Access to Care: Imizamo Yethu 2004 – 2014

As member of the Hout Bay Volunteer Ambulance Service (HBVEMS), I’ve witnessed a shift in the access to (emergency) care within the informal settlement Imizamo Yetu (IY). Most of our calls originate within IY and by applying the 5A’s (Pechansky and Thomas, 1981) the improvement in each dimension of access to care can be highlighted. Same theory, different case scenario to last time.

Background into the Hout Bay and IY community
Hout Bay; a suburb of Cape Town lies 20km south from the central business district on the western coast line of the Cape Peninsula. Despite apparent close proximity to emergency medical services, Hout Bay is relatively isolated from the rest of Cape Town due to mountains surrounding it to the north, east and south. Access and egress is restricted to three two lane roads via the mountains.

The majority of the emergency response calls originate from the informal settlements Imizamo Yetho and Hangberg. Here most residents live in corrugated iron shacks and other self-constructed shelters with limited infrastructure such as plumbing, roads, water, sanitation, health care and electricity. Imizamo Yethu is a particularly dense settlement with approximately 20 000 people living within 18 hectares. The 2011 census estimated that the population of Hout Bay has increased 51% since 2001.

Health care in South Africa
The South African constitution is a human rights-based constitution and is one of few global constitutions that include socioeconomic rights within the constitution. It makes the right to health care in South Africa a constitutional right. Despite the progressive constitution South Africa remains a highly unequal society with informal settlements like IY making up approximately a fifth of all urban population.
The health system is divided into private and public health sectors with the public health sector serving the majority of the population. South Africa’s public health spending is approximately 3.5% of the GDP.

There are various indicators to determine a countries wealth, one indicator are quality of life; this is diminished within informal settlements due to susceptibility to environmental health issues, complex social problems, community conflicts with increased levels of violence and poor access to health care to name only a few.

Changes in the 5A’s in IY 2004 – 2014
The change in Police Station location now on the doorstep of IY has provided IY residents with improved means to call for help and shelter whilst awaiting the arrival of an ambulance. Ambulances can access the patient easier without barriers like lack of roads, road maps, marked roads and house numbers that impacts on response times from call out until arrival on scene. It is appreciated that this is not a core function of the Police however it has improved access to emergency care for the community.

Hout Bay Fire Station (2006) that literally neighbors both the Police station and IY. The Fire Services in Hout Bay has played a substantial role to increase accessibility to care. The Fire Services provides 24hour access with trained staff that can render care, stabilize and “hold” patients until an ambulance become available. The fire services has responded to medical calls within IY and has on numerous occasions assisted HBVEMS to render care, access difficult locations and help in multiple patient scenarios. Yet again access to medical care is not the core function of the Fire Services.

According to the Western Cape Department of Health statistics there are predictable peaks in emergency response calls over weekends and public holidays. The department has acknowledged that there are resource restrictions in meeting the increased demand during peaks periods. Resource restrictions include vehicle; fleet availability and the highest vacancy rate in the department. In 2012 an aggressive overtime strategy in attempt to meet key response times targets failed when funding was exhausted within the first quarter of the financial year and the challenges in meeting the demand remains.
How can this be good news for IY? The good news for IY residents is that these are typically the times that HBVEMS are operational and as such the supply and demand issues experienced by the rest of Cape Town over the peak periods has little/less impact on the response and waiting times for the IY community.

Area for growth
There are limited taxis from Wynberg and Retreat to IY at night and if patients are discharged after hours; they wait at hospital until the following day. More accessible and affordable means to travel to hospital for routine cases and to travel back from hospital after discharge can decrease pressure on the overstretched ambulance services allowing them to focus exclusively on priority calls and not patient transport calls. It would be exciting to see the mycitibus covering the Wynberg route.

Taking into account the population growth and relative isolation, perhaps the time has come to consider a 24hour day clinic in Hout Bay.

The South African Triage Scale has increased accessibility to care. Prior to 2004 there was no accepted triage scale in the country. The aim of any triage scale is twofold; firstly to expedite emergency treatment for patients with life-threatening conditions and secondly to ensure that persons requiring emergency treatment are categorized according to severity which allows for time-critical intervention. Triage has increased access to care for the IY community by allowing for seriously injured or ill persons to be transported to the appropriate facility. Depending on the triage score and discriminators it allows the bypassing of smaller facilities to more appropriate facilities. Triage impacts on the utilization and dispatch of secondary resources.

Technology; the mobile phone industry has grown dramatically over the past 10 years and it is estimated that approximately 75% of low- income groups in South Africa owns a mobile phone. This enhances the ability of IY residents to call for help from home. Western Cape EMS and Dimension Data are in the process of rolling out a sophisticated data-capturing technology that will rely on mobile phone technology to locate patient address.

Area for growth
Geographic accessibility remains an issue. Hout Bay’s relative isolation from the rest of Cape Town due to mountains and access and egress issues are even more pronounced in IY with complicated access due to narrow roads, poor infrastructure, unmarked streets, and houses are not numbered, temporary houses/ shacks, no streetlights. As such any improvement in the infrastructure of IY would increase accessibility to care.

Most serious cases originating in IY are taken to the district hospital in Wynberg (Victoria hospital). The peadiatric wing of Victoria hospital was reopened in January 2014 after receiving a R10 million upgrade and extensions that allow the facility to now care for and stabilize critically ill and injured children. There is now overnight facilities for parents with their child and other than the obvious benefit in patient care; from a transport perspective for parents this implies substantial cost –saving and time. They need not travel as far to Red Cross Children’s hospital, nor consider the cost of transport after hours from Victoria (or Red Cross) back to IY.

2006 demonstrated a milestone for the region’s paramedic profession with the graduation of the first group of National Diploma Paramedics in the Western Cape and since then the amount of Advanced Life Paramedics has grown. The course remains a contentious issue amongst many within field and the advantages and disadvantages are not for discussion here. My focus is on how this impacts and improves access to care for the typical IY patient. HBVEMS membership has grown with paramedic students wanting more hands-on experience prior to qualifying. Once qualified some of these practitioners has remained members and has continued contributing to HBVEMS. This benefits the IY community as they have access without delay to an advanced qualification which impacts the available level of care rendered. IY and Hout Bay are exceptionally fortunate in this regard. In addition the influx of students provides HBVEMS with access to the newest guidelines, standards of care and practice fresh from the tertiary institutions, which again has an impact on quality and level of care rendered.

Area for improvement
The operating hours of HBVEMS creates a gap within off peak times and times when there is no staffing for the Ambulance; fortunately there is the Fire Services and Western Cape EMS. At times when HBVEMS is non-operational EMS has placed an ambulance within Hout Bay. 10 Years ago there was no Ambulances standing by from Hout Bay. 

As mentioned previously the hours of the clinic is a constraint in accessing care; as is the capacity of the clinic to manage emergencies.

The Public Health Sector provides care for free thus the IY community has access to free services.

An indicator of affordability to access care is the cost to call for help. 10177 are a toll free number. There has been pressure to roll out a single toll-free emergency number for South Africa which integrates Police, Fire and Ambulance. Consistent progress has been made to establish a regional interdisciplinary call taking center within the Western Cape. This will enhance communication between services and result in resources distribution as needed, increasing capacity for all involved. This will impact on access to care for IY in 2014.

Acceptability indicators are not typically measured or reported and I’m not sure if it has improved for IY residents.  Beyond IY; the right to health care in South Africa is a constitutional right. The two tiered private and public system are inequitable and private health care remains inaccessible to the majority of the population. It has been mentioned in some sources that whilst access to public facilities has increased, the quality of care within the facilities has continued to fall.

According to Penchanksy and Thomas the five dimensions are only as strong as the weakest link; it implies that access cannot be improved if it is not across all dimensions including equity under the heading of acceptability.

In summary
I think it’s fair to say that access to care for the IY community has improved over the past ten years. Some of the improvements were probably unintentional such as moving the Police Station and the commissioning of the Fire Station.
I’ve been involved in some access to care studies and in retrospect a quick analysis using these headings during those studies would’ve provided value and possibly different insights. I’m eager to refine and apply these dimensions in future.

Due to the interrelations of the dimension my attempts at separating some factors was a mission. Any comment on how you would’ve classified it differently or points that I may have missed would be much appreciated.

Please note that the Western Cape Department of Health and EMS Operational Management have implemented highly successful strategies other than the overtime strategy mentioned. Some of these strategies include changes to shift system, changes to dispatch systems, appointment of fleet managers. The Department met their response time target of 15 minutes for priority calls within urban areas in 2012. There has been changes to the procurement process of vehicles in attempt to reduce turnaround time when vehicles are serviced and the knock on effect that longer servicing times has on fleet size. All of these impact and improve access to care. Mentioning the failed strategy is to highlight human resource restrictions in meeting demand and how HBVEMS assist and not a criticism of the strategy.


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