I was new to the public health services system and the practice rural health as a whole when I was first placed to work in a small town in South Africa as a community service pharmacist.  I was nervous on the day that I arrived.  Though the town’s climate was hot and sparsely populated, it was the home of significant mining activity, and therefore, needed the highest standard of healthcare delivery.

The fact that it was a mining town meant that there was ample migrant labor, with some residents coming even from Zimbabwe, Mozambique, Lesotho, and Botswana.  I was new and didn’t really have an idea of what to expect – after all, I was a pharmacist whose knowledge was largely theoretical knowledge, and I had worked at a university for only a few years.

Although I had little certainty of what my daily work would entail, I was confident in my passion for health and I knew what I enjoyed doing.  I was particularly interested in the health of women, especially in the area of adolescent health.  Previously, I’d worked in various roles as an advocate for the right for girls to have access to sexual reproductive health and rights (SRHR).  This had not been an easy task from an advocacy point of view, but because of it, I knew most of the challenges that the girls I had worked with reported.  However, I had not experienced them as a health worker. Being an advocate, made it easy for me to judge and spot mistakes made by health workers concerning adolescent SRHR.  This time around, I was the health worker providing the services.

Getting to do the actual work

I learned quickly that a large part of my responsibilities was to support primary healthcare centers in the area, through provision of pharmaceutical services as a pharmacist.  I loved this part of the job because it allowed me to interact with not only the community, but also the nurses who provided so much of the day-to-day healthcare.

On one occasion, I had the opportunity to speak at length with a nurse whose role entailed providing reproductive health services.  I wanted to learn about the ways in which she interacted with adolescent girls seeking advice and resources from her, especially school-going girls.  I was eager to gain an authentic insight into the experience from the perspective of the health worker, rather than the patients whom so often contributed the bulk of information about such health process.  I asked whether she gave contraceptive medication to girls who came to her clinic seeking it, and she nodded.  She noted that she was not in support of giving young girls contraceptive services as she felt that their parents should give consent.  She did not want to find herself on the ‘wrong side’ of the law. She was under the impression that parents could file law suits against her and the primary healthcare clinic if she was found giving contraceptive medication to younger girls, without their parents’ consent.

While she was explaining this to me, I couldn’t comprehend how these girls could prove that they had their parent’s consent to her.  I guess having the parents come along for the clinic visit was the only way. I thought to myself that even as old as I am now, I don’t want to visit a reproductive clinic with my mother, nevermind my father. I thought to myself that a 14-year-old must feel worse than me if they are required to bring their parents along. Especially, with the fact that the South African law allows them to seek reproductive health solutions without their parent’s consent.

Pictured: Nsovo and Pharmacy manager Mr P Rheeders

Adolescent health in rural South Africa

Given my professional and academic background, I was aware that South Africa has advanced policy on SRHR when it comes to adolescents, even before I began my placement.  The country has a national adolescent sexual and reproductive health and rights framework strategy that spans the years of 2014 to 2019.  This strategy explicitly states the rights, entitlements, and educational needs of young people relating to their sexual health.

It is legal in South Africa for adolescent girls to seek contraceptive and abortion services without the consent of their parents, though of course, in smaller communities such as the one in which I was placed, health care workers exercise discretion, as they feel necessary.  Though this ran counter to a lot of the advocacy I had spearheaded in the past, it was easier to understand from the frontline.  The nurse with whom I had spoken was a devoted healthcare worker, and it was clear that she had her patients’ best interests at heart.  Her refusal to provide contraceptives to some patients was less out of judgment than self-preservation – to be sued for malpractice can derail one’s entire career.  I was able to update her about the latest policy updates from our government, and hoped that with this new education of the rights of both she and her patients, she would be able to provide better, consistent care in alignment with government directives.

Lessons to take home

From this experience, I came to learn that advocacy for access to SRHR should not only be directed towards policymakers to influence policy, but should also include the implementers of the policies – namely, the frontline health worker.  The sad reality is that lobby and advocacy groups are usually located in cities, and their priorities are structured accordingly.  This is done despite the fact that the majority of South Africa’s population live outside of these parameters.  In rural contexts, healthcare workers risked being under-resourced, under-supported, and even undertrained.  Accordingly, it seemed sensible for policy to be weighted accordingly to compensate for existing priority given to metropolitan health providers.  Then, perhaps, we might see an appropriate delivery of SRHR services against the recorded data from the World Bank that quantifies unmet need for contraception of 12% in South Africa, recorded in 2012, and the national fertility rate at 45.3 in 2013.

As a fledgling health care worker, myself, I was not only able to expand my skill-set during my time in rural South Africa, but similarly learn a great deal more about the complex health structures that influence the delivery of comprehensive, substantive health services.  And I remain optimistic.

After all, I still have so much to learn.

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