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Interview with RuDASA chairperson, Desmond Kegakilwe

Dr Desmond Kegakilwe is the current RuDASA chairperson. Born in Tlakgameng Village in the far west of the North West province, Desmond matriculated from Mafikeng with dreams of being a law enforcement officer, or an engineer. His life changed when he was granted a scholarship to study medicine in Cuba, which became one of the most exciting and challenging moments of his life! He drew on inspiration from the elders in the village, especially his grandfather, and graduated with a medical degree in 2004. Desmond currently works for the Wits Reproductive Health and HIV Institute (WRHI) as a Clinical Quality Improvement Mentor for the Mafikeng Sub district, mentoring professional nurses, mostly on HIV/AIDS and TB clinical issues, in 29 clinics. He works in the hospital one day a week to keep his clinical skills sharpened. In 2012 he was given the honour of being nominated one of the Mail and Guardian’s “200 Young South Africans”. Find out a bit more about Desmond below.

What was it like studying medicine in Cuba?

Cubans are amazing people. They love being Cuban and believe in themselves.I learned a lot from them about simple humanity and was inspired by their history and heroes.They have a strong working health system which I believe results from their good education system, which is free for all from primary to tertiary level.

Can we win the battle for good rural healthcare in SA? How?

I cannot say we are not going to win the battle for good rural healthcare because then I will have to leave Medicine. It is not going to be easy but we have to win at all costs.

How do your current activities contribute to the world/South Africa?

I believe it gives hope to people. In the past I have travelled for more than 100km on very bad roads to see less than 5 patients. On my way I would ask myself, “Is it worth it?” The relief and happiness of the people I treated, who sometimes waited for more than two hours to see me, was my motivation. In 2007-8 I included home visits as part of my work. I managed to deliver 4-5 wheelchairs and examined some patients at home; helped others to get home oxygen, assisted the abused and mentally ill; and helped blind people to go to school. These things are unheard of in rural and remote areas. If I could, I would go and live in rural areas and help those who need it. The difference between rural and urban is that whilst urban people have to endure long queues and waiting lists, rural people wait for days up to months, and then travel if the chance arises - in most instances only to get their names placed on waiting lists and to sit for the whole day in long queues!

What do you love about what you do?

Seeing smiles on patients faces. Farming is my other passion. How do you hope to contribute to society in the future? By being part of healthy nation, living in a rural area, and by making sure that the NHI is implementable and IS implemented in rural areas. Then contribute in farming.

Where would you like to be in 5 or 10 years?

In 10 years time I want to be on my farm as a full time farmer; and to help young people to develop farming skills.

What has helped you the most to achieve all that you have?

I have my wife and three kids; I basically divide what little time I get to be with them. Their understanding is indispensable in order to do what I do. My family is what I am most proud of.

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How golden policies lead to mud delivery – and how silver should become the new gold

Karl le Roux presented at the 2012 RuDASA/Phasa conference. The following article is one he wrote based on his presentation, which can be found originally on the PHASA website (www.phasa.org.za)

"My job today is to describe to you what it is like being at the rural coalface. Though I have loved working in a rural hospital for the past six years, it has also been one of the toughest periods in my life. Working in rural medicine is a bit like sitting on a rollercoaster: a combination of enormous challenge and reward, feeling exhausted and exasperated and then inspired and invigorated, seeing dignity and strength in patients, but also sadness and unnecessary suffering and death. One always feels stretched and one often feels as if one is hanging on by one’s fingertips.  The rural idyll is something that might be experienced on weekends off, but the reality of the working week is that on the whole one is extremely busy and constantly rationing care and doing the best one can with the resources available. It therefore might come as no surprise to the reader that at the coalface “policies” are more often seen as a hindrance than a help to the delivery of health care.  Policies or programmes are often imposed from above, with no consultation and with little understanding of realities on the ground.  There is usually poor data collection and feedback, lots of time-consuming and unnecessary paperwork and a focus on irrelevant aspects of care with the neglect of critical aspects. I need to make clear that good, realistic and helpful policies are greatly appreciated by most clinicians working at primary care level, as they improve care and the health of our patients (for example the new antiretroviral treatment guidelines). But there are also many examples of policies and programmes that aim for an unrealistic gold standard (with its unnecessary and unhelpful complexity) and which, as a result, undermine the provision of good healthcare to as large a population as possible.

The first example of this is the new Road to Health Booklet. Although an extremely well-intentioned document, it is completely unrealistic to expect a busy primary care nurse to use this tool properly.  It appears as if the designers of the document have never set foot in a packed rural (or township) immunization clinic, or tried to fill in the booklet with 60 screaming babies requiring injections in the waiting room outside. A year after it was introduced in our area, we still find that critical data such as mother’s HIV status and type of prevention-of-mother to child transmission (PMTCT) treatment provided is left out, whilst on the old, much simpler Road to Health Card, this was filled out really well. Another example of where aiming for gold results in mud delivery is the District Health Information System (DHIS), a tool with so many parameters and different indicators that it is not actually possible to fill it out correctly unless each clinic has several dedicated data capturers with computers and technical support.

 As a result, much of the data is literally made up (I have seen it happen with my own eyes) and results in very poor quality data. At a recent meeting in my district, for example, several clinics had a higher than 120% coverage for measles vaccination.  Yet managers and health planners scratch their heads and wonder why we get such poor quality data and complain that overloaded nurses at the coalface must just fill the data sheets out correctly. The DHIS needs to be simplified drastically, and nurses on the ground must get regular feedback on certain critical indicators that truly reflect improved care.  Many people balk at the idea of not aiming for a “gold standard” at a policy level – surely we must at least aim for the stars even if this isn’t really achievable? Firstly, I would like to argue that we have ample evidence of how aiming for gold actually undermines the provision of care at grassroots level, and that we instead need to focus on simplicity and doing the basics really well. This would result in the biggest health impact on the greatest number of people. Secondly, I think that we need to be cognisant of our limitations in terms of both human and financial resources in South Africa and recognise that we do not have the capacity to achieve gold right now, although it may be possible to aim for gold 20-30 years from now. In the health sector we should be working within a framework of clear, straightforward priorities, aiming for what is achievable (silver?) and doing the basics extremely well, with simple monitoring and clear feedback to all healthcare workers. I would like to argue that a policy cannot be labelled as “good” unless it is implementable. We need to recognise that putting policy together is the beginning of a long process. Policymakers need to be involved in drawing up implementation strategies, and government must support policy implementation through adequate finances and capacitating and empowering managers to manage the changes that will be required when policy is implemented. Let me end with a final plea from the coalface that those of you who write policy use the following as your guiding principle: good health policies make things better and easier on the ground and result in improved patient care.

Dr. Karl le Roux is the Principal Medical Officer at Zithulele Hospital (Eastern Cape). He is passionate about maternal and child health, breastfeeding and rural medicine. He is running a research project following up 500 mothers and their children for 1 year from January 2013. He served as Chairperson of RuDASA from September 2008 to September 2012.

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