Industry forum identifies barriers and solutions for rural health

Innovative technology, health promotion and private sector collaboration are critical for rural health provision in South Africa. This was made clear when industry leaders gathered at the Metropolitan Health Engage Forum recently to find solutions to the

The Metropolitan Health Engage Forum, held on 13 June in Bryanston, Johannesburg, is part of a regular series of engagements between healthcare industry leaders in the public and private sectors.

From the presentations, a number of areas emerged, which, if urgently addressed, could support the delivery of healthcare to this desperately under-serviced segment of the population. The first was the vital importance of health promotion – maintaining people’s health before they are sick, rather than treating them once they are.

Someone who understands this all too well is Professor Susan Wright, Head of Adelaide Tambo School of Nursing Science, Tshwane University of Technology. She explained that, through health promotion, the need for subsequent healthcare interventions is reduced.

“Health promotion should precede primary care to reduce the burden on primary care, however, health promotion and education are under-researched and under-funded,” she said. “If the same effort is applied to health promotion and primary care as to curative and rehabilitative healthcare, the evidence of the success will be provided by the reduced burden on healthcare in South Africa.”

One of the ways in which health promotion has been successfully carried out in rural areas is through innovative mobile technology that allows primary healthcare providers to access a pool of expertise from around the country, or even the world.

“We live in a curative society; we need to get more prevention into these communities – treating people before they are sick,” said Bradley Soll, a director at Hello Doctor. “Through mobile technology, patients can save time, transport costs, and treatment can happen earlier.”

The disparities between urban and rural health provision – where government is responsible for most of the care given in rural areas – were highlighted by Dr Unati Nemuhuyuni, Head of Public Private Partnerships at Metropolitan Health.

“Recent research has shown that while South African rural areas are home to 43.6% of the population, rural areas are served by only 12% of the doctors and 19% of nurses in the country,” she said. “Of the 1 200 medical students graduating annually, only about 35 end up working in rural areas in the longer term. About 21.3% of households in metropolitan areas belong to a medical scheme, but only 5.4% of households in rural districts have medical scheme cover, suggesting affordable access to private care in rural areas is very low.”

However, she explained that the private healthcare sector is not a growth market and has shrinking margins, while the healthcare expenditure in the public sector is expected to expand rapidly in the coming years. To capitalise on this growth market, she said that the private sector could get involved in services like procurement, funding and the establishment of wellness programmes.

One of the solutions for the ‘disconnect’ between the services provided in rural areas and those provided in urban areas is a process called “rural-proofing”. Daygan Eager, the Programme Manager for the Rural Health Advocacy Project, explained that there are working rural health solutions in countries like the UK, Canada and Mexico thanks to processes like this.

“Rural-proofing is a concept that was first used in the UK in the 2000s – a process that ensures all relevant executive policies are examined carefully and objectively to determine whether or not they have a different impact in rural areas from elsewhere,” he said. “It’s about understanding the rural context and adjusting policy to cater for its unique characteristics.”

One of the biggest challenges facing people seeking healthcare in rural areas is the massive distances that they have to cover to visit a provider. Professor Marthie Bezuidenhout, the Project Manager of a mobile healthcare educational programme at the Adelaide Tambo School of Nursing Science, explained that her unit has received a grant to run a mobile clinic that visits the Ekurhuleni municipality to provide services like cancer screening and counselling, an emergency room, palliative care, family planning, antenatal care and a baby clinic in the community 50 weeks out of the year.

“Our most significant achievements include that we have established a very good service within informal settlements, where 80% of the people live on less that $2 a day. We’ve carried out 21 602 consultations, we see 802 patients a day, our feedback system has risen to 92% positive, and 13 postgraduate students have been able to do research through the unit,” she said. “Our documentation system can now serve as a benchmark for other mobile clinics.”

Dr Hugo Tempelman, CEO of the Ndlovu Medical Trust, which also provides mobile healthcare to rural communities, added that even with mobile clinics, clinical work is not the most important part of rural healthcare, once again highlighting the necessity for health promotion. “Do we really go out in the community and counsel on intervention, better education and prevention? No, we only see them when they are already sick,” he said.

His solution is twofold: firstly, autonomous treatment centres that act as providers of primary, secondary and tertiary care, and secondly, prevention, with the objective of creating community awareness, bringing about behavioural change to encourage early care-seeking behaviour.

Dr Norman Mabasa, the Limpopo Health and Social Development MEC, then provided a view on how budgetary constraints and a lack of professionals are hampering rural healthcare in his province.

“People are overwhelmed, the patients are too many and we don’t have enough professionals,” he said. “There are budgetary constraints – no employment of any new people this year or next year in Limpopo. Our priority is to improve the quality of care, which we do not have. We are weak because the few that there are cannot stand the pressure of looking after the many.”

In closing, Metropolitan Health’s Nemuhuyuni said, “We can see that rural health cannot be ignored. Rural areas are a part of South Africa. Without addressing rural health challenges, people in rural areas will not lead healthy, productive lives and we will not succeed as a country. I’m so encouraged from the case studies we’ve seen. There’s so much happening that has positive outcomes. We can only learn from one other.”