Why rural South Africans don’t get emergency medical care in time

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Drawing on verbal autopsies, a study conducted in Mpumalanga examined what prevented people from seeking, reaching and receiving quality care in a rural part of South Africa.

Justine Davis, professor of global health, Institute for Applied Research, University of Birmingham and Andrew Fraser, consultant, Guy’s and St Thomas’ NHS Foundation Trust, write in The Conversation, these time-critical conditions cause around half of all deaths worldwide, it’s been estimated, and they are more common in countries with lower incomes.

Dangerous delays may happen at three points: the patient deciding to seek care, reaching a healthcare facility, or receiving quality care at that facility. The World Health Assembly has called for improved care for time-critical conditions, but the necessary development and research hasn’t always received enough funding.

One of the reasons for this lack of attention may be a scarcity of information. It’s difficult to record deaths and their causes accurately in settings where civil registration systems and health records are poor. But in some countries verbal autopsies, which are interviews with the relative or carer of the deceased, are performed to find out more about the circumstances around a death and what most likely caused it. Also, during a verbal autopsy, information is asked about where and when the patient sought care. We carried out a study in the Agincourt area of Mpumalanga province, South Africa, to find out more about deaths from time-critical conditions. We wanted to know what prevented people from seeking, reaching and receiving quality care in this rural area of South Africa, where access to multiple healthcare facilities via paved roads is possible.

Our study reviewed 15,305 verbal autopsies. We developed a locally appropriate definition of time-critical conditions and looked at the numbers of deaths due to these, how numbers have changed over time, and how the numbers differed by age and sex. We also looked at delays in accessing care for these conditions and where people went for care (if they did try to get any care).

We found that time-critical conditions are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than delays in reaching care.

We used the definition of time-critical conditions as “those requiring prompt medical care within 12 hours from the onset of symptoms recognised by a layperson to prevent death.” Some of the most common conditions we saw in the study were obstetric haemorrhage (bleeding too much in pregnancy or around the time of birth), pneumonia, and assault.

We found that between 1993 and 2015, 38.45% of all deaths in the study population were due to time-critical conditions. The proportion increased and accounted for nearly 50% of all deaths in 2014. Most of those who died were either very young or over 60 years old. About three-quarters of deaths in the first 28 days of life were due to time-critical conditions. About half of all time-critical deaths were due to non-infectious conditions.

Most commonly, delays in accessing care were seen at the stage of making the decision to seek care. In fact, on looking at patterns of seeking care before death, most commonly, patients did not seek any care and died without going to a healthcare facility. The most prominent single issue identified in causing delays was cost. This is despite the fact that public healthcare in the area is free of charge. It may be that people don’t know this, or that they worry about costs such as transport to a facility or loss of income while in hospital. They may also not seek care because they do not trust the ability of the healthcare system to treat them.

Our study also found that for people who did reach a healthcare facility, quality issues were prominent. Relatives reported that patients experienced problems in timely referral, waiting to be seen, and communication.

Our research supports findings from others that time-critical conditions are problematic in low and middle-income countries. It also shows that these conditions affect all ages, and are increasing, so dealing with them will have a widespread impact.
Patients infected with COVID-19 could also need urgent care, so the findings may help suggest ways to get them the care they need.

Provision of healthcare that is free at the point of use is necessary. But that alone is not enough. Timely access to quality healthcare is essential. This is not only because it can save lives; it’s also because poor quality care influences future decisions of patients or their carers to get help in time.

The type of care available is an issue too. Many of the healthcare services in South Africa have been tailored to infectious diseases or improving maternal and neonatal health. But about half of the urgent conditions in our study were non-infectious. They may not be well provided for in healthcare facilities in South Africa.

To prevent more deaths, research and solutions should focus on patients’ behaviour when seeking healthcare and on quality care provision. There urgently needs to be investment in interconnected health services that prevent and provide quality care for time-critical conditions.

Our study shows that verbal autopsy is a useful method to explore barriers in access to healthcare.

Background: Time-critical conditions (TCC) are estimated to cause substantial mortality in low and middle-income countries. However, quantification of deaths and identification of contributing factors to those deaths are challenging in settings with poor health records.
Aim: To use verbal autopsy (VA) data from the Agincourt health and sociodemographic surveillance system in rural South Africa to quantify the burden of deaths from TCC and to evaluate the barriers in seeking, reaching and receiving quality care for TCC leading to death.
Methodology: Deaths from 1993 to 2015 were analysed to identify causality from TCC. Deaths due to TCC were categorised as communicable, non-communicable, maternal, neonatal or injury-related. Proportion of deaths from TCC by age, sex, condition type and temporal trends was described. Deaths due to TCC from 2012 to 2015 were further examined by circumstances of mortality (CoM) indicators embedded in VA. Healthcare access, at illness onset and during the final day of life, as well as place of death, was extracted from free text summaries. Summaries were also analysed qualitatively using a Three Delays framework to identify barriers to healthcare.
Results: Of 15 305 deaths, 5885 (38.45%) were due to TCC. Non-communicable diseases were the most prevalent cause of death from TCC (2961/5885 cases, 50.31%). CoM indicators highlighted delays in a quarter of deaths due to TCC, most frequently in seeking care. The most common pattern of healthcare access was to die outwith a facility, having sought no healthcare (409/1324 cases, 30.89%). Issues in receipt of quality care were identified by qualitative analysis.
Conclusion: TCCs are responsible for a substantial burden of deaths in this rural South African population. Delays in seeking and receiving quality care were more prominent than those in reaching care, and thus further research and solution development should focus on healthcare-seeking behaviour and quality care provision.

Andrew Fraser, Jessica Newberry Le Vay, Peter Byass, Stephen Tollman, Kathleen Kahn, Lucia D’Ambruoso, Justine I Davies


Full report in The Conversation


BMJ Global Health abstract

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