Lesssons from South Africa

KC JOURNAL NO 20 November 2008

In this article Stevens gives an overviwe of women’s health in a democratic SA, the new legislation and the challenges, including the role of leadership and civil society.

A commitment to primary health care

Following the change of government in 1994 rapid strides were taken to prioritise women’s health. In the first 100 days of President Mandela’s presidency, an announcement was made that primary health care was to be free to pregnant women and children under six. This was to ensure that poor women and their children had access to care. These broad strides were welcomed and heralded a period of significant policy and legal change orientated to the poorest of the poor. This took place when the health care system itself was transforming towards developing an integrated and decentralised health care system based on primary health care. Subsequently primary health care was made freely available to all citizens in the public sector. Health workers were not prepared for this and in retrospect have become overwhelmed with what is commonly termed ‘change fatigue’.

Efforts continued to increase access to health broadly and are clearly defined in the South African Constitution in section 27 in the clause ‘Health care, food, water and social security’. It states: ‘(1) Everyone has the right to have access to (a) health care services, including reproductive health care; (b) sufficient food and water: and (c) social security, including, if they are unable to support themselves and their dependents appropriate social assistance. (2) The state must take reasonable legislative and other measures within its available resources, to achieve progressive realisation of these rights, (3) No one may be refused emergency care treatment’.

An assessment

While efforts have been made to implement this with over 4000 public health facilities employing some 235 000 personnel, care is sometimes sub- optimal. Public facilities have long waiting times and primary-care facilities have too few doctors. In relation to broader determinants of public health, many people do not access clean water, sanitation, nutrition, electricity and safety. This facilitates poor health. Poor people face the high costs of transport, buying medicines, and follow-up visits to a doctor.

Language barriers between patients and health workers mean that many people are not able to fully understand their treatment. Many women experience domestic violence, sexual offences and other forms of violence against women. There are discriminatory attitudes amongst health care workers against people because of their colour and gender. Because of the HIV/AIDS crisis, many hospitals and clinics face a huge increase in patients, but there has not been an increase in the doctors and nurses available to care for all the new patients. The health care system is better equipped and provides better services in provinces like Gauteng and the Western Cape, than in others such as the Eastern Cape and Limpopo.

A facilitating environment

It is perhaps important to underline the period of ‘transformational flow’ or ‘soft boundaries’ during the period of about 1994- 1998. This period was characterised by a flow and political ease in which policy change at addressing the apartheid past was welcomed. This was enabled by relationships that spun a network into various institutions including parliament, political parties, the media, government departments and NGOs. There was an element of trust and the need to work collaboratively to address the past imbalances that characterised South Africa. As Black women were known to have borne the brunt of apartheids evils, women’s rights were acknowledged as human rights and there was an understanding that laws and policies needed to put in place to correct this.

Laws and Policies addressing Women’s health

While there were broad reforms addressing issues of equity and women’s health, there have also been very specific changes. These include: The Choice on Termination of Pregnancy Act 1996 and the Choice on Termination of Pregnancy Amendment Act. 2004, the Notification of and Confidential Enquiry into Maternal Deaths (NCCEMD), The Sterilization Act, 2000, Contraception policy guidelines and the Comprehensive plan for the management of HIV and AIDS and the HIV and AIDS National Strategic Plan 2007-2011. In highlighting a few of these areas:

  1. While South Africa has a liberal abortion law which has successfully reduced abortion related maternal mortality and morbidity, demand for services exceeds supply and health workers have not easily accepted the provision of this service. The law is constantly under attack from anti-choice activists. The media is not helpful and in 2006, services were suspended for two weeks in the Northern Cape as service providers thought the legislation had been repealed
  1. The NCCEMD is a process designed to evaluate, indirectly, the quality of care that women receive during pregnancy and childbirth. It is evident that AIDS is proving to be the largest challenge to addressing maternal mortality in South Africa.
  1. As part of the HIV/AIDS continuum of care, the programme for the prevention of mother to child transmission PMTCT was the first step in improving the health care of pregnancy women infected with HIV in that it helped to identify those pregnant women who were HIV positive. The South African PMTCT programme was largely introduced as a vertical programme to allow for central control and faster implemen- tation; however the result is that it does not function integrally with broader maternal and child health services. The indicators suggest that many opportunities to prevent mother to child transmission are being missed. The orientation of the programme has also been to emphasise the child’s health and not the mothers’ health, which has been problematic.

The period of policy has changed and is not as open and easy as in the late nineties. The Sexual Offences Bill was passed in Parliament in May 2007 and has been in the making for some ten years. While activists have welcomed it as a positive change, it still falls short in including clear regulations concerning integration of health, justice and safety and security, which would make the law implementable.

Health systems challenges

As noted, all of these developments have taken place in a transforming health system. There has been increased expenditure in primary health for capita from – R168 in 2001 to R232 in 2005. The average clinical workload of a nurse was 31.6 patients a day in 2005. The primary health care utilisation rate is the average number of visits a person makes per year to a public PHC facility, which in 2005 was 2.1. The challenges of South Africa are complex as it is a profoundly unequal country. There are consistent efforts to spread the resources and transform the health system. In developing systems to increase the supply of health workers in rural areas health graduates have a compulsory community service year and there is a rural allowance for certain health workers.

The Role of leadership and civil society As noted in this case study, HIV/AIDS is the challenge that is affecting women’s health in their reproductive years. There have been enormous difficulties and complexities in delivering leadership around HIV/AIDS in South Africa.

This has led to a number of missed opportunities, confusion and what is known as ‘denialism’. In the recent past there has been excellent leadership demonstrated by the Deputy President of South Africa (Mrs Phumzile Mlambo Ngcuka) and Deputy Minister of Health (Mrs Noziwe Madlala- Routledge) who have engaged and lead the processes of the South African National AIDS Council and the new National Strategic Plan for HIV/AIDS (Department of Health 2007).

Prior to this there has been a re-emergence of social movements such as the Treatment Action Campaign (TAC), The Social Movements Indaba and the Anti-Privatisation Forum (fighting the privatisation of basic services of water and electricity). TAC has been successful in litigating for the access to HAART and for increasing treatment literacy amongst activists.

It is important to note that the recent past has been characterised by a lack of leadership and a mistrust of politicians. This is a period of ‘hard boundaries’ where there appears to be tiredness and a sense of poor morale.

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