Covid-19: Are SA’s district hospitals government’s coronavirus blindspot?

Isolation unit at Pelonomi Hospital, Free State.
Isolation unit at Pelonomi Hospital, Free State.
Chante Schatz
  • SA's district hospitals may see the bulk of Covid-19 cases.
  • District hospitals are mostly not equipped with ICU capabilities.
  • Experts are divided over whether ICU resources should be directed to district hospitals.

South Africa's hospitals are quickly filling up, as the country's Covid-19 infection rate surpasses the 200 000 mark and shows no signs of slowing down, and the country’s district hospitals are no exception.

But experts say these hospitals cannot cope with treating critically ill patients, and they are often hours away from the nearest hospitals that can.

At over 250 facilities, district hospitals make up more than half of the total public hospitals in South Africa. Many are situated in rural areas, already suffering from poor infrastructure and chronic skills shortages.

They do not treat intensive care unit (ICU) or high-care patients, according to government regulations, and in many cases may not have the capabilities to do this at all.

Government regulations as published in the Government Gazette state that district hospitals are only allowed to provide paediatric health services, obstetrics and gynaecology, internal medicine, general surgery and family physician services.

However, they often have oxygen facilities, meaning they can treat Covid-19 patients who need oxygen, but not those who need to be on a ventilator.

For example, Gauteng has 11 district hospitals in the public sector, with combined beds of 2 565. Only one, Jubilee Hospital in Tshwane, has ICU capabilities, with just four beds.

Experts divided

Experts are divided over whether these facilities need to be beefed up urgently so that they can treat serious Covid-19 patients, or whether they should remain dedicated to moderate cases so as to avoid spreading ICU resources thinly throughout the country.

Dr Ndiviwe Mphothulo, an executive committee member of the Rural Doctors' Association of SA, says doctors and nurses in rural district hospitals must be up-skilled to treat severely ill Covid-19 patients.

In the bigger cities, he says some doctors in the district hospitals do rotations at bigger hospitals where they can train as specialists. But this is not the case in the rural areas.

He said:

The rural areas are plagued by chronic, poor infrastructure and poor governance. And the big problem is they don't have specialists, but they will end up treating Covid-19 patients.

Mphothulo says 12% of doctors and 19% of nurses in the country work in the rural areas in the public sector, serving about 43% of the population.

The North West is particularly concerning for doctors at the moment, with cases in mining areas especially beginning to rise. On Thursday, North West Health MEC Madoda Sambatha issued a "red alert" to the province, warning that the province was experiencing a "sharp increase" in cases and deaths.

A number of hospitals in the province have turned ordinary wards into ICU wards in response to the problem.

But Mphothulo says beds are not the only problem.

"Even if you have ICU beds, you need ICU beds and ICU doctors. There are no specialists in Vryburg or Zeerust. All patients need to be transferred to Klerksdorp hospital about 280km away.

"Even if serious cases are supposed to be transferred, as a doctor, you can't ignore a patient who is in respiratory distress, for example. You have to stabilise before the transfer, and so on."

No testing

A senior North West clinician who spoke to News24 on condition of anonymity says the district hospitals are also not able to test for Covid-19 because of a lack of testing capabilities.

A recent policy change means that a quarter of all hospital beds must be made available for Covid-19 patients, he says. But the smaller hospitals have been consistently ignored since the outbreak of the pandemic and have not been given extra resources to cope.

And moving patients to and from hospitals over large distances is also spreading the disease among health workers, who have to spend two- or four-hour stretches in a confined space with an infected patient.

There is agreement among experts though that the hospitals are an important line of defence for two reasons: they are spread all over the country, and they have beds - something in short supply in the bigger hospitals.

Some occupancy rates in district hospitals are estimated to be as low as 60%, according to some estimates.

Not necessarily outside of use

Professor Alex van den Heever, chair in the field of social security systems administration and management studies at the Wits School of Governance, says they should not be upgraded to treat critically ill patients.

ICU resources need to be concentrated and not spread out and the solution to getting more ICU capacity is to combine private and public sector resources, he says.

"They're [district hospitals] regarded as level 1 care basic care. They may do some surgeries, but not anything that requires ICU post-surgery… They're often not properly staffed, but they do have beds and other facilities. They can be used [for Covid-19 patients]," Van den Heever said.

They can also be used as triage facilities for milder cases, which can then be referred to bigger hospitals.

"They are not necessarily outside of use."

Referrals will remain a problem for provinces like the North West, Limpopo, the Northern Cape and large parts of the Free State where provincial or regional hospitals are far away from district ones.

A strategy for how to use the district hospitals optimally is needed, Van den Heever said.

On Friday, Health Minister Zweli Mkhize visited the Tshwane district hospital and announced that all hospitals will now have triage tents to separate Covid-19-positive patients from negative ones.

This may go a long way to stem the tide of positive patients at district hospitals.

Lessons

But in the absence of skilled specialists in the rural areas, some senior doctors are turning to YouTube tutorials to train doctors in district hospitals on the use of ventilators and other Covid-19 interventions, News24 was told. Others are training doctors over the phone.

There is a longer-term lesson that needs to be learnt from the Covid-19 experience, Mphothulo said.

"The lesson for government should be that long-term planning is essential so that specialists can be attracted to rural areas."

But, in the short term, doctors need to be trained quickly to manage critically ill patients.

"Rural doctors are very versatile. They can do anything," he said.

The Department of Health did not respond to questions. 


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