‘Sea change’ – how the Tshemba Foundation is plugging gaps in women’s health in rural South Africa

The key to destigmatising maternal and menstrual healthcare is education, combined with an increased presence of specialists, enabling more women to feel safer to seek treatment, said Dr Nicole Fiolet, the women’s health project manager at the Tshemba Foundation. (Photo: Supplied)

By Takudzwa Pongweni

31 May 2023

The nonprofit Tshemba Foundation is a volunteer programme that gives medical professionals from around the world the opportunity to share their knowledge, skills and experience with primary healthcare providers. It works in partnership with Tintswalo Hospital, a district hospital in the semi-rural town of Acornhoek in Mpumalanga, and surrounding clinics.

Tshemba was founded in 2014 by Neil Tabatznik – a South African now living in Canada – to significantly improve access to healthcare in underresourced communities in rural South Africa, said Professor John Gear, physician and medical director at the foundation.

“He [Tabatznik] was on a game drive and while chatting to the game guides and trackers, one of them said ‘come and see our village’ and asked if he wouldn’t be them a clinic,” he said. During the planning phase, it became clear that the issue was not a lack of infrastructure, but rather a lack of qualified health professionals.

“I think there was literally a sea change, where they recognised that it was important to find a way to get human resources rather than physical resources to the country,” he said.

The founder engaged with the Mpumalanga health department and the volunteer programme was established to collaborate with Tintswalo Hospital, which serves 14 outlying clinics, has just more than 400 beds and is often 80% full.

District hospitals are the first point of care beyond the clinic, Gear added.

How it works

The volunteers – who stay at the volunteer centre at Moditlo Private Game Reserve, near Hoedspruit – are recruited primarily by the public relations team, said Gear.

“Recruiting is done through our website but we also go further than that. LinkedIn is a particularly potent element of our recruitment, and the other element, which is more and more powerful, is word of mouth as people come and then go back to wherever they came from and advertise it.”

Awareness and stigmatisation are significant barriers when it comes to women’s health, and are compounded enormously in rural areas, said Professor John Gear, physician and medical director at the Tshemba Foundation. (Photo: Supplied)

The foundation also targets specialist conferences, particularly in South Africa, and provides webinars monthly for people who have expressed interest.

The volunteering period varied but longer stays were usually better because there was often resistance to new faces in the hospital. “The longer they stay the better, because then they build up relationships and they are more trusted, which is massively important.”

Since South African graduates were more familiar with the healthcare system and the country, they typically adapted quicker. “South African graduates fit in very easily and very quickly, so we will accept them for relatively short spells of between one and three weeks,” Gear said.

For international graduates the bare minimum was eight weeks, with a two-week intensive induction facilitated by members of the clinical team. “We run a two-week orientation for people who’ve never been to South Africa, where we take them through the various clinical options, and get them up to date with our healthcare system.”

State of healthcare for rural women

Women in South Africa, especially those in rural communities, need better access to specialist healthcare and awareness of how and when to seek treatment.

Sunday, 28 May was International Day of Action for Women’s Health. Read more here.

“In rural communities, clinics and primary healthcare facilities are often not equipped to offer specialist obstetric and gynaecological services. Where these services are available, limited community knowledge, and trust, further inhibit doctors from servicing women in need. As a result, we’ve seen consistently high cases of cervical cancer – one of the most preventable forms of cancer, provided it’s detected early. This is just one example of a health issue that impacts a woman’s ability to look after her family, or secure an income, which has a domino effect on the community,” said Dr Nicole Fiolet, the women’s health project manager at the foundation.

Gear said that in a society with gender equality, awareness and stigmatisation are significant barriers when it comes to women’s health.

Read more in Daily Maverick: Protecting rural health must be a priority in times of economic turmoil – new report

“The most profound issue in healthcare for women, and much more so in rural areas, but generally is awareness of services available, awareness of early symptoms of disease, irrespective of the disease. There is also a stigma attached to seeking healthcare for what one might regard as private female problems,” he said.

Awareness and stigmatisation were compounded enormously in rural areas. For women in urban areas, access to care in a private or public facility was relatively good in terms of physical distance and reasonable transport costs.

“In a rural area, people often have to travel for an hour or two, change taxis three times, or arrange a lift with their neighbours. They get to a hospital, because of the staff shortages, and they often have to wait for a long time. By the time they get to the clinic that they were coming to, that clinic is closed for the day, and then they have to come back the following day,” he said.

The key diseases that affected women were cervical cancer, breast cancer and sexually transmitted diseases. The common STDs were gonorrhoea, chlamydia and HIV. Gonorrhoea and chlamydia infections are mild, but if a patient was an asymptomatic syphilis carrier or an HIV carrier, there was a risk of infection with much more serious illnesses.

Although pregnancy isn’t thought of as a disease, and shouldn’t be, it can be a major contributor to hazards for women concerning their sexual health, he said. “There are many, many complications around pregnancy in particularly high-risk women, women who’ve got HIV and that sort of thing, which make pregnancy in itself a major contributor to hazards for women concerning their sexual health.”

Gender-based violence should not be excluded from conversations about women’s health. “Something which we often don’t call a disease but again is profound, is gender-based violence, and not necessarily physical, but just that huge stigmatisation about it and the emotional violence that goes on in many homes.”

How the Tshemba Foundation is bridging the gap

Gear explained that to bridge the gap, it is vital that they have the expertise within the organisation, which is why Fiolet was appointed to specifically become the champion of the women’s health programme.

Obstetrician-gynaecologist volunteers at Tshemba contribute to this programme through patient care and engagement with the Tintswalo community.

“Very few women in our community who should be getting pap smears visit their health clinic to receive them. This is just one element of female healthcare that is very important for long-term well-being. We also find that many tend to accept, and ignore, abnormal symptoms, such as bleeding outside their menstrual cycle, or after they have gone through menopause. These can be signs of advanced-stage cancer that has progressed too far for treatment to be effective. This is why driving individual and collective health education focused on consistent screening is so important,” said Fiolet.

Maternal and menstrual healthcare remained highly stigmatised in some population groups. The key to destigmatisation was education, combined with an increased presence of specialists, enabling more women to feel safer to seek treatment.

“Through Tshemba’s intervention, we have reduced turnaround time for certain procedures, such as abnormal pap smear treatment, from three separate hospital visits to one 30-minute visit. We have also successfully driven an increase in women visiting the hospital to receive care specific to female health – such as pap smears, ultrasounds and access to safe contraceptive methods,” she said.

Gear said it was also important that they had an accessible service. “It is literally immoral to go out into a community and start to either screen for disease or educate about a disease if you don’t then have the back-up to be able to offer solutions, the expertise within the hospital or the diagnostic equipment.”

The foundation was trying to work through various barriers with its healthcare partners before they became too active in healthcare. “Where we do health education is for the women who come for antenatal care. They are then made aware that after your baby’s born, you may get breast swelling and breast abscesses and things, but if you are worried, come early and don’t wait until you’ve got a massive breast abscess from an infected duct or something like that,” he said.

How obstetric and gynaecological specialists can step up

Because Tintswalo Hospital was a district hospital, it did not have specialist care or specialist doctors. “District hospitals have general doctors who are very good at many things, but none of them have specialist competence. As medicine has got more and more specialised, the need for specialists is there,” said Gear.

All the clinics in the area were run by nurses, not doctors. “Those specialist obstetricians and gynaecologists can go and see that the nurses in the clinics know how to take a pap smear, and that they know how to do it properly and do it with confidence.”

South America and Africa do not have the specialist competencies or equipment that northern hemisphere countries do, but Gear sees this as an opportunity for specialists. “I think it’s very important to recognise that there is a massive opportunity for specialists to come and teach, to supervise, to mentor and to teach new techniques to correct problems.”

Specialists could also come and consult on difficult cases, and train and upskill local staff to make local service more competent. “The more competent the local services, the less that patients have to be referred, which is good for family health, family dynamics and all the rest of it. The knock-on effects of referral of women to remote areas means that their kids are left at home or whatever it be. So, there’s a huge benefit from being able to offer as much as you can, locally,” he said.

Although South African doctors were “damn good”, having a medical officer with at least three years of training and six months in obstetrics may not be sufficient. “If they are doing all the Caesarean sections, they’re going to make mistakes, they’re going to get into trouble and up to a point you’ll accept that.”

District hospitals often had high rates of Caesarean sections with complications and this could be drastically reduced by having specialists. The high rates could be caused by a variety of things, including patients arriving late and their labour being mismanaged at home.

Read more in Daily Maverick: Is SA’s Caesarean section rate too high in the public sector? Yes and no

“A lot of the time, it’s just that there’s a nursing shortage so the patient is not properly monitored. Setting up protocols and standard operating procedures would bring the rate down enormously and that’s another area volunteers can contribute.”

Making a difference

To date, the Tshemba Foundation has hosted 274 volunteers from around the world.

Gear noted that although many hospitals in the country are in an appalling state, with neglect of infrastructure maintenance and lack of accountability, healthcare workers can still make a difference.

“At the end of the day, whether the roof leaks or not, whether a patient survives is actually about the quality of nursing staff, the quality of the medical staff, and that’s what we tend to focus our efforts on.” DM

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South Africa

How it works

State of healthcare for rural women

How the Tshemba Foundation is bridging the gap

How obstetric and gynaecological specialists can step up

Making a difference