Emergency care in Africa: There is no free lunch…

Let hunger be ranked first because if you are hungry you cannot work! No, health is number one, because if you are ill you cannot work! – Discussion group ranking; Musanya Village, Zambia1

The basic economic premise states that our wants are unlimited but our resources to obtain our wants are limited. On an individual level this implies that we are constantly prioritising desires in order to afford the most important ones (I’m using the word desire as an umbrella term for needs and wants). Sometimes we prioritize in a conscious way through budgeting, negotiating with our partners, saving for large expenditures or investing. At other times it’s automatic and we are largely unaware of the process. These ‘automatic’ decisions are based on beliefs and values, rooted in our culture, community and environment.

Every so often the desires are mutually exclusive and choosing one option means giving up on another, thus we make trade-offs or sacrifices. Our willingness to make a trade-off depends on the perceived benefit of the chosen option. The trade-off is not always financial, convenience or time might be valued more than cost. If the benefit is unknown or uncertain, the trade-off is viewed as risky and not worth the effort or cost.

Economics 101

  • Humans have unlimited needs and limited resources
  • We can’t have everything that we need or want
  • What you are willing to give up depends on what you get out of it (the benefit)
  • The decision is not always easy

fsdfs

The relation between income, benefit and trade-off can be seen in the triangle. Income represents the ability to raise financial resources to pay for care and it includes savings, obtaining a loan, etc. Benefit refers to treatment outcome and adequacy of emergency care. The trade-off is the sacrifice made to afford the benefit.

For people living in Africa the benefit is murky and the cost high. Ambulance services are rudimentary limiting the ability to obtain care at the site of injury, transport to definitive care or care during transit. Upon arrival at the health facility, Africans are burdened with out-of-pocket payments prior to stabilisation, resuscitation or basic care. In addition, due to low government investment, healthcare facilities create alternative funding methods to afford supplies, staff etc. These methods generally involve requesting (demanding) supplementary payments, known as informal payments, bribes or gifts. Paying these allows the patient to skip the queue, get a bed and receive care. Other cost considerations are the ‘hidden’ or indirect costs including the travelling costs, transportation, carer accommodation, waiting time and lost income opportunities.

Sadly, these expenditures are incurred to obtain care in facilities where infrastructure is lacking. Running tap water, electricity, basic equipment or medication are not a given. Also healthcare providers are often not well-equipped with basic emergency care skills.

Trade-offs are made in order to afford the care and may include

  • Reducing the household’s food consumption and budget
  • Selling a girl child into underage marriage
  • Selling assets such as livestock or dwelling
  • Removing children from school
  • Child labour
  • Selling foodstuffs like maize
  • Taking out loans at a high interest rates
  • If there’s more than one patient, prioritising care for one member at the expense of another

Basically, accessing emergency care requires massive trade-offs for a very uncertain benefit. An alternative is to not access care and hope for the best. This becomes a reasonable option when one considers that each year approximately 25 million Africans are pushed into poverty due to healthcare expenditure. Catastrophic health expenditure is calculated in various ways; however most methods exclude informal, indirect costs and the depletive sacrifices. The entire household suffers the repercussions of financial ruin.

tradeoff-for-blog

Emergency care benefits only the patient. The household makes the sacrifice so that one person can potentially benefit. It’s further complicated due to the urgency, emergency care requires time-critical interventions and delaying care can be devastating. The decisions taken shortly after a traumatic incident are probably not well-thought through, rational or informed. Predicting the required sacrifices is confounded due to different types of cost, changing costing structures and a whole lot of unknowns. It’s a tough call.

When we are involved in developing and strengthening systems in other communities than our own, we need to be aware that as outsiders we don’t understand the daily reality of those we serve. We can’t assume the local needs, wants, trade-offs and norms. Our observations are clouded by our own bias. This can be overcome by establishing ways to enable community participation that allows the implementation of sustainable and locally owned interventions.

On another level, advocacy for the greater good of accessible care includes continued lobbying for universal access to healthcare. Emergency care, especially out-of-hospital systems can significantly reduce cost as a barrier to access care.

                        For me a good life is to be healthy1 – Old Man Ethiopia

This blog includes some aspects that I addressed at the BADem symposium regarding the trade-offs that people make in Africa to access healthcare.

  1. Dying for change, poor people’s experience of health and ill-health. World Bank Study 2000. www.worldbank.org/poverty/voices

 

 

 

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Gugu Zulu: Another story about the barriers to access emergency care in Africa

In Africa, surviving serious illness or injury is like participating in Survivor.  In order to survive, people need to outwit, outlast and outplay the health system.

The death of the fit, apparently healthy 38-year old Gugu Zulu made news headlines. The events leading to his death are tragic. Zulu, a well-known South African personality died during the Trek4Mandela Kilimanjaro expedition that raises awareness for the #keepingagirlchildinschool movement.

Details on the descent that were supposed to improve Zulu’s condition and allow for further care are sketchy. The timeline in the media reports differ, some saying that it took 4 hours to cover 32 km on a bicycle stretcher, others say 8 hours.  Still, how terrifying the experience must’ve been for his wife that remained at his side throughout the journey.  Despite discrepancies in timelines and the exact cause of death still pending autopsy results, it appears that the lack of timely access to further emergency care was a contributing factor leading to his death.

Photo%20of%20the%20Week%20(15.10.26)%20Kilimanjaro%202011%20porter%20w%20stretcher

Example of the bicycle stretchers used in Kilimanjaro

 

Gugu Zulu required urgent emergency care, and he died because he couldn’t get to care. Sadly, the story repeats itself in various African settings on a daily basis where people frequently die because of health system failures. They die because there is no available transport to the health facilities, which are too far apart and ill-equipped.  They die because care is unaffordable and healthcare staff are not trained to deal with emergencies.  And they die because there are no out-of-hospital care systems (see earlier blogs on access to care and EFAR).

In Zulu’s case (and depending on the route taken) the closest appropriate facility was about 50km away from the National Park. The Kilimanjaro Christian Medical Clinic (KCMC) is a 600 bed facility and it has an emergency care department that doubles as outpatient clinic. It serves the healthcare needs of 15 million people. Time, geographical accessibility and method of transport appears to have been bigger issues contributing to his death than only the availability of an appropriate facility.

The effectiveness of emergency care is dependent on time. The following definition for emergency care was agreed upon at the African Federation for Emergency Medicine (AFEM) consensus conference in April this year: ‘emergency health conditions are those requiring rapid intervention to avert death or disability, and those for which treatment delays of hours or less make interventions less effective.’

Obtaining care for emergency health conditions are a challenge in Tanzania.  The country has a doctor to patient ratio of 2 per 100 000 people. Another constraint as highlighted in this case is the lack of formal out-of-hospital services. Formal systems would facilitate the delivery of care at site of injury/illness and continued care during transportation.

That said, Tanzania is one of the very few African countries that has emergency medicine residency and emergency nursing programmes. Local emergency care practitioners have been supported by international faculty to share expertise.  In 2011 the Emergency Medicine Association of Tanzania (EMAT) was formed.  This organisation works closely with the government to prioritise emergency care and to development emergency care.  EMAT and AFEM works closely together to advocate for the unrestricted access to emergency health care.

Ensuring unrestricted access to emergency care by developing sustainable systems requires awareness and funding.  Sadly, emergency care does not yet share a similar status to that of high-profile diseases like HIV, TB and Malaria.  People are aware of the high-profile diseases and thus they are well-funded and promoted.

The death of Gugu Zulu begs the important question, can global stakeholders in health care continue to ignore the importance of developing strong emergency care and out-of-hospital care systems?

As Olive Kobusingye says,

IMG_3364ok

In future, the stories told in Africa will depend on how well we advocate and continue building emergency healthcare systems.

P.S. I would like to share an idea that we’ve been talking about since the WHO Basic Emergency Course last year. The idea is to travel from clinic to clinic through some countries that has ties with AFEM by cycling and/or using the method of transport that the different communities would use to access care. The purpose is to raise the awareness of how hard it is to obtain emergency care.  I would welcome some ideas on how we could make such an undertaking work. 

Further reading

Gugu Zulu

https://www.ecr.co.za/news-sport/news/small-medical-facility-needed-mount-kilimanjaro-letshego-zulu/

http://www.msn.com/en-za/news/localnews/gugu-zulus-wife-pleads-for-mini-medical-facility-to-be-erected-on-mount-kilimanjaro/ar-BBuZ6G2?li=AAaxc0E&ocid=spartandhp

https://www.researchgate.net/profile/David_Irwin3/publication/267102897_A_Retrospective_Study_of_Acute_Mountain_Sickness_on_Mt._Kilimanjaro_Using_Trekking_Company_Data/links/54da49c70cf233119bc29c23.pdf

http://www.iol.co.za/motoring/industry-news/gugu-zulus-death-is-a-blight-on-tanzania-2049525

http://www.iol.co.za/motoring/industry-news/kilimanjaro-tragedy-the-inside-story-2047032

Emergency care

http://www.afem.info/

http://www.emat.or.tz/

http://www.kcmc.ac.tz/index.php?q=casuality

http://www.epijournal.com/articles/167/hendry-sawe-young-leaders-bring-fresh-energy-to-african-emergency-medicine

Making EFAR stick

There is no question about the need to develop better emergency care systems in low and middle income countries (LMIC).  However, the significant barriers to developing the systems may appear daunting and unattainable.  This is partially because any emergency care system need to start within the community or wherever incidents may occur, continue with care during transportation of the patient and allow early appropriate treatment at a healthcare facility.

Developing a system across the above continuum is complicated in LMIC’s.  It is expensive and requires the presence of enabling factors external to healthcare.  Examples of the enabling factors include sufficient technology and infrastructure such as telecommunications and roads.

As mentioned in a previous blog, an alternative and/or parallel strategy is to enhance the ability of the community to respond during an emergency.  This is feasible even in areas where healthcare facilities are scarce, roads non-existent and telecommunications lacking.

Developing community responder systems are based on a fundamental principle that developing a basic capacity to render emergency care can be simple, efficient and cost-effective. To ensure sustainability, the following should be considered:

  • Mismatching

The trained members need to either live or work within the community.  This might sound obvious, but often it is not.  Also, training economically active people may result in these people not being within the community most hours of the day.  Design should thus involve training the employed, pensioners, people who work within the community (they might even travel from outside the community to work there) and the unemployed.

  • Managing expectation

Training the unemployed and even the employed may lead to another problem: expectation.  People might participate with the expectation of getting a job or advancing their career and receiving job opportunities.  Expectations needs to be managed by being upfront about what the community responder program is about and what is required from trained community members.

Community members may experience a downer after the initial high of being equipped with life-saving skills, or they may be traumatised by exposure to critically ill and injured people.  Early attention to ways to keep members motivated, engaged and supported emotionally is required.

  • Integration of formal/informal system

If there is a formal ambulance system, the informal (community) and formal systems should be integrated. Community members may feel intimidated by formal emergency care practitioners, and the formal practitioners may not help the situation.  This seems to be a major difficulty when implementing community systems.

  • Equipment and innovation

The other barrier to sustaining community first aid responder programs is the availability of equipment and stock, including splints, bandages and gloves.  In LMIC’s even in healthcare facilities these are scarce items.  Yet if it was freely accessible, it may be impractical to carry stock around at all times.  This makes a case for training the community members ways to improvise and innovate.

A deterrent to continued participation is the cost of phones and airtime for telecommunications with formal emergency services and/or hospitals.

  • Other

Concerns from the community may include if and how good Samaritan legislation would protect them, the need for documentation and remaining current with training and skills.

one tier system

The two tier system.  Mould-Millan et al. 2014

Further discussion

Emergency care competes with an existing bias from foreign funders to fund vertical disease programs, with early and easy measurable outcomes.  For policy makers there is competing budgetary priorities and poor economic growth.

So when advocating for the development of emergency care systems, we need to motivate for cost-effective, easy to implement systems whilst simultaneously developing the more expensive formal systems. Formal systems would include tertiary training, specialization of medical practitioners etc.

Training community volunteers to provide early emergency care and stabilisation can save lives and prevent disability.  The training provided and subsequent informal system needs to be context-specific, defined by the community and their needs.  The greatest challenge after obtaining funding is integrating the participatory community system within formal more bureaucratic systems.

Read more

Jayamaran S, Mabweijano J, Lipnick M, et al. First things first: effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda.  PLoS One 2009; 4: e6955

Mould-Millman NK, et al. AFEM Consensus Conference, 2013.  AFEM out-of-hospital emergency care workgroup consensus paper: advancing out-of-hospital emergency care in Africa – advocacy and development.  African Journal of Emergency Medicine. 2014; 4:90-95

Sasser S, Varghese M, Kellerman A, Lormand JD. Prehospital trauma care systems. Geneva: World Health Organisation.

Tiska MA, et al. A model of prehospital trauma training for lay persons devised in Africa. Emergency Medicine Journal. 2004; 21:237 – 9

http://www.who.int/bulletin/volumes/84/7/editorial20706html/en/

 

 

Community Innovation… Volunteer Ambulance turns 21!!!!

Twenty One and still going strong! The Houtbay Volunteer Ambulance Service (HBVEMS) is a community based volunteer service working mostly within the indigent communities of Houtbay and immediate surrounds.

Niche volunteer group

What sets the paramedic volunteers apart is the nature of the volunteer. Qualified and registered people who can perform exactly the same work for monetary gain yet choose to perform it for free.  Just to reiterate….HBVEMS performs unpaid, non-compulsory work in their leisure time using some of their own resources within the organizational setting of a volunteer ambulance service that is a registered legal entity.  Some members are full-time paramedics and yet they spend leisure time working for-free shifts.

Volunteer paramedics are exposed to same occupational risks as fulltime paramedics, including but not limited to ambulance crash whilst responding, working in high conflict areas, exposure to Tuberculosis, HIV and other infectious disease.

It takes a fair amount of courage for volunteers that are from non-healthcare environments to expose themselves to the above risks and commit to emergency services. Volunteers who does a 8-5 job followed by a Friday night shift on an ambulance, that live an hour away and happily drive through to work a 12 hour shift, the students that could be partying but are working a shift, there are sacrifices to volunteer!  These volunteers allow the service to exist and they create a strong foundation for future growth.

HBVEMS provides a testing ground into the system and a few volunteers have given up on their previous occupations to become full-time paramedics or pursue careers in health care including nursing and medicine.

In the beginning

The ambulance service was founded by local community members out of a perceived need for expedient emergency care.   Prior to the HBVEMS, the ambulance response time for a priority one case (life threatening emergencies) measured 35 minutes from the Retreat Area where the closest ambulance was stationed.

A group of community members proactively tackled the problem. They searched for ideas and the framework for the organizational structure was adapted from a volunteer student ambulance service, Harpurs Ferry at Binghampton University, New York.  The first volunteers took eight months to complete their basic training and in January 1994 eleven persons qualified as Basic Ambulance Assistants.

Response times prior to HBVEMS

Due to mountains surrounding Houtbay, it is relatively isolated from the rest of Cape Town. Access and egress is restricted; roads are congested with little space to manoeuvre to make way for an ambulance especially when coming over the mountain necks. This impedes on the ability of ambulances outside of Houtbay to respond in time.

The principle indicator of service performance for the Emergency Medical Services (EMS) is response times. This creates a strong case for community volunteer ambulance services in specific areas that can assist over peak times notably for priority calls.  Obviously boundaries need to be set and since 2004 this has been contractually formalised between the HBVEMS and parent body Western Cape EMS and are renegotiated annually.

The typical HBVEMS volunteer

In 2013 the underlying motivation of HBVEMS to volunteer was studied. The Volunteer Functional Inventory was used.  The inventory is based on the theory of functional analysis and has been used in various volunteer settings.  It is based on the hypothesis that although volunteers perform the same functions, they have different underlying motivations to perform the functions.  Two main motives emerged for the HBVEMS: Practising knowledge, skill and abilities that may otherwise not be applied and to express important humanitarian values and concern for others.

The typical member is 29 years old and more likely to be male. Most volunteers are full-time employed and have a degree. The majority does not live in Houtbay.

57% of the HBVEMS also volunteer at other organizations including Volunteer Fire Fighting, NSRI, Life Saving and other volunteer ambulance services. These organizations share a few characteristics:  They all require specialised skill training, a high time commitment, physical fitness, set criteria to volunteer and all carry high personal risk.

The importance of services such as HBVEMS in the South African health sector

According to the Ministry of Health (2012) the South African health care system is on the verge of collapse and in desperate need for innovative action.   The growing demand for health services as result of population growth and the burden of disease are central to this message of impending doom.  The state contributes approximately 40% of all expenditure on health with the public sector delivering services to 80% of the population.

Volunteer Ambulance services can fill a gap and be part of the solution within the EMS system. As mentioned earlier, the principle indicator of performance is response times.  The challenge for operational efficiency is to maximise the fleet over peak periods. The peak periods coincides with times when the volunteers are typically operating.  In 2004 it was estimate that volunteers in the Western Cape made up approximately 30% of any shift in the metropolitan district of Cape Town.  This increases fleet and reduces response times over peak periods.

Response times are prolonged by travel distances, inadequate roads and street markings. Although it may sound trivial, after years of responding within Houtbay’s informal settlements most volunteers don’t need maps and have a good idea of where and how to approach the trickier areas.  Maps and GPS do not show potholes and obstructed routes.

Houtbay and its informal settlements Imizamo Yethu and Hangberg geographically represent a microcosm with its unique socio economic representation of the diversity in South Africa. The informal settlements are a result of urbanization; most residents living in corrugated iron shacks and self-constructed shelters; the majority of HBVEMS calls originate here.  It is estimated that Imizamu Yethu has a population of 20 000 people living within 18 hectares and the 2011 census demonstrated a 51% growth in Houtbay since 2001.

Within the informal settlements there are complex social problems, community conflict is rife and there are high levels of violence. Injuries account for 18.1% of the burden of disease in the province with injury related mortality in men ten times the global average.  (Women: seven times the global average).

Since the inception of the HBVEMS the level of acuity of patients in the Western Cape has risen sharply. This has not been met with an increase in capacity and the demand completely outstrips the capacity.

I sourced some data from the annual report of the Western Cape DOH to demonstrate the capacity and demand mismatch. Note that this is by no means a complete representation of all their performance indicators!

2009 2011 Demand/Capacity
Total population Western Cape 5391765 5634323 Demand
Percentage of Health budget allocated 5% 5% Capacity
Performance indicator  
Rostered Ambulances 230 132 Capacity
Patients transported 404134 446566 Demand
Total ambulance responses 373940 519228 Demand

I excluded the response times for priority calls, an achievement worth mentioning is that the EMS response times for priority calls has dramatically improved possibly due to the implementation of the CAD system.

Capacity concerns

The rostered ambulances are calculated as hours by ambulance personnel worked x hours in a day x two personnel.  It takes into account average number of ambulances available per hour and absenteeism due to sick leave, leave or training.   It is concerning that the number of ambulances has decreased and a contributing factor could be the vacancy rate.  EMS has the highest vacancy rate in the Western Cape DOH.  According to the annual report 32% of the operational posts in EMS are vacant.

It also appears that the funding is insufficient to meet rising demand; this is unlikely to change soon.

The conclusion is that the provincial services have a problem supplying sufficient ambulances per shift to match the demand.

A solution

When operational HBVEMS reduce response times in Houtbay and provides EMS with trained volunteers. This immediately increases the capacity at no cost to EMS.

The volunteers carry their own expenses for annual individual registration, annual public driver permit, indemnity and insurance cover. Most volunteers use their own jump bags containing equipment purchased by the volunteer.

The solution that services such as HBVEMS provide to the bigger health sector is that they provide a basis to develop and recruit future paramedics for the health sector whilst simultaneously increasing the capacity of an overstretched public health sector.

The above is the by-product, HBVEMS exists is to offer patients better care with quicker response times. Having responders within Houtbay allows for faster response times especially during life-threatening emergencies where every minute counts.

Ultimately HBVEMS saves lives.

Congratulations on your 21st HBVEMS, hopefully the first 21 years was only the beginning!

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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
Availability
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.

Accessibility
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.

Accommodation
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.

Affordability
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
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.

Note
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.