Research Article SANTA vs. public tuberculosis hospitals: the patient experience in the Free State, 2001/2002 JC Heunis, PhD Centre for Health Systems Research & Development, University of the Free State HCJ van Rensburg, DPhil Centre for Health Systems Research & Development, University of the Free State H Meulemans, Ph.D Department of Sociology, University of Antwerp Abstract: Curationis 30(1): 4-14 This paper reflects on the appropriateness of the decision to close down a non­ governmental organisation (NGO), state-aided tuberculosis (TB) hospital in the Free State in 2003. Henceforth hospitalisation of TB patients would take place at public district hospitals. A survey conducted late-2001/'early-2002 revealed a more positive patient experience of hospitalisation forTB in public hospitals than in the NGO hospital. Consideration of the patient experience serves to inform the debate concerning continued outsourcing of TB hospital care to NGOs in South Africa. This study discusses comparative findings in respect of patients’ biographic and socio-economic characteristics, health beliefs, satisfaction with hospitalisation, experience of stigmatisation, adherence to treatment and absconding from hospital. Opsomming Hierdie artikel reflekteer op die toepaslikheid van die besluit om ‘n nie-regerings organisasie (NRO), staat-ondersteunde tuberkulose (TB) hospital in 2003 te sluit. Voortaan sou die hospitalisasie van TB pasiënte in openbare distrikhospitale plaasvind. ‘n Opname wat laat-2001 /vroeg-2002 uitgevoer is het ‘n meer positiewe pasiëntervaring van hospitalisasie vir TB in publieke hospitale as in die NRO hospitaal openbaar. Oorweging van die pasiëntervaring dien om die debat rakende voortgesette uitkontraktering van TB hospitaalsorg aan NROs in Suid-Afrika toe te lig. Dié studie bespreek vergelykende bevindinge met betrekking tot pasiënte se biografiese en sosio- ekonomiese kenmerke, gesondheidopvattings, tevredenheid met hospitalisasie, ervaring van stigmatisasie, trouheid aan behandeling en “dros” uit die hospitaal. Introduction evaluations (Schneider & Palmer, 2002: Excellence within any given hospital 32). Also, the (social) experience of serv ice may be described by means of hospitalisation has not been Correspondence address: standards and criteria in accordance with systematically studied in any of the major Dr JC Heunis the expectations of the different role- hospital settings in South Africa, be they CHSR&D (100) players: funding bodies, service public, private-for-profit, industry-based, University of the Free State providers and patients. Among these state-aided or voluntary. The dearth of PO Box 339 patients are neglected in the South such research can only mean that health Bloemfontein, 9300 African “hospital” literature. This is policy makers and managers are neither Tel: (051)401-2181 contrary to an international tendency to supported by “social statistics” nor by Fax:(051)444-5011 assess the opinions of health service understanding of the patient perspective E-mail: Heunisj.hum(a;mail.uovs.ac.za users as an integral part of quality to inform their decisions about hospitals. 4 Curationis March 2007 This study reflects on the patient standards of care at some of its hospitals dimension also involved a focus on TB experience at the one NGO hospital (Altenroxel, 2001: 6; Kirk, 2001: 3; Van programme managers and staff and their offering TB care in the Free State one Rensburg, 2000:2). views, amongst others, on year before its closure in January 2003. hospitalisation forTB(cf. Heunis, 2005: Ownership of this hospital vested with The era of NGO hospitalisation for TB in 221). This article discusses findings the South African National Tuberculosis the Free State has then seemingly come related to TB hospital patients’ experience Association (SANTA). This NGO has to an end. Barring those few patients who of hospitalisation for the disease (cf. also operated specialised TB hospitals across can afford private care and a small Heunis 2004a: 161 -210). The findings South Africa since the 1950s. In 1999, number of patients in the new provincial are inclusive of these patients’ SANTA had 22 hospitals specialising in MDR-unit, TB patients are at present biographic and socio-economic TB care: seven in the Eastern Cape, six in treated at primary health care (PHC) characteristics, health beliefs, KwaZulu-Natal, three each in Gauteng clinics and public hospitals. Except for satisfaction with hospitalisation, and Mpumalanga, two in the Western MDRTB, this also means that the practice experience of stigmatisation, adherence Cape, and one in the Free State. By 2003, of long-term hospitalisation for TB has to treatment and absconding from not only the Free State, but also North now been abandoned. hospital. In all this data helps to reflect West, Northern Province and the on the research question: how Northern Cape, no longer had a SANTA Despite its unique position as the Free appropriate was the closing o f a hospital hospital (Inpatient Care Team 2003). State’s only TB hospital, and even amidst that contributed to TB control for half a There was clearly a questioning of the an escalating TB epidemic in the century? traditional role of SANTA hospitals and province, Santoord Hospital’s closure a trend to oust this NGO provider from was imminent. Reportedly, the patients Methods intramural TB care. In tjie Free State, at addressed letters to the Free State MEC The imminent closure of Santoord least, this role was largely assigned to for Health complaining, amongst others, Hospital meant that a cross-sectional public hospitals. about food at the hospital and the staff study, i.e. a once-off survey of TB who they (the patients) experienced as hospital patients at Santoord and the The Claudius Brink SANTA Centre “dominating”. All these dynamics sampled public district hospital, would (Santoord Hospital) was established in pointed to the necessity to gain insight be an appropriate design. Similar to 1952 and was operated by SANTA until into how the patients themselves medical procedures like a biopsy or an x- its closure in 2003. Santoord was a experienced Santoord Hospital. As it was ray, cross-sectional studies observe provincially-aided hospital (Van Vuurcn clear that public district hospitals were whatever is being studied as if a section 2001). The annual number of admissions already taking over the hospitalisation of time is being cut out for observation was highest in 1997 at 710 patients. of TB patients previously referred to (Baker, 1994: 106). No suitable instrument During 2001 the hospital admitted 602 Santoord, it was thus also opportune to being in existence an interview schedule patients (442 males, 152 females, and 8 conduct a cross-sectional study to was developed from the literature. This children) of whom 477 were discharged, compare the TB hospital patient schedule contained both closed and 11 transferred, 23 absconded, and 105 experience in these two types of open-ended questions. The open-ended died. Santoord Hospital's budget for hospitals. questions were included so that 2002/2003 was R7 632 756. The cost to respondents in their answering of the Free State Department of Health per The current study formed part of a larger questions would make use of what came patient day for this period was R 104-55. project, the Joint research project on to their own - rather than the researchers’ Santoord was not physically designed tuberculosis control in the Free State: - minds. The instrument was pre-tested nor equipped to accommodate MDRTB from infection to cure. This project to determine its effectiveness and its patients. However, it did so for three studied TB from various angles with the problems and to improve its reliability. years after the closure of the private aim to inform the provincial TB Preliminary informal pre-testing was Allanridge Chest Hospital in 1999. Just programme and enhance the efficiency followed by formal pre-testing under before its closure the hospital of TB control in the province (cf. Van conditions similar to the actual survey. accommodated 145 TB patients. Drug- Rensburg, Meulemans & Rigouts, 2005: For purposes of the formal pre-test the susceptible patients were hospitalised for ii-iv; Van Rensburg, Meulemans, Rigouts, schedule was administered in face-to- two to three months and multi-drug Heunis, Janse van Rensburg, Matebesi, face interviews with a sub-sample of resistant TB (MDRTB) patients for seven Van der Spoel, Timmerman, De Graeve, patients at Santoord Hospital and the five to nine months. The mean length of stay Pauwels, Portaels, Gryseels & Van district hospitals. During these at the hospital was 125 days. MDRTB Houtte, 2005: 1127). Two focal and interviews the interviewers wrote patients at Santoord were treated in complementary dimensions applied in the comments on the questionnaire and collaboration with doctors/specialists larger study, i.e. social aspects and health thereafter discussed these in an from the University of the Free State and service aspects. The social dimension interactive context with the other were discharged once they had produced included, on the one hand, TB patients’ interviewers and the first author. The three consecutive negative sputa. After needs, perceptions, experiences and questionnaire was corrected in respect discharge they would return to the circumstances, health-seeking of skipped items, response set patterns, hospital on a two-monthly basis for behaviour, health service utilisation and and open-ended questions that solicited follow-up