WMJ 05 2011 - World Medical Association

SOUTH AFRICA
Public Health
Conference cited drug shortages, long
queues, and lack of accountability, a broken
referral system, poor treatment of patients
by health workers, a weak primary health
care system and the long distances patients
have to travel as the major problems in the
province. Participants said the lack of ambulances,
for patient transport and trauma
incidents was a major concern. It was also
noted that access for emergency deliveries is
clearly hampered by long distances.
Poku-Boansi [25] in their paper established
that poor state of transport infrastructure
and service adversely affected the ability of
pregnant women to seek healthcare in the
recognised health institutions as a results
they rely on traditional birth attendants
who lack the necessary skills and equipments
to deal with complicated cases.
Fawcus et al. [12] found that up to 50% of
maternal deaths from hemorrhage were attributed
to the absence of emergency transport.
Distance was cited as reason women
choose to deliver at home rather than at a
health facility (see for Philippines [31] Uganda
[17] and Thailand [27]. In other words,
women living farther away are less likely to
choose a health facility for delivery, although
their inferior access makes them the most
vulnerable group in case of an emergency.
Many studies reveal the unsurprising fact
that household use of services tends to decline
with distance, a study conducted by
Tanser, Gijsbertsen, and Herbst showed
that people in rural homesteads travel four
times longer to access care than do their
ore affluent urban counterparts, see table
1 below: Furthermore Literature showed
that 70% of the poor in Ghana cited distance
from a health care facility as a major
obstacle [15]. This is a key reason urban citizen,
who is often also wealthier, use services
more than their rural counterparts. Lower
rural access, reported in many studies, may
well be the impact of an interaction between
longer distances and less knowledge
of treatment [11].
Table 2. Travel time to clinics and adjusted odds ratio of clinic usage
Setting
Travel time
Adjusted odds
(minutes)
ratio
Avg Std. dev OR 95% CI
Urban 20 9.7 1 1
Peri-urban 55.7 31.8 28.2 19.2–41.3
Rural 83.9 29.3 18 12.5–26.0
Source: [33].
The data reviewed in this section revealed
key obstacles that are barrier to accessing
care which includes health care charges,
long distances to facilities, inadequate and
unaffordable transport systems, poor quality
of care especially in public sector facilities.
The following section proposes initiatives
that could be explored to reduce or eliminate
access barriers to health care in particular
the remote areas.
Discussion
Access barriers faced by many South Africans
in particular those residing in rural areas
require governments, policy makers and
health care providers need to better enforce
existing policies and regulations. There is a
need to engage local government and communities
in particular with regard to service
delivery and ensuring that infrastructure is
place [9]. It should also go beyond to just
ensuring that the infrastructure is there, but
the maintenance thereof and both the local
government and the communities need to
play a critical role in this regard.
In addressing access to care, it is important
for governments must avail transportation
options in all communities regardless of
location or population size, this includes
making sure that ambulance services are
accessible. This is critical to the implementation
of the National Health Insurance in
South Africa.
There is a number of initiatives that could
potentially be explored in dealing with
distance and transportation as a barrier to
access health facilities. These include providing
subsidies, ferry discounts or travel
vouchers for patients that have to travel for
medical care these includes transportation
vouchers [4].
The expansion of access to high quality
primary care will make an enormous difference
in health care outcomes in the so
called under resourced areas. It is known
that providing more resources to attract and
retain health care professionals to rural areas
is essential to improving access to health
care in rural areas. It is imperative to deal
with challenges facing residents in rural areas
that compromise accessing public health
services, in particular those that are heavily
struck by poverty. It is pivotal that government
agencies like, Department of Health,
Social development, and the department of
Public works are integrated to work together
in improving service delivery.
Conclusions
Poor South Africans do not benefit public
health spending by the government and
those in poverty are often marginalised. In
many instances due to bad communications
between government departments. Other
contributors include maladministration
of public funds which undermine service
delivery and result in deteriorating public
health care facilities. Indeed unemployment
and poverty lines are the highest in
the Eastern Cape compared to any other
province in South Africa. As a result most
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