Living on a prayer: Navigating a safe passage to healthcare in rural SA

The rape fuelled concerns over the safety of those seeking health care services in the area. The community of Xhora Mouth that include villages of Nqileni, Tshezi, Folokwe and Mgojweni about 100 km from Mthatha, now renewed their calls for a clinic closer to them. They have been pleading for a clinic for almost 15 years.

Nolesile Dodwana, a community member that serves on the local health committee that was created to work on getting a clinic and ambulances for the community, told Spotlight depending on the clinic, residents have to cross rivers either on foot or with a small boat, and walk through thick forests just to get to a clinic. “Sometimes you pray it doesn’t rain because if the rivers are full, the water can come up to your chin,” Dodwana explained touching the base of her neck.

Another community member Ntsikilelo Mbangasini said people coming here are in awe of the landscape. “Many people come here and see beauty, we just see suffering. That hill there, that is just another hill to get over before sick people can get help.”

Mbangasini said getting to Nkanya clinic is the most dangerous. “People have to cross a river and walk through a forest to get to this clinic.”

The young girl was raped after a visit to Nkanya clinic that is more than three hours’ walk from her village, Folokwe.

Navigating the elements on a prayer

When Nosiphe Phandle from Mgojweni village was pregnant, she often missed her clinic visits because she did not feel safe walking alone to Nkanya clinic. “I had to wait for my child’s father every time. It is not safe,” she told Spotlight. Phandle had to cross the Xhora river and make her way through a forest to get to the clinic. In the drier season a part of the riverbank is exposed making it easier for people to cross.

“I used to pray that my baby doesn’t come when it rains because then the river is full and I can’t cross. And I prayed that he doesn’t come at night because then there is no ambulance.”

She was set to deliver her baby, Simvo, now two years old, at Madwaleni hospital. Madwaleni hospital is about three hours from Mgojweni over steep inclines, through a forest and a river. When she went to hospital on the date given to her, she was sent home because she wasn’t in labour yet. “So one night I ended up just giving birth at home. My mother had to help me and the following morning I had to cross the river and walk with my new born to the clinic.”

On choices and bad luck

According to deputy senior traditional leader Nkosi Nosintu Gwebindlala of the Jalamba Traditional Council, safety and long distances to clinics have been a struggle for the community for the last 15 years. The council serves Xhora Mouth area, Mbutye, Mtshekelweni and Mncwasa. “It is very concerning for any member of a village to walk long distances to access basic health care facilities which is constitutionally a violation of a person’s rights.  Our case is even worse because community members have to cross forests and big rivers to access this basic right,” she said.

Those who are too sick to walk and who are desperately ill or in need of emergency care, often have to hire a vehicle costing anything between R600 and R800, Mbangasini explained. “And if it is your bad luck to get sick twice in one month, you’ll have to go to hospital on credit. Some people are literally getting into debt they take months to pay off just to get medical help and some just die. So, your choices are between staying at home and be sick or walk and risk your life or if you do not have money for transport in case of an emergency pay with your life.”

Secretary of the community health committee Phumzile Msaro said three years ago community members from Tshezi village got seriously sick after they ate a dead cow. “Desperate people will eat a dead cow because they’re poor. So, they do not have money to pay for a vehicle to take them for emergency care.”

Ward councillor Anderson Tyali told Spotlight the community has been pushing for a clinic since before the 2006 local elections. “The community together with the chiefs even identified a piece of land for the clinic to be built but all they got was empty promises from the province.” He said the proposed site was at eMazizini village.

A dice with death

All this beauty represents danger for us, Mbangasini said. “People here don’t look at the rivers and the forest and say –‘oh that’s beautiful’. They see danger. There are always men looking for opportunities to do bad. They sit on the hills with binoculars and can see you come from the other side. So they will wait for you between the trees in the forest.”

According to Msaro people were often robbed in the forest making their way back home after they collected their social grants at a pay-point near Mpame clinic. According to him the pay-points were then moved closer to the villages. “So if they can do that for people’s money, why can’t they do it for their health?” Msaro said the municipality now wants to build a community hall when people are crying for a clinic. “That is crazy. The system is broken.”

Access roads to the health facilities from the villages in the area are gravel roads in a state of total disrepair winding through mountainous terrain with ditches more than half a metre deep and wide and unsteady crumbling bridges. “You’re not safe on foot and you’re not safe in a vehicle,” explained Mbangasini. Even a journey with a four wheel drive can easily turn into a dice with death depending on the weather, the village and the clinic or hospital you choose to visit – something the Spotlight team found out first hand.

Roads to health care

The Xhora Mouth Administrative Area falls under the Mbhashe local municipality in the Amathole district. Tyali said the road from Tafalehashe to Bulungula in Xhora Mouth is now being upgraded. “The regravelling of the road started on 24 October this year and will take ten months to complete,” he said. “This will help with tourism and also our new EMS vehicles that will be stationed in the area.”

However, Msaro is not convinced. He told Spotlight regravelling the road is good but it is not solving or talking to the critical challenges like distance to health services. “All these problems are as a result of the distance to health services. So, this is not a permanent solution. The gravel road will erode and deteriorate after the summer rains and then we will have to wait another ten years for it to be fixed.”

Msaro said the road to be regravelled is a provincial road maintained by the provincial department. “The real question is what is the municipality doing to improve access roads between the villages and the clinics.” The Special Investigation Unit is investigating Mbhashe municipality and three other Eastern Cape municipalities for alleged irregular tender processes. The municipality reportedly flouted tender processes and spent more than R72 million buying equipment three years ago to re-gravel about 500km of road.

According to spokesperson of the Mbhashe municipality Nonceba Kolwane there is a  transport forum that is facilitated by the Department of Transport which deals with road infrastructure maintenance. “The forum intends to come up with recommendations to aid the issues raised.”

Kolwane said Mbhashe is the biggest local municipality around the Amathole region and has to spread initiatives across the municipality to ensure fair beneficiation to people in all the municipal areas. Thus far the completed projects for the Xhora Mouth area include Ndalatha access road, Zithulele access road and Mncwasa (road linking to Mncwasa bridge), said Kolwane. But according to Msaro fixing the access roads alone is not sustainable. “What we need is for the health service to come to the people where they stay and not the other way around.”

With Spotlight’s visit to the area in October this year, the community finally after years of pleading and following an investigation by the Human Rights Commission in 2015 got allocated two ambulances which is expected to improve their access to emergency medical care – that is if the current state of the roads allow it. The ambulances set to be stationed in the area are four wheel drive vehicles to better suit the terrain. However when Spotlight’s team joined the ambulances on a drive through the area, it showed that the state of the roads will even make four wheel drive ambulances struggle to navigate half metre wide deep ditches in the gravel access roads.

Tyali however, welcomed this development despite concerns that the poor condition of the roads will mean a very high maintenance budget for these vehicles. According to him, the regravelling of the road is primarily aimed at improving access for the EMS vehicles. “This (the EMS service) will make life much better for our people. They now have to pay R700 to R800 for a private vehicle to take them to hospital in an emergency. At least now there’s light at the end of this tunnel.”

More generally however, for the people of Xhora Mouth the tunnel towards the light still appears to be very long. Based on StatsSA’s 2011 census figures life for those living in the Mbhashe municipal area and ward 28 (Xhora Mouth) specifically, is an uphill battle. Just 7,1% of the working population are employed so any out of pocket expenses to access health care is often a struggle. When every cent counts, having to pay for a vehicle due to the lack of ambulances in an emergency makes for tough choices. The average household income per year totals around R14 600. Almost three quarters of the population (74,6%) have no access to toilets and only 7,6% have a matric qualification and a post school qualification. Women are at the head of most of the households (61%).

Navigating solutions

In a time of austerity, budgets for fixing these problems are limited and excuses for unfulfilled promises many. The pleas of the people of Xhora Mouth are not new but they remain relevant in a time when people are literally risking life and limb to get to and from health facilities.

According to health department standards no person should live further than 5km from their nearest clinic. In a country with rising and competing asks from limited state coffers, this is often not possible. So how do we get to solutions?

Spokesperson for the Eastern Cape health department, Sizwe Kupelo, acknowledged that clinics should be built in line with the World Health Organisation policy stating that in every five kilometre radius there must be a clinic. “However, the area is a very difficult terrain and very mountainous,” Kupelo said. According to him the area was neglected by the Apartheid government and by 1994 primary health care was almost non-existent in the former Transkei.

“Government would spend over R3 billion building new clinics and hospitals in order to ensure high quality public health care and established emergency medical service which was also non-existent in the former Transkei,” he said.

Chief Gwebindlala said the community relies on a local NGO who runs the Bulungula Incubator project that includes a health point for residents.“They have trained and employed over 50 health care workers that help us with community health care like visiting the elderly and sickly at home and administering and monitoring medicine intake.”

It is not clear how many government employed community health workers service the Xhora Mouth communities as this could complement the Bulungula-project and help people get access to primary health care where they are. When Spotlight spoke to one of the Bulungula home based careworkers, Sinoviwe Medwentsi said there is only one woman that she knows of working as a departmental community health worker in the area so they have to do most of the work with the elderly and bedridden in the community themselves.

The Treatment Action Campaign in an earlier report on health access in the Eastern Cape stated there were 426 community health workers (CHW’s) in the whole Amathole region in 2016 but the actual need for the area is 1 620. The Eastern Cape Health Department’s Annual Report for 2017/18 refers to ward based primary healthcare outreach teams that are led by a professional nurse with between two and six CHW’s but provide no actual figures on this.

Another means of providing healthcare services are mobile clinics. According to the department’s annual report there are 187 mobile units in the Eastern Cape. There is no district-level breakdown of the numbers but Msaro dismissed mobile clinics as the solution.

“The department tried with a mobile clinic but it is not sustainable because it comes once a quarter. They then drive all the way and don’t provide adequate service so they’re just wasting petrol.”

“We have tried everything and there is no alternative but a clinic here with the people because the main issues are distance and the danger people face getting to the clinics that are now serving them.”

When asked about alternatives to improve access to healthcare in the area Kupelo did not elaborate. He just said: “ The safety of patients in our facilities is a priority and we have private security services in all our institutions.” This however, does not address the safety concerns on the way to and from clinics highlighted by the community.

Kupelo did say that the Eastern Cape Provincial Government took a resolution to surface all roads connecting hospitals with national roads and that work started with Madwaleni hospital and Elliotdale. According to him the department condemns all forms of violence in particular sexual violence against women as reported”.

Section27 field researcher in the Eastern Cape Thokozile Mtsolongo said the people of Xhora Mouth want health facilities that are closer to where they stay, are allocated in areas that are safe to get to as well as decent road infrastructure. “In addition to that other health services such as a better functioning EMS system are what people want to have as a lived experience and not a fairy tale,” said Mtsolongo.

“How long do communities such as Xhora Mouth have to wait for or how many people should become victims of violence all in an attempt to access basic quality health care services? The cogs of the governance system need to be oiled far better than they are at the moment, otherwise we end up with this situation where people risk their lives in order to access health services that are meant to improve their lives.”

•  This article first appeared in Spotlight.