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RESEARCH
755 September 2012, Vol. 102, No. 9 SAMJ
Public health sector strikes have a negative effect on all of society,
with the poor suffering the most, especially when a health service
is paralysed. In-hospital mortality during doctors’ strikes appears to
be the key indicator in evaluating the consequences of such strikes
on service delivery. The literature reports decreased in-hospital
mortality during doctors’ strikes,
1-3
but an increased mortality
during hospital nurses’ strikes in the USA has been reported.
5
We
assessed the effect of a 20-day doctors’ strike in Polokwane Hospital,
Limpopo Province, during which the peripheral hospitals of
Limpopo Province were rendered almost non-functional, and only
the Polokwane Mankweng Hospital Complex (PMCH) provided
emergency services for the entire province. PMCH is a tertiary
institution receiving patients from Limpopo Province. In 2010, the
province had an estimated population of 5.5 million, of whom 90%
had no medical aid, therefore depending heavily on public hospitals
for healthcare.
Objectives
We studied the impact of a health professionals’ 20-day strike in
Polokwane Hospital, and compared performance indicators during
the strike with a non-striking period.
Methods
Data were collected during the 20-day strike (18 August 2010 - 6
September 2010) from the Hospital Information System (HIS),
Polokwane Hospital Casualty Department (PHCD), surgical wards
and theatres. Coomparison data for a non-striking period were
collected from HIS, PHCD, wards and theatres during a randomly
selected 20-day period in May 2010. Data included the performance
indicators referred to: admissions, operations and deaths.
Results
During the 20-day strike, 262 patients were admitted to Polokwane
Hospital and 40 patients to the surgical department. In the entire
hospital, 96 operations were done and 40 in the surgical department;
50 deaths were reported throughout the hospital and 8 deaths in the
surgical department. During the 20 days of a non-striking period
in May 2010, there were 975 admissions to the hospital and 125 to
the surgical department; 340 operations were done throughout the
hospital and 79 in the surgical department; 61 deaths were reported
throughout the hospital and 12 deaths in the surgical department
(Tables 1 and 2).
Discussion
Service delivery may be expected to be affected seriously and
deleteriously during health professional strikes. However, the
literature reports a lowering of mortality
1-3,6
or no change
4,7
when
doctors strike; but a 19.4% increase in mortality during hospital
striking periods by nurses in New York, USA, between 1984 and 2004
has been reported.
5
A review by Cunningham et al. spanning 1976 - 2003 reported that
mortality reduced or stayed the same.
1
In Israel in 1973, when doctors
went on strike for a month, mortality decreased by 50%. In 1976 in
Bogota, Columbia, when medical doctors went on strike for 52 days,
providing only emergency care for patients, the death rate dropped by
35%. In the same year, the Los Angeles County doctors’ strike resulted
in an 18% drop in mortality. As soon as the strike was over, the death
rate returned to its usual levels.
1-3
Available information suggests
that when doctors strike, mortality is reduced. This contradiction
to expectations might be cynically and inaccurately held against
the medical profession. Comprehensive analysis shows that when a
strike takes place, most emergency cases are attended by non-striking
personnel or by other institutions substituting for striking hospitals.
Elective procedures are deferred until the strike is over. Most cases
are treated outside the hospitals, by general practitioners and private
clinics. The mortality from elective surgical procedures, which are
Impact of 20-day strike in Polokwane Hospital
(18 August - 6 September 2010)
M M Z U Bhuiyan, A Machowski
Background. Doctors’ strikes have a negative effect on hospital
performance indicators. Hospital mortality during such strikes is
the most important indicator.
Objective. To determine the effects of the 2010 strike on
Polokwane Hospital.
Methods. Information was collected from the Hospital
Information System, Polokwane Hospital Casualty Department,
wards and theatres.
Results. During the 20-day strike, a total of 262 patients were
admitted to Polokwane Hospital, with 40 patients to the surgical
department; 96 operations were performed in the hospital and
40 in the surgical department; and 50 deaths were reported in the
hospital (8 deaths in the surgical department). During 20 days of a
non-striking period in May 2010, there were 975 admissions to the
hospital, with 125 to the surgical department. In the entire hospital,
340 operations were performed, and 79 in the surgical department.
For this period, 61 deaths were reported in the hospital and 12 in
the surgical department.
Conclusions. The total number of patients admitted to the hospital
and the surgical department during the strike was significantly
lower than during a non-striking situation. Total mortality during
the strike in Polokwane Hospital decreased, compared with the
normal situation, but it increased when judged against emergency
cases. However, when mortality was qualified by the number of
admissions, it showed a significant increase. Strikes seriously and
significantly affect service delivery.
S Afr Med J 2012;102(9):755-756. DOI:10.7196/SAMJ.6045
Department of General Surgery, Polokwane Mankweng Hospital Complex and
University of Limpopo, Polokwane
M M Z U Bhuiyan, FRCSG, MMed
A Machowski, MD, PhD
Corresponding author: M Bhuiyan (bhuiyanmirza@yahoo.com)
RESEARCH
756 September 2012, Vol. 102, No. 9 SAMJ
not performed during strikes, also reduces the figure. However, the
reduction of in-hospital mortality is compensated by an increased
patient death rate outside of the striking hospitals – in other
institutions or in patients’ homes. Reports reflect only in-hospital
mortality, and not total mortality of the entire population in the
striking areas. The reported mortality is represented by total number
of deaths, and is not qualified by the more appropriate numbers of
admissions.
The strike in Polokwane evidently lowered the quality of service
delivery; there was an overall reduction in the number of admissions
and operations in the hospital. During the strike, mortality reduced
but not proportionately to admissions, either in the surgical
department or the entire hospital. Hospital mortality during the
strike, when correlated with numbers of admissions, increased
threefold for the hospital as a whole and, in the surgical department,
mortality doubled. It is probable that further analysis of mortality
in the population outside the hospital would elucidate the true
reflection of actual mortality and hence the real consequences of a
health professionals strike in our population.
Conclusions
The total number of patients admitted to Polokwane Hospital and
the surgical department during the strike was significantly lower than
during non-striking circumstances. Total mortality during the strike
decreased in comparison with normal conditions, but increased when
judged by emergency cases. However, when mortality was qualified by
the number of admissions, a significant two- to threefold increase was
apparent. The strike seriously and significantly affected service delivery
(elective admissions and operations) in Polokwane Hospital. Every
effort must be made to avoid strikes in health services institutions.
Acknowledgements. We thank Mrs R Mavhungu (research assistant) for
her contribution to collecting data from theatres, and Mr T S Ntuli for his
contribution of statistical inferences.
References
1. CunninghamSA,MitchellK,NarayanKM,YusufS. Doctors’ strikes and mortality: a review. Soc Sci
Med 2008;67(11):1784-1788.
2. Ellencweig AY, Ginat-Israeli T. Eects of the Israel physicians’ strike on the treatment and outcome of
acute appendicitis in Jerusalem. Isr J Med Sci 1990;26(10):559-563.
3. Aro S, Hosia P. Eects of a doctors’ strike on primary care utilization in Varkaus, Finland. Scand J Prim
Health Care 1987;5(4):245-251.
4. Bukovsky I, Herman A, Sherman D, Schreyer P, Arieli S, Caspi E. Perinatal outcome following
physicians’ strike of 1983. Isr J Med Sci 1985;21(10):804-807.
5. Gruber J, SA Kleiner. Do Strikes Kill? Evidence from New York State. NBER Working Paper Series, Vol.
w15855. Cambridge MA, USA: NBER, March 2010.
6. Siegel-Itzkovich J. Doctors strike in Israel may be good for health. BMJ 2000;320(7249):1561.
7. Erceg M, Kujundzic-Tiljak M, Barbic-Erceg A, Coric T, Lang S. Physician`s strike and general
mortality: Croatia`s experience of 2003. Coll Antropol 2007;31(3):891-895.
Accepted 15 June 2012.
Table 1. Performance indicators during the 20-day strike, and 20-day non-strike in May 2010, in Polokwane Hospital, Limpopo
During 20-day
strike
During 20 days non-strike May 2010
(combined elective and emergency)
During 20 days non-strike May 2010
(emergency cases only)
Number of patients admitted to hospital 262 975 382
Number of patients admitted to surgical
department 40 125 73
Number of operations in entire hospital 96 340 177
Number of operations in surgical department 40 79 27
Number of deaths in entire hospital 50 61 30
Number of deaths in surgical department 8 12 7
Table 2. Performance indicators in Polokwane Hospital; comparison of non-striking period with strike period
Non-striking situation Comparison
Combined elective
and emergency Emergency only
Strike
(N)
Strike/non-striking situation
(combined elective and emergency)
Strike/non-striking
situation (emergency)
Number of patients admitted
to hospital
975 382 262 Reduced by 63% during strike Reduced by 31% during
strike
Number of patients admitted
to surgical department
125 73 40 Reduced by 68% during strike
(p 0.301)
Reduced by 45% during the
strike (p 0.298)
Number of operations in
entire hospital
340 177 96 Reduced by 72% during the strike
(p 0.595)
Reduced by 46% during the
strike (p 0.014)
Number of operations in
surgical department
79 27 40 Reduced by 49% during the strike
(p 0.001*)
Increased by 48% during the
strike (p 0.001)
Number of deaths in entire
hospital
61 30 50 Reduced by 18% during the strike
(p 0.001)
Increased by 67% during the
strike (p 0.001)
Number of deaths in surgical
department
12 7 8 Reduced by 33% during the strike
(p 0.079*)
Increased by 14% during the
strike (p 0.227*)
*Fisher’s exact test.