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Historical Roots of current public

health challenges

Dr T. Naidu

Dept of Public Health MedicineUKZN


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Lancet Series

Health in South AfricaAugust 2009www.thelancet.com


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Outline of Lecture

1. Social, Political and economic contexts of health (historical

perspective)

2. Health system through colonialism and apartheid

3. Post apartheid health system


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Historical perspective..

The roots of a dysfunctional health system and the collision of

the epidemics can be found in policies from periods of the

countries history.

Colonial subjugation Apartheid dispossession

Post apartheid period


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South Africa has 4 concurrent epidemics

Poverty related illnesses (infectious diseases, maternal

death, malnutrition)

Non-communicable diseases HIV/AIDS

Violence and injuries


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THETROUBLED PAST

Racial and gender discrimination

Migrant labour system

Destruction of family life

Vast income inequalities

Extreme violence

IMPACT ON HEALTH AND HEALTH SERVICES


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Social context gender and violence

History of war and violence shaped the dominant forms SouthAfricas racially defined masculinities

White masculinity

Colonial natal

School and sport participation inculcated values of racialsuperiority, gender hierachy and class chavunism

Boer republic

Afrikaner boys organised from a young age into a form of militaryorganisation known as the Boer commando.

Black population

Socialisation of boys included childhood training in indigenous martialarts such as stick fighting which instilled discipline, courage and adefence of honour


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Social context cont.

Control of women

Central part of present day constructions of South African masculinity

Violence against women legitimated when the goal is to secure

control or to punish resistance against it

Sexual entitlement exaggerated in gang culture, violence in urban

areas, labour migration ( Gangsters seeing women living in their

territory as belonging to them)

Gang culture

Explanation for many black and coloured men being involved Apartheid rendered many traditional aspects of adult manhood

unattainable, including fulfilling the role of provider.

Manhood refashioned to draw on resources that were available

This meant the application of courage strength, strategy and male

camaraderie to the criminal pursuits of gangs

This provided ways of generating income through crime.


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Families and sexual socialisation

Two competing discourses on sexuality

Christianity

Sex is for procreation and marriage and not a topic for discussion with

young people.

Traditional black ideas

Sex is normal, healthy essential feature of life for all ages and something

about which there should be openess and communication.

The effect of migrant labour

Male migrants had sexual partners in towns as well as their rural homes.

Men often established second families. Apartheid and migrant lanour system had major effect of the structure of the

black family.


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Effect on the structure of the black family

Increasing poverty made marriage unaffordable to groom ( lobola)

Co-habiting

Median age of marriage for black people incr.

40% of household female headed in 2003

Children raised without fathers

Magnified childhood poverty

Undermined the process of socialisation in children esp boys

Children often raised by social and not biological mother

Important implications for adult and child health High levels of sexual, physical and emotional abuse and neglect of children.


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Macroeconomic and socioeconomic context

Poverty and income inequality

One of the most important influences on the Health of South Africans

has been the impoverishment of the black population in the face of

general white affluence.

In the late 19th and 20th century low wages, overcrowding, inadequate

sanitation, malnutrition and stress caused health of black population

to deteriorate.

Had major effect on crime and violence.

Roots of poverty and income inequality lie in unfree black labour

Despite generating great wealth for the mines, mine owners paid black

workers less than a living wage.

The plight of black South Africans exacerbated by legislation on racially

based job reservation, education and wage variation.


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Macroeconomic and socioeconomic cont

Expenditure on education

In 1980/81 expenditure per head on education for white children was

double that for Indian children and 5 times that for black children.

This was caused by policy of deliberate undereducation of black

people.

Low educational attainment, dysfunctional education system worsens

unemployment

Current rate of unemployment

25% with narrow definition that includes only those actively seeking work

37% with the broader definition that includes all unemployed


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National system ofsocial grants provides some relief from the impact of

poverty and unemployment

One of the successes of the post apartheid years has been to unify the

national state pension system and disability grants and introduce new grants.

Bet 1996/07 and 2007/8 beneficiaries of social grants incr. from 2.4 million to12.4 million

New child support grant 8.2 mill beneficiaries

Disability grant payable to people with AIDS 1.4 million

Old age pensioners 1.6 million to 2.2 million


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South African constitution binds the state to work towards the

progressive realistaion of the right to health.

STILL GRAPPLINGWITH:

racial differences in mortality rates and rates of diseases

Inequities between provinces

Mortality rates for children under 5 46 per 1000 live births in

Western Cape to 116 per 1000 in KZN.

Differences between the sexes

Mortality 1.38 times higher for men than women.

Urban rural differences


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The health system through colonialism and

apartheid

Fragmented system

Within the public health sector and between the public and privatesectors

The 1919 Health Act gave responsibility for hospital curative care tothe 4 provinces and preventive promotive health to the local

authorities. 14 separate health departments (by then end of the apartheid era)

Growth of the Private Sector Expansion fostered by government policy of privatisation

1980s 40% doctors in private sector

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0 yrs later 62% generalists and 66% specialists Main cost drivers are private hospitals(>35% of med schemes exp),

specialists(21% of med scheme exp

Driven by fee for service payment

Quality of care ( no mechanism for oversight of quality of care)


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Key challenges facing the health system in 1994

The health system inherited by 1994 government was well resourced

compared to other middle income countries.

More than half the financial and human resources in the private sector

Public sector

Inequalities in distribution of infrastructure and financial and humanresources, between provinces and between levels of care (80% going to

hospitals)

Academic and tertairy hospitals accounted for 44% of total public sector

health care spending

Only 11% to non hospital primary care services


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Post Apartheid system

14 administrations consolidated into one national and 9 provincial health

dept

Primary Health care delivered via district health system made the

cornerstone of health policy

Clinic infrastructure programme

1345 new clinics built and 263 upgraded

Improved availability and access to services

Primary Health care came at no cost

Mass immunisation campaigns

Essential Drug List and standard treatment guidelines developed


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Legislation passes to transform the health proffesional councils to

make it more representative

Public health legistation

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Control of firearms

Cigarette smoking

Strengthen post rape care


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Progress made in redistributing resources

Gap in spending per person dependent on the public

sector , between best and worst resourced provinces

declined from 5 fold difference in1

992/3 to 2 folddifference in 2005/6

Spending in primary health care incr to over 22% of tot.

public health expenditure.

Major constraints to implementation

Confusion and delays incurred in defining geographical

boundaries and governance responsibilities


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Structure of South African health sector

1. NDoH responsible for health policy

2. Nine provincial DOHresponsible for developing provincial policy within

the framework of national policy and public health service delivery.

3. Three tiers of hospital: tertiary, regional, and district

4. The primary health care system a mainly nurse driven service inclinics- includes the district hospital and community health centres.

5. Local government is responsible for preventive and promotive services

6. The private health system consists of GPs and private hospitals, care in

private hospitals mostly funded through medical schemes. In 2008 70%

of private hospitals lay in 3 of the 9 provinces 38% in gauteng alone.


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Key challenges of current system

Inadequate human resource capacity and planning

Poor stewardship, leadership and management

Stress on system by AIDS epidemic

Restricted spending in public health sector


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Human Resource capacity

Challenges

60% health budget spent on human resources

Decrease in Nurse to population ratio from 149 per 100 000 pop in1998 to 110 per 100 000 in 2007

Decline in numbers of nurses graduating due to closure of nursingcolleges in 1990s

Migration to the private sector and to jobs abroad

Retirement and HIV/AIDSm(affects 16% of nurses)

% doctors in private sector rose from 40% in 1980s to 79% in 2007

Important policies Incr uptake medical schools

Legislated community service

Introduction of mid level health workers


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Community healthworker programmes

Little standardization in their work, training supervision

Disagreement on whether they should be paid

Issues

Inexperienced managers

Insufficient political will and leadership to manage undeperformance

and incompetence


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Poor stewardship, leadership and management

Evident in highly variable quality of Care delivered in public sector

TB programme

In 1996-2004 key outcome indicators deteriorated

HIVmanagement

HIV/AIDS epidemic allowed to spread

Annual antenatal surveillance prevalence rate increased from 0.7% in 1990 to

8% in 1994 and 20% in 2005

Aids denialism by the countries president at the time resulted in a great cost

to the south African people.

Inability to deliver intersectoral programmes Primary School NutritionProgramme (no clear designation of responsibilities between Dept of

Education and DOH)

Need to change national thinking on accountability


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Without concerted efforts to change National

thinking on accountability, South Africa will

become a country that is not just a product of

its past, but one that is continually unable to

either address the health problems of the

present or to prepare for the futureThe Lancet 2009


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conclusions

Distinctive features of South African history that account for

current health problems

Racial and gender discrimination

Income inequalities Migrant labour

Destruction of family life

Persisting violence

Lack of progress in implementing core policies


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To meet the Millenium Development Goals

Address the unacceptable levels of income inequality

Improve access to the broad range of social services

Introduce broad ranging development policy

Promote gender equality Macroeconomic policy that centres on redistributive growth

Intervention to treat major problems HIV/AIDS, TB, other

communicable and non communicable diseases, sexual and

reproductive disorders, substance abuse, crime, interpersonalviolence and trauma

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