THE PROVISION OF PRIMARY HEALTH CARE IN TWO RURAL DISTRICTS OF THE EASTERN CAPE PROVINCE WITH PARTICULAR REFERENCE TO HUMAN RESOURCES AND ACCESSIBILITY PART 1

The provision of Primary Health Care Services (PHC) is still a problem in developing countries like South Africa. In other coun­ tries, one finds enough human resources whilst in other coun­ tries there may be enough material resources. A both qualitative and quantitative research was conducted at Mqanduli and part of the Eastern Elliotdale districts in the Eastern Cape Province with the aim of investigating the provision of Primary health Care Services, reference was made to the availability of human re­ sources and accessibility of PHC services.

An explorative, descriptive and contextual design was selected for the purpose of this study..

Research
INTRODUCTION " Health for all by the year 2000" is the slogan of the W orld Health Or ganisation, of w hich Primary Health Care is a vehicle (Vlok : 1991).Ac c o rd in g to van H eerdeen (1989), " Health for all by the year 2000 does not mean that disease or disability w o u ld be elim inated.It does not mean nurses and doctors will repair p e o p le 's bodies.
The goal " Health for all by the year 2000" is to create the necessary in frastructure by which prim ary health care could be m ade accessible to all the am ount of health education given to the com m unity is in fact not re flected by the people's practices.In most instances a m other will bring a child suffering from diarrhoea to the clinic or hospital, when she is asked about home-made Darrow's solution, she knows about it and how it is pre pared but she has not prepared it for the child she has brought to the clinic suffering from diarrhoea.
Another observation made by the re searchers was that, m ost people in this district are still engaged in tradi tional practices which affect people's lives, for instance, the application of

STUDY PURPOSE
The main purposes of this study were to: The researchers have observed that the am ount of health education given to the community is in fact not reflected by the people's practices people, and in this way to teach them to live healthy lives.In order to attain this goal, in dividu a ls and fam ilies need to be m otivated by health edu cation to assum e responsibility for their own health.Also to respond to social and econom ic developm ent in such a way that they are transform ed from passive recipients into active participants" (van Heerden:1989).This study attem pted to answer the question: How is the provision of the p rim a ry h e a lth c a re s e rv ic e s in M qanduli and Elliotdale districts as pertaining to their accessibility and the availability of human resources af fected?

DEFINITION OF TERMS
Primary health care: See the theo retical framework.
Services: P ro visio n fo r e ssential needs of an individual or a group of people.

Onompilo or Village Health Worker:
are m em bers of the health team who assist the individual and his/her fam ily tow ards the attainm ent of better health.They receive training and sup port from the Ministry of Health.
Professional Nurse: is a registered nurse w ho provides " a service un der Section 38A of the Nursing Act who prescribe diagnosis, treatm ent and care in the m edical sense of the word, although they do so as nurses" (Searle, 1986).
Human Resources: are personnel appropriately trained and developed to ensure that RH.C. services are ren dered and that the services becom e m ore responsive to consum ers.
The Distance: is the am ount of sepa ration in space or tim e between ar eas.

THEORETICAL FRAMEWORK
The definition of the W orld Health Or ganisation fo r Primary Health Care was used as a theoretical fram ework guiding this study.In this study, the investigators are in terested in exam ining the accessibil ity of the health service and the avail a b ility o f th e hea lth p e rs o n n e l to render these services.

LITERATURE REVIEW
The provision of Primary Health Care is a w o rld -w id e concern.The W orld Health Organisation has seen Primary Health Care as the vehicle tow ards achieving " Health for All by the year 2000" (WHO , 1978).
Extensive research on Primary Health Care has been done internationally.
The literature reviewed revealed that although the countries in the w orld were aware of the concept, they did not fully engage them selves in prac tising it with the exception of a few countries.Attention was still given to curative health service than to preven tive health.(Mellish, 1990 andMorley, 1985).
The literature reviewed also revealed that nationally, som e research had been conducted and the issues of the apartheid era were exposed.Since these issues were exposed during the a p a rth e id era th e y w e re n o t a d equately addressed.
During the Reconstruction and Devel opm ent era, in South Africa, very lit tle literature was found on the provi sion of Primary Health Care Services.
A lthough the objectives of the G ov ernm ent are very positive on health of the South Africans, very little had been im plem ented by the tim e of the literature review fo r this study.
The lite ra ture review o f th is stud y com es in tw o broad sub-headings i.e. an international and a national per spective.

AN INTERNATIONAL PERSPECTIVE
The evolution of PHC throughout the world Before one actually starts em barking on a very great task, that is, to assess how the concept o f prim ary health care cam e into being, it is necessary to describe the reason why the w hole w orld started looking at health from this perspective.
One of the objectives of the Alma-Ata Conference on Primary Health Care h e ld in 1978, w as to a sse ss th e present health and health care situa tion th rou gho ut the w orld, then, and to see how it could be im proved by Primary Health Care.
Following this objective the confer ence recognised the special needs of those w ho were least able, for geo graphical, political, social or financial reasons to take the initiative in seek ing health care.The great concern was expressed for those w ho were the m ost vulnerable or at least great est risk.Recognition of the develop m ent depended on the attitudes and capacities of all health workers and also on a health system that was de signed to support the frontline w ork ers (WHO, 1978).

The utilization of health services in the whole world
The lack of health services is a strik ing issue th rougho ut the world.This was addressed by a study conducted in C olum bia in 1987 about the risks w hich affected the child survival and the im portance of the road to health.A large gap between the resources and know ledge of the people as well as what had been achieved was iden tified (Galwan, W olff & Sturgis, 1987).
The results revealed that the lack of available health services to address local needs im peded the survival of the child.
It was also noted that, in spite of the technically available health services, in acce ssibility of services to those p e o p le w h o co u ld afford th e m or reach the hospitals was marked.

Evaluation of problems and progress in pursuing health for all
Once a specific health strategy has been im plem ented, it is im portant for one to evaluate its im pact.Ten years after Alma-Ata Conference the ques tion o f the problem s and progress in p u rs u in g H e a lth fo r a ll w as a d dressed.This question was applied to six continents, more than 160 coun tries and countless cultures and com munities.This question had social, econom ic, ecological, political, bio m edical and organisational aspects.Bryant (1988) pointed out that Pri mary Health Care is not " ... m edical care; not only first contact m edical or health c a re ;... it is intended to reach to the hom e and fam ily level and not be lim ited to health facilities; it is in tended to involve a continuing rela tionship with persons and fam ilies " Bryant (1988).
The health problem s of the urban poor were identified in this conference as ineffective health services which had the m ixture of high technolo gy care for those w ho could afford; and a few or no service designed to reach the needy com m unities.
Inadequately prepared health person nel to function effectively in com m u nity-based health service was another problem .In this review of literature it is clear that rural areas were over looked.This led to a review o f avail able literature within South Africa.

THE SOUTH AFRICAN EXPERIENCE
Since, this study was carried out dur ing the period of change within South Africa, the review of literature took into considaration both the apartheid as well as the reconstruction and devel opm ent era, respectively in the follow ing manner:  They noted that there are very few supergeneralists and many Primary Health Care Nurses.They discovered that the Primary Health Care Nurses are a crisis intervention in the short age of health personnel to render Pri mary Health Care Services.

Redressing the effects of apartheid in health
The Governm ent of National Unity in South Africa com m itted itself in re dressing the effects of apartheid in the delivery of health services.Objectives for meeting the needs of the com m u nities w ho were disadvantaged per taining to health delivery were d ocu mented by the governm ent.Com plete transform ation of the National Health Care delivery System and all relevant institutions was in the gov ernm ents' plan (A.N.C., 1994).

More emphasis on health than m edical c a re
The concern of the South African gov ernm ent of today is to see that the goals of the National Health Plan are attained.The goals are to ensure that the em phasis is more on health than m edical care.The governm ent en courages the developm ent to com prehensive health care practices that are in lin e w ith th e in te rn a tio n a l norms, ethics and standards.The government also ensures that mecha nisms are created for effective com munity participation and involvement, the control, the reduction of the bur den and risk of diseases affecting the health of all South Africans.(ANC, 1994).

RESEARCH DESIGN
An explorative, descriptive and con textual survey was chosen by the re searchers as a research design for this study.A survey is a "type of nonexperim ental research that focuses on obtaining inform ation regarding the status quo of som e situation, of ten via direct questioning of a sam p le o f re s p o n d e n ts (P o lit & Hungler,1991).

Population a n d sample
In this study, tw o different population sets were used.There is a popula tion of professional nurses working in the clinics and clients served by the same clinics.A population is the "the total p o ssib le m e m b e rsh ip of the g ro u p b e in g s tu d ie d (W ils o n , 1889:124), whereas a sam ple on the other hand is "a subset of a popula tion selected to participate in a re search study" (Polit & Hungler, 1991).
The p o p ula tion fo r this study was 267,803, and this total num ber con stitutes all the localities w hich are served by the ten clinics of Mqanduli and the Eastern area of Elliodale dis tricts.
A sam ple of two hundred people was drawn from patients attending at ten different clinics and twenty patients were selected from each clinic by means of purposive sam pling tech n iq ue .W hilst all the p ro fe ssio n a l nurses w orking in these clinics, that is tw e n ty nurses, c o n s titu te d the p o p u la tio n fo r the study i.e. each clinic was represented by two profes sional nurses.

METHODS OF DATA COLLECTION
A interview schedule and a question naire were used as m ethods of data collection, respectively.
A structured interview schedules was a d m in is te re d to 200 c o m m u n ity mem bers attending at the clinics and the questionnaires were handed to 20 professional nurses staffing these clinics.Twenty com m unity m embers were interviewed by the researcher in each clinic whilst, only tw o profes sional nurses participated from ten clinics.

linterview schedule
The interview schedules were used to elicit inform ation from the com m u nity members attending the clinics un derstudy.
The interview schedule was divided into six com ponents, addressing the different aspects as follows: * Component A: The distance of the clients' hom es from the clinics.

* Component B:
Frequency of the clinic visits by cli ents.

* Component C:
M ode of transport used to visit the clinics.

* Component D:
Other places of treatm ent utilised by the clients.

* Component E:
Home visits by people preferred by the clients.
The interview schedules were used am ong subjects by the researchers themselves, for clarity of those sub jects who did not understand English.
The interview schedule contained both open and closed ended ques tions.This m ethod was chosen be cause of its response rate and the face-to-face interaction it prom otes between the interviewer and the in terviewee (Polit & Hungler, 1991) The questionnaire Structured questionnaires were used to collect data from the professional nurses working at the ten clinics.
The questionnaire had the follow ing four com ponents:

Validity a n d reliability
The researchers developed a ques tionnaire and interview schedule, tak ing into consideration the linkage of both q u e s tio n n a ire and in terview schedule to the theoretical fram e work.Furthermore, the role of the re searchers as the co-supervisors of the clinic was identified.
In order to ensure validity and reliabil ity, the tools were further tested (Ten questionnaires were completed in dif ferent clinics).
The interview schedules were used am ong the patients by the research ers them selves so that clarity was made for clients who did not under stand English.These tools were fur ther handed over to the researchers to identify if all the aspects of Primary

Curationis June 1998 25
Health Care provision pertaining to the to p ic were addressed; this was found to correspond.

ETHICAL CONSIDERATION
An inform ed consent was obtained from all the respondents w ho partici pated in interviews.A covering letter was also addressed to all professional nurses w ho participated in this study.Each letter explained the purpose of the study.Further to this, consent was obtained from chiefs and headm en of the localities under study as means of involving them.
Anonym ity was guaranteed by the re searchers in that their names were not going to be revealed.Confidentiality of inform ation was also ensured by allocating alphabetical letters to ques tionnaires sent to ten clinics.Privacy during interviews was ensured.

METHODS OF DATA ANALYSIS
In this research study, data were ana lysed by m eans o f a com puter soft ware package called SAS.

CONCLUSION
in this article, an introduction, problem statement, literature re view and research methods have been detailed.In part two of this article, the researchers will present findings, discussion of results and recommendations with the aim of ensuring appropri ate dilivery of primary health care in rural areas.

June 1998 23 "
Primary health care is an essential health care based on practical, sci entifically sound and socially accept able m ethods and technolo gy m ade universally accessible to individuals a n d fa m ilie s in th e c o m m u n ity through their full participation and at a cost that the com m unity and cou n try can afford in the spirit of self-reli a n c e a n d d e te r m in a tio n " (M a c Donald, 1993).
Due to the shortage of health human resources in South Africa, South Af rica has em barked on the training of health personnel to render Primary Health Care Services, this however is insufficient.Evian, W augh & Buch    Inadequately prepared health personnel to function effectively In communlty-based health service was another problem...

(
1984) co m p a re d the ratio of the superspecialists, specialists, general practitioners and Primary Health Care Nurses in South Africa.