Rural Health Clinics
A little jet-lagged yet excited to hit the ground running, our first meeting was with a researcher studying children’s rights. Her work is focused on measuring effective governance as it relates to funding; and her analysis of children’s access to health and education has resulted in a hypothesis which suggests there has been a legal failure to deliver guaranteed social services to children - an instance of indirect structural discrimination. Two major insights emerged from our conversation with this researcher. First, low performing provinces often receive low funding as historic budgeting determines year to year budgets i.e. the less you spend in a given year, the less money you receive the next year. This is somewhat concerning, given that increased support for the delivery of social services should be a function of tangible measures - population size, demographics, spatial distribution etc. The lesson: we need precise variables that accurately reflect need states and, in so doing, that facilitate appropriate and targeted policy interventions. Second, this researcher stressed the need to disaggregate data in order to better capture success cases of failures - this is an approach we have adopted since beginning our research in 2015. The challenge has been obtaining local, disaggregated data. As colleagues of ours have written in the Bolsa Familia report, quoting Anthony Lake of UNICEF, “Disaggregate the data and we find that our statistical national successes are masking moral and practical failures.” The researcher’s examples of her work in Mozambique around education drop out rates illustrated this nicely - in one province, there were high levels of immigration because of the planting season resulting in poor school attendance. In another, the drop out rate increased drastically after Gr.5 because of standardized tests being administered. In other provinces, pregnant girls cannot attend school. The lesson: it is imperative that we do not bury such practical failures in Big Data.
Following our meeting at the Children’s Institute, the team split into two with half remaining in Cape Town to meet with an academic expert in child statelessness and the other half travelling to the Avian Park Clinic in Worcester to study rural health clinics.
120km north-east of Cape Town, or an hour and a half drive through mountains regions that evoke an Apple desktop background before evolving into the Karoo, lies the town of Worcester. Worcester is home to a satellite campus of the University of Stellenbosch, which in turn houses the Ukwanda Rural Clinic School (URCS) at the Avian Park Clinic (APC). South Africa faces a striking shortage of trained medical doctors, particularly in rural areas. At the APC, medical students train to complete the final year of their schooling (a 6 year endeavour!) and are exposed to health issues facing rural and underserved communities - realities they will face upon embarking on the 2-year internship that follows medical school. We met with the management of the Rural Clinic School as well as with students rushing between medical consults.
The APC was set up when the former director of URCS realized that sickly locals weren’t coming to their appointments at the district hospital because of several barriers to access - distance (the day hospital is 5km away from the APC), time (the opportunity cost of travelling to a hospital is is far too high for workers living on low wages) and money (which is invested in more critical needs such as food). Among these, distance seems to be the most significant barrier to access and one that medical students are acutely aware of. This was vividly apparent as we observed differential diagnoses of patients - one of whom show symptoms of lung disease and the other (in absentia) who suffered from paraplegia. While the medical students were eager to run tests on these patients - only available at the district hospital - such earnestness was quickly tempered as they noted that the real challenge would be getting the patient to the hospital for testing, particularly if the patient required funding or assistance to travel from Point A to Point B, or if the patient was immobile. The lesson: proximity is a mission critical feature of successful rural interventions, and such interventions must be rooted in human-centred design thinking.
Back in Cape Town, the day continued in the trendy suburb of Tamboerskloof where we met with with an academic expert in child statelessness. Her work focuses on the development of children’s rights in South Africa. And as we sat down to chat with her, we sought to look at birth registration through a different lens: registration as a vehicle by which to establish identity and citizenship. A major takeaway from our conversation centred around the manner in which the codification of legal protection for children is linked to South Africa’s history. In the years immediately following Apartheid, the politics of identity - that is, the concept of being “South African” - became increasingly important; this is a notion that the expert stressed as a cornerstone of the new, participatory democracy that is the Rainbow Nation. However, in order to participate effectively, millions needed to be recognized by the state - a process that begins with registering births. This massive undertaking was particularly challenging in the established homelands of the Apartheid-era. The tearing down of Apartheid vestiges reflects, according to the expert, the “destruction and reconstruction of the South African state”; this is an ongoing process. Key evidence for this includes variation in birth registration across provinces, despite a high national average. For example, registration rates in Western Cape far exceed those of provinces where the homelands were previously located, including Limpopo and the Eastern Cape. The lesson: Capturing the entire story of birth registration demands a comprehensive analysis of the issues through a socio-historical lens. History and demographics matter.