Introduction
Health workers in the public healthcare sector in South Africa have seen a steady decline in public health services and programmes. Chronic underfunding of public health has negatively influenced the ability of existing health systems in South Africa to respond to healthcare needs. Together with fraud and corruption, this has resulted in deterioration in infrastructure, staff shortages, poor laboratory support, inadequate equipment maintenance, and intermittent supply of adequate consumables, all contributing to the steady decline in the quality of care we can offer our patients. Unfortunately, many health workers at the front line also suffer. Faced with an unsupportive management environment, staff shortages and health system deficiencies, health workers find it increasingly difficult to uphold their professional code of ethics and provide good quality of care.
Now more than ever, physician advocacy needs to become a core component of medical training and professionalism of all undergraduate medical training. We cannot entirely fulfil our Hippocratic oath if we do not speak up for our patients, raise the alarm, and hold those in power to account.
So what is our role, and where do our responsibilities start and end?
The moral, ethical, legal and professional burden healthcare workers carry is not to be underestimated. From the first day in the wards as a junior medical student, we are exposed to violations of human rights and disrespect for patients’ dignity, such as lack of running water to toilets, absence of toilet seats, or the unavailability of the correct size cannulae to drip a patient, to cite just a few examples. Our medical students’ moral injury starts on day one. Constant, repetitive moral injury causes many to become numb, others to self-medicate, and yet others to burn out. A sense of helplessness and futility is a vital contributor to moral injury.
Public sector healthcare workers are bound by a framework of rules and regulations, which often contradict our duty to report suboptimal service conditions that compromise patient care and outcomes. How can we effectively advocate for change within the restrictive framework of rules and regulations? Our ethical obligations to patients urge us to be constructive whistle-blowers.
Legal frameworks and channels for reporting
Public servants in South Africa are required to adhere to the Public Service Regulations of 2016. These regulations, part of the Public Service Act, forbid communication with the media unless authorised to do so by the head of the department.(1) However, South Africa also has the Protected Disclosure Act (Act 26 of 2000).(2) This Act applies to employees from the public and private sectors and allows “protected disclosures” regardless of the employer-employee agreement if certain conditions are met. These conditions include allowance for a “general disclosure” if the impropriety has previously been reported to an employer without subsequent action being taken in a reasonable amount of time. The act also highlights additional mechanisms of protected disclosures, such as disclosing to the Public Protector or to the Health Ombud.
Any adverse report to the employer must be clearly documented. At the authors’ institution, Rahima Moosa Mother and Child Hospital, an electronic form can be used to report “Major Incidents and Critical Shortages” (MICS form).(3) These forms are automatically forwarded to management. Even if no corrective action ensues, the employee can prove that a particular issue was reported previously. Since April 2014, when this reporting methodology was initiated, over 700 forms have been submitted by healthcare workers at our hospital. These submissions have been used by the heads of the various clinical departments to write several detailed reports of the deteriorating conditions in the hospital. Although “MICS fatigue” prevails at our institution, the form is still used to report and document problems. In 2022, when one of the authors of this paper received a precautionary suspension for having disclosed the hospital's dire state to the media, these forms and reports were used as proof of prior reporting.
The need for considered advocacy
Whilst patient advocacy takes on many forms, we call on our colleagues not to disregard the daily injustices arising from the deteriorating conditions within our public healthcare services. Our role is not to investigate the cause of the shortages and poor infrastructure but to point out the effect these have on our vulnerable patients. By doing so, we are not only discharging our duty as committed employees of the healthcare services we seek to protect and build but also speaking out on behalf of our patients at the receiving end of such lapses. These shortcomings are often the result of inadequate budget allocations, which are compounded by maladministration, corruption, and poor healthcare management at various levels. The highlighting of such failings and effects is necessary and noble but often at significant personal cost to the whistle-blower.
Recognising and reporting on poor service delivery, no matter the cause should become part of the culture of all committed healthcare providers. Such reports and reporting mechanisms need to be seen by all as a way of lifting the standards of care. Offering solutions to address the system's shortcomings is hoped to result in fewer adverse events and complaints. Hospitals today spend a lot of time and energy investigating and addressing complaints (as they should), but much of this can be averted if there is a culture of intolerance to these conditions within the administration. These cultural shifts can be simple things, such as not accepting a broken window or litter in the wards and corridors of the hospital.
Reporting on an issue may come at a cost and include occupational detriments such as being subjected to disciplinary action, harassment, or intimidation by the employer. This psychological stress on the individual and their family is another significant contributor to burnout. The 11th Revision of the International Classification of Diseases (ICD-11) describes burnout as a syndrome resulting from chronic, unmanaged workplace stress.(4) It is characterised by energy depletion, negativism or cynicism related to one's job, and reduced professional efficacy. Risk factors include a dysfunctional workplace, lack of control, and moral injury, factors most public healthcare workers in South Africa face daily.
Disclosure to the media requires careful thought, and one must weigh the potential benefits and harms. Firstly, has this been reported formally within the institution? Are there other persons to whom the disclosure can be made (a member of the province's Executive Committee, the Public Protector or the Auditor General)? Does this public action have any chance of improving conditions on the ground? Will it add to the general public's knowledge of the healthcare crisis? Do you trust the journalist or media involved to represent your words truthfully? Will it ease or worsen your moral injury?
Case example: Rahima Moosa Mother and Child Hospital
Returning to the situation at Rahima Moosa Mother and Child Hospital, has anything changed on the ground? The initial flurry of political attention that followed the Daily Maverick article on 22 May 2022, which detailed the deteriorating state of affairs at the hospital, had mainly subsided.(5) However, the spotlight was shone again on the Department of Health by a report on the state of the hospital by the Health Ombud, Prof Malegapuru Makgoba, almost a year later.(6) The Ombud made several recommendations and gave clear timelines for their implementation. While some were implemented (creating a discharge lounge for maternity patients and installing security cameras), most critical ones remain unfulfilled. As of writing, there are still no 24-hour blood bank or laboratory services (deadline May 2023), the hospital has not yet been gazetted as a tertiary institution (deadline November 2023), nor has a permanent Chief Executive Officer been appointed (deadline June 2023), and the list can go on.
Furthermore, despite being the second to third busiest maternity and neonatal service in South Africa, Rahima Moosa Mother and Child Hospital still faces water supply challenges. It does not have a functioning Computed Tomography (CT) scanner for the past year. Perhaps the most significant change since the initial Daily Maverick report has been the hospital's senior management change. While many areas still require attention, the advocacy focused national attention on the crisis has shifted attention to improved patient care as a hospital's primary goal, not just political window dressing.
Conclusion
The pursuit of health and social justice in our country and beyond needs a critical mass of healthcare workers, doctors in particular, to challenge what is wrong and to speak out on behalf of patients. Faculties of Health Science schools must give doctors the relevant knowledge, skills and tools to advance their advocacy role for health and social justice. As healthcare providers, we must not lose this voice and ignore this moral responsibility. In the words of President Mandela, “As long as poverty, injustice, [and] gross inequality persist in our world, none of us can truly rest.”