- SA's North West province faces healthcare challenges like long waiting times, medicine shortages and difficulties getting to medical facilities.
- Part of the problem is that the majority of medical staff in the public sector don't work in rural areas, which are home to half of the country’s population.
- According to an official, the North West health department is, however, continually improving access to healthcare in rural areas by building new clinics and upgrading others.
Residents of several rural communities in the North West province cite hours waiting for emergency medical services, medicine shortages, high travel costs, and long walking distances to clinics as some of the challenges they face when trying to access healthcare services. Meanwhile, expensive mobile clinics that the provincial government purchased from the Gupta-linked Mediosa are gathering dust.
Long waiting times for emergency services
Dunga Tshilo, whose aunt Lydia Jotwe (83) lives in the remote village Cokonyane near Taung in the Dr Ruth Segomotsi Mompati District, says they waited nine hours for an ambulance for his aunt. She passed away in the ambulance while it was transporting her to a nearby hospital in Taung.
The nearest health facility to her home is Cokonyane Clinic, a mobile container clinic which cost the North West Health Department nearly R1.2 million, according to the Democratic Alliance’s (DA) constituency head Sello Seitlholo. The mobile clinic that serves 70 to 170 patients a day does not have enough shelter and patients sometimes have to wait outside in the wind and rain.
There is no space to store patient files and medication inside the clinic. There is also no privacy for pregnant women to deliver their babies, says Seitlholo, who has been monitoring the situation since 2020. There is only one flush toilet, intended for health workers, while patients have access to only one pit toilet outside, which some say smells very bad.
At night, Seitlholo says it is very dark because the only high mast light for the area often does not work.
Cokonyane Clinic also serves five other surrounding villages, including Sethabeng, Mamashokwane, Madibaneng, Modimong, and Helenspan.
Tshilo, who is from a neighbouring village called Modimong, says some patients have to travel nearly 11km to reach Cokonyane Clinic. Some use donkey carts, while those with motor vehicles can charge up to R300 for a trip to the clinic.
“Sometimes when children and the elderly get to this facility, they are told that some of the medication they require is not available,” says Tshilo.
He went on to say that a departmental mobile clinic only comes once a month to check the blood pressure of the elderly and give them chronic medication.
“This year we tried to go to Premier [Kaobitsa] Bushy Maape’s office to complain about our situation which has been persisting for nearly five years, but we were told (by officials in the Premier’s office) to go through our district health office first,” says Tshilo.
Before the temporary clinic in Cokonyane was built, the clinic was housed in a dilapidated asbestos structure, Seitlholo says. According to Tshilo, the roads in the area are mainly dirt roads and poorly maintained, which causes cars to break down frequently.
Long waiting times
Lerato Modise (18) says she wakes up at 5 am so that she can access antenatal care at Ratlou Clinic. She told Spotlight that she can wait up to six hours to receive the required services and sometimes there is a shortage of infant immunisation vaccines. Then she has to come the following month.
“I have to wake up at 5 am on the day I visit the clinic. If I don’t get a lift along the way, I have to walk nearly two kilometres. Sometimes I have to wait nearly six hours or spend the entire day at the clinic. In some instances, I come back with my baby not receiving her infancy vaccine. I will then be told to come the following month,” says Modise.
High transport costs
Thapelo Modise, who was in a car accident resulting in a temporary disability, has to walk nearly 2km to the Itsoseng Community Health Centre to access treatment. When he needs to access X-ray and physiotherapy services, he has to pay nearly R60 for a round trip to the Mafikeng Provincial Hospital in Mahikeng, which is the nearest facility that offers tertiary services.
“I am unemployed and depend on a disability grant to purchase basic foodstuffs, which do not even last for a month. My foot hurts and sometimes I cannot afford to pay for a local taxi, which costs R30 for a local trip,” he adds.
Grace Maake* (80) has a 38-year-old daughter who suffers from bipolar disorder. She told Spotlight they have to use a bus or taxi to see specialists and collect her medication at the Mafikeng Provincial Hospital.
“Every month we have to travel about 90km so that my daughter can access her treatment. We spend about R120 for a round trip and this excludes the money we spend on food because sometimes we spend the entire day at the hospital,” says Maake.
She is, however, pleased that her daughter receives adequate care at the provincial facility, but she hopes that health services could be brought closer to home so that she can save some money and use it on food.
Lerato Dithipe*says she regularly undergoes chemotherapy at the Tshepong Provincial Hospital in Klerksdorp, about 140km from her home in Itsoseng township. She says her husband drops her off at the Mafikeng Provincial Hospital and then a patient transport vehicle takes her to Tshepong Hospital.
“We spend about R250 on petrol for a round trip to and from Mafikeng Provincial Hospital. This translates to R500 because I have to get dropped and picked up. My husband and I are both pensioners, so I really wish we could get picked [up] at my residence so that we could save on travel costs,” she says.
A patient transport driver who works in the Ngaka Modiri Molema District tells Spotlight that they hope for more buses since they work under extreme pressure.
“There are only two buses which serve the Ngaka Modiri Molema District. Our duty is to ferry patients who require tertiary services to Mahikeng Provincial Hospital. In a day we can carry about 4–10 patients who require specialised care,” the driver says.
North West budget allocation
Provincial health spokesperson Tebogo Lekgethwane says the total budget allocation for the department in the 2021/22 financial year was about R14 billion. Around R7 billion of that was allocated to District Health Services which services rural health. Over R468 million was allocated to emergency services (EMS), while over R618 million was allocated to health facilities and maintenance, which are also programmes targeting rural areas.
According to Statistics South Africa, the North West had an estimated population of just over 4.1 million in 2021.
According to Lekgethwane, the North West’s emergency medical services (EMS) unit has a total of 63 operational ambulances, 10 advanced life support (ALS) response units and 15 planned patient transport buses. There are also 45 private ambulances on standby should the need arise. (In 2018, Spotlight reported on the controversial use of private ambulance services in the province – a practice we understand has stopped.)
In 2019, a report titled Protecting Rural Healthcare in Times of Economic Crisis by the Rural Health Advocacy Project (RHAP) revealed that only 12% of doctors and fewer than 20% of nurses in the public sector work in rural areas, even though people living in these areas make up half of the country’s population.
Spotlight visited the Ratlou Community Health Centre (CHC) which is about 100km outside Mahikeng, the provincial capital of North West. Some villagers say they either have to travel to Mahikeng Provincial Hospital or Vryburg Hospital, which is about 80km from where they reside to access tertiary care.
Ratlou CHC is where the controversial Mediosa mobile trucks are parked. The trucks have specialised equipment such as X-ray machines and tools for dental services but have rarely been used. The argument in favour of such mobile clinics is that they offer a means with which to take healthcare services to remote or isolated areas.
It has been alleged that the former head of the province’s health department, Thabo Lekalakala, approved payments of R30 million to the Gupta-linked Mediosa before they rendered any services.
Lekalakala was charged on four counts, which included fraud, corruption, and contravention of the Public Finance Management Act (PFMA). In February, he appeared at the Mmabatho High Court and is expected to appear again on 23 May. He was acquitted of fraud charges last year relating to his appointment as superintendent-general. He also allegedly went on an all-expenses-paid trip to India, which was funded by the Guptas, a week after a payment of R30 million was made to the company for services it had not rendered. The Service Level Agreement (SLA) was allegedly signed in India.
Lekgethwane says the provincial health department is currently seeking legal advice to find out what to do with the Mediosa trucks. The company, Mediosa, has been liquidated.
A senior official at the Ratlou CHC told Spotlight that he does not know when these vans will be collected and that they are just standing idle.
The department’s plans
Lekgethwane told Spotlight the department is continually improving access to health care in rural areas by building new clinics where there are none and upgrading others.
He says there are 389 primary health care facilities in the province, which include clinics and Community Health Centres.
On the issue of staff shortages, Lekgethwane says the department has developed a strategy to recruit scarce skills. “Moreover, the province has a strategy to recruit scarce skills to rural areas to ensure access to specialised services that were previously only available in towns. The strategy includes building modernised staff accommodation in rural health facilities. There are also medical specialists who have arranged visits to rural health facilities,” he says.
A 2021 report released by Ritshidze, a community-led healthcare service monitoring project, revealed that 23.5% of patients reported they or someone they knew left a North West clinic without the medicines they needed. Out of the facilities monitored, 79 facilities reported stockouts of ARVs, 17 facilities reported stockouts of TB medicines, and 78 facilities reported stockouts of vaccines.
In June 2020, Spotlight reported that the Stop Stockouts Project had found that the North West had the most shortages of South Africa’s nine provinces during the country’s first Covid-19 lockdown.
However, the provincial health department says it has improved and is meeting nationally set medicine availability targets. “The department has achieved the set average medicine availability target according to the national essential list of 80.5% at the end of March 2022. The different categories of medicines, such as ARVs and vaccines for children’s immunisation remained above 90% since the third quarter. The delivery of TB treatment remains consistently above 80%,” says Lekgethwane.
He says the department is continually improving efforts to increase its budget in rural areas.
Although the department did not have exact numbers on how many health workers were stationed in rural areas, Lekgethwane says the department has a total staff complement of 27 987. Of this total, 18 515 are health professionals, inclusive of doctors, nurses, pharmacists, EMS personnel, community health workers, medical officers, dentists, specialists, and others. There are 9 472 administrative support posts.
Regarding patient transport, Lekgethwane says this is available from the local health facilities or clinics. The challenge is that some rural areas are vast and there are still patients who have to travel long distances.
‘Important to invest in rural healthcare’
Russell Rensburg, director of the Rural Health Advocacy Group (RHAP), says it is important to invest in rural healthcare because rural areas are the places where most of the people who require medical attention in the country reside, but the healthcare system in these areas are weak.
“It is important to deploy community healthcare workers in rural areas to ensure that people can access health services like testing and access to chronic medication,” says Rensburg.
He says most people in rural areas do not have the correct information on which health services they can access and where they are accessible, which then creates a barrier to utilising the system to its full capacity.
“It is equally important for health departments to ensure that they conduct regular surveys to see where their shortfalls lie,” he says.
In 2015, RHAP indicated that only 47% of the medical doctors in the North West were employed in the rural districts.
On the issue of staff shortages, Rensburg says government can say they have increased the number of nurses and doctors, but the most important issue is finding out where these workers are stationed and whether they are utilised to their full capacity and need.
“What we have also come across in our line of work are long waiting times and medicine shortages, but health committees and management are not looking at what causes these issues and how each facility can develop a unique model to solve their problems,” he says.
*Not their real names
*This article was published by Spotlight – health journalism in the public interest.