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Thousands face disability as orthopaedic services collapse

Mpumalanga has the country’s highest rate of road accident deaths, but when survivors are pulled from the wreckage, there are just four doctors in the province who can mend their bones – and the wait to see them may kill and maim many.

Wheel chair

About 8000 patients a year are at risk of suffering disabilities including osteomyelitis, amputation and infection from delayed surgeries. This could translate into about R137 million in new disability grants annually, say experts.

Poor roads and long distances are a deadly combination in Mpumalanga, which sees about 57 percent more road accident fatalities than the national average, according to the South African Health Review 2013.

Petrus Mokete Mofokeng survived a January head-on collusion on the N17 but the crash snapped his thigh bone in half. He was rushed to Bethal Hospital. Over the next three months, he would come face-to-face with the reality that orthopaedic services in Mpumalanga have collapsed.

He would also lose the woman he loved and his children would mourn her without the comfort of their father.

Only for orthopaedic surgeons work in the public sector in the province of about four million, one each at at Nelspruit’s Rob Ferreira Hospital and Themba Hospital 30 kms to the north east in Kabokweni. Another two surgeons work at Witbank Hospital, according to the Mpumalanga Department of Health spokesperson Dumisani Malamule.

Orthopaedic experts conservatively estimate that at least 11 500 patients present annually in the province for conditions including broken bones, torn tendons or muscles and clubbed feet. If operating theatres are running properly – with working air conditioners, clean linen and adequate stocks of the metal plates and screws needed to rebuild broken bones – these three hospitals can operate on about 2 900 patients a year.

More than 8 000 remaining cases will never make it to the operating table.

A long, painful road

“I asked the hospital for permission to leave to attend the funeral but they said, ‘you must know that when you come back, if there is no bed then you must leave’”

When Mofokeng landed in Bethal Hospital, he had no idea he was far down on a waiting list for operations that now stands at more than 1 100.

A month and half into his hospital stay, Mofokeng had not received the operation to rejoin his broken thigh bone. After he threatened to go to the media, he was transferred to Witbank Hospital.

“I had been there for a couple of months up until 30 March, when I was transferred after I asked for help,” he said. “I had been at the hospital all that time without a salary. My kids were suffering and I was depressed.”

He waited another week at Witbank for his surgery, which eventually took place on 8 April – about three months after the crash and a month too late to bury his fiancé and the mother of his children.

“There was nothing I could do,” Mofokeng told Health-e News. “I asked the hospital for permission to leave to attend the funeral but they said, ‘you must know that when you come back, if there is no bed then you must leave.’”

He never saw her before she was buried, never attended her burial and told her family to go on out without him.

“I told them, ‘you can’t even wait for me because I can’t even walk,’” he added.

Mofokeng never received a follow-up consultation after his surgery and although he can now walk, says he experiences frequent pain in his leg.

Salvage treatment

Elderly

In desperate need of a hip replacement, No. 400 on the waiting list Suzanne De Klerk has realised that what lies between her and a life worth living is a bill she cannot pay.

Number 400 on the department’s waiting list is Suzanne de Klerk*. Most of her life was spent behind a broom as a cleaner. In May 2013, the 64-year-old fell and by March, she could no longer walk. Her medical aid will only pay R40 000 of the R140 000 surgery needed to replace her hip.

The last nine months have been a descent into pain and depression. Last week, she approached every bank in her small town to ask for a loan to cover the cost of the surgery. Without a bank account, no one would give her a loan.

“I can’t go on like this. The pain is just too much,” said De Klerk, her voice is weary, rimmed with something that at first sounds like anger. When her voice begins to quiver, it becomes clear that it is not anger but desperation. She has realised that what lies between her and a life worth living is a bill she cannot foot.

“I don’t sleep at night and I have to take pain tablets every four hours so eventually my kidneys will start picking up problems,” she says perched on crutches. “I haven’t got any money so how am I supposed to buy a wheel chair?”

De Klerk had originally agreed to be named for this article but later asked to remain anonymous for fear it would comprise her ability to secure additional hospital cover.

She also knows what came before the 399 names before her on the list – a provincial health budget in shambles.

“The doctors have said…there are no hours for theatre and there is no money to pay staff,” she told Health-e News. “There’s money for nothing.”

Shortages of equipment as suppliers owed

In recent months, health workers have reported month-long stock-outs of wheel chairs, crutches, bandages, and orthopaedic implants such as screws and metal plates used to repair broken bones.

One implant manufacturer is reportedly owed more than R8 million. The Mpumalanga Department of Health declined to name how many medical suppliers were owed payments or how much but spokesperson Dumisani Malamule said that the department is currently reviewing all outstanding debts and that measures were being put in place to ensure timely payment.

The Department of Health has been under administration by the provincial department of finance since October 2013 due to budget problems.

Linen shortages and non-functional air conditioners, lack of sterilising equipment and lights have periodically shut down operating theatres, further delaying surgeries.

Around 2011, a fire destroyed government’s prosthetic workshop in Ermelo. Two years later, this workshop was still not functional and there is an eight-month waiting period prosthetic limbs.

According to the Department of Health’s latest annual report, about 44 percent of specialist posts in the province are vacant.

In February, the Rural Health Advocacy Project (RHAP), the Rural Doctors Association of Southern Africa and Professional Association of Clinical Associates in South Africa sent a letter to the Mpumalanga Department of Health regarding the crisis in orthopaedic services – in particular the province’s inability to produce orthopaedic specialists.

The Department of Health officials agreed to meet with them but requests for a date for the meeting have been unanswered. However, Malamule added that the province has started an orthopaedic training programme with the University of Pretoria and recently advertised additional orthopaedic posts.

Sick system

MP Elderly woman Itumeleng English

An old woman walks from her rural home in Mpumalanga to the main road. There she will catch a minibus taxi to the nearest town and sleep over in order to queue early for the clinic.

RHAP’s Dr Prinitha Pillay says that the lack of budget and the province’s inability to produce or retain orthopaedic specialists is behind the delays that force doctors to make difficult decisions about which patients will get surgeries.

“If an air conditioner doesn’t work, or there’s no linen or a part for a machine has not arrived … the operation is cancelled,” she tells Health-e News. “The next day’s list of patients gets bumped or changed.”

Rural patients who spend up to R800 for transport to one of the three hospitals able to perform orthopaedic surgeries may be turned away as operating lists are bumped back.

“The waiting list and waiting times between the ‘haves’ and ‘have nots’ really is so disparate and ultimately tends to prejudice rural populations,” she said. “What we can see is that households tend to plunge into poverty because of those escalating medical and travel costs.”

Delays also increase the risk that patients will be left permanently disabled due to injuries from which they could have recovered. Following a fracture, swelling can block blood supply to limbs, putting patients at risk of amputations. Patients can also develop severe infections, including a condition called osteomyelitis in which infection develops in the bone.

“The waiting list and waiting times between the ‘haves’ and ‘have nots’ really is so disparate and ultimately tends to prejudice rural populations”

“Osteomyelitis is a very severe complication…and that’s what we see a lot of today,” said Pillay, who previously worked in the public sector. “It’s very difficult to treat and extremely difficult to manage so you do need specialist services and it becomes even more costly for the health care system. “

“That person has to go to hospital more often, you have extended periods of antibiotic treatment and you have a disability that could have been prevented,” she added. “If that patient has to go to theatre, they end up going many more times than if they had just got the operation at the right time.”

According to conservative estimates, about 8000 patients a year are at risk of suffering disabilities including osteomyelitis, amputation and infection from delayed surgeries.

This could translate into about R137 million in new disability grants annually. In comparison, a 24-hour orthopaedic theatre could cost around R30 million a year, according to expert estimates.

*Name changed upon request

A shorter, edited version of this story was originally published in 22 August edition of  The Star newspaper.

Read more on Mpumalanga’s health crisis as part of Health’e News’ “Deadly debt” series:

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