THE PROVISION OF PRIMARY HEALTH CARE IN TWO RURAL DISTRICTS OF THE EASTERN CAPE PROVINCE WITH PARTICULAR REFERENCE TO HUMAN RESOURCES AND ACCESSIBILITY PART 2 : THE RESULTS AND RECOMMENDATIONS

Mvulakazi Thipanyana


SAMPLE DESCRIPTION
The sample for the study was drawn from all the residential clinics of Mqanduli and eastern area of Elliotdale districts; and also from all the professional nurses working in these clinics.
Two hundred interview schedules were administered to interview two hundred clients, and twenty questionnaires were distributed to twenty professional nurses.The response rate of both interviews and questionnaires was 100%.
Each clinic was assigned an alphabet for identification purposes.Alphabets from "A" to 'U" were used for ten clinics.
Analyses of data collected was performed by using a computer soft ware package called SAS, since the University of Transkei uses SAS programme for the analysis of data.
The results in this study are presented in two broad sub -headings : Part I will ad dress the results obtained from the use of the interview schedules among 200 clients attending at the clinics around M qanduli and the Eastern part of Elliotdale districts.Part 2 will address results obtained from 20 professional nurses working in these ten (10) clinics.

PHASE I; CLIENTS RESPONSES FROM TEN CLINICS
The distance between homes of respondents and the clinic The distance of the respondents homes from the clinics varied, ranging between 2km and 20kms.The majority of re spondents, (N = 78), 39%, stayed within 6 -10kms range (see Table 1).
Normal distance according to Vlok (1991) should be 2 -5km from the consumer' homes to the Primary Health Care Cen tre.

The mode of transport used by respondents when visiting the clinic
The respondents revealed that (N = 3), 1,5%, respondents visited the clinics by bus,(N = 3), respondents, 1,5%, got on horseback in order to reach the clinic.The majority of respondents, (N = 152), 76%, walked to the clinic, and about (N = 42), 31%, used taxis to visit the clinic.
The frequency of visits made to the clinic Twenty one respondents, 10,5%, visited the clinic weekly; (N = 63), 31,5% of re spondents, visited the clinic bi -monthly, whilst (N = 10), 5% also visited the clinic bi -monthly.The majority of respond ents, (N = 93), 46,5%, went to the clinic when it was necessary.About (N = 13), 6,5%, were visiting the clinic for the first time on the day of the study.

Clinic activities or comments
The respondents were asked to comment about the daily activities of their clinics.In addition to the services they got from the clinics they were requested to state problems they encountered at their clin ics.The minority of respondents (N = 1), 0,5%, stated that the clinics had short age of water.The majority of respond ents (N = 151), 75,5%, commented about medicines which were usually out of stock in the clinics.About (N = 2), 1%, of respondents who stated that the clinic was too far.The respondents who com mented about good attitudes were (N = 6), 3%.Those respondents who stated that nurses had bad attitude were (N = 9), 4,5%.About (N = 30), 15%, of re spondents had no problems with the clin ics activities, whereas (N = 1), 0,5%, of respondent stated that the clinic structure was too old.

Other sources of treatment visited by the respondents
The majority of respondents (N = 93), 46,5%, visited private doctors.Seven percent (N = 14) visited traditional heal ers when ill.Another great number of people 40.5% (N=81) preferred a hospi tal setting, whilst only 6% (N=12) had no preferences.

People preferred by the respond ents for home visits
The respondents were requested to men tion people whom they preferred to visit their homes.A few respondents, (N = 2), 1%, preferred to be visited by their neighbours.About (N = 8), 4%, of re spondents wanted the relatives to visit them; (N= 67), 33,5% of respondents preferred to be visited by "Onompilo" or village health workers; whereas the ma jority (N =82), 41%, of respondents pre ferred nurses' visits.About (N =3), 1,5%, stated that they would like to be visited by the social workers; (N = 14), 7%, of respondents preferred traditional healers to visit them at their homes; and (N = 2), 1%, of respondents did not have any choice of people.
See table 2 which forms the basis of this discussion.

PHASE II .PROFESSIONAL NURSES RESPONSES
It has been indicated earlier at the begin ning of this article that phase two of the results deals with the information ob tained from professional nurses staffing ten clinics.Therefore, the following sub headings discusses such results.

GENERAL AGE DISTRIBUTION OF RESPONDENTS
The minority of respondent's age (N = 1), 5%, ranged between 20 -30 years, whilst the majority of the respondents (N = 9), 45% were between 3 1 -4 0 years of age.See table 3 for age range of profes sional nurses who participated in this study.

THE MARITAL STATUS OF RE SPONDENTS
A few of respondents (N = 6), 30%, were single, the majority of respondents (N = 13), were married and only (N = 1), 5%, was a widow.

CLINIC STAFFING
About (N = 5), 25%, of respondents indi cated that the staffing of the clinics was good; few respondents (N = 4), 20%, commented that the clinic staffing was average; and the majority (N = 11), 55%,indicated that the staffing of the clinic

THE CLINIC WORKING HOURS
All the respondents (N = 20), indicated that they work 8 hours per day for 5 days and are on call for 24 hours a day.

THE CLINICAL WORKLOAD
The majority (N -10), 50%, felt that the workload was heavy (see Table 4) very heavy workload (N = 7), 35% and (N = 3), 15% had no problem with the clinic workload.See table 5 as the basis of this discussion.

THE PERFORMANCE OF DAILY WORK AT THE CLINIC
The respondents were requested to ex plain how they find the duties performed at their clinics.The majority of respond ents (N = 12), 60%, stated that they found it hard to perform well because of large numbers of clinic clients as against the number of clinic nurses, who were few.

THE REASON FOR NOT CO N DUCTING HOME VISITS
The respondents who did not conduct home visits gave the shortage of nurses and workload as the reasons for not vis iting the homes.

THE DISTANCE OF HOMES OF THE CLIENTS FROM THE CLINIC
A few of the respondents (N = 3), 15%, indicated that the homes visited were far from the clinic.

MODE OF TRANSPORT TO VISIT THE HOMES
A great number of respondents (N = 19), 95%, walked to the homes of the clients.

COMMENTS ABOUT HEALTH EDUCATION GIVEN TO CLIENTS
All the respondents (N = 20), 100%, indi cated that formal and informal health education was given to individual clients and groups.There were comments like, "...but clients show a very negative atti tude and if I evaluate them they know nothing, they continue giving birth at home, others with no toilets and vegeta ble gardens...."

FACTORS THAT EFFECT THE PROVISION OF PRIMARY HEALTH CARE
The distance between the respondents homes and the clinics is wide, the major ity of respondents (N = 78), 39% staying within 6 -10 kms range, with the majority of respondents (N = 152), 76% walking to the clinic.
The majority of respondents from profes sional nurses (N = 11), 55% indicated that there was shortage of staff in the clinics, which resulted in a heavy work load felt and a few homes, 1 6 -2 0 , visited in a month.

DISCUSSION OF RESULTS OF CLIENTS
Considering the distance between the respondents' homes and the clinic, only 17,5% stayed within the normal distance which is between 2Km and 5Km.Vlok (1991) states that "The PHC clinic must be accessible to the community, i.e. it should be within 5km of the consumers of health care" .The majority of the re spondents, 82,5%, stayed beyond 5Km but at different distances.
The respondents who used buses as the mode of transport to the clinic were 1,5%, the majority, 76%, walked to the clinic and 21% used taxis to the clinic; only 1,5% went on horseback to the clinic.
The clients who were visiting the clinic weekly were 10,5%; those who went monthly to the clinics were 31,5%; only 5%; of respondents went to the clinic at bimonthly interval, the majority 46,5%, went when it was necessary, to the clinic and 6,5% were going to the clinic for the first time during the interview.
The comments of medicines which got finished at the clinic was voiced out by 75,5%; 45% commended nurses for their good attitude; 3% was not pleased about the nurses' attitudes at the clinic and 1% commented about the clinic which was very far, 0.5% stated that clinic had water problems and 15% had no problems.
Looking at other places visited by the respondents when not feeling well the majority 87% visited both the private prac titioners and the hospitals, 7% consulted the herbalists and witch doctors and 6% went to the clinic only for treatment.
The 23,5% of respondents, stated that they wanted "Omompilo" to visit them at their homes; 11 % preferred medical doc tors to visit them; 7% said they wanted to be visited by herbalists and witchdoctors; whereas 41% stated that they wanted to be visited by the nurses; and 45% pre ferred social workers visit.
In conclusion, the vast majority of peo ple in these two rural districts are living far from the clinics, that is, health care services are inaccessible to the people in these localities The inaccessibility of health services in these districts is aggravated by poor or no roads to the clinics where the major ity of people, 76% walked to the clinic and only 1,5 used buses, 21 % used taxies and 1,5% used horseback.
Since it was stated before, that the two districts are predominantly rural and grossly underdeveloped, these districts experience all the disadvantages of un derdevelopment physically, socially, and psychologically.
The small percentage of people who vis ited the clinic bimonthly, 5%, as com pared to 46,5% which visited when nec essary explain that people stayed at their homes with their sufferings, probably because of financial constraints or inac cessibility of the health services.
The shortage of medicines in the clinic is a problem in delivering health care serv ices to the localities as many people re sorted to traditional healers who always had treatment for them.
The higher percentage of people, 41% who wanted to be visited by the nurses, and 33,5% by "Onompilo" when sick ex plains that the communities see health workers visiting them as an intervention in the inaccessibility of health services.
The researchers appreciate the fact that there are people who wished to be vis ited by faith -healers, traditional healers and social workers.WHO, cited in Searle and Brink (1984:142) state that "No less than 80% people in rural area and poor urban areas and poor neighbourhoods still lack access to any form of health serv ices".

DISCUSSION OF RESULTS OF PROFESSIONAL NURSES
Only 25% of the professional nurses in dicated that the clinics were well -staffed, 20% saw them as average in staffing whereas the majority, 55% indicated a gross -understaffing.This percentage of understaffing corresponds with the percentage of heavy to too heavy clinic workload which is 85%.
The World Health Organisation's defini tion for Primary Health care states that, "...And it does mean that essential health care will be accessible to all individuals and families, in an acceptable and afford able way, and with their full involvement" .(Who;1981 : 79-85).The staffing norms of Who state that a Registered Nurse at tends to 500 people.
The shortage of personnel is aggravated by the fact that nurses work 24 hours because of the on -call system practised in these clinics.
Each clinic serves many localities, the greatest number being more than ten lo calities as indicated by 40% of the re spondents.The number of the localities under one clinic explains the problem of home -visits which is not well done as reflected by the number of home -visits in a month, ranging from 2 -20 homes.
Another reason of poor home -visits are the conditions of the roads which are not good, as well as the distance of homes from clinics and unavailability of transport for the nurses.
This was explained by the greatest of percentages of respondents, 76% who walked to the clinic inspite of the distance between their homes and the clinic and only 24% took buses, taxis and horse back.
The unhealthy practises by the commu nity in spite of the health education given at the clinics by the nurses indicates the inability of nurses to visit the communi ties at their homes, because of shortage of personnel and the work overload.
PART III: RECOMMENDATIONS The following recommendations were made in order to improve the provision of primary health care in rural districts investigated in this study.

PRIMARY HEALTH CARE CENTRES
There is a need for building more Primary health care centres in Mqanduli and Elliotdale districts as to facilitate accessi bility of Primary health care to communi ties.Vlok (1991:264) states that "the PHC clinic must be accessible to the commu nity, i.e. within 5km of the consumers of health care".

INFRASTRUCTURE OF RURAL COMMUNITIES
Attention to the infrastructure in the com munity is to be paid especially roads which are poor, they need to be recon structed."Rural health services will be made accessible with particular attention given to improving transport" (African National Congress 1994:19).

TRAINING MORE VILLAGE HEALTH WORKERS
Recruitment, selection and training of vil lage health workers to establish formal and informal links between the commu nities and health care system, is neces sary."One approach is the use of the community health workers as the inter face between the resources of the com munity and those of the health care sys tem" (Bryant, 1988:144).According to Gray, Raudony, Martin, Bang & Cash (1990:92) the government of Mali did not pay much in salaries of the professional personnel because the village health workers who were utilised in the health services needed only incentives.

CLINIC STAFFING NORMS
Staffing of the clinics according to the Who staffing norms is needed, that is, one professional nurse to attend to 500 cli ents.

BUDGET FOR PRIMARY HEALTH CARE
Autonomy of the Primary Health Care should be considered so as to ensure that all the equipment needed for these serv ices is having its separate budget ex cluded from the hospital budget.

FURTHER RESEARCH
A further research study needs to be con ducted on the guidelines of the provision of RH.C. in rural areas.

CONCLUSION
The results of this study could be used by district managers, community health nurses and community doctors.

Table 3 The SAS System Age of Professional Nurses
were interesting and the clinic work was running smoothly except that there were no material and human re sources, "...they are interesting except that there is no equipment, we are impro vising all time..."\ "...the duties are man ageable and routine flows smoothly, the only problem is the shortage of equipment and staff..." and many others.Only (N = 1), 15%, of respondents stated that, "...the duties are not easy because most of the patients come from far homes and arrive late..." the numbers are high..." "...it's difficult because of overload, overwork and short age of staff..."; "...there is work overload as there is gross shortage of s ta ff..." ; and many others.About (N -2 ), 10%, remarked that they found duties heavy on certain days like Tuesdays and Wednesdays.A few of re spondents (N = 5), 25%, commented that the duties