Sub-Saharan Africa has the lowest density of health professionals despite having the highest burden of disease.
Within sub-Saharan African countries, it is widely recognised that rural and remote communities are the most socio-economically deprived, have the greatest health needs and the poorest access to healthcare.
Studies have shown a worldwide bias in the distribution of health workers within countries, towards urban and wealthier locations. This is true of nearly every country in the world, however, disparities between urban and rural areas have been found to be especially acute in developing counties. In South Africa for example, 46% of the population live in rural areas where only 19% of health professionals are based (WHO 2010). In Tanzania 70% of the population are in rural areas, while 69% of health professionals work in urban facilities (SARA Country Data 2012). Together with the well-established correlation between health workers : population ratio and the survival of women during childbirth, and early infancy, this paints an extremely disconcerting picture for people living in rural communities in African countries. A picture only too well recognised by the local leadership of the communities in which Africa Foundation is active, who consistently identify access to healthcare as a priority need on their road to development. Healthcare, therefore represents one of the organisations core focus areas, and for 25 years the Foundation has been supporting initiatives which increase access to medical services. Contributions in this area include the development of two new clinics and support to a further five in the form of additional infrastructure, access to safe water and provision of medical equipment. However, this is not sufficient to overcome a healthcare crisis which has the absence of adequately trained healthcare workers at its heart.
Many studies have been undertaken to identify the cause and ergo, the solution, to overcoming the disinclination of clinicians towards rural hospitals and clinics. Commonly raised issues were the poor working conditions and lack of equipment and below par living environments. Attention to the provision of quality accommodation was frequently identified as a key element in the recruitment and retention of health professionals in rural areas. With this in mind, Africa Foundation recently embarked on two projects to address the issue of inadequate nursing accommodation at the rural clinics of Mduku community in KZN, South Africa and Mayoka community, Lake Manyara, Tanzania.
Mduku Clinic was built by Africa Foundation in 1993, in response to the community identified need for a permanent healthcare facility in an area only being serviced by a mobile clinic. Initial construction consisted of 3 consulting rooms, a maternity room, post-natal care room, dressing room, pharmacy, duty room, staff kitchen and two cottages for 4 nursing staff. Nurses for rural clinics in South Africa are employed by the District hospital, under the Department of Health, and deployed to the clinics in its jurisdiction. Factors such as availability of accommodation can override clinic patient turnover and complexity of medical needs, in terms of the allocation of staff. As Mduku clinic expanded, more make shift accommodation was created using a previous treatment room, however this was still not adequate to meet the growing demand for staff, at the increasingly popular clinic, or meet the standard acceptable to attract health workers. The absence of accommodation was becoming detrimental to the progress of a clinic that by 2015, was providing treatment to over 2,000 HIV/AIDS patients in the South African province most affected by the epidemic.
Through the generosity of our donors, in 2016 Africa Foundation had enough funds to build new accommodation on the grounds of Mduku Clinic. Working in partnership with the Dept. of Health the new houses were constructed to the national standards and were inclusive of furnishings. In line with all the research, the impact of the accommodation has been far reaching. The clinic was recently converted to a 24 hour facility, providing around the clock care. Previously outside of business hours, only emergencies could be attended to. It is the presence of health workers covering a range of specialisms now being deployed to the clinic, and their ability to stay on site, that has made the difference. The presence of the CEO of Mduku Clinic’s parent Hospital, is testament to the hospital management’s commitment to support the clinic as it takes steps towards increasing its scope and capacity. The quality of the accommodation has proven to be a motivator that is sure to contribute to staff retention. Africa Foundation’s regional manager Bheki Ntuli stated that the resultant moral boost could not be over-emphasised. Allocation of the new accommodation was based on seniority and length of service. Two male nurses now reside in the houses, and according to Bheki, it was clear to see that they felt this was a sign of recognition and appreciation for their role, position and positive contribution at the clinic. The hopeful spin-off for wider staff retention being the evident benefits to remaining at the service of this clinic.
The official handover took place in November 2017 with Mrs Khumalo (CEO Mseleni Hospital) doing the honours of cutting the ribbon on the new accommodation. She was joined by Mseleni Hospital Finance Manager, Mduku Clinic committee members, staff, community members, and of course representatives of Africa Foundation and the andBeyond Phinda Private Game Reserve team. The event was a large and very joyous occasion at which the impact of the clinic on the surrounding communities was wholeheartedly celebrated.
In the small village of Mayoka, on the South-Western edge of Lake Manyara Tanzania, a clinic was built by missionaries in 1972. It is the only healthcare facility for approximately 50km, with the main hospital in Babati, some 100km away. After a refurbishment of Mayoka Clinic by Africa Foundation in 2006, the Government deployed a Doctor to be based there, housed in accommodation specifically built for him by community members. The clinic serves Mayoka, and neighbouring Moya community, a total population of around 7,000. Over time, the demands on the clinic have increased, as the communities have grown, and with support from Africa Foundation and the Government, its facilities and capabilities have improved. A recent survey taken in the area indicated that many more village women are choosing to attend the clinic for child birth, feeling confident in the care and treatment options available. Unfortunately the Doctor left to work elsewhere, leaving the clinic team consisting of a midwife, two general nurses and a lab technician. Recently one nurse opted for transfer to another clinic.
The communities who have come to depend on the facility identified lack of on-site accommodation as a major factor in the difficulty to retain staff – a viewpoint supported by research focusing on the retention of nurses in rural facilities in Tanzania. Africa Foundation was thrilled to be able to assist Mayoka with the construction of a double cottage for staff employed at the clinic. Completed at the end of 2016, one house is now occupied by Nurse Tumaini, while the other is soon to become home to a new Doctor. The presence of the onsite accommodation specifically referenced as a motivator to the Government in deploying the Doctor to Mayoka Clinic. Nurse Tumaini expressed much appreciation for the increased comfort that the high quality accommodation is affording them. The other nurse, Lucy, lives in the house originally built by the community – allocation of accommodation being based on seniority and length of service.
The result of the additional cottages is that the complete emergency care team (two nurses and incoming Doctor) can reside on site. This eliminates staff concerns around having to walk after dark, and be subjected to harsh weather conditions, in order to reach the clinic. The broader impact is the capacity of the team to respond extremely quickly to emergencies, and mothers attending in labour, buying critical time that can often be the difference between life and death.
The official handover which took place on 21st September 2017, was attended by District Health Department Medical Officers and staff, Mayoka community leadership, villagers and representatives from andBeyond Lake Manyara Tree Lodge and Africa Foundation. The occasion was made even more special, and valued, by the additional handing over of medical supplies donated biannually by Africa Foundation supporters. These supply packs of items pre-selected by the clinic staff, relieve another key concern for health workers based in rural clinics, of being ill equipped to do their jobs effectively. The collective result being a motivated and resourced team of clinicians, ready and able to serve their community.
Shemdoe et al. Human Resources for Health (2016) 14:2 Explaining retention of healthcare workers in Tanzania: moving on, coming to ‘look, see and go’, or stay?
WHO 2010. Increasing Access to Health Workers in Remote and Rural Areas Through Improved Retention: Global Policy Recommendations.
Lyn Haskins et al. Health SA Gesondheid 22 (2017) 174-183 Factors influencing recruitment and retention of professional nurses, doctors and allied health professionals in rural hospitals in KwaZulu Natal
Michael A. Munga et al. Health Policy and Planning, Volume 29, Issue 2, 1 March 2014, Pages 227–236 Using incentives to attract nurses to remote areas of Tanzania: a contingent valuation study
Uta Lehmann et al. BMC Health Serv Res. (2008) 8: 19. Staffing remote rural areas in middle- and low-income countries: A literature review of attraction and retention Manzi et al. Human Resources for Health 2012, 10:3 Human resources for health care delivery in Tanzania: a multifaceted problem