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. The sister in charge told me that the technician had told her that “it could not be done faster” and gave a long list of technical reasons for it. I asked her: If Nelson Mandela had moved in at the clinic, how long would it take before there was a functioning telephone available? She just laughed at me.
Context is crucial. A rural clinic with Madiba staying there 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, the poor rural areas are dragged in to justify whatever is needed. Sadly, after the funding is allocated, often very little ends up actually improving the situation in rural areas.
Thankfully this is not the only way to understand the context of rurality and rural health. The Rural Doctors’ Association of Southern Africa (Rudasa) has been working to improve rural health for the past decade. It has had a number of successes in shifting the context and 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 initiated and since then more than 300 foreign doctors have been recruited, increasing the pool of rural doctors.
The success of the agency (now called African Health Placements) relates 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 approach included emphasising that it is possible to practise good medicine in rural areas, and it is possible to change the systems and processes that institute poor medicine. By managing the recruitment process and the image of rural healthcare as well as supporting rural hospitals, it has been possible to do what seemed impossible.
Reflecting on the context, how did it come about that a quiet, committed doctor in a very 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 was in line with the policies of the department (see “Patients before process, say doctors“, February 15)?
The healthcare authorities say that we cannot have the situation where “everyone does their own thing”, and this is understandable. However, if the concern was 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 Aids and drafts guidelines on the implementation of dual-therapy prevention of mother-to-child transmission (PMTCT). It seems that the process of getting the guidelines through the bureaucracy was holding things up.
It appeared easy to charge Pfaff, as this was just a little hospital in the middle of nowhere; “merely a bureaucratic procedure”, to quote the Department of Health.
In order to provide better healthcare 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 Pfaff need to be supported and the model of care he developed needs to be examined for the lessons we can learn from it. 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 programme so efficiently in such a short period of time?
A deeper issue is the interface between the bureaucracy and a profession. While on the surface the intentions between the Department of Health and healthcare professionals seem to overlap considerably, in the implementation there are many instances where the tension sits uncomfortably, and 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 Pfaff, one way of formulating the dilemma is whether bureaucracy is a good enough explanation for limiting a doctor to act in the best interests of the people he serves.
To change the face of rural health we do need local and dedicated doctors and nurses, like 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.
In South Africa, we seem to have the means and the technology to address these issues, but what is missing in many instances is the larger vision and commitment from officials and politicians within the bureaucracy.
The crisis in human resources for health limits 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.
The KwaZulu-Natal health department has since dropped the misconduct charge against Pfaff, following a storm of protest.
The issue with Pfaff has the potential to open the debate on how positive energy within the bureaucracy can be harvested in a way that improves the outcomes for local communities to the maximum. To get to such a positive outcome, managing the context is crucial.
Bernhard Gaede is chairperson of Rudasa