Re-Imagining Rural Health – The State of Rural Health 20 years into Democracy

Re-Imagining Rural Health – The State of Rural Health 20 years into Democracy

Originally published in the May 2014 newsletter of the Public Health Association of South Africa (PHASA).

Daygan Eagar, Rural Health Advocacy Project (RHAP)’s health budget specialist and Programme
Manager for the Rural-Proofing Policy and Budgeting Programme. He provides health budget and
policy monitoring training to communities and civil society structures and has published extensively on the issue.

I recently spent a week visiting clinics in the Quakeni Local Service Area (LSA) as
part of a research project looking at the resourcing of rural facilities. Quakeni is a subdistrict of the OR Tambo District and encompasses the rolling hills of the Eastern
Cape hinterland, dotted with small villages and subsistence allotments, and a small
stretch of the Pondoland marine reserve—amongst the most arrestingly beautiful
coastline in the world.While working in rural settings like this—where the beauty of the landscape is matched by the warmth and humility of its people—is certainly rewarding, I am
presented with constant reminders of how far we still have to go to ensure that all
people, regardless of the personal circumstance or where they live, have access to the
kind of healthcare that our constitution demands.

How far did we come with rural health care?
Let me start by saying that we need to remember where areas like Quakeni started
from in 1994. The social, economic and spatial legacies of colonisation and apartheid
meant that at the turn of democracy rural areas such as this one had little health or
social infrastructure beyond what was being provided at mission hospitals. While
these institutions were certainly remarkable examples of what could be done with
limited resources and a great deal of commitment and care, without significant
investment in infrastructure and personnel at all levels of the system, there was no
way that they could respond adequately to the growing burden of HIV, tuberculosis
(TB) and non-communicable diseases (NCDs) that have shaped demand for care over
the last two decades.

To say, without qualification, that there has been no progress in the rural health
system over the last 20 years would be disingenuous. For those who access rural
facilities and those who work there, there are certainly clear markers of progress. One
can take hope from the fact that some of the most remote rural facilities are now
electrified, have reliable access to potable water, and many have extraordinary health
workers staff. One can also not deny that since at least 2008 there has been a
consistent commitment to improving access to care for the most underserved
populations in the country. The fact that rural patients who need antiretrovirals
(ARVs) are increasingly able to access treatment at their nearest clinic stands
testament to that.

Problems with the availability of care in rural areas
The reality is, however, that as a country we are still a long way from meeting the
promise of the Constitution and other commitments such as the Alma Atta Declaration
and the Millennium Development Goals (MDGs). Access to healthcare, its quality,
and outcomes are still all too dependent on ones income and where one lives. This is
true for the vast majority of both urban and rural populations; for rural populations
though, the barriers to access are often more acute and more difficult to overcome.
Generally, rural populations continue to experience higher levels of deprivation than
their urban counterparts. According to the Health System Trust’s (HSTs) Deprivation
index, the ten most deprived districts in South Africa are all rural (1). This means that
on average people living in these districts have the least access to education, piped
water, sanitation, electricity, adequate nutrition and in general are highly
impoverished. All of these factors are social determinants of health that make rural
populations more vulnerable to ill health and its impact.

In the context of access to health care, poverty is an especially pervasive barrier. A
recent study into equity in health care access in South Africa revealed that the cost of
transport was the most significant factor in determining if or when rural people
accessed care (2). These costs were compounded by additional direct costs such as
food, childcare and communication, as well as greater opportunity costs associated
with longer travel times, than urban users. The financial impact of these higher costs
of accessing care was highlighted by the fact that when rural patients sought
outpatient care, expenditure on transport was catastrophic in 15% of all cases (>10%
of monthly household expenditure).

Problems with access to care in rural areas do not end with whether or not users are
able to get to the facility or not, they extend to the kind and quality of care they
receive once there. Arguably the most important determinant in this regard is the
presence of sufficient and adequately trained human resources for health (HRH).
In South Africa the distribution of HRH remains skewed in favour of urban areas.
Despite the fact that more than 38% of the population live in rural areas they are
serviced by only 12% of doctors and 19% of nurses (3). There are indications that
things are not improving; of the 1200 medical students graduating annually, it has
been estimated that only 35 of these graduates will choose a career in rural health over
the long-term (4).

The reasons for this skewed distribution of HRH can generally be distilled into a
combination of factors that includes the absence of/poor accommodation for health
workers and their families, fear of safety, lack of opportunities for schooling for
children, shortage of work opportunities for spouses of health workers, poor social
infrastructure and few additional benefits for working in inhospitable settings (5).
For anyone who works at or has accessed services at rural facilities the effects of
understaffing are painfully obvious. Patients are often required to wait the entire day
to be seen, often without the comfort of shelter from the sun, cold or rain. When they
are seen, they are often attended to by health workers who are overstretched and
unable to give them the full attention they may need. In those instances where health
workers are unable to provide the care needed, patients are forced to travel a long
distance to a facility in a large town or city where they can see a doctor or receive
specialized care—again, at a significant cost to them and their households.
Problems with the availability of care in rural areas are then exacerbated by supply
management systems that are not equipped to respond to the needs of understaffed
and difficult to access rural facilities that often have little administrative and
pharmaceutical management capacity. This in combination with weak oversight and
accountability mechanisms all too often results in stock-outs of basic drugs and
essential medical supplies.

Difficulties in addressing barriers to accessing rural health care
Overcoming these barriers to access requires that we not only address the substantive
issues of transport, HRH in rural areas, supply chain management, infrastructure,
oversight and management. It requires that we start to address how rural health is
understood and catered for in both policy and the allocation of resources.
In this respect there are two broad issues that are at the heart of why it has been so
difficult to address barriers to access in rural areas over the last 20 years. The first of
these is that health policy in its current form does not explicitly and hence adequately
address the rural health context. This is largely because policy makers have tended to
view rural as underserved in the same way as impoverished urban settings are
underserved. While treating rural as underserved is certainly appropriate in most
instances, it does not go far enough in identifying policy interventions that deal with
rural specific issues relating to access (e.g. transport) and availability (e.g. HRH).
The second broad issue is that the current system of allocating resources, largely
through health budgets, does not account for the differing needs and costs of
providing services in rural areas. At the provincial level resources are allocated
historically, incrementally and based on a crude understanding of absorptive capacity.
This results in what some researchers refer to as an ‘infrastructure inequality trap’
where funds continue to flow to settings with established infrastructure and human
resource capacity, reinforcing historical and spatial inequities (6).

As the Rural Health Advocacy Project (RHAP) we believe that the starting point in
addressing challenges in rural health is to systematically address each of the
substantive barriers to access through the development of rural friendly policy and
resource allocation processes that include rural factors.
Popularly referred to as rural-proofing (7), this demands that policy makers recognise
the importance of adjusting policy and resource allocation processes in ways that
progressively improve health care access and delivery in rural contexts and then are
provided with the technical support to do this. This is something that the RHAP, with
its rural health partners (8), has started to do with some positive progress already.
The National Department of Health has included a rural chapter in its most recent
HRH Strategy and is partnering with the RHAP and other rural health stakeholders to
find ways that it could be integrated practically into policy implementation. This
engagement should have far reaching implications for HRH in rural areas by
extending recruitment and retention strategies beyond just remuneration to include
key areas such as health education, improvements in living conditions and personal
development for rural health workers (4).

This kind of engagement is starting to develop in other areas too. Even the Treasury, a
notoriously difficult institution to influence, is starting to accept the need to reevaluate
resource allocation processes and how they can be more responsive to rural

It is often easy to forget the lived realities of users and health workers in rural areas
when engaging with these technicalities at the policy level though. When crunching
numbers as part of a review of health care expenditure one often forgets that reality on
the ground. For example, the decision to spend R500 to hire ‘private transport’ to get
a sick family member to a hospital because the ambulance never comes is one fraught
with anxiety because it means that the rest of the family may have to go hungry
because there is no money for food. When working on rural proofing the HRH we
need to remember the many frustrations health workers face in providing the most
basic services in contexts that are far removed from their home comforts and support

If we are going to finally see true progress in addressing the historical and structural
neglect of rural health it is incumbent on all of us to ensure the voices of both users
and health workers inform decision-making. Social justice demands that we do not
allow technocratic considerations of efficiency and cost-effectiveness, although
important, to be the primary factors that shape the health system.
Driving through Qunu on the N2 back to East London from Quakeni I was reminded
that rural areas in South Africa have produced many of the most important leaders of
the struggle against apartheid. 20 years into democracy it is important to remind
ourselves of the potential inherent in rural people and landscapes. To do this we need
to re-imagine rural areas as dynamic and desirable places to live and work. This reimagining
does nonetheless require that we change the material conditions of rural
areas through sufficiently rural proofed policy and resource allocation processes.

Note that the views expressed in this article are those of the author and do not necessarily represent the views of PHASA.

1. Massyn N, Day C, Barron P, Haynes R, English R, Padarath A, editors. District Health
Barometer 2011/12. Durban: Health Systems Trust; 2013.
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in access to health care in South Africa. Journal of public health policy, 2011;32 Suppl
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editors. South African Health Review 2011. Durban: Health Systems Trust, 2011. p. 107–118.
4. Matsoso MP, Strachan B. Human Resources for Health for South Africa: HRH Strategy for the
Health Sector 2012/13-2016/17. In: Padarath A, English R, editors. South African Health
Review 2011. Durban: Health Systems Trust, 2011. p. 107–118.
5. Cooke R and Versteeg M. (2013). The WHO global policy recommendations on increasing
access to healthcare workers in rural and remote areas through improved recruitment and
retention: the south African context. Rural Health Advocacy Project Discussion Document.
6. Stuckler D, Basu S, McKee M. Health care capacity and allocations among South Africa’s
provinces: infrastructure-inequality traps after the end of apartheid. American journal of
public health, 2011;101(1):165-72
7. Eagar D. Rural proofing policy: an overview of international best practice. Rural Health
Advocacy Project Discussion Document. 2013.