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This is the first in what is intended to be a regular column addressing issues related to rural hospitals, rural practitioners and rural district health care. The aim is for this to serve as a discussion starter. Responses will always be welcome.
Initially I will look at the three major problems encountered in almost every rural hospital I have worked in or visited, here in South Africa or elsewhere in the world (including South America, Canada, China, Malaysia and Australia) viz. staffing, accommodation and transport.
Let me focus first on the issue of staffing, i.e. the problem of getting sufficient doctors with appropriate qualifications and experience to practice in rural areas. This 'definition' already introduces a debatable point - staffing is not just about numbers of doctors, it is also about the type of doctors! I will return to this shortly.
One only has to open the SAMJ and scan the job advertisements to notice that staffing rural health services is a world wide problem: we have all seen the adverts for rural doctors in Canada, Australia and New Zealand, and probably know colleagues working there. Professor Jim Rourke, a Canadian rural practitioner and teacher, suggests there is an international directional flow of doctors from West and Central Africa, to South Africa, to Canada, and to the United States, each preceding country filling the gaps for the next country.
South Africa is definitely no exception to this phenomenon. Any rural hospital medical superintendent will tell you that s/he spends a lot of time and energy on recruitment, with little response. We all know that foreign qualified doctors make up the majority of rural hospital doctors.
One might argue that urban centres also have staffing problems. The reality though is that when an urban hospital advertises a vacant post, they are often able to hold interviews to select the best candidate out of a group of applicants, whereas a rural hospital advertising a post usually considers itself very fortunate if one suitably qualified person even shows interest!
The National Department of Health has made some attempts to address this problem. The first strategy was to bring in Cuban doctors. They have certainly made a significant contribution in many places. However, they are at best a short-term solution. The need is to get more South African doctors to these areas. The second strategy aimed to do that viz. Community service. Although community service is not aimed only at rural hospitals but at all government hospitals, it has certainly made a major impact on staffing levels. This is very positive.
However, community service can only be seen as a small part of the solution (if it is to be any part - my focus here is not to debate community service yet again). To assess the impact of community service one would need to see how many community service doctors stay on in rural hospitals after their compulsory year. Of the first group, very few did, and it seems likely the same will apply to the present group.
A hospital or district health service cannot function effectively with recruits who stay for only a year. A solid core of doctors is needed to provide continuity, ongoing quality improvement, and support and development of short-term doctors and other staff. My experience is that it takes new doctors from 3 to 6 months to settle down into rural hospital work and to make a positive contribution.
Thus senior doctors need to be supported and encouraged by the system. They are the essential backbone of the rural health service. They are the ones who are needed to support, nurture and teach community service doctors. It is on this group that there has been too little focus - in fact, no attention has been given to them at all in my opinion. It is for this reason I defined staffing as a problem of quality as well as quantity.
To recruit and retain such senior doctors we need to explore all the different strategies which have been used internationally, such as:
- Structural vocational training, with a rural focus
- Incentive, such as rural allowances, locum schemes, study support, relocation bonuses, sabbatical leave, promotion opportunities, etc.
- Recruitment of rural students into medical school and monitoring of students during their training
- Transformation of the undergraduate curriculum to allow for rural attachments
- Preferential access to postgraduate training for rural doctors; etc.
The South African Medical Association (SAMA) has established a Rural Health Task Team which incorporates representatives from the SA Academy of Family Practice/Primary Care and the Rural Doctors' Association of Southern Africa to address some of these issues.
Constructive contributions to this debate will be useful.
Ian Couper
Department of Family Medicine & Primary Care
MEDUNSA
Chairman, RuDASA
Present address: Wits Medical School, University of the Witwatersrand
Parktown, South Africa
Republished 7 May 2003; address modified 6 June 2003.