In 2012, 38% of the South African population resided in the rural areas of the country. The professional healthcare services are concentrated in the urban areas, resulting in an imbalance between urban and rural healthcare services.
The aim of this study was to evaluate the use of a non-governmental organisation (NGO)-supported mobile healthcare service in a remote area.
Eastern Cape Province in South Africa.
The walking distance between the community and the nearest fixed government healthcare service was evaluated and compared with the recommendations of World Health Organization (WHO). Services provided to people visiting the mobile community service were recorded, and descriptive data were analysed and compared with the anonymised patient records of the nearest fixed service clinic.
Of the 30 outreach points served by the NGO, 24 points were at a distance more than the WHO-designated walking distance and 11 points were more than twice the WHO-designated distance from the perspective of fixed clinic. The average headcount per annum of the outreach NGO mobile clinics exceeded those of the fixed Department of Health (DoH) clinics by an average of 250 patients per clinic session. The increase in services was also noteworthy, with a mean differential of 1774 services per annum for the same day above that of the DoH clinics.
Mobile services could make a difference to the utilisation of essential healthcare facilities. The provision of augmented NGO-led mobile clinical outreach services and joint government–NGO partnerships holds possibilities for improving healthcare for those living in remote rural areas.
The concept of health for all incorporates the social environment, economics, national politics and policies that drive the health user and provider practices.
As of 2010, half global population was living in remote and rural areas.
The right of access to health services, regardless of geolocation, is a non-negotiable human right; however, the type of services, the extent of health service delivery and non-negotiable minimum core standards are not standardised internationally.
Section 27 (1) (a) of the Constitution of the Republic of South Africa (Act 108 of 1996) guarantees the right of access to healthcare for all, and Section 27 (3) states that no one should be refused emergency medical treatment.
The Eastern Cape province of South Africa, specifically its northeastern area, known as the wild coast, encompassing the district of Mbashe, is the most deprived area in the country with a disproportionate burden of unemployment, poverty and disease.
Even with the required resources to service a rural population, knowing who to serve, with which kind of intervention, would enable the service providers – governmental or non-governmental – to make the best use of their resources. Incomplete or non-existent vital event recording and insufficient health service registration pose challenges for the provision of adequate health services to rural areas.
In South Africa, rural and urban populations face differing health challenges.
Even if free healthcare is available, transport costs and distance to travel often affect to have timely treatment.
As identified in 2005, factors that could improve health include having a regular water supply, provision of sanitation services and improvement in the population’s knowledge of proper sanitation and hygiene.
Such improvements, notwithstanding access to health services in rural areas, as well as the means to deal with the challenges of access to and payment for transportation and absentee parents of children living in rural areas, all affect the uptake of health services, even if these are available. Government and NGO partnership has worked well in the rural areas of Africa if both sides of this partnership are committed to the process and the partnership is tailored to the requirements of the community.
A case in point is the rural area surrounding Mbashe and the King Sabatha Dalindyebo district of Mbashe in the rural Eastern Cape. Donald Woods Foundation (DWF), an NGO, provides adjunct health service in these areas. This service is provided to remote rural village inhabitants living at a distance from central government health clinics, and includes assessment services, immediate remedial treatment and referral to fixed government primary or secondary healthcare services for both older population of the community and children. The DWF mobile tented clinical outreach service focuses on screening, onward referral, treatment of minor ailments and emergency medication. This service supports the most overloaded government primary healthcare clinics in addition to serving some of the least accessible areas.
The catchment area for the study: The white arrows show the walking distances from the outermost villages to the nearest fixed clinic.
This study was an evaluation of a rural augmented mobile healthcare service. The walking distance between the central point of the community (the cluster of dwellings that constitute a ‘named village’) and government’s nearest fixed primary healthcare clinic service was assessed. This distance was compared with the WHO recommendations for walking distances to healthcare services to determine the points where mobile health services were most required. Secondly, services provided to people visiting the mobile community service were recorded in a detailed attendance log sheet to ascertain the community’s use of multiple screening and minor ailment services provided. These services included (but were not limited to) testing, emergency treatment and referral services for HIV, tuberculosis (TB), hypertension, diabetes, child immunisation and minor ailments. Descriptive data from detailed logs were analysed and compared with the anonymised patient records of the nearest fixed service clinic.
The study settings were the greater Mbashe area of the Eastern Cape Province, South Africa. According to the Statistics South Africa as of 2016, the total population of this area was 270 068 (125 084 males and 144 984 females); there were 56 995 households, of which 39 689 were housed in traditional dwellings with a poverty density of 44.1%.
A four-wheel vehicle was used to access remote area communities, and the distance travelled from the centre of the community to the nearest fixed service was assessed. Secondly, a detailed log sheet was used to record the number of people visiting the mobile NGO service and ascertain the services provided to them. This log data were entered into a Microsoft Excel spreadsheet. The descriptive data were analysed using the Statistica data analysis programme. The data were compared with the anonymised patient records of the nearest fixed service clinic, which would normally provide services for that specific remote area community.
Ethical approval to conduct the study was obtained from the University of Cape Town Human Research Ethics Committee (Ref. no. R033/2016).
The designated ideal distance to walk to a primary healthcare clinic should not be more than 5 km.
Villages served by the Donald Woods Foundation clinical outreach services and their respective walking distances to the nearest fixed primary healthcare clinic.
Village name | Walking distance in kilometers |
---|---|
Ganizulu Summit | 0.17 |
Gqubhuzeni Outreach Point | 3.00 |
Nyangilizwe Junior Secondary School Outreach Point | 3.66 |
Nqileni Outreach Point | 3.99 |
Desi Outreach Point | 4.35 |
Ntshingeni Outreach Point | 4.91 |
Khohlo outreach Point | 5.30 |
Lalini Outreach Point | 5.39 |
Phokoloshe/Kwelomthombe Outreach Point | 5.58 |
Mabholobela Outreach Point | 5.59 |
Mgashe Outreach Point | 6.38 |
Ntabozuko EFT college Outreach Point | 6.79 |
Xuba Outreach Point | 7.42 |
Nobangile Summit Outreach Point | 7.67 |
Kwatshezi Outreach Point | 7.88 |
Cwebe Outreach Point | 8.10 |
Ngqakayi / Tsholora Point | 8.26 |
Sirhosheni Outreach Point | 8.57 |
Ntilini Outreach Point | 9.83 |
Geya Outreach Poin t | 10.00 |
Botwe Outreach Point | 10.60 |
Folokhwe Outreach Point | 11.00 |
Mcelwane Admin Area Outreach Point | 11.10 |
Ngqatyana Outreach Point | 11.80 |
Mgojweni Outreach Point | 12.80 |
Mcelwane Outreach Point | 15.40 |
Mbelu Outreach Point | 16.50 |
Riverview Outreach Point | 17.10 |
Qinqana Outreach Point | 18.20 |
Xobo Outreach Point | 22.40 |
For four communities, to reach the outreach clinic was hampered by a river crossing, requiring a rowing boat to cross the river.
Summary of the clinical outreach service personnel, patients and services for the 3-year period of research.
Personnel, Patients and Service | Descriptive Statistics (Outreach Reports Data Collection – 36 months – June 2017) | ||||
---|---|---|---|---|---|
Valid N | Mean | Minimum | Maximum | s.d. | |
Total-DoH-Personnel | 103 | 4.59 | 0.00 | 14.00 | 2.21 |
Total-DWF-Personnel | 103 | 8.97 | 3.00 | 29.00 | 3.82 |
Total-OPS-Personnel | 103 | 2.17 | 0.00 | 18.00 | 4.20 |
Total-Personnel-All | 103 | 15.74 | 5.00 | 33.00 | 5.24 |
Total Serv ice | 103 | 429.32 | 13.00 | 1329.00 | 239.60 |
Clinic-Patient-Headcount | 103 | 185.16 | 10.00 | 471. 00 | 100.87 |
Av Patient per Staff | 103 | 12.66 | 1.00 | 61.20 | 8.50 |
Av-Ser-PP | 103 | 2.39 | 1.00 | 4.10 | 0.71 |
Note: Figures are given in whole units for personnel and services.
DoH, Department of Health; DWF, Donald Woods Foundation; OPS, Other (volunteer) Personnel Services; Av-Ser-PP, average service rendered per patient; s.d., standard deviation; NGO, non-governmental organisation.
Matched sample of clinical outreach service (Bomvana, Hobeni and Melitafa areas), patient headcount and total number of services with average service per patient for the 3-year period of research.
Patients and Average Service | Descriptive Statistics (comparative – 36months condensed-Aug 2017) | ||||
---|---|---|---|---|---|
Valid N | Mean | Minimum | Maximum | s.d. | |
Total Serv ice | 3 | 3323.67 | 1512.00 | 5789.00 | 2212.16 |
Clinic-Patient-Headcount | 3 | 1298.67 | 511.00 | 2094.00 | 791.53 |
Av -Ser-PP | 3 | 2.60 | 2.07 | 2.96 | 0.47 |
Note: Figures are given in whole units for the number of services. Av-Ser-PP, average service rendered per patient; s.d., standard deviation; NGO, non-governmental organisation.
Matching sample of the Bomvana, Hobeni and Melitafa Department of Health clinics’ headcount for the 3-year period of research with that of sample outreach clinic’s patient headcount and total number of services provided with average service per patient on the same day for the same period of research.
Patients and Average Service | Descriptive Statistics (comparative – 36months clinic same-date-Aug 2017) | ||||
---|---|---|---|---|---|
Valid N | Mean | Minimum | Maximum | s.d. | |
Total Service DoH | 3 | 1550.00 | 1301.00 | 2035.00 | 420.07 |
Clinic-Patient-Headcount | 3 | 1048.33 | 828.00 | 1299.00 | 236.96 |
Av-Ser-PP | 3 | 1.48 | 1.29 | 1.57 | 0.16 |
Av-Ser-PP, average service rendered per patient; s.d., standard deviation; DoH, Department of Health.
Figures are given in whole units for the number of services.
International NGOs such as Medicines Sans Frontiers, the International Red Cross/Red Crescent and the Gift of the Givers often work in areas of crisis and conflict. Locally operating internationally funded NGOs, such as The United States Agency for International Development (USAID), often focus on specific and critical needs such as HIV and TB testing and treatment, as opposed to ongoing primary care at community level. Public–NGO collaboration in the healthcare sector has increased in low- and middle-income countries as a means of improving healthcare.33 This type of organisational collaboration works with government department, which provides some salaried local staff as a support working with locally recruited NGO workers receiving an NGO-funded stipend. Medications may be provided and/or funded by the government, but transportation of staff and supplies is often the responsibility of NGOs transport and logistical department. Advantages of such collaborations are that locally staffed NGOs, with external expert training, often build trust to have a better understanding of both needs and challenges of local population.33 Over the longer period, the intention of the government could be to take over the services of NGO once the local staff are trained and funding for the services is secured; however, the public sector may not be able to continue services alone once the NGO has left the region.34
Understanding the spatial distribution of disease is necessary for the provision of adequate services and facilities in rural areas.
Furthermore, road conditions and cost of travel come into play when determining the feasibility of travelling to the nearest healthcare facility. In this respect, the nearest service available may not be the most accessible one.
The population served in each area was the same for both government’s DoH clinics and NGO-led mobile outreach clinics; however, the NGO-led outreach clinics served those living on the outer edges of catchment areas. Hence, for such rural populations, the mobile NGO outreach clinics were more convenient and easier to reach. This could have put demand pressures on NGO-led mobile clinics, although this was hard to measure as there tended to be a higher population density surrounding government clinics, with schools and other facilities. The skill levels of both NGO staff and government staff were comparable as all staff had to be registered with the Nursing Council of South Africa or Health Professional Council of South Africa (HPCSA), but the NGO had more resources to recruit and pay their staff; in addition, they were able to recruit retired experienced government staff. The authors acknowledge that initially there may have been a ‘novelty’ factor in the provision of NGO-led services; however as the services ran for many years and the study was conducted over a 3-year period, this was likely to be a minor factor to visit mobile NGO-led outreach clinics. The full expenditures of the NGO-led services were not ascertainable as the accounts were confidential and not shared with researchers.
The study has further limitations in making an adequate full comparison of all NGO services with that of formal government fixed clinics. Insufficient staffing and computers and intermittent electric supply were some of the factors resulting in inadequate recording of patient details and service provision in the government sector. Such situations are not unusual in the public sectors in low- and middle-income countries, and similar challenges were found to hamper NGO provisions and evaluation of rural healthcare services in Ghana
Further evaluation of NGO-led clinical outreach services could add to our knowledge about communities, their needs of type of services and where these communities are located. Such information could reduce wastage of expenditure and increase the effectiveness of available resources.
Distance is only one aspect of access to healthcare to be considered in rural communities. Other aspects include complementary services, condition of roads, access to vehicles, and local topography and community acceptability of services. Mobile clinical outreach services could make a measurable difference in utilisation of essential services. Furthermore, provision of augmented NGO-led mobile clinical outreach services and joint government–NGO partnerships hold possibilities for improving healthcare facilities for those living in remote areas. Essential screening services offered at remote outreach points add value to the overall screening and referral services in rural areas with limited resources. The extent of utilisation by the community illustrates the need for NGO involvement in remote areas for provision of healthcare services. The ability of such NGO-led healthcare services to provide for the needs of the rural population appropriately, as required, may be a critical factor in filling the service provision gaps found in rural areas. As this investigation covered a very specific NGO–government health provision partnership, further research could clarify the broader role of NGOs in providing health services.
The authors would like to thank the staff and management of the Donald Woods Foundation, and especially acknowledge the contribution to the research and reporting made by the late Sister Rose-Marie Gail Ewing, MSc, who sadly passed away on 12 February 2019.
The authors declare that no competing interests exist.
A.A.M.-P. was responsible for background and literature review, data analysis, editorial layout and referencing. S.R., professor and director of primary healthcare, was responsible for the research methodology, editorial layout and content. R.-M.G.E. was responsible for the research methodology, data collection and management.
This programme was designed and implemented by the Donald Woods Foundation with the University of Cape Town as monitoring and evaluation partner. The programme received a range of funding, but the primary funder was Eli Lilly and Company, through the Lilly Non-Communicable Disease (NCD) Partnership.
Data sharing is not applicable as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors or the funder.
, 1960–2019.
The four highlighted areas depict villages where there is no bridge to cross the river to reach the clinical outreach service; residents are required to use a rowing boat to access the outreach clinic tents.