CHAPTER 7
In spite of the efforts invested to transform the National Health Service since 1995, evidence from recent surveys conducted in South Africa, indicates that urban-rural differentials in MCH service utilization and MCH status continue to exist. Research conducted in developing countries shows that under-utilization of health services and poor health status are a function of inadequate accessibility of health services. There is therefore, reason to believe that the urban-rural differentials in South Africa are still prevalent as a result of inadequate accessibility of MCH services offered at PHC clinics, since these facilities are the primary point of contact for health care in rural areas.
While accessibility refers to much more than straight-line or absolute distance, evidence from developing countries including Sub-Saharan Africa, shows that absolute distance from PHC facilities is a major determinant of health service utilization and health status in rural areas. For this reason, absolute distance has always been an important consideration in health planning and health facility placement in these countries. Internationally, a distance of 5 km has been set as a norm for placement of health facilities.
In South Africa, there is very little evidence about the relationship between accessibility and health service utilization and health status, in particular, about the absolute distance of homesteads from PHC clinics. This clearly highlights the need for more information that will contribute towards a better understanding of the relationship between accessibility of health services and health service utilization and health status in South Africa. This information is critical in health planning and placement of PHC facilities particularly in rural areas. This study has attempted to contribute towards the understanding of the relationship between accessibility and MCH service utilization and MCH status by exploring the effect of absolute distance of homesteads from PHC clinics on several indicators of MCH service utilization and MCH status in a rural district of
South Africa. To achieve this aim, three broad methodological steps were followed. Each of these steps included calculation of absolute distance using GIS technology. While GIS offers easy and quick applications for relating large spatial and attribute datasets, at the time of this study, GIS in South Africa was an emerging tool, which had not been fully explored to analyse health issues. This chapter summarizes the findings, draws conclusions based on these findings and makes recommendations.
7.2 Study subjects and MCH service utilization patterns and MCH status
The findings reveal that the study population is characterized by a high level of poverty, functional illiteracy, fertility and unemployment rates, which have remained the same for more than a decade. Since these factors have been shown to influence health service utilization and health status in South Africa outside of study area and developing countries, these characteristics were considered in the analysis of the effect of distance on MCH service utilization and MCH status. Other characteristics of the study subjects and homesteads that may influence the effect of distance on MCH service utilization and MCH status include mode of transport, the distribution of homesteads in relation to clinics, maternal age, parity, child's sex and visit by CHW.
Contrary to expectations, the findings show that half the study subjects accessed their PHC clinic on foot. Furthermore, more than half of the homesteads were located at greater distances away from the clinic. While the ages of the women were well distributed, there was a high proportion of teenagers among them. The levels of parity and gravidity suggest that there were relatively few miscarriages and stillbirths in this population.
With regard to CHW visits, the majority of the homesteads have confirmed that CHWs were a well-established part of health services. Since the role of the CHWs is to provide health promotion, it seemed unlikely that their presence would significantly confound the effect of distance on health service utilization and health status.
Of direct relevance to the research question was MCH service utilization patterns and MCH status. The findings show that almost all the women in the survey had attended ANC at some stage during the previous pregnancy and the majority of these women obtained this service from clinics. Again, almost all women had made two or more ANC visits. The findings also showed that the majority of the deliveries occurred at hospitals.
Although not specifically asked, evidence elsewhere has shown that distance from health facilities was responsible for the deliveries that occurred at home. Although there was a low rate of family planning uptake, the majority of women obtained this service from the clinics. Since the reasons reported by the women for not utilizing family planning services were personal, it was anticipated that absolute distance would have no effect on this service.
With regard to child health service utilization; possession of RTHCs, vaccination coverage and clinic attendance for growth monitoring and for treatment of minor ailments were high. This left little room to demonstrate the effect of absolute distance of homesteads from clinics on these indicators. An analysis of the indicators of child health status revealed low levels of LBW, underweight and wasting and high levels of stunting.
There was reason to believe that the levels of LBW may have been an under-estimate.
This is because most LBW children may have been missed by sampling of children aged 12-23 months since LBW children are at a higher risk for neonatal and infant mortality than normal weight children. The levels of stunting remained similar to those reported in South Africa over the past 10-15 years.
Stunting is a reflection of social and environmental factors. Therefore, it is less likely that absolute distance would have an effect on this indicator of child health status. An assessment of the MCH-related knowledge and practices revealed suboptimal levels.
Since such information is likely to come from PHC clinics, analysis of the effect of distance on MCH service utilization and MCH status included the indicators of MCH- related knowledge and practices.
7.3 Physical accessibility of PHC clinics
When accessibility was assessed based on catchment areas for PHC clinics, it was found that more than 90% of the catchment population utilized their nearest clinic, suggesting that distance was a valid construct for the planning of health services for this population and other populations in similar settings.
When the assessment of accessibility was based on clinic usage patterns it was found that on average clinic usage decreased with increasing distances above 5 km, but this decrease was much steeper at distances beyond 10 km. An analysis of clinic usage for individual clinics showed that clinic usage decreased at distances above 5km for some clinics and at distances beyond 10 km for most clinics. Although, it is not clear why these two patterns of clinic usage were found, this suggests that cut-offs of 10 km will be adequate for some clinics. However, more investigation is needed before any conclusions can be made regarding this cut-off distance. Furthermore, the decrease in usage at distances above 5 km translates into a considerable reduction in effective coverage of the target population by PHC clinic services, if it is considered that the majority of the population lived greater than 5 km from these clinics.
An assessment of accessibility defined by the determination and comparison of minimum, maximum and mean absolute distances travelled by homestead members for the entire study area before and after the CUBP, showed that the study population travelled a maximum of 30 km and an average of 8.5 km before the CUBP. This assessment also showed that these distances have been significantly reduced after the CUBP. This suggests that the CUBP has improved physical accessibility of clinics by reducing these distances.
However, the full impact of the CUBP on MCH service utilization and MCH status is not known for this population. It was not possible to assess this impact because the new clinics that were introduced through the CUBP were not functional during the data collection phase of this study. Based on these findings it has been concluded that the physical accessibility of fixed PHC clinics in the study area before the CUBP was suboptimal when compared with the WHO recommendations.
7.4 Effect of accessibility on MCH service utilization and MCH status
An assessment of the effect of distance of homesteads from clinics on specific MCH service utilization and MCH status has shown little effect on these indicators. In spite of the fact that many homesteads were located at distances greater than the mandatory limit of 5 km from their nearest clinic, very few significant differences have been found between mothers and children living at 0-5 km, 6-10 km or >10 km from these clinics.
This observation was consistent even after adjustment for the effects of potential confounding factors i.e. maternal age, parity, maternal educational, mode of transport, child's sex and regular CHW visit.
Although not central to this thesis, an analysis of the effects of these factors as independent variables on MCH service utilization and MCH status, found strong effects of the first three factors. This finding is similar to what has been demonstrated elsewhere and in South Africa and reflects that social, environmental and economic conditions of the study population, particularly functional illiteracy, have not improved for more than a decade. This suggests that there is little that the health sector can do to address these conditions, unless other sectors of the government become involved.
In conclusion, at the time of this study physical accessibility of PHC clinics in the study area was not adequate. Furthermore, general clinic usage decreased with increasing absolute distance of homesteads from the clinics. Contrary to expectations, very little evidence was found to support the study hypothesis that increasing distance of homesteads from PHC clinics will result in a decrease in MCH service utilization and MCH status.
The fact that the study found a distance effect for general health service utilization, suggests that distance from PHC clinics provides a reasonable proxy for health service utilization and may have implications for health planning and for health facility placement in South Africa. However, the finding that little or no distance effect was found for MCH service utilization and MCH status is unexpected and could be explained by a number of possibilities. One of these includes the fact that half of the study population accessed their clinic by transport. Initially, it was assumed that the majority of the population in this rural setting would access their PHC clinic on foot. Since the use of transport enables the people to overcome the distance barrier, this makes distance a weak variable for explaining MCH service utilization and MCH status.
Again, since literature has shown a strong association between distance and high mortality rates, it is possible that a distance effect was not demonstrated in this study because mortality rates in the study area and South Africa are currently low. This indicates that the population is already benefiting from health services.
It is also possible that a distance effect still exists, but that methodological limitations in the study design and data collection have prevented this study from demonstrating the effect. For instance, the fact that people use mobile clinics for some MCH services may have confounded the effect of distance from fixed clinics. Again, the fact that people use different facilities for different services even though they are further away. For example, use of fixed clinics for vaccinations and hospitals for deliveries. The reason for this behaviour was discussed earlier in Chapter 5 and has a lot to do with health policies and procedures rather than with distance. Therefore, improving physical accessibility of PHC clinics is unlikely to improve utilization of clinic services for deliveries.
Another explanation could be the fact that certain health outcomes such as stunting, do not exclusively reflect health service inputs, but are a function of social and environmental accessibility rather than physical accessibility. Therefore, a distance effect will be much more difficult to demonstrate for such indicators. Based on these findings and these explanations the following recommendations are made.