotiations do not produce the desired result. The CCMA can be asked to act as facilitator, arbitration can be resorted to and, when all else fails, those dissatisfied with their lot are free to resign and seek greener pastures elsewhere, either in the private sector or, lamentably with increasing frequency, in foreign climes.
The doctors who have been protesting and picketing know all this, yet they have persisted, in the face of strong criticisms, to demand the “cash injection” treatment which they say the public health sector requires. It has long been the case that the sector is under-resourced. Vacancy rates in key professional areas are alarmingly high. Facilities are crumbling, the availability of sufficient beds for patients is problematic, equipment in good working order is in short supply, and drugs have been known to run out long before the next budget allocation. The queuing and waiting times are notoriously long. Management is sub-standard, working hours are long and exhausting. Much of the bed linen has been stolen and has not been replaced; the coffee is grey and the food often unappetizing. Our public hospitals have unhappily but increasingly become places where ordinary folk go to die rather than for healing treatment and cures for their ailments.
The doctors know all this too. They are self-interested in improving their own lot, but they are also expressing concern, as they should do, about the state of the public health system. Their own lot impacts directly on it. Public health has long been neglected by a government more interested in the acquisition of arms with which to fight imaginary foes and the creation of a “gravy train” on which a junior parliamentarian gets paid six times as much as a junior doctor. The latter is required to perform life saving feats needing heroic skills for a well nigh impossible 36 hours at a stretch while the former need do no more than follow the instructions of the party bosses at voting times; no degrees, no training nor expertise is needed, simple obedience to the party line suffices.
Our new Minister of Finance anticipates that this year there will be a shortfall of R 60 billion on the revenue which the government budgeted that it would be able to gather. “The Economist” suggests that we, like many other nations, will come up short by between 5 and 7%. These are symptoms of the recessionary conditions in the world economy. Borrowing is seen as the way to make up the shortfall. Borrowing to address the crisis in public health care is however not under consideration.
To make matters worse, the government has seen fit to dismiss some 400 of the doctors who have participated in the protesting while simultaneously seeking to deal with the issues by, in effect, meeting the 50% across the board increase demanded with what works out as a 26% increase. The wisdom of firing those in short supply – rather than addressing their issues constructively is questionable. After 400 doctors were dismissed in KwaZulu-Natal, those doctors who did not initially participate were so angered as to join in the protests of their dismissed colleagues. It is reasonably anticipated that if the government sticks to its “final” offer many more doctors will leave the system in disgust at the way the occupation specific dispensation has been handled. Cosatu warns that this dispensation has not been properly thought through by government and has not been budgeted for adequately. Government promises that “Conditions in our public health facilities will improve with time” and that “working conditions of our doctors need to be addressed.” But it does not seem to have the political will or the administrative skill to do anything concrete. The goals set by government are laudable, the means of achieving them are not, unfortunately, stated in the cabinet’s press release. When, how and what exactly government plans are all mysteries.
A holistic understanding of the structures and practices that would maintain and strengthen the health service needs to be articulated by those responsible for creating policy in the sector. The state has a constitutional obligation to respect, protect, promote and fulfill the right to access to health care. This right is available to everyone in the country, young and old, local and foreign. The progressive realization of the right must be the subject matter of measures taken by the state. Firing 400 doctors who express legitimate gripes about the system is not such a measure.
The health service is part of the public service, and the principles and values according to which the public service has to be run are prescribed in the Constitution. Efficient, economic and effective use of resources must be promoted. Accountability is required. Good human resource management practices which develop careers and maximize human potential must be cultivated. It is not beyond the wit of those already involved in the public health sector to pay proper attention to these principles and values. Vague promises do not suffice – decisions that are justified and steps that can be explained reasonably are required. All role players are all in this together and the continued collapse of the public health system will benefit no-one. Shearing off doctors by their hundreds is likely to be counter-productive.
Improved service delivery with wider benefits for users and providers of health services implies better working conditions and pay for doctors. How else will sufficient numbers be attracted into the public sector? Without sufficient numbers of appropriately qualified and suitably motivated doctors it will simply be impossible to bring about the much needed improvements in the public health sector.
Paul Hoffman SC
July 2009

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