Rural health: The context is crucial

Submitted by Bernhard Gaede

A few years ago I visited a small clinic in a remote area that had been waiting for more than a year for a telephone connection. In the discussion with the sister in charge, she told me that the technician had told her that “it could not be done faster”, giving a long list of technical reasons for the delay.

I asked her how long, if Nelson Mandela had moved in at the clinic, it would have taken before a functioning telephone was available — and she just laughed at me.

Context is crucial. A rural clinic where Madiba is staying is likely to get more attention and resources than many clinics that are struggling to survive. It is not so much about what is possible in rural areas — the context determines what is allowed to happen.

So how is the current context constructed? Rural areas are seen as a disaster. Every time there is a need to motivate for more money, more support and additional resources, poor rural areas are dragged in to justify whatever is needed. Sadly, often after the funding is allocated, very little ends up actually improving the situation in rural areas.

Thankfully this is not the only way to understand the context of rural life and health. The Rural Doctors’ Association of Southern Africa has been working towards improving rural health for the past decade. It has had a number of successes in changing how people see rural health. Its vision is to inspire for rural health — to get people excited about improving the health of rural people.

A good example of this is the recruitment of rural doctors. For a long time it has been very difficult to recruit and retain doctors — and most other healthcare workers — in rural areas. No one wants to work in rural areas.

Three years ago, a recruitment agency was started and more than 300 foreign doctors have since been recruited. The success of the agency (now called African Health Placements) is due to selling the idea effectively. Rural medicine is exciting medicine. One gets to do and see things with which few other practices can compare. This includes emphasising that it is possible to practise good medicine in rural areas, and that it is possible to change the systems and processes that constitute poor medicine. By managing the recruitment process, changing the image of rural healthcare and supporting rural hospitals, the seemingly impossible has been achieved.

Reflecting on the context, how did it come about that a quiet, committed doctor in a remote hospital was charged with misconduct for not seeking “adequate permission” to run a project (with no cost to the department of health) to provide medication that is in line with the policies of the department? (See “Patients before process, say doctors” in Mail & Guardian, February 15 to 21.)

The health authorities say that we cannot have the situation where “everyone does their own thing”. This is understandable. However, if the concern is merely the bureaucratic process, there are many ways of correcting this without having to resort to disciplinary action.

Dr Colin Pfaff was managing the context in Manguzi. Clear direction had been set by the national strategic plan on HIV/Aids and drafts of the guidelines of how dual-therapy prevention of mother-to-child transmission (PMTCT) of HIV would be implemented. It seems that the process of “getting the guidelines through the bureaucracy” was what was holding things up.

Just as many rural healthcare workers assume that they are outside of the gaze of politicians, bureaucrats and even at times academics; so do politicians, bureaucrats and academics, it seems. It was easy to charge Dr Pfaff — as this was “just a little hospital in the middle of nowhere”. To quote the department of health: “It is merely a bureaucratic procedure.”

In order to provide better health care in the country, the context needs to be managed aggressively. If we are serious about fast-tracking dual-therapy PMTCT in rural areas, people like Dr Colin Pfaff need to be supported and the model of care he developed needs to be examined for the lessons we can learn from it. Dr Pfaff and the team of doctors and nurses working in Manguzi managed to reach approximately 80% of pregnant women in the area with their programme. Where in the country have others managed to implement a program so efficiently over such a short period of time?

A deeper issue, though, is the interface between bureaucracy and a profession. While on the surface the intentions of the department of health and the healthcare professionals seem to overlap considerably, in the implementation there are many tense instances where a compromise needs to be sought.

Is it unacceptable to implement guidelines before one has explicit permission? Is this true for all actions of healthcare workers? In the case of Dr Colin Pfaff, is bureaucracy a good enough explanation for limiting a doctor’s actions in the interests of the people he serves?

To really change the face of rural health, we do need local dedicated doctors and nurses, like Dr Colin Pfaff, who are creative and innovative. But there also needs to be a greater commitment to addressing three more fundamental limitations to improving rural healthcare: inequity of resource allocation, difficulty in access to services and resources and isolation.

Roy Jobson has referred to this in his blog “Why I am not a rural doctor“. In South Africa, we seem to have the means to solve these problems and the technology to do so; however, what is missing in many instances is the larger vision and commitment from officials and politicians within the bureaucracy.

The human resources available for health limit service delivery to the most marginalised. The vacancy rate for medical-officer posts in the public sector in South Africa is 34%. In KwaZulu-Natal, it is 39% (2007 data from Health Systems Trust ).

The National Human Resources for Health Plan, published in 2006, recognises that retention of health personnel is about more than just money; working conditions also play a significant role. Health workers who feel supported by management to do the best they can for their patients are more likely to stay than those who are alienated by the department of health.

It is of huge concern that the Southern African Migration Project found that almost half the health professionals surveyed in a recent study said they were likely to leave South Africa within the next five years.

We are delighted that the charges against Dr Colin Pfaff were withdrawn on February 20. This case has certainly opened debate and reflections on how positive energy within the bureaucracy can be harvested in a way that improves the outcomes for the local communities. To get to such a positive outcome, managing the context is crucial.

Bernhard Gaede is a rural doctor at Emmaus Hospital, Winterton, KwaZulu-Natal and the chairperson of the Rural Doctors’ Association of Southern Africa. He is passionate about the right of rural people to access healthcare.