The most northerly of South Africa’€™s nine provinces, Limpopo is a land of contrasts. It is a vast province of more than 120 000 square kilometres where the extreme poverty of local inhabitants is contrasted starkly by world famous game lodges where tourists and visitors enjoy the rugged landscape in fantastic luxury.

For most, life in the drought stricken province is harsh and the concept of ‘€œliving off the land’€ is a reality in this predominantly rural province. While paw-paw, mango and avocado trees on some of the world’€™s largest commercial vegetable and fruit farms buckle under the weight of their yield, poverty stricken local inhabitants survive using branches to stir up the earth in the hope of swatting locusts that are dried and eaten.

For these Limpopo residents, visiting a clinic or hospital could mean an entire day’€™s travel or waiting for hours for taxis to fill up. Waiting for an ambulance could prove fatal.

One of the poorest provinces in the country, Limpopo spends only 16% of its budget on health. This is in contrast to an average of 22% in other provinces.

Health spending in Limpopo last year totaled R637 per capita on health, almost 30% below the national average and about one third of Gauteng’€™s R1 668. And this figure has been decreasing.

It shows. Primary healthcare utilisation is very low, access to termination of pregnancy services is scant, ambulances are few, the HIV/AIDS programme is trailing other provinces, inequity is rife, malnutrition is endemic and staff turnover in the health sector is high.

HIV-related tuberculosis and lower respiratory tract infections are among the leading causes of death.

Although still unacceptably high, the province has managed to lower its infant mortality rate from 57 per 1 000 live births in 1994 to 37 in 2000. The infant mortality rate refers to the number of children under 12 months who die annually and is generally used as an indicator to measure the success of a health care delivery system. The under five mortality rate has also decreased from 83 per 1 000 live births in 1994 to less than 53 six years later.

There are high hopes that the recently announced increase in the rural allowances for doctors and nurses will attract health professionals to Limpopo.

Presently one doctor in the public sector must serve a population of 8 544 while a professional nurse must serve 1 001 people. Health and Welfare MEC Sello Moloto, a pharmacist, has admitted that the below average allocation for health is ‘€œan issue we are battling with’€.

He acknowledges that not enough is being spent on health, but points out that this is worsened by the ‘€œextremes’€ in the province.

‘€œWe have either very young or very old people. There is a very small, active middle class so our (provincial) budget is eaten by welfare and education,’€ he laments.

Compared with the rest of the country, Limpopo has recorded the highest expenditure on social grants ‘€“ 90% of the provincial social development budget. With almost 63% of people in Limpopo living in poverty most rely on old age pension and child support grants.

But some like Dr Paul Pronyk, director of the Rural AIDS & Development Action Research (RADAR) Programme based in Limpopo, believe that more money is not necessarily what the province needs.

RADAR is attached to the University of the Witwatersrand’€™s School of Public Health that has been working with Tintswalo Hospital, Limpopo’€™s second largest hospital, for the past 20 years. Pronyk has been based at Tintswalo, a rural hospital in Acornhoek, for the past 6 years. A softly-spoken American, Pronyk does not fit the archetypal image of a rural doctor. Dressed in chinos, trendy leather sandals and wearing a bandana on his head, Pronyk believes the fact that he has been at his post for six years is evidence that things are improving. He shares a bustling and cluttered office located a few metres from the hospital with several field workers, researchers and other doctors.

Situated in the former Bushbuckridge homeland area, Acornhoek is historically inhabited by Shangaan and Sotho-speakers.

Acornhoek presents an interesting profile of an area that suffers from significant population level factors that influence HIV transmission. These include mobility and migration; gender inequality (rape and gender based violence are common) and extreme levels of poverty and underdevelopment.

Historically people who now live in Acornhoek settled all the way up to Phalaborwa in the north and down to Nelspruit in the south, but in the 1940s and 50s people were forcibly removed to ‘€œhomelands’€ including Acornhoek. Today at least 750 000 people have settled here. About 25% of residents in the Bushbuckridge area are Mozambican refugees, chronically displaced as a result of the civil war. This has resulted in ongoing trans-migration between Acornhoek and southern Mozambique.

Also, 60% of the local men migrate to work, mainly to the mines and other industries in Gauteng and Mpumalanga, some working as labourers on Limpopo farms. Men often only return home twice a year and this has profound implications in terms of social and familial cohesion and gender relationships.

Visitors to Tintswalo Hospital in Acornhoek cross a small bridge over a railway track. It’€™s impossible to ignore ‘€œElite Funerals’€ an undertaking concern painted a cheerful purple and that is situated just to the left of the hospital’€™s main gate.

Tintswalo is a collection of outbuildings, some prefabricated, others with peeling paint. A few new brick buildings house the admin section. The buildings are linked by covered walkways that offer scant shelter when the heavens open.

Before 1994, the bridge divided Acornhoek. Below the line was declared Shangaan while above was Sotho. If you happened to be Sotho and fell ill, you’€™d be treated at Mapulaneng Hospital, about 30km to the south.

Pronyk explains that doctors and nurses refused to treat patients deemed to be from the ‘€œwrong area’€.

‘€œDoctors   wouldn’€™t care for you, nurses wouldn’€™t care for you, pastors wouldn’€™t minister to you in your language. You needed an ID to come in and it was a pretty dramatic thing at the time. Since transition it’€™s been a real struggle to define district boundaries and rationalize referral patterns based on geographical proximity rather on what ethnic group you belong to,’€ he explains.

Often those who are successful in managing regional structures in Limpopo are outsiders who don’€™t get caught up in old political squabbles.

Getting anything to grow in Acornhoek is almost impossible. The climate is extreme and water is scarce, a situation exacerbated by the commercial forestry industry in the area. The water infrastructure that does exist is mostly stand alone and not well co-ordinated. Apart from this, maintenance of this infrastructure is poor.

The result of poor access to water and food is borne out in the nutrition ward at Tintswalo that is often filled with children with Kwashiorkor or Marasmus, consequences of severe malnutrition.

The 2000 South African Health Review rated Limpopo as the province with the worst levels of stunting in the country – 34.2% of children between six and 71 months.

‘€œYou see this all the time here at Tintswalo Hospital and that was long before HIV was a problem,’€ Pronyk adds, pointing out that malnutrition and diarrhoeal disease are the primary causes of death in young children in the area.

He adds that these serious health issues are the same as those that plague sub-Saharan Africa yet they exist alongside the extraordinary wealth of the game farms. Much of this wealth isn’€™t necessarily trickling into the former homelands generally the poorer and more underdeveloped areas in the province.

Pronyk believes that the healthcare policy and infrastructure exist, but that the problem is delivery. He is careful to point out that government has attempted to deliver, in a very short time, services that would usually take place over five decades in developing countries.

‘€œThe issue is not simply access to money, but rather having systems in place to use it and account for it effectively,’€ he asserts.

Professor David Sanders of the University of the Western Cape’€™s School of Public Health agrees that implementation of health policy is very poor across the country.

‘€œThe physical infrastructure is there but the human resources infrastructure is lagging,’€ confirms Sanders who attributes the problem to policies not being explained to ground staff and ‘€œapartheid era’€ education at medical and nursing schools.

But there are glimmers of hope in Limpopo.

Primary health care nurses are currently receiving intensive training enabling them to deliver services equivalent to those offered by doctors in the rural areas.

This is crucial as the bulk of health services in the province are located far from urban centres and usually nurse-driven. Despite a lack of senior support at the Tintswalo hospital (between 80 and 90% of doctors are interns and community service doctors), Pronyk believes the quality of care offered is ‘€œexcellent’€.

About three hours northwest of Acornhoek is the provincial capital Polokwane. The economic hub of the province, Polokwane has an impressive physical health infrastructure with two huge hospitals, Polokwane Hospital and the national Health Department’€™s flagship, Mankweng, which is 25 km out of town.

A gateway to South Africa’€™s northern neighbours Mozambique, Botswana and Zimbabwe, the town accommodates the majority of the province’€™s urban dwellers.

Dr Zola Ntshona is an obstetrician at Polokwane hospital, a massive 450 bed teaching institution run in collaboration with the Medical University of Southern Africa.

A slight, but fiery woman, her gravelly voice is familiar to her patients who struggle to pronounce the Xhosa surname, preferring to call her ‘€œDr Zola’€.

Not afraid to speak her mind and declare her ambition to one day be the minister of health, she also harbours a dream of establishing a blues and jazz club in Melville, Johannesburg.

‘€œI used to work at Umtata General Hospital. Most of the time I was frustrated and angry. My patients were lying, two, three in a bed. When I arrived at Polokwane I was given the assurance that this would never happen in this hospital and it hasn’€™t,’€ she says.

‘€œYes, there are many frustrations here as well. The equipment is old, the knives and scissors are blunt and the referrals are never-ending. But then I hear we are sending back R3-million of unspent funds,’€ she says.

Dr Ntshona who qualified as an obstetrician while in exile in the United States, says her mother had always encouraged her to become a paediatrician. ‘€œI told her then that I loved children and did not want to see sick children. Now, I am delivering dead children on a daily basis,’€ says Dr Ntshona, who performs an average of three Caesareans a day.

According to Dr Ntshona, at least 50% of her patients are HIV positive.

Why is it so high? ‘€œPoverty, poverty, poverty!’€ she exclaims. ‘€œPoverty kills you in more ways than one. There is no food security in this province. When you ask people whether they want ARVs, they look at you and ask you when they will be given water.’€

Dr Ntshona is quick state that she believes that the provision of ARVs will bring hope.

Does the province have the capacity to dispense anti-retrovirals in line with Government’€™s plan?

The provincial government claims all eight regional hospitals and 33 district hospitals offer Nevirapine for the prevention of mother to child transmission. The programme is running at both Tintswalo and Polokwane hospitals, but uptake seems low.

‘€œPeople don’€™t want to know their status, so it’€™s a real battle. They tell me that they have so many problems already,’€ says Dr Ntshona.

Pronyk however says he has witnessed ‘€œa significant investment’€ in preparation for the ARV rollout.

Statistics

• Total population: 5,8-million
• 86% live in rural areas.
• 54,3% are women.
• 36,9% are aged
• 3 641 orphans
• TB cure rate: 62%
• Malaria case fatality: 51 per 100 000 population
• Immunisation coverage for children under 12 months: 67%
• Antenatal coverage: 82%
• Literacy rate for 20 years and older people was 63,1% in 1996.
• Unemployment rate:   46%
• GDP contribution: 4,2% in 1996
• Poverty rate: 65%
• Six districts, 43 hospitals and 477 clinics.
• 92% of patients are not on medical aid.
• 48 067 patients per public health sector pharmacist
• 60 084 patients per public health sector radiographer
• Infant mortality rate (the number of children younger than 12 months who die in a year) 37,2 per 1 000 live births
• Under five mortality rate 52,3 per 1 000 live births
• Major causes of death: Cardiovascular disease, stroke, Tuberculosis, lower respiratory infections and diarrhoeal disease.
• Vacancy rate in public health sector 41,2%
• 50% of vehicles (including ambulances) in for repairs
• Teenage pregnancy: 16,4%

E-mail Anso Thom