As the government went on the offensive last week by scaling up testing and screening in communities across the country, some in the rural health sector are also proactively taking measures to curb the spread of Covid-19.

Health Minister Dr Zweli Mkhize last week said there must be “clearly defined targets at district and sub-district levels structures with a clear short command line led by experienced professionals who can take clinical decisions quickly and act on the spot”. He also said additional beds need to be acquired as well as dedicated treatment centres where Covid-19 patients will be treated in every town.

Rural healthcare workers across the country have been taking Mkhize’s words on board and fleshing out what it means to be prepared for the expected increase in Covid-19 cases in their various settings.

Early priorities

Chair of the Rural Doctors Association of Southern Africa (RudaSA) Dr Lungile Hobe-Nxumalo, in an interview with Spotlight, said the association has been working through its networks to share “best practices” of what works and doesn’t work in the different rural settings.

“The big thing for us right now is just identifying the population at risk and then identifying the individuals at risk; for example, persons that have been in contact with Covid-19 cases,” she said.

“I’m very concerned about people who were moving from urban areas to rural homes before the lockdown. I’m also concerned about pension payout points. Last week there were large gatherings of people at these pay points and people are exposing each other. So, as rural health facilities we need to start screening and identifying people that are potentially exposed, and test them.”

Never enough resources

Hobe-Nxumalo said some of the rural areas in KwaZulu-Natal facilities had already taken the national standard operating plans that were issued and “made it their own” despite resource constraints.

“We are never going to have enough,” she said. “Countries like the USA is already complaining they’re running out of N95 masks. In South Africa the problem is that we hardly manufacture our own consumables, and now with the country being in lockdown, where is it going to come from?”

A shortage of human resources is also a challenge. She said rural communities form 42% of the public health system in the country. “And for that population size only 15% of the doctors are actually based in rural areas, and 20% of nurses. This is a human resource deficiency that is chronic,” she said.

“And now going into this Covid-19 pandemic, rural communities are not only among the poorest, but there are a lot of co-morbid conditions in rural populations – malnutrition as well – and we all know with these things it means your immune system is not functioning very well.”

Hobe-Nxumalo predicts this is why rural populations will be hit hard by the pandemic.

She said that like the rest of the country they are also worried about personal protective equipment (PPEs). “As a country, we probably don’t have enough masks, gowns and gloves so, if we run out, will we get more in? Even if we can manufacture it locally there are standards for this equipment before it can be certified, and that takes time.”

Crash course

Hobe-Nxumalo said some rural hospitals and clinics in KwaZulu-Natal (where she works) had already started modifying their premises and adjusted to the new normal. “We have made sure nurses, doctors and emergency medical service personnel have been trained.”

Responding to questions on the quality of training, she said: “Unfortunately, it’s going to be a crash course. This is an emergency; we are also trying to not get people in the same environment which is the education format that most people are used to. But we have been targeting specific teams for training like for the ward nurses; we decided it will be the infection control doctor with a nurse, or the nursing manager with another nurse.”

She said the training is limited to what Covid-19 is, how the virus is transmitted and what actions to take to curb the spread. More importantly, the medical personnel are trained in the standard operating plan. “This means we look locally at what are the things we’ve been dealing with, and what are things we have prepared to make sure we are ready, how are we going to handle a case from the home, to the clinic to the hospital.”

What is the new normal?

Getting Covid-19 ready means health facilities are changing how they operate and certain modifications to facility premises have to be made. Hobe-Nxumalo explains: “Among the things we are doing is to screen staff members upon every shift change, coming in and out. We look for symptoms, take their temperatures and so forth. But we find some rural facilities are still not doing this for patients or their staff,” she said. “It is very important. We really need our rural facilities to start thinking differently, especially on what they can do to safeguard their own facilities.”

She told Spotlight about one hospital in the poorest rural area of northern KwaZulu-Natal with a district population of 110,000 that already started gearing up. This includes putting up a screening station close to the main entrance gate. “They’ve basically converted an old parking lot into a screening station. It was repainted, three tables with six chairs for screening staff and six chairs for patients were put up. So, everybody coming into the hospital gets a screening done.”

Hobe-Nxumalo took Spotlight through the new process of handling patients. “When a patient presents at the facility, the security guard at the gate provides hand sanitiser and asks people if they are coughing. If they are, they are offered a mask. From there the patient will go to the screening station where again they are asked whether they are coughing and if so, a mask will be offered.”

She said public health facilities often are not geared for social distancing as waiting rooms are often packed. She said the lockdown has helped to keep numbers down for now, as many people are staying at home rather than presenting at the facilities.

“From the screening station patients will go to OPD (outpatient services) or this particular hospital’s gateway clinic. In the clinic and OPD there are chairs spaced two metres apart.”

Hobe-Nxumalo said because the waiting areas inside then become too small to accommodate many patients, chairs are placed outside under gazebos, also about two metres apart.

For services like pharmacy scripts, people wait outside until their number is called. “Almost like when you are at a bank,” Hobe-Nxumalo said. “So, they get a number upon entry and have to register their name and cellphone number in case they get exposed to anyone. It then makes it easy for us to trace them. So, when someone turns out to be Covid-19 positive, medical staff will know what time and with which group of people they came in.”

Some services like dentistry and optometry have since been suspended at this hospital and the staff now help out in other areas, like crowd-marshalling patients or making sure the floor plan is working. “The facility discontinued those services as it is high risk for transmission as you have to work close to someone’s face,” she explained.

For hospital admissions, the hospital has a male and female isolation ward with eight beds each. Hobe-Nxumalo said the plan is to create a unisex ward where suspected cases will be admitted and once confirmed as a Covid-19 positive case they’ll be allocated a bed on the basis of their sex. In coordinating with clinics, one staff member is in charge of a cellphone that serves as a hotline to coordinate what happens to the case when it gets to the hospital.

Resources are limited so staff are divided into eight Covid-19 teams who rotate. “So, we may not have much, but we make do,” she said.

Getting more confident

Hobe-Nxumalo noted it is understandable that many staff members in health facilities will be scared to be nursing a Covid-19 patient at first. “It’s like Covid-19 is the new kid on the block, so nobody knows much about it, but as we get more suspected cases people are getting more confident in nursing these cases,” she said. She said training and support from facility management helps a lot.

She told Spotlight that the hope is that facilities in other rural areas across provinces can replicate these basic measures. “So, what we want to get out there as well is that as long as you’re prepared and have a way of screening people and testing suspected cases, and as long as you have someone who can guide when you’re unsure about a case and what you should be doing, we can do a lot, even if we have little. If we take these types of measures to make prevention work, we will have a better chance at fighting this pandemic. We have to get ready.” DM/MC

Rural healthcare workers can get more information by visiting RudaSA’s website here.

This article was produced by Spotlight – health journalism in the public interest.