GQEBERHA, South Africa – The remote, seaside village of Nqileni lies tucked away between rolling green hills and the bright blue Indian Ocean in South Africa’s Eastern Cape province. It’s a nearly four-hour drive to the nearest major city on rough roads.
Many elderly people here say they’ve never seen an ambulance. Access to emergency healthcare is so bad in Nqileni and neighbouring rural communities that it was the subject of a 2015 national inquiry.
Meanwhile, to reach the nearest hospital, people in Nqileni must hike through the hills before reaching the wide Xhora River. There, they pay a fee to be rowed across, often in rickety wooden boats. Once on the other side, it’s another trek to the tarred road where people must pay again to climb onto local taxis to reach Madwaleni Hospital.
In June, when vaccines became available here for the area’s elderly people, that’s precisely where Nqileni’s COVID-19 vaccines were – through the hills, across the river, down the road and in the hospital.
In surveys, about 7 out of 10 adults in South Africa say they would take a COVID-19 vaccine. Still, as of mid-December, only about 45% actually had. How much of the gap is because of hesitancy and what proportion is logistical is hard to say, David Harrison, the CEO of philanthropic foundation DG Murray Trust, said in September. Harrison leads a national team working to increase vaccine uptake.
In a country where almost half of all people are unemployed, even the cost of a R20 (about £2) taxi ride to and from a vaccination site could be enough to put many off getting a free jab – and that price in rural areas is often steeper.
“The tyranny of distance” is how Western Cape health department’s chief director Gio Perez has described the way vast distances between sparsely populated rural communities and health facilities make care harder to access and more expensive to provide. Historically, areas like these have also been under-resourced in health budgets and workers.
Still, some of South Africa’s rural areas are charting better COVID-19 vaccination coverage than many towns and cities.
“What has been surprising from the beginning is how well the uptake has been in the rural areas, particularly in older people in rural areas compared with young, urban populations where one would anticipate easier access to vaccinations,” South African Health Department Deputy Director-General Nicholas Crisp told VICE World News.
Publicly available COVID-19 vaccination statistics do not distinguish between urban and rural areas. As of September, the country’s 22 districts with the lowest vaccination coverage were a mix of heavily-populated urban centres and rural communities – many with historically poor-performing health systems. Still, 15 districts home to some of the largest numbers of rural areas have delivered, on average, about 553,000 doses each since the May start of the rollout, putting them on par with some small towns and cities on the outskirts of Gauteng but just an hour from downtown Johannesburg.
To do this, South Africa is using non-governmental organisations to stretch the capacity of rural hospitals and clinics to take vaccinations deep into distant communities. But experts warn there may be an unexpected price to pay.
About a decade ago, healthcare worker Lynne Wilkinson helped pioneer HIV patient collectives in Khayelitsha, one of Cape Town’s many townships – often cramped and underdeveloped areas to which Black, Coloured and Indian South Africans were forcibly removed to during apartheid.
Today, these patient collectives help streamline how some people collect their medications, whether that’s at a clinic, a community hall or even a neighbour’s home.
Changing the way you provide healthcare isn’t rocket science, Wilkinson says: Communities have to be involved in thinking about, mobilising around and providing healthcare.
“Most important is bringing healthcare as close to people's homes as possible,” Wilkinson explains. “Especially in rural areas where transport is expensive, the opportunity cost of leaving your home, of childcare, of missing out on farming… is high. You can’t afford to go and spend the day getting to a hospital for a vaccine.”
She continues: “You need to make it easy for people to take up the service you're delivering at no huge personal cost.”
In June, Wilkinson was the acting director of Nqileni’s health and education nonprofit, the Bulungula Incubator, when COVID-19 vaccines became available here several weeks after immunisations began in major cities. The incubator serves about 5,000 people in Nqileni and three other villages.
“We knew we had to get the vaccines provided in the villages,” Wilkinson remembers. “but the health department was very reluctant still, in June, to provide vaccinations in places other than in clinics.”
So the Bulungula Incubator fundraised to hire vans to transport 200 of the area’s elderly to and from the hospital for vaccination over four days.
It cost the non-profit more than R15,000 (about £710). The project couldn’t afford to keep transporting people via bus for vaccinations, but it had proven to local health authorities that it could manage a vaccination drive. So the health department let the incubator expand its services, holding immunisation drives at schools and the homes of local leaders. In October, a new village mini-clinic became a health department-accredited vaccination site in the village, offering jabs on Wednesdays. The incubator also held immunisation drives at schools and even the home of a traditional chief.
Ultimately, the Bulungula Incubator was able to vaccinate about 1,500 of the almost 5,000 people it serves.
“Having a well-functioning public hospital and clinic system with good outreach teams definitely help in a rural vaccination drive but I don't think you have to have it,” Wilkinson tells VICE World News. “You have to leverage partnerships with community-based organisations, traditional leadership and anybody that's already working on the ground."
She continues: “Our healthcare workers already had the community’s respect because they come from the community.”
But almost 1,000 kilometres north, near South Africa’s dry and dusty platinum mining belt, Jacqueline Pienaar’s teams weren’t as lucky.
Pienaar is the health non-profit Aurum Institute’s Global Health Specialist. She’s spent South Africa’s epidemic deploying the institute’s teams into rural areas in the Eastern Cape, KwaZulu-Natal and North West provinces to support COVID-19 vaccination and, early on, screening.
But because Pienaar’s teams travel, it means communities don’t know them.
“What we learned early on is that people will kick us out of the communities if they don't trust what we are doing,” she says. In KwaZulu-Natal, some Aurum COVID-19 screening staff even received death threats.
Today, the organisation spends up to two weeks having repeated meetings with traditional leaders and local elected officials to build trust and gain access to communities before a single vaccine dose is even administered.
She continues: “Many rural communities will not come forward unless they have received a blessing or the approval from the chief.”
South African hospitals are now bracing for the country’s fourth wave of COVID-19 infections, driven by the recently identified and more highly infectious Omicron strain. Originally concentrated around Johannesburg and the capital Pretoria in Gauteng province, the fourth wave is only now beginning to spread to other, more rural provinces.
Cases are rising in the country but, so far, haven’t led to surges in hospitalisations or deaths.
Still, healthcare workers told VICE World News that some hospital units in KwaZulu-Natal are already struggling with healthcare worker shortages as infected workers – although still relatively healthy – are forced to isolate at home.
What Omicron means for the country’s rural areas is still unclear, but some experts are already worrying about COVID-19’s impact on the country’s rural health system.
Although the country has hired more healthcare workers to cope with COVID-19, director of the Rural Health Advocacy Project Russell Rensburg warns most of these positions have been allocated to urban areas that have likely been harder-hit by COVID-19 deaths.
“Ironically, some of the investments in health that were made during COVID will negatively impact rural areas because those posts will be in urban centres because that was where the need was,” he says. “Moving those positions back out to rural areas – and the crisis that is coming for us now is going to be much more difficult to navigate.”
The crisis, Rensburg warns, is that South Africa – like many African countries – is struggling to pay for the behemoth task of responding to an outbreak no one saw coming and that shows no signs of abating. The majority of South Africans, particularly in rural areas, rely on the public health system and health budgets in the country are already struggling to fund some regular, non-COVID health posts.
“South Africa ran on debt for the last 10 years, and now the chickens are coming home to roost,” he warns. “The government is spending 25 cents on every rand on debt repayment. Revenue is reducing, and debt repayments are rising – the amount of money that’s available to spend on public healthcare is reducing.”
“Publicly funded healthcare – on which the majority of the country relies – is reliant on tax receipts,” Rensburg continues, “We have a very dire situation.”