Rural Proofing Guidelines - Rural Health Advocacy Project

RURAL-PROOFING FOR HEALTH: GUIDELINES A GUIDE TO ACCOUNTING FOR RURAL CONTEXTS IN HEALTH POLICY, STRATEGIC PLANNING AND RESOURCING

R u r a l

H e a l t h

A d v o c a c y Founded by:

P r o j e c t

RURAL-PROOFING HEALTH POLICY AND STRATEGIC PLANNING A SYSTEMATIC PROCESS

DEFINE THE ISSUE: THINK RURAL

WHAT DO YOU WANT TO ACHIVE

SYSTEMATICALLY REVIEW YOUR POLICY THROUGH A RURAL LENS

• •

Think about your policy or strategic plan’s purpose and objectives Think about the current situation in rural areas where implementation will take place and list the factors that my influence how your policy or strategic plan is implemented and how services are accessed

• •

Consider what it is you want to achieve by rural-proofing. List what the outcomes of a rural-proofed policy or strategic plan should be

•

Use the attached rural-proofing toolkit to systematically review your policy or strategic plan for rural appropriateness Identify specific areas or interventions that need to be revised to account for rural implementation

•

• DECIDE ON RURALPROOFING ACTIONS AND MAKE ADJUSTMENTS

• •

MONITOR IMPLEMENTATION AND ADJUST WHERE NECESSARY

• •

Decide on the specific adjustments that need to be made to your policy or strategic plan to ensure that it is rural-proofed Identify options for how these adjustments could be made and select those that are most appropriate Make the necessary adjustments

Monitor the implementation of your policy or strategic plan and its impact on service delivery and access in rural areas If something is not working make adjustments where necessary

JANUARY 2015 Contact RHAP: Email: [email protected] • Tel: 011 880 0995 • www.rhap.org.za

RURAL-PROOFING FOR HEALTH: GUIDELINE

TABLE OF CONTENTS

Foreword 02

1

Introduction

03

2

What is rural proofing?

04

3

Key facts and figures: rural health in South Africa

06

4

Defining rural for the purposes of rural-proofing health policy

12

5

How to rural-proof health policy

16

6

Define the issue: think rural

17

7

Set priorities: what should rural-proofing achieve

18

8

Rural-proofing for health: using World Health Organisation (WHO) Health System Building blocks as a guide Building block 1: Service delivery Building block 2: Health workforce Building block 3: Health information systems Building block 4: Essential medicines Building block 5: Financing and budgeting Building block 6: Governance and leadership

References

19 22 27 31 34 38 42

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Foreword

FOREWORD

As rural health care providers and advocates for the rights of our patients we are all too aware that what works in Johannesburg or Cape Town will not necessarily work in Lusikisiki or Manguzi. While this may come as little surprise to you, addressing the specific rural health context in policy design, budget allocations and implementation plans is not yet a standard process in South Africa. The rural-proofing guidelines in front of you have been developed to assist with this task; to ensure that “the rural health context” is addressed adequately when new policies and budgets are drawn up and implemented in the beautiful rural parts of our country.

Over the last few years the South African health care sector has been undergoing an important phase of reform. We have seen a renewed commitment to the revitalisation of Primary Health Care through initiatives such as ward based outreach teams, school health teams, district specialist teams, and most recently the contracting in of private General Practitioners (GP) to public facilities. There is no doubt that these are all have great potential to improve access to healthcare for all who live in South Africa. Fixing health care in this country is no easy task though. Our health system is struggling to overcome the legacy of apartheid and the consequent inequitable distribution of resources based on factors such as race, class and geographic location. This is particularly apparent in rural contexts where historical neglect, high levels of material deprivation, longer distances to facilities over difficult terrain, a lack of infrastructure and equipment, and a chronic shortage of critical health care and well-skilled support personnel requires contextually appropriate solutions to improving access to care.

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RURAL-PROOFING FOR HEALTH: GUIDELINES

As rural health partners we are very excited about this development and many of us have actively contributed to the design of these guidelines. It is important to note that addressing rural health does not mean neglecting any other area of health. As rural health partners we stand for “health for all!’. What it does mean is that the specific rural context is taken into account in the policy and implementation processes. This is a critical step if we are to support and achieve our national goals of improving the nation’s health and eradicating the persistent inequities between urban and rural, public and private health care. We would like to offer our voices and experience to this process and become active partners in ruralproofing for health. DR DESMOND KEGAKILWE, Chairperson of RuDASA On behalf of the Rural Health Partners: Rural Doctors Association of Southern Africa (RuDASA) Rural Rehab South Africa (RuReSA) Professional Association of Clinical Associate South Africa (PACASA) Rural Health Advocacy Project (RHAP) Wits Centre for Rural Health UKZN Centre for Rural Health Ukwanda Centre for Rural Health The rural health student clubs at WITS and UKZN Africa Health Placements (AHP)

Introduction

INTRODUCTION

Approximately 40% of South Africa’s population reside in rural areas, which constitute more than 85% of the county’s landmass. Not only are rural areas significant in terms of population size and land mass they also play a vital role in South Africa’s economy, particularly in terms of agriculture, mining and tourism. Historically, rural areas have been central to social and political struggles against colonial and apartheid oppression. Despite their obvious importance to the country’s social, economic and political landscape, rural areas continue to suffer from the effects of historical neglect in terms of development and social investment. Rural communities remain the most impoverished in the country and have the least access to basic social and economic necessities. In terms of health, this means that rural communities in South Africa carry a disproportionate burden of disease and can expect to have significantly less access to care than their urban counterparts. One of the major contributors to the continued neglect of rural communities in general, and particularly with regard to health, is that little attention has been paid in policy and service delivery to explicitly address inequities between urban and rural contexts. This has meant that there have been few coherent strategies that target rural communities and address their needs within the rural context. Currently there are no standards or methods for accounting for rural in the policy making process in South Africa. This means that critical elements of what makes rural different - geographically, economically, socially - are often not fully considered when designing programmes and interventions; there is no systematic method for avoiding unintended consequences for rural areas in the design of policy; policy is sometimes

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inappropriate for the rural context; and in some cases it entrenches inequities between urban and rural settings. One of the difficulties in accounting for the rural context in policy development and strategic planning is that there is little guidance on how this could be done. For many it is not clear which aspects of a policy or strategic plan need to be adjusted to meet the service delivery needs in a rural setting nor is it clear what specifically could be done to ensure rural contexts are treated appropriately and equitably. The Rural Health Advocacy Project (RHAP) has developed these guidelines in an effort to assist health policy makers and those responsible for strategic planning at the National, Provincial and District to engage with policy development, policy review and strategic planning processes in ways that will allow them to methodically consider the impact that interventions will have on rural contexts and account for rural factors in the design and implementation of policy. More specifically the guidelines have been designed to: • • • • • •

Ensure that the rural context is explicitly considered in the design, review and implementation of policy. Assist with the identification of possible barriers to policy implementation in rural areas. Help with the assessment of rural needs and specific rural factors during the design of policy. Elicit possible policy solutions to meet rural need and overcome barriers to implementation. Promote the development of rural appropriate policy interventions that are effective, efficient and sustainable. Ultimately, to make sure that rural areas are treated fairly in policy and its implementation.

TIP Training on these guidelines and the rural-proofing of health policy and strategic plans is available from the RHAP at no cost. The RHAP is also able to assist with the rural-proofing of specific policies and strategic plans. For more information on how to obtain assistance you can make contact with the RHAP at [email protected]


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WHAT IS RURAL-PROOFING?

Rural-proofing is an approach to the development and review of government policy and strategic planning that recognises that the needs of rural areas and communities are different to those of their urban counterparts.

There are several different approaches to ruralproofing that are currently being implemented in countries such as England, Canada, Finland, Mexico and China (see Good Practice 1). While these approaches may differ in many ways, the broad principles of rural-proofing are generally the same. These principles are: •

KEY CONCEPT Rural-proofing may be defined as a process which ensures that all relevant executive policies are examined carefully and objectively to determine whether or not they have a different impact in rural areas from that elsewhere, because of the particular characteristics of rural areas: and where necessary, what policy adjustments might be made to reflect rural needs and in particular to ensure that as far as is possible public services are accessible on a fair basis to the rural community (DEFRA, 2002: 2)

• •

• • • •

Courtesy of Africa Health Placements

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It is a systematic approach to accounting for rural factors in policy and strategic planning processes. It is a process of mainstreaming rural into policy as well as developing targated rural policy. There is a statutory body - government department or committee - that oversees ruralproofing and coordinates activities between line departments. There is often legislation that makes rural-proofing mandatory and guides its implementation. There are toolkits and guidelines that assist policy makers with the implementation of rural-proofing. It includes the rural-proofing of budgets to ensure that policy changes that affect rural areas and communities are funded. There are a set of clear indicators that are used to monitor progress in implementation.


Grant Difford courtesy of Africa Health Placements

GOOD PRACTICE 1: RURAL-PROOFING IN PRACTICE: THE ‘NEW RURAL PARADIGM’ Recognising the many weaknesses of uncoordinated rural policy approaches, there has been a shift internationally since the early 1990’s, particularly within countries that make up the OECD, towards re-thinking how rural regions and communities are approached in terms of both policy and governance. This has been driven largely by the recognition that rural is not synonymous with agriculture and that single sector policy is wholly inadequate to deal with the complexity and heterogeneity of rural areas (OECD, 2006: 56). As part of its ‘New Rural Paradigm’ the OECD has advocated for cross-sectorial approaches to rural development that focus on infrastructure, economic development, public service provision and the “valorisation of rural amenities” (natural and cultural) (OECD, 2006). A number of countries within the OECD have sought to introduce new rural policy approaches that seek to promote equity and sustainable rural development that are in-line with the OECD’s general approach of mainstreaming rather than the development of stand-alone rural policy. Rural-proofing in the United Kingdom (UK): more than 20% of people in the UK live in rural areas, with this population steadily growing. Recognising the importance of appropriately catering for this population, the UK has been developing and fine-tuning its approach to rural-proofing since the mid-1990s. In 2000 the government established the Department for Environment, Food and Rural Affairs (DEFRA) as the statutory body to oversee rural development and rural-proofing. Since then rural-proofing has become mandatory for all policy processes. DEFRA has also developed a set of guidelines that can be used to mainstream rural into policy and planning. Canada’s rural lens approach: about 90% of Canada’s land mass is considered rural and rural Canadian’s have higher than average levels of deprivation and poor access to basic services such as education and healthcare. Like the UK, Canada has been implementing rural-proofing since the mid-1990s. They have a Rural Secretariat as a statutory body that oversees rural-proofing across government departments. To assist with rural-proofing of policy, a Rural Lens tool has been developed to provide technical guidance for policy-makers. The Mexican micro-regions strategy: about 23% of Mexico’s population is considered rural, of which 60% are living in extreme poverty. In 2001 Mexico enacted the Law on Sustainable Rural Development and in 2002 formed an InterMinisterial Commission to oversee the implementation of the law at the state, district and local government levels. While the law has been enacted at the national level, authority on how it is enacted is delegated to the local level to ensure rural-proofing considers local contextual factors fully. A unique feature of the strategy is the development of a rural budget that identifies and monitors the resources being allocated to rural interventions. More examples of where rural-proofing is being implemented can be found in RHAP’s ‘Rural-Proofing: International Best Practice’ report, which is available on the RHAP’s website (http://www.rhap.org.za/international-bestpractice-and-the-rural-proofing-of-policy-opportunities-for-the-south-african-context/) or directly from the RHAP ([email protected])


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KEY FACTS AND FIGURES: RURAL HEALTH IN SOUTH AFRICA

The relationship between poverty, poor health and healthcare outcomes has been well established; not only do poor people experience higher burdens of disease because of various social determinants, they also have less access to care (Peters et al, 2008). Globally research continues to show that this is particularly acute for rural populations, which

tend to carry a disproportionate burden of both communicable and non-communicable diseases and across almost all indicators experience worse health outcomes (Smith et al., 2008). The South African context is no different.

RURAL REMAINS A SIGNIFICANT PART OF THE SOUTH AFRICAN LANDSCAPE According to figures provided by the World Bank (2013), approximately 38% of South Africa’s population are considered rural. This population is not

spread evenly across the country though and there are five provinces where the rural population exceeds 50% of the total (see Table 1).

TABLE 1: RURAL POPULATION BY PROVINCE EC

FS

GP

KZN

LP

MP

NC

NW

WC

58

20

4

53

88

59

29

55

7

Source: Kok & Collison (2006)

RURAL POPULATIONS EXPERIENCE HIGH LEVELS OF RELATIVE DEPRIVATION The provinces with the largest rural populations are also those with the highest levels of relative deprivation (Graph 1). GRAPH 1: RELATIVE DEPRIVATION BY PROVINCE (1= MOST DEPRIVED; 5= LEAST DEPRIVED) Provinces: EC FS GP KZN LP MP NC NW WC

WC GP FS MP NC KZN NW LP EC 10

20

30

40

50

Number (Source: SASPRI using Census) Source: District Health Barometer 2013/14

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In fact, the 10 most deprived sub-districts in South Africa are all considered rural (Table 2). TABLE 2: RELATIVE DEPRIVATION BY LOCAL MUNICIPALITY PROVINCE

DISTRICT

LOCAL MUNICIPALITY

POPULATION WEIGHTED NATIONAL RANK AVERAGE RANK OF WARDS (WHERE 1=MOST IN THE LOCAL MUNICIPALITY DEPRIVED) (WHERE 1=MOST DEPRIVED)

KwaZulu-Natal

uMzinyati

Msinga

176

1

Eastern Cape

Alfred Nzo

Ntabankulu

280

2

Eastern Cape

OR Tambo

Port St Johns

304

3

KwaZulu-Natal

Ugu

Vulamehlo

383

4

KwaZulu-Natal

iLembe

Maphumulo

388

5

Eastern Cape

Alfred Nzo

Mbizana

395

6

Eastern Cape

OR Tambo

Ngquza Hill

399

7

KwaZulu-Natal

uMkhanyakude

uMhlabuyalingana

400

8

Eastern Cape

Chris Hani

Engcobo

449

9

KwaZulu-Natal

Uthungulu

Nkandla

453

10 Source: District Health Barometer 2013/14

It is also important to recognise that rural deprivation is highest in those areas that formed part of the former homelands and in these areas historical inequalities and neglect are still pervasive (Noble

et al, 2012). These areas tend to have large rural populations that have little access to basic necessities such as water, sanitation, electricity, education and adequate nutrition.

RURAL POPULATIONS RELY ON THE PUBLIC SYSTEM Rural districts also generally have the lowest levels of medical scheme coverage, which means they

depend most heavily on the public health system for healthcare (Graph 2).

GRAPH 2: MEDICAL SCHEME COVERAGE IN MOST RURAL DISTRICTS uMzinyathi: DC24 Capricorn: DC35 Zululand: DC26 Harry Gwala: DC43 RS Mompati: DC39 T Mofutsanyana: DC19 C Hani: DC13 uThukela: DC23 Joe Gqabi: DC14 OR Tambo: DC15 uMkhanyakude: DC27 A Nzo: DC44

Provinces: EC FS GP KZN LP MP NC NW WC

SA average: 16:9

10

20

30

Percentage (Source: Modelled from Stats SA GHS) Source: District Health Barometer 2013/14


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THE CONSEQUENCES OF OUT OF POCKET (OOP) EXPENDITURE FOR HEALTHCARE ARE GREATEST FOR RURAL PATIENTS The consequences of having to pay for healthcare at private or public facilities and providers are greatest for

rural populations where OOP is often catastrophic for rural households (Table 3).

TABLE 3. CATASTROPHIC OOP EXPENDITURE BY LOCATION TYPE OOP transport to outpatient care

Variable

5-9%

>10%

Rural

22.4

Informal-Urban Formal-Urban

OOP Outpatient Public

OOP Inpatient Private

Public

Private

5-9%

>10%

5-9%

>10%

5-9%

>10%

5-9%

>10%

15.3

2.9

2.1

11.5

54.1

10.1

8.2

9.7

17.9

8.6

10.6

1.7

1.3

16.6

30.7

4.1

5.2

0.0

1.2

6.7

5.0

1.4

0.7

8.6

14.4

4.8

5.2

1.2

7.5

Adapted from Harris et al. 2011 *Expenditure is catastrophic if it exceeds 10% of a household’s monthly income

ACCESS TO FACILITIES TAKES LONGER AND IS MORE COSTLY FOR RURAL POPULATIONS Research (e.g. Harris et al, 2011) has shown that accessing services in rural areas generally takes more

time and is more expensive than in urban centres (Table 4).

TABLE 4. COST AND TIME OF TRAVEL BY AREA TYPE Urban COJ

Urban CT

Rural BBR

Rural HLA

Total

Urban COJ

Urban CT

Rural BBR

Rural HLA

Total

Urban COJ

Urban CT

Rural BBR

Rural HLA

Total

Mean costs of travel (ZAR)

CEOC

2.11

3.77

23.15

23.42

12.86

14.20

9.70

39.95

35.34

24.36

36.44

51.72

148.83

99.387

82.52

Mean travelling time**

ART

40.1

41.8

88.3

121.0

71.7

66.7

46.9

152.0

134.4

98.3

47.5

59.8

94.9

177.8

90.0

Proportion of total costs of use***

TB

100%

95.4%

81.8%

80.6%

85.3%

94.5%

94.5%

79.8%

69.3%

84.6%

29.1%

34.8%

42.5%

51.7%

40.6%

Figure 1: cost of transport urban and rural patients (both ways) * costs collected in 2008/9 ** to and from facility *** other costs including food, child care and air time. Source: Harriss et al, (2011)

HISTORICALLY URBAN AREAS HAVE BEEN FAVOURED WHEN IT COMES TO HEALTH EXPENDITURE Research has shown that provinces that are the most deprived and with the least developed health systems have historically received the smallest share

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of healthcare funds. This has been explained as the ‘infrastructure inequality trap’, where provinces with comparatively well-developed health infrastructure


is an indicator of Department of Health Services (DHS) expenditure excluding expenditure on district management and district hospital services. In this instance, quintile 4 (second least deprived) had the highest median expenditure of R927 in 2013, while quintile 3 had the lowest median expenditure of R927. Quintile 5 districts had the second highest median per capita PHC expenditure of R856, while quintile 1 median district expenditure was R20 less per capita at R836 (District Health Barometer 2013/14).

and human resourcing compliments tend to receive a larger share of available resources (Stuckler et al, 2011). Over time this pattern has started to shift and there is some progress in achieving vertical equity between quintiles. In terms of total per capita District Health System expenditure median per capita expenditure in the least deprived districts (quintile 5) in 2005 was R686 while median expenditure for the most deprived districts (quintile 1) was R926, a difference of 34%. In 2013 median per capita DHS expenditure for quintile 5 has increased to R1261 while median expenditure for quintile 1 has increased to R1783. This represents a difference of 41% in favour of the most deprived districts (District Health Barometer, 2013/14). This trend changes, however, when we consider per capita Primary Healthcare (PHC) expenditure in relation to deprivation quintiles. Per capita PHC expenditure

In some instances intra-provincial inequities are greater than inter-provincial inequities. In the Eastern Cape for example the two metros Nelson Mandela Bay (R1069) and Buffalo City (R980), which are the two least deprived districts in the province, have per capita PHC expenditure that is substantially higher than Alfred Nzo (R516) and OR Tambo (R647), the two most deprived and rural districts (District Health Barometer, 2013/14).

THE DISTRIBUTION OF HUMAN RESOURCES FOR HEALTH (HRH) IS SKEWED IN FAVOUR OF URBAN CONTEXTS The equitable distribution of HRH remains one of the most persistent challenges confronting access to healthcare for rural populations in South Africa. The number of HRH per 10 000 population is lowest in

provinces with large rural populations. For example, the North West Province, a largely rural province, has less than half the HRH per 10 000 population than the Western Cape (Table 6).

TABLE 6: TOTAL HUMAN RESOURCES FOR HEALTH (HRH) PER 10 000 POPULATION EC

FS

GP

KZN

LP

MP

NC

NW

WC

SA

44.83

52.01

69.21

58.83

48.83

45.24

55.53

33.06

74.08

55.67

Source: NDoH Human Resources for Health Strategic Plan (2011)

Western Cape, for example, has nearly three times as many doctors working in the province as Limpopo (Table 7).

The differences become particularly stark when one considers the difference in the number of doctors between largely rural and largely urban provinces. The TABLE 7: MEDICAL PRACTITIONERS PER 10 000 POPULATION Province

MEDICAL PRACTITIONERS

Year

2008

2009

2010

2011

2012

Eastern Cape

17,9

20,9

22,4

25,5

24,9

KwaZulu-Natal

34,7

33,7

33,2

34,6

33,9

Limpopo

17,4

18,8

20,1

20,7

21,6

Mpumalanga

18,3

21,3

22,5

22,5

23,1

North West

14,1

18,3

16

19,9

20,2

Northern Cape

35,7

30,3

32,9

36,1

38,8

Free State

23,2

25,4

24

24,1

27,2

Gauteng

32

27,6

31,5

33,7

34,6

Western Cape

37,9

35,5

34,2

34,8

34,7

South Africa

26

26,5

27,3

29

29,4 Source: Health Systems Trust 2013


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These inequities are repeated when it comes to pharmacists. In this instance the Western Cape

has four times as many pharmacists working in the province as Limpopo (Table 8).

TABLE 8: NUMBER OF PHARMACISTS PER 10 000 POPULATION Province

PHARMACISTS

Year

2008

2009

2010

2011

2012

Eastern Cape

2,9

3,5

4,3

5,7

6,2

KwaZulu-Natal

5

4,5

4,3

5,7

6,4

Limpopo

4,5

4,5

6,2

7,2

7,9

Mpumalanga

4

3,9

8,4

10

6,3

North West

3,1

3,8

4,3

5,3

5,8

Northern Cape

5,7

5,9

9,1

11,2

11,9

Free State

3,7

3,9

4,7

8

10,7

Gauteng

4,2

3,6

9,5

10,5

11,8

Western Cape

8,7

8,3

16,2

17,2

18,4

South Africa

4,5

4,5

7,2

8,6

9,2

Source: Health Systems Trust 2013

The pattern shifts with nursing where the spread of nurses between rural areas appears to be more even.

In fact, rural provinces tend to have more professional nurses than largely urban provinces (Table 9).

TABLE 9: NURSES PER 100 000 POPULATION BY CATEGORY Province

PROFESSIONAL NURSES

Year

2008

2009

2010

2011

2012

Eastern Cape

114,2

131,7

140,5

153,5

160,1

KwaZulu-Natal

136,3

132,6

135,1

149,4

154,8

Limpopo

127,5

143,4

151,1

163,5

172,1

Mpumalanga

102,9

112,1

118,5

130,9

132

North West

81,1

105,5

110,8

116,6

122,1

Northern Cape

155

125,4

129

133,2

130,1

Free State

94,5

79,6

78,1

81,3

91,2

Gauteng

111,7

109,5

119,3

129

132,3

Western Cape

123,4

110

108,2

109,7

114,4

South Africa

116,6

120,4

125,6

135,4

140,8

Source: Health Systems Trust 2013

There are a number of factors that contribute to difficulties in recruiting and retaining healthcare professionals in rural settings. Research has revealed that these include both push and pull factors such: difficult working conditions; inadequate

accommodation; lack of employment opportunities for partners; shortage of schooling for children; few opportunities for career development; and social and cultural isolation (WHO, 2013).

RURAL POPULATIONS TEND TO HAVE WORSE HEALTH OUTCOMES THAN THEIR URBAN COUNTERPARTS All the factors described above mean that rural populations tend to have poorer health outcomes than their urban counterparts. For example, TB treatment 10


success rates in the most deprived districts in South Africa, while improving, tend to be lower than in the least deprived districts (Graph 3).


TB Success all TB

Median IndValue

GRAPH 3: TB SUCCESS RATES BY DEPRAVATION QUINTILE 75 70

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

End of IndYear Source: District Health Barometer 2013/14

Children are particularly vulnerable in rural settings and mortality rates for treatable conditions such as diarrhoea and pneumonia tend to be far higher in

deprived rural districts than they are in better off urbanised districts (Graph 4).

Child