The SA Medical Service and the RDP

Lt Gen Niel Knobel;

Surgeon General SA National Defence Force

Paper delivered at a conference on RDP Guns and Butter, held jointly by the Institute for Defence Policy and the Institute for Strategic Studies, University of Pretoria, 1 September 1994 at Pretoria.

Published in African Defence Review Issue No 20, 1994

INTRODUCTION

Before discussing the possible role of the SAMS in the RDP of the GNU it is necessary to provide some background about the SA Medical Service of the National Defence Force. In particular its origins, present status, mission, role and functions must be clearly understood, before its potential in terms of the RDP can be appreciated.

It is an internationally accepted principle that members of the Armed forces that risk physical exposure, injuries, disablement or death in the service of their country, must be able to depend on a dedicated health service that is complete, comprehensive, selfsupporting and available at all times. Furthermore, such a service should integrate fully into a military command structure, with an intimate knowledge and experience of military doctrine, strategy and combat handling under all battle conditions in the field, air and at sea. In terms of the principle of the "golden hour" which determines that an injured or wounded soldier should immediately become the responsibility of such a dedicated field medical organisation, the service should also possess communications, cross country capability and mobility equal to that of the combat forces it must support.

The above conditions will ensure that any casualty will enjoy the highest standard of operational health care comprising resuscitation, stabilisation, evacuation, definitive treatment and after care. If we add to this the functions of medical standards, selection, preventative medicine and rehabilitation as well as the specialized services of underwater or diving medicine, aerospace medicine, trauma - psychology and psychostrategy, defensive nuclear, chemical and biological warfare and the ability to acquire, stockpile and distribute medical logistics in the field, you have the comprehensive system that fulfills the moral obligations of the State as mentioned before.

SAMS AS THE FOURTH ARM OF THE SANDF

The existence of a formal dedicated military medical structure in the RSA can be traced back as far as 1887 when the King Williams Town Ambulance Corps was formed. In 1903 existing military medical structures were renamed as the Cape, Natal and Transvaal Medical Corps respectively. During 1913 the South African Medical Corps (Zuid Afrikaanse Geneeskundige Diens) of the Union Defence force was restructured with the Cape Medical Corps as 1 Mounted Brigade Field Ambulance and the Transvaal and Natal Medical Corps as 1 and 2 Field Ambulances respectively. In 1921 the Reserve of Nurses evolved into the South African Military Nursing Corps. After the South African Air Force was established, an aviation medical service came into being with the secondment of Major H. Porteus from the RAF. A naval medical service was established in the early 60's, as a result of the requirements of the SA Navy.

In the early 70's therefore the Government and the Defence Force were confronted with separate medical services in support of the Army, Air Force and Navy. Although the American concept of a Surgeon General for each arm of service was very popular at this time, it was evident that the RSA could not afford the luxury of a military health service equal to that of the super powers. To optimise operational efficiency and unity of command, the first step was to rationalise the SA Medical Corps and the SA Military Nursing Corps. The next step was taken on 1 July 1979 when the SA Medical Service supporting the Army and the Medical Directors of the Air Force and Navy were rationalised into a single independent military health organisation under command of one Surgeon General for all Combat Forces, with the additional responsibility of providing operational support to the SAPS as well.

During the planning and inception of the National Defence Force earlier this year this concept of a single independent military health organisation for the SANDF was re-emphasized and accepted by all participants in the process.

This position of the SAMS as a fourth arm of service in the SANDF happens to fulfil all the requirements of the UN Commission on participation in disaster relief and/or peacekeeping operations namely that any participating element:

should have its own identy, image and culture;

must be able to function independently;

must be professional with a clear Command and Control system;

must be selfsupporting and mobile with a reliable communication system;

must be cost effective and productive at all times; and

must fulfil all requirements of readiness and impartiality in the execution of its functions.

The above functions are structurally organized as indicated by the following in specific and support as follows:

Operational Medical Support - designed to requirement

Base Orientated Crime and Hospital Service - designed to requirement and affordability

Specialist Advisory Service - unique capability/collateral value

Logistical Support - centralised nationally deployed capability

Training Service

This support to the SAPS is presently also being extended to the Department of Correctional Services (DCS) on a limited scale.

The RDP further states that all policy decisions affecting health, must take into consideration the fact that South Africa is an integral part of the Southern African region and has regional responsibilities to prevent and to contain the spread of disease. During the Defence Vote the Minister confirmed the role of the SANDF, and thus SAMS, to render service in compliance with South Africa's international obligations. The SAMS contribution can be summarised as follows:

To make a contribution toward the establishment of a national strategy for the management of all the various categories of migrants, in co-operation with the Army, SAPS and other role players.



The hospitalization, training, specialist advice, medical logistic support and other actions directed at military personnel from South Africa as military assistance and support.



Aid to the Department of Foreign Affairs in support of diplomatic initiatives that could include disaster relief actions, containing epidemics and epizootics, immunisation programmes, provision of medical supplies, specialist advice and service. These actions can be done autonomously, in co-operation with or as agent of the GNU and national or international authorities.



Performing certain medical selections, and confirmations of all aviation medical examinations, as well as examinations of professional divers on behalf of the Departments of Transport and Manpower respectively.

In terms of social upliftment in the form of assistance to other departments or authorities the SAMS could also:

Act as medical rapid deployment force for the State during disaster relief and the maintenance of essential services. Floods in the OFS and N Cape over the last few years, continuing strikes at various hospitals and the Typhoid epidemic at Delmas in 1993 are good examples of this assistance.



The provision of medical supplies via the Standard Stock Account to authorities who do not posses their own capability.



Medical selection of teams to the Antarctic for the Deptartment of Environmental Affairs.

All the above assistance is not provided for the income that it could generate but to prevent the duplication of means which have been established for military purposes. The direct costs involved in actions such as those in Delmas are negligible in terms of the total SANDF budget, but when measured against the SAMS budget and their impact, they cannot be disregarded. The capability to launch a Delmas operation is not readily available elsewhere in South Africa and would consequently have been slower and far more expensive to mobilise.

CONCEPT OF PROVIDING SERVICE

During the past three years serious shortages in professional manpower have caused the SAMS to move toward a concept of providing services based on Art 38(a) of the Nursing Act. Art 38(a) Nursing staff are utilized in military medical clinics and the majority of sick-bays, assisted by private medical practitioners acting as locum tenens, and medical officers from military hospitals who rotate to peripheral regions. An example of this is the creation of the Policlinic in Voortrekkerhoogte, whereby 6 service points have been scaled down to a military medical clinic with an Art 38 (a) nurse, with only schedule 1-4 medicine available with the medical consultation consolidated at the Policlinic. At the same time Dental services are maintained by rotating a dentist between service points.

The situation has changed drastically however, with the establishment of the SANDF through integration of forces, given that the numbers provided do in fact integrate. Actions, as addressed above, remain valid except that most of the reserve capacity in terms of medical infrastructure will be needed by the integrated Defence Force, and additional manpower will be required for at least 3 years.

The SAMS was, before integration, responsible for 184 519 potential patients. The indications are that it will become responsible for an additional 137 466 patients upon completion of the integration process.

At the existing ratio of 0,2% of the SANDF patient population being hospitalized daily, this would mean a resultant 80% bed occupancy. In order to cope with this hospital occupancy, additional professional personnel will have to be recruited. One should bear in mind that these figures are conservative estimates as the exact number of integrating dependents are unknown. It further does not provide for patient numbers emerging from the SAPS, DCS, the civilian employees of the SANDF or patients from the private sector.

Furthermore, the SAMS of the integrated National Defence Force results in an expansion of 17 service points, while the relevant ex-TBVC personnel which we hope to integrate, with the exception of one dentist, comprise only nursing and orderly staff. The establishment of a Service Brigade also implies that the increased load will be distributed between an additional 4 service points which will have to be created and which will further undermine concentration of effort.

As already indicated in the strategy and implementation plan for the SAMS of the SANDF, funds will be required in addition to the allotted SAMS budget in order to accomodate 2 400 new members and to appoint additional staff to cope with the patient load that increases to 321 985. Uncertainty still exists regarding the number of health professionals which form part of the non-statutory force members to be integrated, which will naturally reduce the number of additional personnel required.

CONCLUSIONS

A detailed appreciation of the SAMS possible contribution to the RDP has been completed and is under discussion. Space does not permit me to deal with this document in detail, however in it all possible contributions are stated per function, i.e., training, social services, legal services, ancillary health services, veterinary services, medical services, psychology, nursing, oral health, dietetics, logistical/pharmaceutical services and environmental health.

The conclusion which is reached is that for at least the next 3 years, during which time integration and rationalization will occur, the SAMS will experience problems merely to accomodate the SANDF potential patient load. Aid to other departments will still be provided according to available means.

As previously stated, aid to other departments provides only a small direct return supplemented by a saving for the State and the prevention of duplication.

SAMS must act as medical rapid deployment force for the State in disaster relief operations and when essential services collapse.

During the opening address on the President's budget debate, the President announced that arrangements were being finalised for a major clinic building programme. Immunization, clinic and ambulance services can be provided for the community at specified centres by the SAMS, determined according to means. Joint planning of facilities and services can ensure that the effect of the clinic building programme be optimised. Once again, the State will saves costs ito relief of demands on their resources.

The President also pointed out that progress made in reconciliation will determine the pace at which the RDP is implemented. Integration of the medical elements of the SANDF and the management of 321 985 potential patients is the SAMS's first contribution to the programme.

In respect of dental logistics, the Directorate Oral Health of the SAMS is already responsible for the co-ordination of the complete State tender for dental instruments and materials. This entails the draft of specifications, the codifications of items, the draft and updating of a catalogue and the co-ordination of the tender process.

Where the establishment of an independent means proves not to be cost effective, the SAMS can provide the required medical supplies to certain of the new provinces by way of the Standard Stock Account. This will result in a saving of the cost of each province having a depot and procurement systems.

As part of the RDP an essential drug list must be established to reduce the current wasteful expenditure on inappropriate drugs. Studies have shown that the SAMS per capita cost is lower than the comparative per capita cost of private and civilian authorities. One of the steps the SAMS implemented to optomise, was to implement such a drug list. The knowledge and experience that the SAMS developed in this field is available to all health authorities.

In the public debate the thought to create a fund for disabled members of non-statutory forces is under discussion. In reality there is no need to create another fund since project CURAMUS, a project for present and former members of the South African Security Forces who were physically, psychologically or socially disabled whilst in the service of the Security Forces, already exists. One of the benefits of being a member of the Curamus Association is access to the Curamus Fund which provides financial assistence for aids and equipment not provided for by the State. Depending on the number of disabled non-statutory force members, the capital of the fund might need to be increased. The SAMS skill and infrastructure with regard to rehabilitation which enjoys international recognition, is also available to disabled members of integrating forces, as well as selected patients from the private sector.

In the Health Care component of the RDP policy framework retraining and training of health workers is addressed. The training infrastructure of the SAMS is already utilized in its Project Fairway to train Primary Health Care workers and Emergency Health Care workers to help satisfy the need of all health authorities in the RSA, while at the same time providing essential manpower to the SAMS.

In order to prevent duplication of services, it is also considered to utilize medical facilities within Defence Force territory and security areas, as Public Health Centres (OHC) for the population within the specified area. This means that all persons who are not the responsibility of the SAMS, but who live or work there, will be able to use this facility.

As part of the social upliftment responsibility of the SAMS, its Project Harmonia, which strives through harmony in song and music, to achieve harmony in body, soul and spirit between members of the Security Forces and the public at large, has done a lot in the last five years to pave the way for reconciliation and the RDP.

The contribution that the SAMS can make to the RDP has been dealt with in concept. The cost involved for the SAMS and the benefit it holds for the RSA can only be calculated when detail planning with representatives of the RDP can be done per function and per location at the appropriate level. President Mandela stated during the President's budget debate that central government can only provide the framework and that implementation has to be carried out by local structures.

The determining factor with regard to the ability of the SAMS to cope with the increased patient load of an integrating SANDF, and to utilize the collateral utility of the SAMS to it's full potential depends on the ability of the SAMS to acquire the human resources. The outflow of professionals from the RSA has caused a general shortage in manpower for health authorities. Given the present remuneration package for the respective professional dispensations, of which the majority are below that of the military practitioner, as a result of the old Commission for Administration principle of the transverse positioning of each professional group in the State system, the probability exists that the SAMS will not be able to recruit the necessary professional manpower to enable it to provide the expected service to the SANDF and other approved clientele.

The establishment of a form of Community Service for professional graduates and the negotiation for specific benefits for military health personnel, will enable the SAMS to make an appropriate contribution to the Reconstruction and Development Programme and will bring about savings for the State in other areas.

Clearly the SAMS of the SANDF is a National asset which can and must make a significant contribution to the RDP of the GNU. Whatever the role it will play, it will be carried out in the spirit of the immortal words of Abraham Lincoln at his second inaugural address as President of the USA (1865):

"With malice toward none; with charity for all; with firmness in the right, as god gives us to see the right, let us strive on to finish the work we are in; to bind up the nations wounds; To care for him who shall have borne the battle, and for his widow and his orphan - To do all which may achieve and cherish a just and lasting peace among ourselves and with all nations."