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In the first article in this series, I stated that in my experience there are three problems common to most rural hospitals, viz. staffing, transport and accommodation. I went on to discuss issues related to staffing. This time, I will focusing on the issue of transport which I believe to be essential for effective functioning of rural hospitals.
In the COHSASA [Council for Health service Accreditation of Southern Africa] Accreditation Programme for hospitals, transport does not warrant even a mention. How can this be? It is a matter of focus. I think if one focuses very narrowly on the hospital, and what goes on within its walls, as health planners tend to do, then it is easy to see why transport is not seen as an issue - especially if one comes from an urban centre. However, if one begins to look outside the walls, even through a window, the issue of transport becomes critical.
Knowing you, the reader, already to be amongst the converted (otherwise you would not be reading this), I will nevertheless risk preaching to you, in that I will try to explain why I believe transport is key to effective rural hospital functioning.
Firstly, we can consider how our patients get to us. Usually they are scattered far from the hospital, wherever it may be located in the district. Often there are not the established transport routes and services that exist in more developed areas. Thus the patient who needs to go to hospital - because s/he is referred, or has a relative admitted, or requires special treatment etc - is faced with the obstacle of getting there in the first place. It is not unusual for patients to walk for up to a day (and even 2 days!) to reach the hospital. (Heaven help you if you are a disabled patient on top of it all). In the past, hospital transport services would often assist those patients referred from clinics, but bureaucrats have increasingly insisted this be reserved for emergency cases only, and in a situation of limited resources it is difficult to argue against that. Of course, getting home after the hospital visit is no less problematic.
The next difficulty occurs if the rural hospital cannot sort out the patient's problem and refers her on to a regional or tertiary hospital. Few rural patients can afford the expense of such a trip, and it becomes incumbent on the rural hospital to organise transport for such referrals. If this is not done, patients inevitably do not go - the core district health system principles of access and equity are violated.
Thirdly, there are the patients needing emergency transfer to a higher level. Whether the hospital has its own ambulances or relies on provincial ambulance services, this is a major problem. One transfer from a rural hospital to the city can use up a vehicle for up to a whole day. Anyone who has worked in a rural hospital will have experienced the dilemma of deciding when to send an emergency patient because doing so - if it is indeed possible in the first place - may mean there is little chance of being able to transfer any other emergency patient for a number of hours. This can create a terrifying situation for any doctor in an isolated rural hospital, and has certainly been the cause of many deaths. It is significant that the report on the Confidential Inquiry into Maternal Deaths, 'Saving Mothers' (National Department of Health), mentions this issue.
Fourthly, transport is required for outreach to, and support of, district services. A host of hospital-based health workers at the primary care level need to reach out into the community, from rehabilitation teams to social workers, to psychiatric teams, to dental services etc. Also there is a need for visiting doctors, dentists and other staff to reach clinics and to give regular support to clinic-based staff. Where this does not happen the quality of services deteriorates, the range of access to services is reduced and staff morale decreases. Once again, patients furthest from the hospital suffer.
Another aspect of support is keeping the clinics supplied - with drugs, stationery, equipment, linen etc. Along with this there is the need for equipment to be repaired, buildings to be maintained etc. While in theory this is the function of the district or sub-district office, the district hospital inevitably is involved, through the resources it has - or would be involved where there is transport.
Finally, staff in district hospitals need to go to meetings, workshops, courses etc. In the city this is fairly easily achieved and often staff will go directly with their own, or public, transport. In rural hospitals, meetings are often held hundreds of kilometres away from the base - because that is where district, regional or provincial offices are located. Often there is more than one meeting on the same day in different places, putting extra strain on transport resources.
What complicates this all is that very often rural hospitals are located in areas with bad roads which increase the inevitable wear and tear that always occur when vehicles are used by many people.
Vehicles are expensive, as is maintaining them. However, there are ways to reduce these costs - proper management of vehicle fleets (eg allocating vehicles to specific drivers or sections or tasks, vehicle monitoring systems), or subsidised vehicles, or paying staff for use of their private vehicles.
Despite the expense, money must be budgeted for and spent on acquiring, replacing and maintaining vehicles if the rural district hospital is to achieve anything with respect to primary health care.
1. Anon. No Transport, No Primary Health Care Initiative for Sub-District Support . Durban, SA: Health Systems Trust), 2000.
Ian Couper
Department of Family Medicine & Primary Care
MEDUNSA
Chairman, RuDASA
Present address: Wits Medical School, University of the Witwatersrand
Parktown, South Africa
Republished 20 May 2003; address modified 6 June 2003.