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Update: Ending Circumcision Deaths, Mutilations and Abuse (support letter)

On 13 August 2013, the Rural Doctors Association of South Africa, in conjunction with the Junior Doctors Association of South Africa, issued a letter of support for National and Provincial Task teams to end the unnecessary deaths, mutilations and abuse that are associated with traditional circumcisions each year. 

The letter may be viewed here

In addition, an analysis of the root causes, conducted in Pondoland, is available and may be viewed here

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Rural healthcare is crying out for a good plan and a real budget

Madwaleni is one of those rural hospitals that has managed to attract and retain health professionals. Currently the hospital has 10 doctors with pharmacy, radiology, nutrition and rehabilitation health professionals as well," said the 2009 report of the integrated support team appointed by Barbara Hogan, then the minister of health, to investigate the severe overexpenditure of provincial health departments. Madwaleni hospital emerged as a shining example of good rural healthcare. By 2012, however, Madwaleni, deep in the Transkei, was "running" on a skeleton staff of only one doctor and one health professional. Nurses, under enormous pressure, were left to run the maternity ward without doctors'' support – this in a district with the highest maternal mortality rate in the country. Pregnant women needing Caesarians had to go elsewhere. The causes of the Eastern Cape health crisis are well known: the provincial health department's chronic inability to manage its resources and the historical underfunding of rural health has brought the provincial health system to its knees. In 2012, misguided attempts to deal with the department''s snowballing debt led to a moratorium on the filling of vacant posts. This has meant that, despite a number of applicants for positions at the hospital, these remain unfilled.

Across the province the story is the same. The Lusikisiki village clinic was relocated from a building to a tent because the department could not afford the monthly rent of R8600. Komga clinic, 70km from East London, halted its mobile service because its nursing staff shrank from six to three. Parts of the provincial system were propped up by civil society. In December 2012 thousands of patients who lacked life-saving drugs were saved by the emergency intervention of the Treatment Action Campaign and Médecins Sans Frontières, which took over the Mthatha medicines depot.

Non-supportive work environment.

The Rural Health Advocacy Project and Section 27 collected reports by various stakeholders on the human resources crisis in health, with scores of healthcare workers not receiving their salaries at all. Madwaleni eventually received the much-needed healthcare workers through the efforts of Africa Health Placements.

Financial mismanagement, weak leadership and understaffed facilities are not unique to the Eastern Cape. Tintswalo hospital in Mpumalanga has had an exodus of healthcare workers because of the hostile, non-supportive work environment. As we know from the Gauteng health crisis, not even the country''s wealthiest province can keep it together. The difference, though, with rural health is that for poor people there are so few alternatives, if any, to the one rural clinic or hospital an hour's travel away. The few interested candidates for rural posts would have long moved on to places where they feel wanted – urban areas, the private sector, overseas.

Yet the Madwaleni example of four years ago shows what can be achieved by engaged local leadership supported by the provincial and national governments. Unfortunately, it also shows that rural health services can break down rapidly. The Positive Practice Environment Campaign recently launched by the South African Medical Association and the Democratic Nursing Organisation of South Africa is spot on: what should have been the priority for 2012, and should be a top priority for this year, is the upliftment of the public health career (a rural health career, for that matter) as appealing and desirable.Is this possible? Of course. We can learn from other countries with large rural populations. Trained as a doctor in the Cuban health system, I am excited about South Africa''s intention to move to a real primary healthcare system, one that brings health closer towards the people through prevention, promotion, rehabilitation and cure. I also celebrate the country''s first rural chapter in the new national Human Resources for Health Strategy 2013-30. The plan includes the following:

  • To provide personal and professional support to health ¬professionals working in rural areas, including outreach from referral hospitals, accommodation, a safe and supportive working environment, and opportunities for career development;
  • To develop norms for minimum numbers of health professionals for district facilities; and
  • To recruit more students of rural origin into the health sciences (they are seven times more likely to return to rural practice).

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Open letter in support of Positive Practice Environments

The Rural Doctors Association of Southern Africa (RuDASA) and the Rural Health Advocacy Project (RHAP) commend DENOSA and SAMA for initiating the Positive Practice Environment Campaign.

Rural health care workers are often faced with minimal resources to provide a health care service to communities in the poorest districts of the country, which are faced with high burdens of disease. RHAP receives regular reports from RuDASA members and other health care workers regarding the dismal working conditions and the right to quality health care denied to the communities they serve.We know for a fact that areas with the greatest need receive the least resources. This is not only in terms of health care workers, but also in terms of financial support. In a North West hospital in deeply rural Ganyesa, it took more than three years for a generator to be replaced and in the meantime an infant died an entirely avoidable death during childbirth. In that same hospital, as elsewhere in North West, doctors in severely understaffed facilities are expected to be on standby for overtime every second weekend, yet do not get compensated. A recipe for a high turn-over. In the Eastern Cape, Komga Clinic went from 6 to 3 nurses and entirely halted its mobile outreach clinic service. The issue has been addressed repeatedly with the National and Provincial Department of Health yet no response nor has relief been forthcoming. Rehab professionals have gone without correct payment for months, and have not been able to procure any equipment since 2009.

In Mpumalanga, Tintswalo Hospital, an exodus of committed doctors is taking place due to the hostile work environment. These are just some examples. Rural health continues to lose scarce resources to other areas, private sector and overseas opportunities. To realise the right to health for all, we need to make the provision of health care for under-served populations an attractive career, through Positive Practice Environments! While safeguarding ethical conduct by health care workers, we also need to provide an ethically sound work environment.

We urgently need staffing norms for nurses, doctors, rehabilitation professionals and so on, to share the scarce human resources for health equitably. A health care user's place of residence, or wealth, should not determine his or her access to sufficient and caring health care workers! We also call for the implementation of the chapter on rural health in the HRH Strategy: 2013-2030, which amongst others commits to:

  • Provide personal and professional support to health professionals working in rural areas, specifically:
  • Outreach from referral hospitals
  • Improved living conditions including accommodation (where that is not easily available locally), a safe and supportive working environment, opportunities for career development and CPD programmes
  • Establish a system to support continuing professional development programmes in each rural district
  • Develop, use and evaluate financial incentives to attract rural health care professionals

We pledge our support and wish to join hands in making the Positive Practice Environment campaign a success.

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Calling an end to initiation deaths and mutilations

Press Statement:
15 July 2013

In 2010, Dr. John Lazarus wrote in the South African Medical Journal:  Twenty years ago two Eastern Cape urological surgeons documented their experience with treating initiates (...), they followed up 45 consecutive patients and documented a mortality rate of 9%. The death toll for the 2010 winter initiation period stood at 40 at the time of writing. These statistics not only point to the fact that little has changed, but suggest that the situation may in fact be deteriorating.”

From 2008 until 2012, the Eastern Cape Province recorded 323 deaths, with 126 initiates suffering genital amputation. At the beginning of July 2013 the EC province recorded 30 deaths and 293 hospital admissions from dehydration, septic circumcision wounds, and gangrene of the penis. We view the apparent absence of improvement with great concern. The worst affected area is Pondoland, where the ritual re-emerged in the 1980s and 1990s. A key cause of the problems is inexperience on the part of the traditional attendants. The initiation schools are poorly supervised resulting from insufficient involvement of local traditional leadership, the community and the secrecy that surrounds the ritual. We hereby call on all stakeholders and in particular the House of Traditional Leaders and Department of Health, to intervene in the Eastern Cape and the other affected provinces. A strong and committed task team is needed to coordinate all efforts in preparation for the next season that includes representation from the National Prosecuting Authority, SAPS and the Co-operative Governance and Traditional Affairs. Active participation of local traditional leaders is urgently needed, and awareness should be raised in schools and communities via education campaigns. Legislation should be enforced perpetrators should be held accountable and tried. We as doctors in the affected areas have a thorough understanding of the problems underlying the ritual, and are willing to be part of the solution. We cannot turn a blind eye while our young men are dying at the prime of their age. Traditional circumcision and initiation into manhood should be a beautiful and valuable experience for all initiates.

Contact details:

  • Dr Desmond Kegakilwe, RuDASA National Chairperson (This email address is being protected from spambots. You need JavaScript enabled to view it.) 082 9607571
  • Dr Dingeman Rijken, RuDASA Eastern Cape (This email address is being protected from spambots. You need JavaScript enabled to view it.)  079 372 8862
  • Dr Lunga Mfingwana, JuDASA EC PEC Chairman,(This email address is being protected from spambots. You need JavaScript enabled to view it.) 072 381 6775

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Introducing RuReSA

RuReSA (Rural Rehabilitation of South Africa) is a newly formed interest group for rehabilitiation professionals who have an interest in Rehabilitation in rural places. Members have the chance to input on policy, give and receive personal and professional support, work with universities to promote rural-friendly curricula and encourage students to go rural. "We believe that rural work can be inspiring and fun, and with a little support we can achieve great things". RuReSA provides support to rehabilitation therapists in rural are as through our resource website, an online discussion forum, and advocating for change through input on policy and service strategies as well as working with the National Department of Health, professional bodies and universities.

To join, or for more information about RuReSA, visit their website.

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