Published: 27/05/2004, Volume II4, No. 5907 Page 17
There are moments when you know you make a difference and there are times when you wonder how you can make a difference at all. I felt a mixture of these emotions last week, when I led a six-strong acute and primary care chief executive team to Cape Town, South Africa. It marked the five-year conclusion of the UK-South Africa EU-sponsored exchange and development programme.
The UK team spent a week talking to ministers, the Western Cape director general, the chief executive of the South African health department, numerous policy officials, chief executives and senior healthcare professionals.We visited primary and community healthcare centres, secondary care hospitals and tertiary acute and paediatric centres. Our most striking conclusions were that:
nmuch has been done to improve healthcare provision for the black majority since 1994 - it is difficult to appreciate the wide disparity that existed under the old regime;
n the government is struggling to meet the burgeoning health needs of the black majority after decades of neglect;
n HIV and tuberculosis threaten to eradicate the Western Cape 2010 plans for re-directed investment in enhanced and 'beefed up' community health centres;
n while 8 per cent of GDP is spent on health, only 3 per cent is directed to public services while a selective private sector pervades every aspect of emergency, tertiary and primary care.
Better secondary and tertiary care alignment and rationalisation is needed, but political immaturity (or at least political sensitivity in a fledgling democracy) stifles meaningful debates.
While we must guard against making value judgements about a political democracy that is only 10 years old, it is clear there is an enormous, unquenchable spirit for improvement in the new South Africa. People's pride in, and enthusiasm for, their country caused enormous embarrassment to the more cynical UK delegates, while the unswerving commitment of healthcare staff was very impressive. During a week in which the Royal College of Nursing dared to consider that nurses were 'too posh to wash', we saw nurses with truly extended roles in primary care caring for hundreds of people who had queued since 3am.
Set against these dynamic movements and trends sits an oldfashioned bureaucratic health hierarchy. The vertical columns of doctors, nurses and administrators are heavily managed by the country's health department. There is, however, widespread recognition of the need for change and the UK chief executives have been asked, with the Modernisation Agency, to help coach, mentor and develop chief executives and advise policy officials on healthcare systems reform.
Technical skills like business management, information management and budgeting need to be coupled with greater devolution and a systems of incentives linking accountability to responsibility. Last week's announcement that the 2010 World Cup will be held in South Africa will be a further boost to the economy which should see a greater proportion of the GDP flow into health.
Mark Britnell is chief executive, University Hospital Birmingham foundation trust.
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