RHAP Discussion Document: Defining rurality within the context of health policy, planning, resourcing and service delivery

The RHAP has developed a discussion document on the definition of rurality. Please send any comments to Daygan Eagar at Daygan@rhap.org.za.

Summary and Recommendations: Section 27 of South Africa’s Constitution (1996) affords everyone who lives in the country the “right to have access to health care services, including reproductive health care”. The constitution also gives the state the responsibility for taking reasonable legislative and other measures, within available resources, to progressively realise this right. Poor infrastructure, a shortage of critical health care personnel and the unreliable supply of basic medicines continue to prevent nearly 40% of South Africa’s population who live in rural areas from having full access to good quality health care. The South African government is not unaware of the many challenges facing the health system. It is currently undertaking a number of reforms (under the banner of the National Health Insurance (NHI) and PHC re-engineering) that are aimed at improving access to quality health care for all. These reforms will, however, only benefit rural communities if factors such as geographic inaccessibility, under resourcing and systemic neglect that continue to characterise the rural health context are not explicitly targeted in health policy, planning, resourcing and service delivery. Targeted policy and resourcing will only be possible if rural is clearly defined and if this definition has practical utility for policy development and implementation. An examination of the evidence from abroad has demonstrated that due to vast contextual diversity within rural settings themselves the exercise of identifying a single definition of rural is impossible in practice and has no practical benefit. Instead, most commentators have argued for the development of definitions of rural that emerge out of the questions they are trying to answer. In other words, the definition of rural should depend largely on what it will be used for in practice. In some sectors this is an approach taken in South Africa. There is currently no single definition of rural used in government policy. Instead there are a number of examples of where government departments and agencies have developed definitions and typologies, with varying degrees of success, that are meant to be used in the design, resourcing and implementation of targeted rural policy interventions. Rural typologies developed by the Centre for Scientific and Industrial Research, Department of Water Affairs, and the Department of Social Development are all good examples that have important policy implications for rural service delivery. Unfortunately some of the government’s largest departments, such as Health and Education, have been reluctant to take such an approach and have preferred to treat rural as underserved and deprived. While there is certainly a need for a focus on underserved and deprived in policy, this does not allow for policy that effectively deals with the rural service delivery environment. With regard to health the following factors all prove to be significant barriers in rural contexts: • Geographic accessibility: high average distances to facilities and a lack of/ expensive transport to and from facilities. • Availability of healthcare: inequitable distribution of healthcare workers between rural and urban areas and a shortage of health care facilities and supporting infrastructure such as roads, piped water and electricity. • Acceptability: services are often not of an acceptable quality or acceptable based on social and cultural norms of the people accessing them. RHAP Discussion Document: Defining rurality June 2014 6 • Financial accessibility: Socio-economic disadvantage of rural populations, additional and higher costs in seeking care, and lower levels of health insurance. If health is going to implement reforms and policies that are aimed at improving access to care and equity in the resourcing of health care, under the banner of the NHI for example, it is imperative that it develops rural typologies that will guide the development of policy, strategic planning, resourcing and service delivery that effectively target rural need. For this to work to be taken forward a consensus approach must be used to ensure buy-in and ownership of the process by all stakeholders, particularly the Department of Health. Practically this would require that: 1. The argument is made that there is value in embarking on a process of developing rural health definitions, typologies and/or indices’. This approach should be based on evidence that can demonstrate the equity and efficiency gains of taking this work forward into the policy process. 2. The purpose of definitions and typologies of rural must be clearly defined. The purpose may only be for HRH and Budgeting or for a broader set of activities and services; but this must be established. 3. Factors/variables that can be used as measures of rurality (e.g. population density, distance, deprivation) must be identified. These factors should be meaningful, valid, quantifiable, replicable and derived from high quality data. 4. Typologies should then be developed, tested and refined. They should be simple enough to implement that they do not add unnecessary complexity to policy and resourcing processes. 5. Their use should be promoted and monitored. There is no use in defining rural and developing typologies if they are not put into action.