Dr. Karl le Roux, Principal Medical Officer at Zithulele Hospital (Eastern Cape). He is passionate about maternal and child health, breastfeeding and rural medicine. He is running a research project following up 500 mothers and their children for 1 year from January 2013. He served as Chairperson of RuDASA from September 2008 to September 2012.
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There is a general perception amongst academics, government officials, non- governmental organisations (NGOs) and the South African public at large that as a country we have good policies, but that we implement these policies poorly (1). In fact, one of the fundamental issues that we need to address as a country is to try to understand why, despite good policies, adequate amounts of money and more skilled workers than in most parts of Africa, South Africa performs so badly (especially in health and education) when compared to other African countries. The tendency of policy makers is to blame downstream factors, such as general lack of capacity , “lazy managers” or “obstructive clinicians”,  which to some extent is reflected in the research (2).

But my job today is to describe to you what it is like being at the rural coalface. Though I have loved working in a rural hospital for the past six years, it has also been one of the toughest periods in my life.  Working in rural medicine is a bit like sitting on a roller coaster: a combination of enormous challenge and reward, feeling exhausted and exasperated and then inspired and invigorated, seeing dignity and strength in patients, but also sadness and unnecessary suffering and death. One always feels stretched and one often feels as if one is hanging on by one’s fingertips. The rural idyll is something that might be experienced on weekends off, but the reality of the working week is that on the whole one is extremely busy and constantly rationing care and doing the best one can with the resources available.

It therefore might come as no surprise to the reader that at the coalface “policies” are more often seen as a hindrance than a help to the delivery of health care. Policies or programmes are often imposed from above, with no consultation and with little understanding of realities on the ground. There is usually poor data collection and feedback, lots of time-consuming and unnecessary paperwork and a focus on irrelevant aspects of care with the neglect of critical aspects. I need to make clear that good, realistic and helpful policies are greatly appreciated by most clinicians working at primary care level, as they improve care and the health of our patients (for example the new antiretroviral treatment guidelines).