Rural hospital beats the odds in South Africa.

www.thelancet.com Vol 374 September 5, 2009 771 He dashes, then swerves, the rubber of his wheelchair squeaking as it rolls over the gleaming linoleum fl oor. 14-year-old Aphiwe Velelwandle circles, comes in for the kill, breaks through doctor Karl Le Roux’s porous defence and snatches the basketball away to the cheers of the clinical team. It is diffi cult to believe this scene is being played out at the end of a ward round in an isolated rural area in South Africa’s Eastern Cape Province. The province is the most impoverished with the worst health outcomes in the country. Despite this, Zithulele Hospital stands out for its commitment and excellence in health delivery. “This is special to see”, says Zithulele physio therapist Marlie Enright. “Disabled children are usually hidden in homes and if they do get to a rural facility there are most often no allied health professionals to treat them.” Moments before, Enright had presented Aphiwe’s case to the gathered multidisciplinary clinical team at the 120-bed hospital. Perched on a rolling coastal hill, about 100 km from the town of Mthatha, the hospital is at the end of a long, dusty, pot-holed road. It serves a community of 130 000 people in which education levels are low and unemployment is high. Tuberculosis and HIV/AIDS are endemic. Aphiwe arrived at Zithulele Hospital in mid-May with severe pressure sores. He has never been to school, and had a spinal chord injury when he was a toddler. In a few months, in the care of the staff , he has moved from being unresponsive to ruling the paediatric ward. He is one of the examples of what can be done in the face of impossible logistical, staffi ng, equipment, and procurement challenges that are accepted as the norm in most health facilities in the country. Started by missionaries in 1956, and now run by the provincial health department, Zithulele, like most rural hospitals, had been unable to attract professionals. District hospitals are historically under-resourced (the ratio of doctors is below 18·5 per 100 000 population) in the four