When you are working in a government hospital as a health practitioner, every day is not set in stone and you eventually learn to adapt to your surroundings. It is your job as a physiotherapist to provide the best service that you can to your patients even though there may be obstacles in the way. Over time, you try and make use of what there is in the respective hospital, but is it ever enough when trying to provide each patient with equality in health care when there is a lack of resources? In an orthopaedic ward, patients are evidently dependent on assistive devices post-op to help promote their level of independence. The rehabilitation in these wards are often repetitive until there are times in the rehabilitation period when you find yourself in a situation where a patient’s human right is violated and it therefore delays their discharge date. A human right is defined as the basic right and freedom that belongs to every person from birth until death. The human right to health care means that hospitals, clinics, medicines and doctors’ services must be accessible, available, acceptable and of good quality for everyone, on an equitable basis, where and when needed (Jovic Vranes, Mikanovic, Vukovic, Djikanovic & Babic, 2014).

Every day, a new patient is being admitted to the hospital, has surgery, awaits to be seen by a physiotherapist and is then discharged. A 36-year-old female was referred to physiotherapy after falling at work and sustaining a neck of femur fracture. A total hip replacement surgery was done and according to the doctor, she was required to start mobilizing day 1 post-op. The patient is the breadwinner (works as an administrator and uses public transport), stays in Nyanga township with her 3-month-old baby and mother who is able assist her. The first thought that came into my head was “she will need an assistive device to aid her in mobilization and the best after care that she can get once discharged to get her back to work”. On day 1 post-op, a walking frame was used to assist the patient in safe mobilization and for her to gain confidence after bed exercises were done. On day 3, the aim was to progress to crutches and discharge but the patient did not cope well and was not safe so the plan was then to discharge her with a walking frame. Provided that the physiotherapy management had to be adapted to the patient’s level,  the patient was still motivated everyday and ready to mobilize. In order to issue an assistive device, it had to be ordered a day before– and unfortunately, the department had many crutches available and only one walking frame which was used to mobilize other patients in the ward. The next stock of walking frames was meant to be delivered only two days later. However, the patient still had to be discharged on day 3, as requested by the doctor. According to United Nations (2006b), the provision of assistive devices to compensate for loss of function is an essential part of rehabilitation. An assistive device allows users to realize basic human rights and helps improves their quality of life (Visagie, Scheffler, & Schneider, 2013).

From a personal physiotherapist perspective, I was put in a dilemma because the doctors are constantly trying to discharge patients as soon as possible to ensure that there is enough bed space for the next patient. “Should I have issued the crutches and hoped for the best knowing the patient would not be able to immediately mobilize efficiently or should I have issued the last walking frame to her knowing that the next walking frame would only be delivered two days later?” – these were thoughts that were constantly playing in my head. As the above picture shows, my thoughts were conflicted between who should get the walking frame vs who should get the crutches because in the end, one patient in the scenario had to settle for crutches after both needing the walking frame.

It is said that one of the ways to allocate limited resources is to ration the resources which is based on priority – by viewing the patient holistically and their circumstances (Katz, 2015). This option could have been applicable for my patient, due to her young age and the fact that she stays in a township, works as an administrator and only has her mother able to assist her.  Another suggestion made by (Katz, 2015) is to not ration at all (everybody gets the resources) but this would not be realistic based on the specific hospital settings and the general lack of medical facilities in South Africa. The issue with regard to differential access to health care services is that the government does not spend a sufficient amount of resources on health care, relative to its general wealth and does not use the resources it devotes to health care appropriately (Lie, 2004). If the government does not allocate sufficient resources to the health care, or the hospitals use the available resources inappropriately, a patient could claim that the state violates her right to health. Although, one thing I was able to reflect on in this time is that as a health care professional in the government hospitals, you are not always going to be able to treat everyone with the quality of care that you desire to solely based on the reality of the hospital set-ups. The government aims to improve access to health care by expanding the health care facility network but despite these efforts, health outcomes remain polarized, unequal and unfair in South Africa (Burger & Christian, 2018).

As a physiotherapist, you want your patient to be discharged feeling confident to mobilize safely. Patients who are discharged too early are often in a vulnerable state where they are anxious and (Hesselink et al., 2012) and this could therefore have a negative outcome on their rehabilitation. The patient coped well with the walking frame and if that was going to get her back to work sooner, to be able to look after her child and be able to mobilize efficiently, it felt like the right thing to do in the moment. I learnt that it is always important to keep in mind of the social history to know what the rehabilitation goals outcomes are. Although, despite her meeting all the discharge requirements using the walking frame, I still asked myself “what if somebody with a worse fracture or someone older is admitted to the hospital a day after she is discharged” because then that next patient’s rehabilitation will be delayed and may cause secondary complications.

There were many older patients who have been admitted throughout the weeks to the hospital and sustained fractures due to falling which made me overthink whether I did the right thing or not. It is estimated that 35–40% of community dwelling adults age 65 and older fall each year (Gell, Wallace, LaCroix, Mroz & Patel, 2015).  Be that as it may, how does one know if another patient was definitely going to be admitted in that two-day period? For a moment, I put myself in the patients shoes and I knew it was in my patient’s best interest to receive a walking frame after being educated on hip precautions and contraindications – she deserved the best care, as part of her individual human right. Health care professionals in hospitals are responsible for providing services to patients to meet their acute-care needs, optimizing their function and supporting them with community services as they return home (Matmari, Uyeno& Heck, 2014). This is challenging as it tests what you are capable of. I learnt that it is best to be prepared for the worst, so that if the worst happens, you know you are competent. Ordering a bulk of walking aids more often would prevent future situations like these.

The challenge is now to further entrench these health care rights and to make sure that patients are involved in their rehabilitation keeping their social background in mind. Therefore, it is important to remember that when one is faced with this dilemma in future, that the patient you are treating at that moment comes first. Recognition of human rights is a political responsibility and it is necessary for the political leadership to take the bold step and to commit the country to respecting, protecting and promoting equal health care rights at all times – even though it is still not fully done until this day. Having access to resources is not enough – the health care facilities need to be supplied with the necessities in order to provide the health care people are entitled to receive consistently. Sometime it is best  to follow up on any trends so that a plan can be made to prevent future complications and inequality among patients.

References:

Burger, R., & Christian, C. (2018). Access to health care in post-apartheid South Africa: availability, affordability, acceptability. Health Economics, Policy And Law, 1-13. doi: 10.1017/s1744133118000300

David L. Katz, M., Casey Hribar and Carolyn S. Quinsey, M., Hussain Lalani, M., Edward Hoffer, M., Galewitz, P., & Nancy L. Schoenborn, M. et al. (2019). There are only 3 ways to allocate health care resources. Retrieved 29 August 2019, from https://www.kevinmd.com/blog/2015/07/there-are-only-3-ways-to-allocate-health-care-resources.html

Gell, N., Wallace, R., LaCroix, A., Mroz, T., & Patel, K. (2015). Mobility Device Use in Older Adults and Incidence of Falls and Worry About Falling: Findings from the 2011-2012 National Health and Aging Trends Study. Journal Of The American Geriatrics Society, 63(5), 853-859. doi: 10.1111/jgs.13393

Hesselink, G., Flink, M., Olsson, M., Barach, P., Dudzik-Urbaniak, E., & Orrego, C. et al. (2012). Are patients discharged with care? A qualitative study of perceptions and experiences of patients, family members and care providers. BMJ Quality & Safety, 21(Suppl 1), i39-i49. doi: 10.1136/bmjqs-2012-001165

Jovic Vranes, A., Mikanovic, V., Vukovic, D., Djikanovic, B., & Babic, M. (2014). Education on human rights and healthcare: evidence from Serbia. Health Promotion International, 30(1), 101-105. doi: 10.1093/heapro/dau093

Lie, R. (2004). Health, human rights and mobilization of resources for health. BMC International Health And Human Rights, 4(1). doi: 10.1186/1472-698x-4-4

Visagie, S., Scheffler, E., & Schneider, M. (2013). Policy implementation in wheelchair service delivery in a rural South African setting. African Journal Of Disability, 2(1). doi: 10.4102/ajod.v2i1.63