Summary Bulletin 7 - DHS-LG Discussion List

RURAL HEALTH POLICY DEBATE

1. Should South Africa develop a rural health policy?

The call for a rural health policy is raised because, despite DHS and transformation of local government, there is still a gap in dealing with issues affecting rural health workers and provision of rural health services. These issues are difficult to address without a coherent policy. An office for rural health in the National Department of Health may be required, although it could be housed within the present structures.

There is general consensus that such a policy is needed and that it has the potential to:

• Address the inequity of the current health policies – urban areas are generally favoured over the rural areas. A special effort is required to redirect resources towards rural areas, particularly in the context of decentralisation, which can lead to increased inequity if not properly planned and implemented.
• Bring together current policies that impact on rural health.

A number of cautionary notes/warnings were expressed that need to be considered in drafting a Rural Health Policy.

• Care must be exercised to ensure that this is not just another policy and to include practical guidelines for all levels of the health system. It must not become another vertical programme but must be part of a whole integration of services at the district level.
• There is still a challenge to implement the many policies already in existence and it may be preferable to integrate the needs of the rural areas into these policies, rather than developing a new policy.
• The Integrated Development Plan (IDP) process in the District Municipalities has a role in addressing the health issues in rural areas. Rural health is part of the whole package of rural development.
• There must not be a protracted policy development process. This could result in further fragmentation of the health services.
• There is currently heavy lobbying for and allocation of resources to HIV/AIDS that could widen the gap between rural and urban. A balance is required.
• Rudiments of rural health policy probably already exist and just need to be pulled together.

One contributor initiated a debate as to whether rural areas should be given special attention. More people are moving to the cities and a pro-cities strategy could potentially make an impact at less cost. Rural areas must not expect the same level of services as their urban counterparts. Further, even small towns are suffering because of the movement of people to the big metros. Urbanisation is good and urban poverty is better than rural poverty. Resources have been wasted through being pumped into non-sustainable projects, mostly in rural areas. It will take 65 yrs to address service inequalities at current capital investment rates. This does not mean that rural areas should get nothing, but rather that urban areas be prioritised for allocation of resources and that rural areas must justify allocations on more than just social benefits.

This view was not generally supported and a number of counter arguments were put forward. There is need to improve services to the rural areas. A balance is required – rural-periurban-urban are part of a continuum of care. Remember that the drive to urban areas is due to poor services in rural areas. Improving the rural services will benefit the urban – approximately 46% of the population is rural. Breakdown in the continuum of care is clearly illustrated by increasing referrals from rural hospitals to central hospitals and rising number of preventable complications, especially with obstetrics. A good health service, especially in rural area will decrease poverty by enabling people to work; builds relationships and says ‘some-one cares’; creates employment through formal and informal posts (cash added to local economy); encourages development projects.

Process issues were discussed, as these are as important as the product.

• The ANC Health Plan of 1993 gives guidance on over-arching policy framework.
• The process could be informed by a new publication Health for All Rural People that is presently being drafted following the WHO-Wonca consultation: Health for All Rural People held in May 2002.
• Start with a small task team
• Define key tenets of the policy document
• Identify the task
• Commission some papers
• Develop first draft, that would then go through a refining process
• Advocate with stakeholders to ensure ownership, implementation, monitoring and evaluation

During the period of the debate a number of other issues were raised:

• There have been mixed messages from Treasury as to their long term commitment to rural development e.g. in the equitable shares formula for Provincial Allocations
• The policy should address the country’s long term plans for rural development – in collaboration with other sectors, such as education and welfare. Rural people are a disadvantaged group and the further one moves from the centre, the more desperate the situation. Health services in rural areas without employment opportunities will not be sustainable
• Process should be co-ordinated through the NDoH, with an early meeting with external stakeholders such as RUDASA, Equity project, HST, other sectors (Treasury, Education, Social Development, Local Govt, University Depts of Rural Development, Traditional Healers, Trade Unions, rural consumers) to identify broad framework and tenets of such a policy.
• Concern was expressed that too much focus on policy could become a substitute for delivery. It is essential to go beyond policy development and to consider ways of implementation and monitoring.
• The notion of Rural Proofing from UK was introduced. This is a process whereby all policies must be tested against set questions as to their possible effect on rural areas. Could such a concept be introduced in SA?
• The whole referral system for patients coming from the rural areas needs to be looked into – this includes payment for the transfers to ensure that the primary level budget is not all expended on moving patients between levels of the health system.
• Good strategic plans are essential with clear definition of the needs for the next 5 years or so
• Need to consider the policy from the perspective of the user and the perspective of the provider – the linkages and overlaps between the two.
• Indicators to monitor the progress towards closing the gap between rural and urban areas are required. These could be through use of the DHIS. Such parameters as population density, travel distance, average patient fees, services provided, average household income, km of tarmac road/household, etc could be used.
• Health services are delivered within a health district – but managers within a health district are not able to redistribute resources due to various constraints, such as financial, human resources and physical infrastructure. The question is – will a new directorate or policy be able to ensure this redistribution? Are DHS managers incompetent to shift resources, or is it a policy issue? The constraints on district managers need to be identified and addressed.

2. How should one define rural in the South African context?

This is difficult to define, as it is subjective. Rural has been defined in terms of a number of issues, such as population density, distances from a city (or remoteness) and/or available facilities. There are different definitions for such things as rural versus rural practice versus rural health care versus rural development, etc. Rural is not non-urban, and rural and underserved are not interchangeable.

Access to services is a serious issue for rural health services. The cost of transferring patients to secondary or tertiary care is high and comes out of the primary level budget.

Three characteristics of rural were shared –

1. Effort – to travel for access and to keep services going
2. Range of services – these are often limited in these areas
3. Becoming ‘jack of all trades’ – health professionals are often called upon to do things beyond their training or experience

Therefore a definition needs to incorporate these as well. Additional effort is also required to ensure that there is support for staff working in these areas.

There is some urgency to clearly define rural and underserved as there is a proposal to extend the rural allowances to other health workers other than doctors.

Formal census StatsSA definitions could be used, but these are limited in respect to underserved or difficult to staff. Rural areas differ such as ex-white farmlands are vastly different to ex-homelands – a South African situation requires a South African solution and a South African definition.

Definitions that were offered included: -

• Rural health care relates to the provision of health services to areas outside of metropolitan centres where there is not ready access to specialist, intensive and/or high technology care, and where resources, both human and material, are lacking. This service may be within hospitals, health centres, clinics or independent practices. It is best provided by a team of health care workers and is based on the principles of Primary health care.
• Rural medical practice is health care provided by generalist medical practitioners whose scope of practice includes care that would be provided by specialists in urban areas. It is appropriate technology health care, appropriate to the needs of particular communities that are served. It usually includes elements of family/general practice, public health, and extended procedural work, within the context of primary health care and the PHC team.
• All areas served by mobile clinics – includes farm areas, non-urban rural dwellings and slums (unplanned dwellings)
• Definition needs to be broadened as there are some very remote areas that are cannot be accessed through mobile services
• From Stats South Africa’s Labour Force Survey gives following definitions: -
  • An urban area is one that has been legally proclaimed as being urban. These include towns, cities and metropolitan areas;
  • A semi-urban area is not part of legally proclaimed urban area, but adjoins it. Informal settlements are examples of these types of areas. In the Labour Force Survey (2001) semi-urban areas were included with non-urban areas;
  • Non-urban areas include commercial farms, small settlements, rural villages and other areas that are further away from towns and cities.

Rural health may be defined as health/health needs of people living in non-urban areas.

• Identify all formally designated urban areas (metros, cities, towns) and then assume other areas are rural.

(Clear definition of some of the terms used within each definition is also required e.g. what does ‘ready’ access mean?)

Bulletin complied by Wendy Hall (hstwendy@sai.co.za) ,
Health Systems Trust,
27 March 2003