RHAP Newsletter: COVID-19 AND RURAL HEALTH “Rural-proofing the Response”

Rural Health Update
A word from our director, Russell Rensburg
We are nearing the end of the third week in lockdown and RHAP has been hard at work from our various homes to support the collective response to COVID-191 in South Africa.

As a rural health hub, RHAP remains focused on its core competencies: rural-proofing the COVID-19 response; partnering with civil society to monitor accountability mechanisms; and facilitating access to information, food, and other essentials to communities in need.

While we support the government in its emergency response, we are devastated by the impact of the lockdown on people’s livelihoods and food security and are calling for more urgent social relief measures for the most vulnerable households and children. We have also called for the private sector and government to collaborate in a universal health system response to this crisis. You can view some of our statements online:

Influential coalition urges President Ramaphosa to increase child support grants

Escalation of measures to combat COVID-19 epidemic prioritizes lives, but not livelihoods

A Programme of Action in the time of Covid-19 – a call for social solidarity

Civil Society challenges the private sector to step up support for the COVID-19 response

As we learn more about the novel coronavirus, we are beginning to understand what we know and more importantly, what we do not know.

 “COVID-19 is the disease caused by the novel coronavirus. The novel coronavirus’s scientific name is severe acute respiratory syndrome coronavirus 2, (SARS-CoV-2)

We do not yet know the prevalence of the novel coronavirus within our communities, and accordingly, we support the government’s mass screening and testing campaign. The results of this campaign will help the country better understand what the next stage of the response should look like.

Without increased testing, active case finding, and improved surveillance, it is difficult to know how or when rural communities, particularly those residents in former bantustans, will be impacted, and the extent to which the virus is already prevalent within those communities.

However, it is encouraging that health workers in many rural hospitals have already begun developing innovative approaches to prepare for the novel coronavirus. To learn more about some of these preparations, read Spotlight’s conversation with Dr. Lungi Hlobe-Nxumalo, Chair of the Rural Doctors Association of South Africa (RuDASA), one of RHAP’s founding partners:

COVID-19: How rural healthcare workers are preparing

RHAP is working closely with RuDASA as members of its Executive Committee to rural-proof some of the national COVID-19 guidelines for rural hospitals. You can review the COVID PHC Facility Readiness Guide on  RuDASA’s shared drive containing rural healthcare resources. Refer to the bottom of this newsletter for an overview of these and other rural resources.

We have also been discussing how rural hospitals can serve as a hub to support primary health care networks to best employ available capacity in rural health systems.
Rural-proofing is an approach to the development and review of government policy and strategic planning that seeks to ensure that the unique context and needs of rural areas and communities are addressed and budgeted for equitably.
In addition to the impact of the virus on people’s health, RHAP is gravely concerned about the devastating social and economic impact of the country’s lockdown.  In rural areas in particular hundreds of thousands of households are almost completely reliant on social grants and remittances from families, many of whom are engaged in precarious work. Communities that are already food insecure now face further disruptions to sufficient and reliable food access and are at increased risk of undernourishment, malnutrition, and hunger. In addition:
– While food support has been slow to reach urban localities, it has been even slower to reach rural areas. Many people are faced with extreme hunger under lockdown conditions.
-The restricted hours for public transport to operate and the reduced passenger occupancy requirements means that people living on farms or in areas far from the closest town either cannot get to the town to buy food or if they manage to get there, become stranded in the town in the middle of the day. These transport restrictions also impact people’s ability to access medical care – not only for suspected cases of COVID-19 – but for a range of other conditions that may require medical treatment.
– Due to desperation to access food, there have been reports of people in rural areas walking distances such as 7km, 12km, and even 25km to buy food and return home.
– Seeing that people are restricted from getting to the shops, some farm stores have hiked up prices, just as retailers in urban centers have done.
– In some parts of the country, there is an ongoing drought and many areas do not have reliable access to water. For people in rural areas, the distances to access water are often far greater than in urban areas.

It is important that the government’s disaster response and consider the particular impact of the lockdown regulations on rural communities, and address the specific needs and challenges rural communities face to effectively respond to this pandemic. Our recommendations include:
– Amendment to transport regulations to allow public transport to operate from 5 am to 8 pm.
– The Disaster Management Act, lockdown regulations and recently issued Treasury regulations allow municipalities to access unspent funds from capital budgets to support disaster relief. Treasury must urgently provide clarity on how these funds can be used and authorize municipalities to do so through the adjustments process.

While we stand behind the government in protecting South Africa’s people from the spread of this virus, principles of the right to food; equity; human rights and dignity; transparency; and solidarity must underpin the country’s and rural responses. These principles not only apply to our national healthcare response but extend to our social and economic impact response.

What do we know about rural preparedness and risk?
If community transmission of the novel coronavirus advances, rural communities may be at greater risk of the health impact for a number of reasons.
Firstly, rural health facilities have traditionally not been as well funded as urban health facilities, operating with even fewer resources – equipment, staff, space/infrastructure – than health facilities in urban areas. Secondly, evidence suggests that people living with certain comorbidities, including TB, diabetes, and advanced HIV- may be at greater risk of complications if they become infected with the novel coronavirus. at greater risk. In an interview by Mark Heywood, Prof Abdool Karim, who heads the COVID-19 ministerial task team, raised particular concern for the over 2 million South Africans who are living with HIV but do not know their status. We also know that there is a rising non-communicable disease (NCD) epidemic in rural South Africa. These factors combined with the fact that government communication does not reach all faraway areas means that some rural communities in deprived contexts may not be as aware of the different risks and thus need greater outreach to support better preparedness and information sharing.

As RHAP’s Karessa Govender stated in the Daily Maverick:
“Information is being put out there in different languages, but to what extent has the government tried to get that information to more remote areas? I think what this pandemic has really identified is the need for health communication messaging that is appropriate for the context,” said Govender.
How does RHAP work at this time of deep crisis?
Our mandate as RHAP is to advocate for rural health equity and our specific focus areas are policy advocacy; human resources for rural health; health budgets and active citizenry.

Our first response to COVID-19 at a policy level has been to collaborate with others in the health and civil society sector in support of the one country plan.

During this crisis, we continue to engage our colleagues working within the national response coordination team to stay abreast of national plans and guidance. We also initiated and support the CSO Health Working Group which facilitates a sector-wide response. Amongst others, the CSO Health Working Group is exploring how the implementation of the disaster management response will impact health policies.

To address anticipated human resource shortages in health facilities, we are working with SECTION27 and others to understand the contracting conditions of private sector hospitals and private practitioners to public healthcare. In a letter to Minister of Health Dr. Mkhize, we identify core principles for agreements with hospital groups and private healthcare services providers with respect to COVID-19 and request that details of agreements with the private sector be made public.

Given that the private sector is almost non-existent in rural areas, we are also investigating how capacity can be shifted to rural areas in the event of mass community transmissions. At present, there is a more immediate risk that many rural professionals could be moved to urban areas.

We are also monitoring and engaging with partners and the government on the financing of the COVID-19 response. The South African public health system has been in crisis for some time with health budget allocations declining over the past years. South Africa’s current resource allocation approach is to direct funding for health to the provinces, who are responsible for oversight and ensuring the provision of public health services. Provincial health and treasury departments then distribute the province’s health funds to health districts, who are responsible for the direct provision of public health services.  So while health funding allocations to provinces may be adjusted to address health needs, provinces have discretion in how those funds are distributed interprovincially. Therefore, provincial allocations may not always result in equitable allocations to districts that have a higher need for public healthcare services.

In rural areas with its largely youthful populations, high unemployment  and low economic activity, almost 90% of people are completely reliant on the public health systems. Sadly rural health systems are amongst the weakest in the country with poorly resourced clinics and inconsistent availability of medicines.

As we gear up for the next level of the COVID-19 response, now is an opportune time to strengthen primary health care systems, including district hospitals, to support improved prevention, detection, management and surveillance of the communicable and non-communicable diseases which impact our communities. Rural district hospitals can play an important role in coordinating this much-needed response.

Another area of concern at this time is how disaster management funds, as well as funds in the social solidarity fund, are being coordinated and allocated. In respect of the former, it remains unclear how funds are being distributed and the extent to which line departments are involved or whether political executives such as premiers and executive mayors are coordinating.

Lastly, RHAP recognizes the need for increased community organizing at ward level to ensure that information reaches all communities and that communities are taking the appropriate actions to prevent transmission of the novel coronavirus. More on our active citizenry work in the next section.
Exchanging Knowledge with Rural Communities and Allies
It has been just over a year since RHAP established its Active Citizenry for Health Programme. The programme was created to increase user voice in RHAP’s advocacy and to facilitate deeper learning and knowledge exchange with rural communities and rural stakeholders. The programme was formalised within the Nyandeni Sub-District, located in the former Transkei region in the Eastern Cape. Nyandeni has long been a learning site for RHAP through which the organisation has collaborated with healthcare workers to advocate for health systems strengthening. We are intentional about expanding our relationships to better understand the recipients of rural health services (rural communities themselves) and the intersections between the varying rural stakeholders such as traditional leadership, local government, the health district, local NGOs and healthcare workers.

In 2019 RHAP implemented a Water, Sanitation and Hygiene (WASH) in healthcare facilities project in Nyandeni, OR Tambo District. Through this project we have gained an understanding of the communities experiences at their local clinics. Through this project, we were able to train a small group of community members on WASH, the right to health, and advocacy strategies they can implement at a local level to improve the standard of WASH services at their health facilities.

The COVID-19 pandemic has forced us to now take stock of our current initiatives in the learning site and determine how we are best suited to amplify and support the voices of rural communities. In the context of the novel coronavirus, we have been actively reaching out to our Health Advocates, traditional leaders, ward councillors, healthcare workers, community health workers, and local NGOs to understand the challenges they are experiencing. Our interviews with rural healthcare workers confirmed reports from other parts of the country that availability of PPE was a challenge and we have made healthcare workers aware of the stopstockouts project reporting line:

Some healthcare workers including community health workers have expressed dire concerns around the lack of training around the management of COVID-19.

The community members we interviewed had a good understanding of the virus, how it is transmitted and the precautions they should take. Concerns, however, were expressed around access to information for residents who do not have access to phones, television or radios and that there was strong consensus around the need for the door to door campaigns. We are informing the relevant authorities of this gap.

As per the Minister of Health, Dr. Zweli Mkhize’s public briefing on Sunday 12 April, there will be an increased need for community surveillance led primarily by community health workers. It is, therefore, necessary that this cadre of health workers is well equipped with accurate information and the necessary PPE (hand sanitiser, gloves, masks) to be able to screen community members safely. We will continue monitoring the status of training and access to appropriate PPE and provide a link between health workers and organisations that can support with PPE. We will also update the relevant state officials on the shortages of PPE and the urgent need for training to be provided. Another point of attention is transport for community surveillance. Healthcare workers reported to RHAP the transport challenges they are experiencing in conducting COVID outreach work

Celebrating Local Initiatives
Local NGOs have been phenomenal in their timeous and well thought out response to the virus. Below we highlight two NGOs that have done remarkable work in supporting communities during this time.
The Bulungula Incubator is based in one of the poorest and most remote regions along the Wild Coast in the Eastern Cape. From the President’s announcement on 15 March, they immediately, in partnership with the traditional leadership, mobilised their staff and community into developing a proactive strategy to keep their community members safe from the coronavirus. A main focus of their plan was keeping the most vulnerable, the elderly, safe. The Bulungula Lodge, usually a paradise location for tourists and 100% owned by the community, was quickly turned into a Safe Home for the elderly. This Safe Home Venue is now looking after 60 Makhulu and Tatomkulu and follows careful protocols that no-one will be allowed to move in or out, including staff. Groceries and other essentials will be carefully cleaned before entering. No social distancing is therefore necessary inside, given the strict protocols. So fun and support can abound. Funds used to run the venue will also serve to save community jobs while providing life-saving facilities during the crisis. They have also taken other initiatives such as sustained information campaigns on their Bulungula Radio Station, creating isiXhosa resources for keeping safe at the communal tap and spaza shops, handing out bleach at the spaza shops, educating spaza shop owners about safe ways to handle money as well as handing out free seedlings for sustainable farming over this period.

For more information about the Bulungula Incubator and how to donate to their efforts, click here.
One to One Africa runs a community health programme in Nyandeni municipality in the Eastern Cape, where their Mentor Mothers provide support, advice, information, and referrals on issues pertinent to maternal and child health. When the nation went into lockdown on the 26th of March, One to One Africa had already developed a contingency plan for both their field- and office-based staff to comply with national regulations, as well as ensure the safety and health of their staff members and beneficiaries, many of whom would be considered high-risk in terms of the pandemic.

The plan included providing all staff with airtime and data to do their work from home, and to adopt a ‘no-touch’ policy in their (usually field-based) work. They’ve provided validated resources to provide relevant information to their staff and beneficiaries about the symptoms of COVID19, and prevention methods. All their field workers are providing telephone services to their clients, including a basic screening for COVID19 signs and symptoms. One to One Africa has purchased additional sanitizers for all their Eastern Cape staff to use at work and at home with their families. The sanitisers were also shared with local facilities. One to One Africa has also outsourced transport with a local taxi owner to assist with transport for at-risk beneficiaries who need medical attention during the pandemic. The organisation continues to look for more ways to support its beneficiaries who are affected or infected by the COVID19 and is actively looking for additional funding to further support their team and work in the field. They are also actively engaging with partners – including the Community Health Impact Coalition – to develop fit-for-purpose responses to the pandemic from the perspective of rural, community health workers.
A Mentor Mother providing remote support to community members

Find out more about One to One Africa

HEALA and RHAP intensifying their collaboration
 RHAP has been a member of the Healthy Living Alliance (HEALA) since inception and we are excited that we are now gearing up for a more intensified role in the alliance going forward. During the current COVID-19 crisis, our immediate concern is the rural health system response and food justice. This then also relates to our longer-term goal within the HEALA collective, which is to rural-proof HEALA’s campaign overall and in specific the front of pack labelling campaign and the sugar drinks tax campaign. If anything, the COVID-19 crisis has put a magnifier on the pervasive inequities in South Africa and we must work harder, in progressive partnerships, to ensure all South Africans are empowered to live healthily and fulfill their potential. As RHAP we hope to play our part by working with HEALA’s rural members and allies in rural-proofing our joint efforts for justice.
Rural Resources
RuDASA Coronavirus Library
Link for all the information from South Africa’s Disaster Management, Department of Health infographics for the community, Department of Health and National Institute of Communicable Disease clinical guidelines, and other resources & research we have gathered from WHO, Australia, UK, and Canada.

RuDASA Facebook for stories, news items and DIY PPE

RuDASA Facebook for links to South African resource sites

RuDASA Facebook for links to international resource sites

RuReSA COVID-19 Library Link for rehabilitation & disability aspects of corona virus

RuReSA Facebook for stories, news items, posters on COVID-19

Rural Rehabilitation:

Reduce Contact

Prevent death

Educate the Community

For more information visit www.sacoronavirus.co.za, whatsapp 0600 123456, or dial USSD *120*1341*100# (data free)