Rural area

This study is the first attempt to assess the effect of the new rural allowance on the motivation and movement of health professionals working in rural areas. Although methodologically limited, the study gives some indication of the likely impact of the funds allocated by Treasury, namely that almost one-third of health professionals working in rural areas say that they have changed their career plans next year as a result of the new allowance. It is difficult to assess whether this is the effect of the RA alone, or in combination with the SSA. Further evaluations will be necessary to assess the longer-term impact of these strategies.

RURAL HEALTH POLICY DEBATE

There is a major shortage of doctors in rural areas in South Africa. About 46% of the population in South Africa live in non-urban areas (1), and they do not always have the same access to health services as their urban counterparts. One example is Mount Frere district, where the doctor to population ration is 1:30 000 (2).

Rural doctors operating on limited budgets, often alone on duty, working more than 60 hours a week, seeing as many as 150 patients a day - are suffering. Up to one-third say they are considering throwing in the towel. The first comprehensive research into the challenges facing rural doctors in the Western Cape, undertaken by Stellenbosch University's department of family medicine and primary care, in co-operation with the Western Cape provincial administration points to an even bigger challenge for health authorities to provide top-level care, especially to people living in the rural areas so that they do not leave for abroad. Researchers, led by Professor Marietjie de Villiers, head of Stellenbosch University's school of public and primary health sciences, canvassed full-time, part-time and community service doctors at 27 district, or level one, hospitals, across the province - and the picture that emerged is not one that inspires confidence. The district hospitals, took care of more than 91 000 in-patients, only 18 000 less than Cape Town's three tertiary hospitals combined, but with only 147 medical practitioners, including community service doctors and out of 141 community service doctors allocated to the Western Cape, only 20 have ended up working at these hospitals. However, Western Cape is still much better staffed with rural doctors than the other provinces. Only a few foreign-qualified doctors work in this province's district hospitals, whereas in KwaZulu-Natal, you can hardly find a South African doctor in rural hospitals. Doctors at rural hospitals are strongly committed to working for the benefit of these communities, but the stress of keeping up with the patient load and other challenges of rural medicine leaves little time for personal advancement or skills development that would be useful in guiding the development of rural health resources. Whereas permanent staff relied heavily on community service doctors as a buffer to deal with primary healthcare patients who arrived for treatment at rural hospitals, their inappropriate training pushed up costs. Almost 21 percent said they needed supervision to undertake neo-natal resuscitation: about 20 percent wanted help dealing with HIV/AIDS; nearly a third felt ill-equipped to deal alone with family violence; to deal with severe childhood asthma, 23 percent said they needed supervision; when it came to abortions, 42 percent of doctors who responded said they would not perform abortions for moral and ethical reasons, although they were capable of performing the procedure. The research showed the most common operation done in rural hospitals was caesarean section, followed by female sterilisation. Statistically younger, less experienced, doctors, particularly women, carried this burden, the research results showed. Although some universities, including Stellenbosch, had started exposing doctors to rural conditions while they were undergraduates, this was limited and insufficient as preparation. Appropriate experience during the intern year was crucial in preparing doctors for rural practice. Dr Joey Cupido, the provincial head of rural regions, has now asked De Villiers to develop educational programmes to help fill the gaps identified. It's essential that the role of district hospitals in the health system be examined, particularly its interaction with primary healthcare services.One of the big problems is that clinics in these areas shut up shop at 4pm and then the doctors at district hospitals find themselves working long, frustrating hours having to deal with relatively minor complaints, De Villiers said. For permanent, experienced doctors too, career paths needed to be defined to make them feel valued. Doctors said they had been working in the same hospital for ten years and longer, but had no chance of a rank increase. Although many doctors saw rural work as a wonderful opportunity and had a real sense of benefiting the community, ways needed to be found of training them and supporting them so they progressed. Ways must also be found to cut down their after-hours duties. That's what is making them leave, she said. (Source: Cape Argus, 17 September 2002)

Source: id21 Why are the inhabitants of remote rural areas (RRAs) chronically poor? Do we know enough about the effects of risk, exclusion and marginalisation for RRA residents? What is the relationship between remoteness and conflict? Do decentralisation and economic liberalisation offer any prospect of escape from spatial poverty traps? A paper from the Chronic Poverty Research Centre analyses the factors underpinning chronic poverty in remote rural areas. Arguing for the restoration of considerations of ‘place’ in development theory, it assesses the prospects of initiatives to improve well-being. Information from around the globe draws out the correlates of chronic poverty and indicates that much RRA poverty is imbedded and not transient. RRAs are huge. Islands of poverty with bleak prospects for economic growth and human development include swathes of sub-Saharan Africa, the Andes, the Himalayas, northern and western China, the ‘poverty square’ of East-Central India, north-eastern Thailand and much of Bangladesh. Their total population is around 1.8 billion. RRAs experience deficiencies in all forms of physical infrastructure : electricity, telecommunications, market places, irrigation and domestic water and sanitation and, above all else, transport links. Frequently, out-migration has left behind insecure, asset-depleted ‘residual’ populations with the odds stacked against them: high dependency ratios, stigma (based on age, gender, disability, ethnicity and/or language) and low reserves of social capital. Parents may be unenthusiastic about schooling, doubting the likelihood of returns on investment in education. To make matters worse, RRAs are often insecure and conflict-prone. In countries with such easy pickings as diamonds, ivory, drugs or minerals, grasping outside (as well as local) elites have bypassed the state. From Nepal to Chiapas, there is evidence that many contemporary conflicts emanate from and are fought out in border regions that have historically suffered from marginality, limited voice and hard core poverty. The paper also notes that: Roads are crucial: Tanzanian households who live within a hundred kilometres of an all-weather road with bus services earn a third more per capita than the rural average. A common feature of African RRAs is that they include large areas reserved for national parks: conservation continues to impose high costs on local populations. Both levels of theft and sexual violence against women are particularly high in RRAs. In many countries it is foreign NGOs and experts who have been most influential in driving RRA policy. The report does not underestimate the difficulties in turning things round. Development efforts in RRAs will only succeed if: *there is greater security *livelihoods can be diversified *there is action to reduce the frictional distance (distance expressed as journey time) to markets and services *a better educated and confident generation emerges to participate in local politics and challenge collusion between property-owning elites and state administrators *the centre can flexibly steer development to meet local priorities, recognising that the parameters of good governance in *RRAs may not be the same as the prescriptions at national level *policy-makers recognise that while integrated rural development projects may have gone out of favour, they could, nevertheless, be a relevant policy response where market led development is not happening. Contributor(s): Kate Bird, David Hulme and Karen Moore Source(s):‘Chronic poverty and remote rural areas’, Chronic Poverty Research Centre Working Paper 13, by Kate Bird, David Hulme and Karen Moore, January 2002 More information http://www.id21.org/society/s5bkb1g1.html and mail: k.bird@odi.org.uk.

A three phase study was designed to describe and analyse the range of procedures carried out by rural doctors, and how they experience what they have to do to determine which procedural skills they should possess and to develop appropriate training programmes based on these needs

If the principal aim of the public health sector is to improve the health of South Africans, then our focus must be the health of rural people. In other words, the reform efforts and upheavals which have left the South African health system creaking and groaning in protest must continue until it is turned on its head - and is explicitly biased towards rural health. Rural people bear the greatest burden of disease, mainly because rural people bear the greatest burden of poverty. But paradoxically, urban dwellers are better served by both public and private health care resources. Simply put, rural people are generally poorer and less healthy -and have less access to health care.