Rural communities make up 42% of South Africa’s population. Yet only 15% of the country’s doctors and 20% of nurses are servicing the healthcare needs of people in rural areas.
How then do these areas ensure that they are prepared for a possible Covid-19 coronavirus onslaught?
As government went on the offensive last week by scaling up testing and screening in communities across the country, some in the rural health sector are also proactively taking measures to curb the spread of Covid-19.
Health Minister Dr Zweli Mkhize last week said there must be “clearly defined targets at district and sub-district level structures with a clear short command line led by experienced professionals who can take clinical decisions quickly and act on the spot”.
Mkhize also said additional beds need to be acquired as well as dedicated treatment centres where Covid-19 patients will be treated. Rural healthcare workers across the country have been fleshing out their plans for the expected increase in the coronavirus cases.
Dr Lungile Hobe-Nxumalo, chairperson of the Rural Doctors Association of Southern Africa (Rudasa), said the association has been working through its networks to share “best practices” of what works and doesn’t work in the different rural settings.
“The big thing for us right now is just identifying the populations at risk and then identifying the individuals at risk – for example persons that have been in contact with [people infected with] Covid-19,” Hobe-Nxumalo said.
“I’m very concerned about people who were moving from urban areas to rural homes before the lockdown. I’m also concerned about pension payout points.
“Last week there were large gatherings of people at these pay points and people are exposing each other. So as rural health facilities, we need to start screening and identifying people that are potentially exposed and test them.”
Never enough resources
Hobe-Nxumalo said in some rural areas in KwaZulu-Natal health facilities had already taken the national standard operating plans and “made them their own” despite resource constraints.
“We are never going to have enough [resources],” she said. “Countries such as the US are already complaining that they’re running out of N95 masks. In South Africa the problem is that we hardly manufacture our own consumables, and now with the country in lockdown, where are these going to come from?”
A shortage of human resources is also a challenge. She said rural communities make up 42% of the population in the country.
“And for that population size, only 15% of the doctors and 20% of nurses are actually based in rural areas. This is a human resource deficiency that is chronic,” she said.
“And now going into this Covid-19 pandemic, rural communities are not only among the poorest, but there is a lot of co-morbid conditions in rural populations, malnutrition as well. And we all know that with these things, it means your immune system is not functioning very well.”
Hobe-Nxumalo predicts this is why rural populations will be hit hard by the pandemic.
She said that like the rest of the country, they are also worried about the shortage of personal protective equipment.
“As a country we probably don’t have enough masks, gowns and gloves. So, if we run out will we get more in? Even if we can manufacture the personal protective equipment locally there are standards for this equipment [that need to be met] before it can be certified and that takes time.”
Hobe-Nxumalo said some rural hospitals and clinics in KwaZulu-Natal where she works, had already started modifying their premises to accommodate Covid-19 patients. And they had adjusted to the new normal.
“We have made sure nurses, doctors and emergency medical service personnel have been trained.”
Responding to questions on the quality of training she said: “Unfortunately, it’s going to be a crash course. This is an emergency; we are also trying to not get people in the same environment which is the education format that most people are used to.
“But we have been targeting specific teams for training. Like for the ward nurses we decided it will be the infection control doctor with a nurse or the nursing manager with another nurse.”
She said the training has been limited to what Covid-19 is, how the virus is transmitted and what actions to take to curb the spread. More importantly, the medical personnel are trained on the standard operating plan.
“This means that locally we look at what are the things we’ve been dealing with, and what are things we have prepared to make sure we are ready, how we are going to handle a case from the home to the clinic to the hospital.”
What is the new normal?
Getting Covid-19 ready means health facilities are changing how they operate and certain modifications to the facilities have to be made.
Hobe-Nxumalo explained: “Among the things we are doing is to screen staff members upon every shift change, coming in and out. We look for symptoms, take their temperatures and so forth. But we find some rural facilities are still not doing this for patients or their staff.
“It is very important [that we do this]. We really need our rural facilities to start thinking differently, especially on what they can do to safeguard their own facilities,” she said.
She told Spotlight about how one hospital in the poorest rural area of northern KwaZulu-Natal with a population of 110 000 had already started gearing up, including setting up a screening station.
“They’ve basically converted an old parking lot into a screening station. It was repainted, three tables with six chairs for screening staff and six chairs for patients were put up close to the entrance.
“So, everybody coming into the hospital gets a screening done.”
Hobe-Nxumalo took Spotlight through the new process of handling Covid-19 patients.
“When a patient presents at the facility, the security guard at the gate provides them hand sanitiser and asks people if they are coughing. If they are, they are offered a mask.
“From there the patient will go to the screening station where again they are asked whether they are coughing and if so, a mask will be offered.”
According to Hobe-Nxumalo, public health facilities often are not geared for social distancing as waiting rooms are always packed with people waiting to be attended to.
She said the lockdown has helped to keep the numbers down for now, as many people are staying at home rather than presenting at the facilities.
“From the screening station patients will go to outpatient services or this particular hospital’s gateway clinic. In the clinic and at outpatient services there are chairs spaced 2m apart.”
Hobe-Nxumalo said because the waiting areas inside became too small to accommodate many patients, chairs have been placed outside under gazebos, also about 2m apart. To get prescriptions at the pharmacy, people wait outside until their number is called.
“It’s almost like when you are at a bank,” Hobe-Nxumalo said. “So, they get a number upon entry and have to register their name and cellphone number in case they get exposed to anyone.
“It then makes it easy for us to trace them. So, when someone turns out to be Covid-19 positive, medical staff will know what time and with which group of people they came in.”
Some services such as dentistry and optometry have been suspended at this hospital and the staff now help out in other areas such as crowd marshalling or making sure the floor plan is working.
“The facility discontinued those services as they are high risk areas for transmission as you have to work close to someone’s face,” she explained.
For admissions, the hospital has a men and women isolation ward with eight beds each. Hobe-Nxumalo said the plan was to create a unisex ward where suspected cases would be admitted and once confirmed as a Covid-19 positive case.
In coordinating with clinics, one staff member is in charge of a cellphone that serves as a hotline to coordinate what happens to the case when it gets to the hospital.
Resources are limited so staff are divided into eight Covid-19 teams who rotate. “So, we may not have much, but we make do [with what we have.”
Getting more confident
Hobe-Nxumalo said it was understandable that many staff members in health facilities would be scared to nurse a Covid-19 patient at first.
“It’s like Covid-19 is the new kid on the block so, nobody knows much about it. But as we get more suspected cases, people are getting more confident in nursing these cases,” she said.
Training and support from facility management also helps a lot. She told Spotlight that the hope was that facilities in other rural areas across provinces can replicate these basic measures.
“So, what we want to get out there as well is that as long as you’re prepared and have a way of screening people and testing suspected cases, and as long as you have someone who can guide you when you’re unsure about a case and what you should be doing, we can do a lot even if we have little.
“If we take these measures to make prevention work, we will have a better chance at fighting this pandemic. We have to get ready.”
- Rural healthcare workers can get more information by visiting Rudasa’s website here.
- This article was produced by Spotlight – health journalism in the public interest.