This conversation was first published in the Global Labour Column where Fikile Dikolomela-Lengene (who is in quarantine) spoke about the launch of the #Care4carers campaign and report1, which reveals just how deeply the erosion of work rights of nurses and community health workers is undermining patient care and the pandemic response in a South African healthcare system already deeply divided by private and public care.
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The deepened Health Crisis during Covid-19 and The Neglected Cries of the Nurses
Health care is in crisis. Nursing as a profession is in crisis. We have seen the lack of political will to hear the cries out there. Sometimes when you’re speaking and there’s no research, people will say you’re just making noise.
This report - a lot of things came to light. The poor working conditions that we find nurses working - it makes you wonder, where is the Labour Relations Act? How are all these nicely drafted legal protections not implemented in the conditions of service in health care? We found insecurity of work, gender based violence, exploitation especially for nurses in private health care. And we found that, because this is a gendered profession, there is a lack of political will because most people who are taking decisions are actually not female. For an example I put maternity services. People who are running it are males. So you find you have to push a gendered view on how this should be structured to accommodate women.
‘60% of private-sector employees are agency nurses’
In the private sector, about 60% of employees are agency nurses, based on this report. When you hire this nurse, most would get about R700 (about US$40) per shift. Insecurity comes with labour brokering - agency work - for nurses and also community health workers. They do not have benefits like your medical aid, your skills development training that goes with being permanent, or even joining a trade union. They cannot have bond [mortgage] houses – how can you when you do not know how much you are going to make? They are given what they are given. If you are not working you would do just about anything to get a job.
Now remember when you [in the private healthcare sector] hire this [agency] nurse, you are saying you are not giving them any benefits, medical aid, occupational health: now that is cheap labour, so that tomorrow, you discuss without any regard for any labour laws.
What becomes very sad, currently, is you get these agency nurses and care workers being thrown into Covid-19 areas only, and should they refuse, they will never be booked again. You find them between should I go, should I not go? If I don’t, I will not have bread in front of my children. Then, they will be moved from one institution to another, and these are the workers who may be harbouring the very Covid and taking it to other institutions.
Labour brokering was actually outlawed in 2018, so it’s funny that this very government is using labour brokering in the public sector, instead of putting new permanently employed nurses. Agency nurses are used to avoid paying overtime, because [public sector] nurses’ advanced status will cost more in overtime, so you’d rather hire an agency nurse.
With care workers, it has become so exploitative. In the NGOs and the private sector, they are being left to manage wards: their skill is now being used as cheap labour.
Nurses’ hours really are too much. The Basic Conditions of Employment (BCEA) of South Africa has always been clear: you can work a 40 hour week, you can stretch it to a 45 hour week. But you find that due to the shortage, a nurse who is supposed to work 12 hour shifts now, in a seven day week, has to work four or five days, 12 hours full, sometimes going to 16 hours, based on how you are relieved. For instance, you cannot leave an operation while it is still ongoing. Nurses work way more than the 45 hours they are supposed to work; they may be given hours or leave, but their department is not adhering to the BCEA.
In SA a minimum wage of R3500 [a month] was passed for care workers. As a trade union we advocated for R12500 minimum wage, based on the average from your mining sector and others fighting for a living wage. Now these women, out of R3500, use about R1000 for travelling from home to the clinic and to [patients’ homes]. With these wages, they walk a radius I don’t know of how much, depending on the catchment area they are given. There is a limit to how much a person can walk so they end up on a local [15-seater] taxi just to be able to reach that other side of town because some houses they have to visit are there.
The report found that nurses’ salaries in the public sector were two to three times lower than those of medical practitioners.
That’s very worrying, especially when you have specialised services in nursing, like primary healthcare nurses. You do not have a doctor every day in the rural facility, so you want to have such skill that whatever comes in, this nurse is able to deal with it at that level, be it a gunshot, be it a delivering woman with a complication, until we can get to the next level of care - but you find that nurse earning R 18000, and a newly qualified doctor earns close to R49000 a month. Even in urban areas: myself I’m a primary healthcare physician; I sit in consulting room A, the doctor in room B. We see the same number of patients, the same conditions, but my salary is two times less.
Demoralised to the point of insanity
These poor labour conditions have made the nurse demoralised to a point of insanity. When you have one nurse in a labour ward, and five women come in about to give birth, you are putting this nurse in a position of thinking they are god, because this nurse has to triage: who do I start with? Who is more important?
Or ARV treatment: one nurse is expected to see about 200 patients a day]. Really, how can you smile at patient number 200? How do you have time for health education? Sometimes patients just need a listening ear. But by the time you want to listen and do your comprehensive care, there are others outside complaining, ‘We’ve been here!’
Those issues have made patients very frustrated at clinics, and compromised our maternal services, which are wracked with malpractices and negligence. It’s bleeding the public purse because they do not want to look at nurse-to-patient ratios. In ICU, we know, one nurse, one patient. Currently its one nurse to four or five patients. When they have to resuscitate a patient, what must happen when the other one starts gasping? The nurse is asked why did the patient die, but why are they charging her when she was alone? We [the trade union] said, come on CEO, show how you can actually resuscitate five people being alone, not going for tea, not going for lunch, and some patients need your undivided attention 24 hours.
Our employers are used to not taking care of the carer, not doing what they want nurses to do. Currently there is a document saying to nurses: after seven days of being Covid-infected, go back to work if you do not have any symptom. How do you make nurses accomplices of murder? It was never confirmed that those without symptoms cannot pass the virus. Is that a code of good practice for any employer, to send someone with an active virus into the health system? And then, this is a human being. Is this not the cause of their mental breakdown at that functional level? Where is occupational health and safety for the worker, when our own government is saying, go and work up until you cope or you die? Now that nurse is going to pass the virus to how many community members? Just because of not wanting to take care of the carer.
“Dignified work means dignified health care”
In mother-and-child we are running without baby warmers. What is always happening with budget and corruption and looting, yet you never get any people being held accountable? Everybody will be blaming the nurse. There is no light, it is the nurse; the patient wasn’t fed, it is the nurse. Yet those services are not being procured correctly.
I fear the type of nurses we are going to have, with how they are being marginalised and their rights being trampled upon. Nurses are displacing their tiredness, their burnout, their frustration, on the incorrect people. Hence we said to them, as a trade union, let us start forcing employers to uplift the rights of people and nurses.
The report is very clear: dignified healthcare work means a dignified healthcare system. Start listening to the drivers of the system, which are your nurses. The #Care4Carers campaign is when we hear the cries of the nurses and the cries of the community. Truly we found that our nurses and community health workers are not cared for. We are saying to government: the way you want nurses to take care of the person, can you start exhibiting that? Can you start by actually listening to the nurses and community healthcare workers, and try to change their working conditions?
1The report, produced by YNITU and Oxfam South Africa, (which also details outrageous profiteering in the private healthcare industry in South Africa) can be downloaded from Oxfam, where you can also join or support the campaign.
About author: Fikile Dikolomela-Lengene is a nurse clinician, as well as deputy president of the Young Nurses’ Indaba Trade Union (YNITU) in South Africa.