The Health System in South Africa. Historical Perspectives and Current Challenges

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Chapter 9

THE HEALTH SYSTEM IN SOUTH AFRICA. HISTORICAL PERSPECTIVES AND CURRENT CHALLENGES

Peter Delobelle Institute of Tropical Medicine, Antwerp, Belgium Vrije Universiteit Brussel, Belgium

ABSTRACT

South Africa as a society is characterised by huge inequities, rooted in the political history of the country, which had a devastating effect on the health status of the largely black African population. Despite continued government efforts to redress the imbalances of the past, limited progress has been made towards achieving the health Millennium Development Goals. The large and under-resourced public health sector is burdened by urban-rural inequalities in access to health care and a quadruple burden of disease including HIV/AIDS, pre-transitional diseases, non-communicable diseases, and violence and injuries. Closely related to HIV/AIDS is the increasing TB epidemic, the leading underlying cause of death associated with HIV. In this chapter, a description is provided of the growing inequity and impoverishment occurring in South Africa, followed by an overview of the history of the current health system and status of its citizens, as driven by political economy. The research included primary and secondary data analysis including official reports and records, and was based on extensive literature reviews of international and local studies in the fields of public health, medical and nursing science, medical sociology and demography, social epidemiology, medical anthropology and a vast array of published and unpublished reports contained in the grey literature, consisting of working papers, case reports and policy guidelines, best practices and bulletins.

INTRODUCTION

South Africa is often called a ‘rainbow nation,’ because of its wide diversity in cultures, languages, and religious beliefs, comprising sixteen different ethnic groups and eleven 160 Peter Delobelle official languages. Each ethnic group has its own customs and traditions, but all share equal rights in the newly founded democracy, including the right to equal health. South Africa is, however, a country of extreme differences, and the economic and social inequality inherent in the Apartheid regime has continued, or even increased, since a majority rule was instituted in 1994. Political transition has aimed to decrease inequities in health care through expansion of basic services and a massive increase in social welfare grants, but health problems and social inequalities rooted in poverty still persist. Although some progress has been made towards achieving the Millennium Development Goals (MDG), the progress has been insufficient and even reversed for many of the goals (Chopra et al. 2009). Private sector spending on health care still exceeds public sector expenditure, which mainly serves the black African majority, in turn leading to unequal access to high-quality health care services and many missed opportunities for early prevention and care, with potentially lethal outcomes (Shisana 2001). The resulting differentials in mortality have been compared with those of nineteenth century Europe (Chopra and Sanders 2004) and are influenced by the enormous impact of the HIV/AIDS epidemic, which has taken away the economically active population and left nearly two million children orphaned (Statistics South Africa 2010). As a result, life expectancy has dropped by almost twenty years since democracy, and maternal, neonatal, and child mortality remain exceedingly high. This paradox of high government expenditure and persistently poor health outputs has many different reasons, among which the failure in leadership to tackle HIV under the Mbeki regime features foremost (Abdool Karim et al. 2009). For example, it has been estimated that more than 330,000 lives have been lost to HIV/AIDS between 2000 and 2005, because government failed to implement a feasible and timely antiretroviral treatment (ART) program (Chigwedere et al. 2008). An estimated 35,000 babies were also born with HIV in the same period, resulting in 1.6 million person-years of life lost, due to the reluctance of government to install a prevention-of-mother-to-child transmission (PMTCT) program with freely donated nevirapine and grants obtained from the Global Fund.1 Although South Africa could hence have helped half those in need by 2005, only 23 percent was reached, whereas Botswana, for example, was already providing treatment to 85 percent of those in need and Namibia to 71 percent (Chigwedere et al. 2008). The impact on society has been devastating, profoundly affecting its social fabric and economic development. In 2004, a media survey reported that South Africans spent more time at funerals than they did having their hair cut, shopping, or having barbecues, and that more than twice as many people had been to a funeral in the previous month than there had been to a wedding (SA Advertising Research Foundation 2004). The burden of HIV/AIDS, and its twin TB epidemic, continues to affect not only the population, but also the health care sector, through a loss of staff due to illness, absenteeism, low staff morale, and an increased patient load (Shisana et al. 2003). Although government policies have changed recently and renewed commitment has been shown through publication of a new national plan to combat HIV/AIDS, STI and TB (Department of Health 2011a), it remains clear that the country will still grapple with the dual HIV/TB epidemic for decades to come.

1 The Global Fund to fight AIDS, Tuberculosis and Malaria is a worldwide public / private partnership created in 2001 at the G8 Summit in Genoa in order to mitigate the burden of disease in needy countries and aid poverty reduction as part of the MDG (Maciocco and Stefanini 2007). The Health System in South Africa 161

In addition, the quality of public health care seems to have declined in the last decade, based on studies which cite underfunding, mismanagement, shortages of health personnel and deteriorating infrastructure as possible contributors (Keeton 2010). Migration of health care workers from rural to urban, public to private, and secondary to tertiary institutions has also impacted health care delivery, especially in remote and rural areas, in turn compromising the quality of care and worsening health inequity (Aitken and Kemp 2003). The health system moreover struggles with a disproportionately large burden of disease, which not only consists of infectious diseases and HIV/AIDS, but also a growing prevalence of chronic diseases, a silent epidemic of maternal, neonatal and child deaths, and a high rate of violence and crime. Many of these problems are rooted in distinct features of South African history, which sustained health inequity through its successive segregationist policies. During apartheid the health system was driven by professional, political and financial interests impeding equal distribution and creating service delivery gaps across regions and population groups. The current inequality in health is hence closely related to the socio- economic, racial, and political disparities of the past, reflecting wide inequities in the social context, whereby access to wealth and power was dominated by a small white political elite (Van Rensburg and Fourie 1994). In order to understand the public health challenges facing contemporary South African society, it is hence necessary to describe the development of the health system and its associated burden of disease from within a historical perspective. This will be complemented by an overview of the present status and a summary of implications for health policy planning, in view of the renewed government commitment towards addressing health inequity within the country.

1. THE HEALTH SYSTEM IN SOUTH AFRICA

1.1. Overview

The health system in South Africa may be described as characteristic of what Field (1980) has termed a pluralistic system, consisting of a partly privatized and partly socialized health care. The relatively large public health sector predominantly serves the black African population, with services ranging from free primary health care services (PHC) to secondary and tertiary care offered at state owned hospitals, while the private sector offers world-class facilities for the insured minority, or for those who can afford care on an out-of-pocket basis. Although the public sector is responsible for the wellbeing of the majority of the population, most resources are concentrated in the private health sector, which consumes 55-60% of the total health care budget, but caters for less than 15% of the population (Chopra et al. 2009). The public health sector largely depends on general tax revenues, which consume around 11% of the government budget, allocated and spent by the nine provinces according to their needs and priorities. Quality of care, however, depends to a large extent on the budget allocation by individual provinces and districts (DHB 2009). With less resources and higher levels of poverty, cash- strapped provinces like Eastern Cape and Limpopo face greater health challenges than wealthier provinces like Gauteng or the Western Cape.

162 Peter Delobelle

Source: Department of Health 2006.

Figure 1. Macro organization of the National Health System, Republic of South Africa.

People in rural areas are also more dependent on public health care than private health services compared with urban dwellers, leading to urban-rural inequalities in access to health care across the country which often discriminate against the poor (Booysen 2003, Harris et al. 2011). The factors affecting health and health care in South Africa are associated with the legacy of apartheid, persisting poverty, income inequality, HIV/AIDS, and the more recent influence of neoliberal economic policies and globalization (Mooney and McIntyre 2008). The implementation of large-scale policies and programs with pro-equity objectives introduced by the new legislation were indeed hampered by fiscal restraints and prioritising technical rather than developmental considerations, leading to rapid worsening of health inequalities in the country (Sanders and Chopra 2006). Lack of commitment, competencies and low morale among health care workers further contributed to the poor performance of the public health sector, further increasing the split between public and private care and, in turn, affecting inequalities in health. The public sector is under-resourced and overused, whereas the private sector continues to grow. Most health care professionals, except nurses, work in private hospitals, which have begun to take over many tertiary and specialist health services since the public sector started shifting towards PHC in the view of national health reform. The brain drain of skilled health care workers to more developed countries, due to concerns about the quality of working conditions, pay, and career opportunities, created a shortage of health care staff, which profoundly affected the public health sector and in time resulted in a number of nationwide strikes which were prominent within the hospital sector. In addition, the migration of health care workers from rural to urban, public to private, and primary to higher levels of health care (Padarath et al. 2003, Awases et al. 2003) resulted in a highly uneven skills distribution which further affected the equitable provision of health care (Anyangwe and Mtonga 2007). The Health System in South Africa 163

Box 1. Traditional ways of healing

There are five types of traditional healers in South Africa, including herbalists, diviners, faith healers, traditional birth attendants and traditional surgeons (Cook 2009). Herbalists (inyanga) are usually male and possess knowledge of the medicinal properties of herbs and substances of animal origin. Diviners (amgqira), who are commonly known as sangomas (Zulu) and are ‘called’ to work by the ancestors, are usually female and work in a religious supernatural context, providing spiritual counselling and acting as medium for the ancestral spirits. Faith healers integrate traditional practice into modern Christian rituals and usually belong to one of the independent African churches, healing by prayer or by holy water, or by touching the patient, whereas traditional birth attendants assist with childbirth and traditional surgeons perform male circumcisions as part of African initiation rituals. Traditional healers are established health care workers in their communities (Pretorius 1999) and each has their personal field of expertise. While herbalists trade in directly derived healing powers, diviners concentrate on diagnosing the unexplainable through casting of objects, or through dreams and visions, in order to intercede with irate ancestors or to operate against the curse of witchcraft to indirectly effect healing, sometimes combining both sets of skills. Both treatments are holistic and involve muthi, which literally means ‘tree’, but also translates into medicine, which can be serving the positive end of healing, involving cleansing, strengthening and protecting people from evil forces, but also the negative end of witchcraft, illness, misfortune, and death (Ashforth 2005). As the dual application of muthi indicates, mysteries abound in the arena of traditional medicine, and its acknowledgement is especially important in appreciating the benefits, but also the potential harm of traditional healing.

In addition to the western orientated health system, and as in many other African countries, there is also widespread use of traditional health care among the black population. Traditional healers already existed before the Dutch colonisation in the 17th century and flourished in the face of competition from modern medicine (Kale 1995). Although traditional healers were initially banned from practicing by the Health Act of 1974, their importance in contributing to PHC was eventually recognized and regulated by the Traditional Health Practitioners Act of 2007. This Act allowed the estimated 200,000 traditional healers operating in South Africa to practice legally (Cook 2009), although they were prohibited to diagnose or treat patients presenting with HIV/AIDS, cancer, and other terminal illnesses. Traditional healers mainly include herbalists and diviners, each operating within their own field of knowledge (see Box 1).

1.2. Historical Development

In order to understand current public health challenges in South Africa it is important to take a look at its history, since this has had a pronounced effect on the health of people as well as the health policy and services of today (Coovadia et al. 2009). Early developments largely centred around the development of a hospital based system, offering community and tertiary public health care, while the apartheid era was characterised by development of a poorly organised, highly fragmented, and deregulated health sector. Basic health care hence 164 Peter Delobelle remained out of reach for most of the population for a prolonged period of time as a result of political ideology based on racial segregation.

1.2.1. The Colonial Period (1652-1910) The white population of South Africa traces its roots back to the first settlement of the Cape in 1652, when European settlers found a land inhabited by the KhoiKhoi and San tribes who had social systems and structures of their own. The Khoi-San had substantial knowledge of home remedies and herbal medicines, which were extensively used by the Dutch settlers. In the next century, subsequent waves of colonial settlers brought their respective medical influences and practitioners, which resulted in a mix of traditional and private health providers. In 1755 two hospitals were established as result of the smallpox epidemic, segregated along racial lines. State contributions, however, were limited to District Surgeon services, control of epidemics and transmissible diseases, and medico-legal services (Jaques and Fehrsen 2007). Health challenges included diseases related to poverty, epidemics, poisons, malaria and other tropical diseases, and famine (Coovadia et al. 2009). It was not until 1807 when health matters became legislated through the establishment of the Supreme Medical Committee under British colonial rule (Jaques and Fehrsen 2007), registering the persons who practiced medicine, and decreasing population reliance on poorly trained barber surgeons. The 19th century saw the introduction of many laws, including the 1883 Public Health Act which made notification, as well as inoculation, of smallpox compulsory and which replaced the Colonial Medical Committee with a Medical Council. In 1877 the training of nurses was formalized and hospitals were constructed in most major towns due to discovery of gold and diamonds, which created rapid growth of urban centres in the second half of the 19th century, in turn transforming the economy from agricultural to industrial, and initiating a process of migrant labour on the mines (Coovadia et al. 2009). In the meantime, Afrikaner farmers had begun an inland migration in order to occupy farming land, and churches and missionaries started building hospitals and clinics in the interior of the country, providing the only health care based on western principles for rural black populations (Jaques and Fehrsen 2007). Until the end of the 19th century, however, government regulation of western and traditional medicine remained limited. The period was characterized by violent struggle and the subjugation of indigenous populations by the professional British army and the Afrikaner ‘Boers’, which led to the instalment of two British Colonies (Cape and Natal) and two Afrikaner Republics (Transvaal and Orange Free State). The British and Boers then fought two wars, until the latter were defeated by the British Empire in the second Anglo-Boer war from 1899 to 1902.

The Health System in South Africa 165

Figure 2. Private dispensary and surgery, Bloemfontein, 1850s.

1.2.2. The Segregation Years (1910-1948) The provision of social and health services in British protectorates in Africa and the Transvaal after 1902 resembled the services in Britain, whereby the colonial administration provided health services to both civil servants, indigenous Africans, and the community – under colonial control at hospitals built specifically for that purpose (Verhoef 2006). The understanding was clear: basic health services were to be provided in hospitals for officials and the community for free. When the Union of South Africa was formally constituted in 1910, however, health services were largely fragmented among the provinces, and it was not until the Public Health Act of 1919 that the first Union-wide public health department was established and attempts were made to redress the differences and inefficiencies of the existing health system by introducing a new three tier system. Under the 1919 Public Health Act, control of hospitals was assigned to individual provinces, but the municipalities needed to provide clinics with preventive, environmental, antenatal, and child care. Central government was responsible for national health issues (Jaques and Fehrsen 2007) but as available resources were unevenly allocated with a larger part going to provinces, a relatively large emphasis was put on hospital based curative care, attracting more specialists and excluding poor sections of the population, in turn worsening racial inequalities. As labour migration to the economic heartland of the country intensified, so did diseases caused by 166 Peter Delobelle overcrowding and poor working and living conditions of African workers, spreading syphilis, tuberculosis, malaria and venereal diseases (Coovadia et al. 2009).

Figure 3. Grey's hospital, 1910.

Following the passage of the 1913 Land Act, the African population groups, which comprised some 85 percent of the total South African population, were also relegated to 13 percent of the available land area (Thompson 1990). This decisive enactment was to prove deleterious for the health of the African population for the next eighty years by creating a perverse system of circulatory migrant labour, in which the capitalist mining sector, settler farms, and industrial complexes would increasingly attract black labourers from their ‘reserves’ in order to serve the economical interests of the white elite. This internal labour migration would severely disrupt the social fabric of family life, undermine rural black agricultural economy, and lead to high levels of stress and social disintegration. As the demand for cheap labourers became insatiable, segregationist health policies and taxes were put in place in order to restrict the access to land and means of production to the white population. These measures, however, together with a strict and punitive control of desertions caused increased labour migration to the towns. Despite legislated attempts to restrict black people back to the reserves, the urban black population grew by 94% between 1921 and 1936 (Union Government 1948). Due to the lack of adequate living conditions the situation quickly became untenable, leading in forced repatriation of labourers too ill to be productive, in turn spreading diseases to the reserves. At the end of the 1920s, more than 90% of adults in parts of the rural reserves of Transkei and Ciskei were, for example, infected with tuberculosis (Packard 1989). The Health System in South Africa 167

In 1928, recommendations of the Loram Committee with regard to training of black doctors in order to deal with health issues in the black communities were ignored.

Figure 4. Black miners in Kimberley, early 1900s.

On the contrary, only one year later a detailed social science investigation was initiated into the poverty among whites named the Carnegie Commission of Investigation on the Poor White Question in South Africa (Seekings 2008). The commission was conducted by white South Africans dedicated to reducing poverty among Afrikaners, which threatened white political solidarity (Pick et al. 2008). The commission issued recommendations, such as the need for improved schooling, health and adult education, and the establishment of local committees and social workers, all geared towards improving the wellbeing of poor whites. The report was permeated by notions of white supremacy and provided a template for apartheid among future leaders of the Nationalist Party (Pick et al. 2008). Another report from the Commission of Enquiry into Old Age Pensions (the so-called Pienaar Commission of 1928), indicated the need for a compulsory sickness insurance for black and white workers in the urban industrial sector, based on the British health insurance (Verhoef 2006). The commission proposed that the services of district surgeons be expanded with more regular visits to rural black areas, and suggested that specific health practitioners be trained to offer health services to the communities living in these areas. 168 Peter Delobelle

None of these recommendations were implemented, but reference was often made in Parliament to the deplorable state of health in rural areas, whereby the most prevalent diseases, such as malaria and tuberculosis, were thought to be preventable (Verhoef 2006). Henceforth the call for a comprehensive medical service which would integrate preventative and curative medicine and meet the needs of the population gradually arose, leading to a passionate plea by the then President of the Medical Association of South Africa for a unitary medical service administered by the State (Napier 1931). Most of the prominent advocates of public health, however, regarded health care for African people as a separate issue, envisaging a separate component of state medical service, administered by either the Department of Public Health or Native Affairs (Van Rensburg and Harrison 1995). Eventually, the Public Health Amendment Act 57 of 1935 provided for the extension of health services to ‘native territories,’ and in 1936 the formation of a ‘native medical service’, coupled with an expanded training of ‘native medical aides’, was proposed. In accordance with the government policy of segregation, the Department of Public Health decided to push for the establishment of a completely segregated health service for Africans, which in 1940 led to the creation of an embryo ‘native health and medical service’ (Van Rensburg and Harrison 1995). The distribution of medical doctors in the Union was, however, largely unequal, as illustrated by a report published at that time (Ravenscroft 1944). In 1939, nearly two thirds of registered doctors were working in the main cities and towns, and around three quarters were employed in private practice throughout the three industrial regions of the country. The remainder had permanent appointments with government or in mining or general hospitals. As illustrated in Table 1, the geographical distribution showed a marked clustering of professionals in the Cape and Transvaal provinces, while the near absence of doctors in the native territories led to large population-to-doctor ratios for the indigenous population. The report also provided a detailed account of the distribution of medical doctors within the provinces, showing a large variation both within and between regions.

Table 1. Geographical distribution of medical practitioners, Union of South Africa, 19392

Province Population (000 omitted) Population per Doctor May, 1936 (nearest 10) Nb. Total Europeans Non- Total Europeans Non- Total Europeans Europeans Cape 907 1,007 774 1,572 2,346 850 1,730 2,580 Transkei 68 70 18 1,166 1,184 260 17,150 17,410 Natal 352 365 184 1,400 1,584 520 3,980 4,500 Zululand 21 22 6 356 362 290 16,970 17,260 Transvaal 1,088 1,153 821 2,521 3,342 750 2,320 3,070 Orange 231 236 201 571 772 870 2,470 3,340 Free State Union 2,667 2,853 2,004 7,586 9,590 950 2,840 3,590

2 Based on Ravenscroft, A.R. (1944) The geographical distribution of medical practitioners in the Union, South African Medical Journal, 18(1), p. 34. The Health System in South Africa 169

The 1945 Gluckman Report The second South African inquiry into poverty and health was implemented by the National Health Services Commission (NHSC) in 1942. The commission, chaired by Henry Gluckman, was inspired by the British Beveridge Report with its radical blueprint for a visionary welfare state in post-war Britain (Digby 2008). In South Africa, the suggested reform was politically motivated, since the nation was strongly divided on the question of participation in WWII on the side of the British after the Anglo-Boer war several decades earlier. Post-war reforms with promises of benefits for all sections of society were seen by the pro-war party in Parliament as a strategy with potential unifying effects (Phillips 1993). The NHSC was hence mandated to:

...enquire into, report and advise upon the provision of an organised National Health Service, ... which will ensure adequate medical, dental, nursing and hospital services for all sections of the people of the Union of South Africa; and the administrative, legislative and financial measures that would be necessary in order to provide the Union of South Africa with such a National Health Service (1945, p. 1)

The commissioners undertook a three-and-a-half month tour of the country, learning firsthand through observation, evidence and discussions with representatives from government and civil society, including commerce, voluntary organisations, industry, academics, traditional leaders and other parties, while paying special attention to pioneer work done in existing health units established in three rural areas3 (Phillips 1993). After two years of diligent work and based on high quality research, the commission submitted its findings in what came to be known as the Gluckman Report. The report denounced the unacceptable level of disease in South Africa and advocated the creation of a National Health Service to provide primary health care for all its citizens, based on extensive reform of existing health services. In the report, authors described how health services were the antithesis of the reforming ideal, and four major problem areas were identified: (1) lack of coordination due to the three tier system, complemented by mission and mine hospitals, as well as private service providers; (2) a shortage of services, including hospital beds and personnel; (3) a large private practice sector, which was profit orientated, encouraged curative services, and was concentrated in rich, white urban areas; (4) and an inappropriate emphasis on curative and institutional care, not adapted to ‘modern’ concepts of health (Jaques and Fehrsen 2007). With an almost messianic tone, the report argued in favour of a National Health Service based upon a comprehensive reorganization of administrative structures of health services at national, provincial, regional, and local levels (Phillips 1993). The report recommended that all health care services should be supplied free of charge and that the state should provide all the necessary personal and preventive services, which included taking over hospitals from the provinces. Based on the concept that health services needed to include both health promotion, prevention, cure, alleviation of disease or injury, and rehabilitation of the disabled, the report advocated for the development of a network of community health centres, staffed by a medical team and linked to a network of general practice, specialist and teaching hospitals (Phillips 1993). These community centres were

3 Much of the scientific evidence quoted in the report was based on research at the first health centre established by Drs. Sidney and Emily Kark in 1940 in Pholela, a rural area in Natal (Kark and Cassel 1952). 170 Peter Delobelle modelled after the Pholela Health Centre developed by the Karks in 1940 in rural Natal (see box 2), and were defined as:

the practical expression of two of the most important and universally accepted conclusions of modern medical thinkers. The first is that the day of individual isolationism in medical practice is past, and that medical practitioners and auxiliaries can make their most effective contribution to the needs of the people through group or team practice. The second is that the primary aim of medical practice should be the promotion and preservation of health (1945)

The NHSC proposed implementing 400 health centres under twenty regional health authorities, each looking after roughly 25,000 people, and was self-confident in evaluating its role as ‘one of the most important investigations’ of South African government since the Union of South Africa was established (Digby 2008). When Gluckman became Minister of Health in 1948 the health centre plan was initiated, and around forty of the envisioned 400 health centres were founded, mostly in black communities. State funding, however, remained limited and over time the health centres dissolved, or reverted to the old-style model of services under the influence of provincial administrations and the medical profession itself. No serious attempt was made to establish a National Health Service, and when the Nationalist Party took power in 1948, the momentum of change declined rapidly and segregation politics, which had started with Dutch colonialists and developed under the British regime, were further institutionalized.

Box 2. The Pholela experience

In 1940, Sidney and Emily Kark founded a health centre in Pholela, a rural and impoverished Zulu tribal reserve in the eastern province of Natal. They were given the chance to implement this plan after Kark was noticed for his interest in studying the medical conditions among the ‘Bantu’ (the then polite and scientific way to describe the black African population). Kark had conducted a health and nutrition survey among African schoolchildren in Johannesburg and its environs and was recruited by the deputy chief medical officer of Government to conduct a nationally representative nutrition survey, supported by an anthropometrist and his assistant. The one-year survey covered more than 7,000 black African schoolchildren in urban and rural areas and reported widespread malnutrition and infectious diseases (Kark and le Riche 1944). The health centre in Pholela was the first innovation of the Karks, serving as a field model for establishment of health centres in the country (Tollman 1994). The model started with primary care as a substrate for preventive medicine and community care, based on the collection of demographic as well as epidemiological data, but also on detailed ethnographic, sociological and psychological accounts (Susser 1993). The Karks recognized that poverty played a crucial role in the health problems in their region and expanded their medical duties to cover housing, sanitation, and access to food for the neighbouring communities. The project proved successful and soon included more communities, offering health education and home visits by trained ‘health assistants’ under supervision of the medical officers (Kark and Cassel 1952). The health centre practice included a general service with out-patient treatment and antenatal care, and an extended family health and medical care program. Staff members The Health System in South Africa 171

were moreover regularly asked to assist in the outbreak of infectious diseases in the area (Kark and Cassel 1952). This resulted in an integration of curative, preventive and promotive health services, which soon led to a decrease in major communicable diseases, such as typhoid and typhus fever, or smallpox and diphtheria. The continued efforts of the health assistants to educate the local community on improved environmental and personal hygiene, improved diets, and the appreciation of the value of periodic health examinations and early disease treatment also resulted in a significant reduction in morbidity related to nutrition. During the first decade of the Pholela Health Centre infant mortality rates hence declined from an estimated 275 to just over 100 deaths per 1,000 live births (Kark and Cassel 1952). The training of health workers for the health centres was a second major innovation which occurred at the Institute of Family and Community Health of the University of Natal in Durban. The Institute was formed in early 1945 in order to provide personnel and research in support of the planned health centres and was later affiliated as teaching health centre with the new Department of Social, Preventive and Family Medicine at the Natal Medical School headed by Dr. S Kark (Horwitz 2009). After legalisation of apartheid politics, however, it became increasingly difficult for the Karks to pursue their ideas and by 1958 they left South Africa, taking the many lessons of the Pholela experiment abroad. The innovative approach inspired many projects around the world and provided a model for the first ever community health centres in the United States. The model was also refined at the Hebrew University Hadassah Medical School in Israel, where the Karks started a teaching health centre after their relocation (Susser 1999). Their ideas continued to attract global attention, and led to the development of community oriented primary care (COPC) as strategy for implementation of community centred health care (Epstein et al. 2002, Nutting and Connor 1986, Braveman and Mora 1987), which eventually culminated in the model being adopted as core strategy for the implementation of PHC by WHO/UNICEF in the landmark conference of Alma Ata in 1978.

Courtesy Norman A. Scotch, PhD.

Figure 5. Pholela Health Centre, South Africa, late 1950s. 172 Peter Delobelle

Courtesy Jeremy D. Kark, MD, PhD.

Figure 6. A class on child care, Pholela, early 1940s.

Courtesy Jeremy D. Kark, MD, PhD.

Figure 7. Drs. Sidney and Emily Kark in South Africa, early 1940s. The Health System in South Africa 173

Figure 8. Article by Sidney Kark in the South African Medical Journal, anno 1944.

1.2.3. The Apartheid Era (1948-1994) When the National Party came to power, racial discrimination, prejudice and segregation were legally enshrined and further institutionalised under the system of ‘apartheid’.4 According to the Population Registration Act of 1950, all citizens were assigned to a racially defined population group, consisting of black, white, or coloured, which radically defined their opportunities for education, residence, marriage, employment, and access to healthcare. The Group Areas Act of 1950 forced physical separation between races by creating residential and business areas for each ethnic group, resulting in forced removals of people living in the ‘wrong’ areas and wholesale destruction of communities. In this way, the apartheid system engineered a society deeply divided by social inequalities, which had a profound impact on the health and wellbeing of its different population groups. In the 1950s, for example, infant mortality was less than 15 deaths per 1,000 live births among white South Africans, but under five mortality was 30-50% among black South Africans in rural areas, while life expectancy among the white population was nearly twice that of the black population (Horwitz 2009). In 1951, the Bantu Authorities Act established a basis for ethnic government in the reserves or so-called ‘homelands’ (Figure 10), consisting of independent states to which black Africans were assigned based on their record of origin. All political rights of black Africans, including voting, were hence confined to the designated homeland, thereby relinquishing their South African citizenship. From 1976 to 1981, four of these homelands became independent (Transkei, Bophuthatswana, Venda, and Ciskei), although six administrations refused to adopt the nominal independence, maintaining the pressure for political rights within South Africa as a whole. In this period more than 9 million South Africans were denationalized and

4 The meaning of the word ‘apartheid’ is ‘separateness’, or ‘setting apart’ in Afrikaans, which was popularized in political language and translated as: ‘Separate development of each race in the geographical zone assigned to it’. 174 Peter Delobelle several strict laws enforced, which required black Africans to carry a passport at all times in order to be allowed entry into their former country of citizenship.

Figure 9. Location of the former homelands (Bantustans) in South Africa.

With the creation of homelands, degrees of poverty and poverty related diseases increased. For example, in Ciskei, a Bantustan that became independent in 1981, severe deprivation and widespread malnutrition were reported (Turshen 1986), whereas in 1982, Dr Mphahlele, Secretary for Health in Lebowa, quoted a survey done in 400 schools which stated that 100,000 children in Lebowa were malnourished (de Beer 1986). A study of children aged less than five indicated gastro-enteritis, protein energy malnutrition, and respiratory diseases, to be major reasons for hospital admission in southern Lebowa (Booth 1982). Lack of sanitation and poor hygiene resulted in waterborne disease outbreaks, such as typhoid and cholera, which in the early 1980s led to an explosive epidemic in the Northern Transvaal (Kustner et al. 1981). The absence of a well-organized infrastructure in the homelands reduced the effectiveness of health services, as illustrated during the 1982 polio outbreak in the Northern Transvaal, where the much needed vaccine was either out of stock or simply ineffective, resulting in fully immunised children contracting the disease (de Beer 1986).

The Health System in South Africa 175

Figure 10. Report of notifiable conditions, Department of Health RSA (1981-1986).

Source: Mayibuye Archives.

Figure 11. Overcrowding in hospitals during the apartheid era.

The situation in the homelands hence created life threatening conditions, which were by some described as tantamount to genocide (de Beer 1986, p.47). Uncontrolled infectious diseases outbreaks of malaria, measles, and diphtheria were rampant, as illustrated in Figure 11, and pulmonary TB was also rife, although declining according to official government statistics.5 In addition to widespread malnutrition and infectious diseases, the social circumstances of life in the homelands had also disastrous effects on the mental wellbeing of its populations.

5 Data are based on official statistics from the South African government and exclude health statistics from the ‘independent’ homelands (Ciskei, Transkei, Venda, Bophuthatswana). 176 Peter Delobelle

Courtesy Cecil de Beer © Link.

Figure 12. Rural clinic in the Lebowa Bantustan.

The hopelessness and desperation of the situation led to alcoholism, psychological disorders, personal violence and crime (de Beer 1986), and psychopathology due to family disruption in view of the migratory labour system was rife. In addition, the impact of apartheid policies on public mental health, of which the systematic human rights violations of persons held in detention, could not be underestimated (Dommisse 1985). These observations led WHO-AFRO in 1981 to conclude that ‘apartheid is the cruellest governmental assault on the health of a people ever known to man’ (WHO 1983):

Apartheid has a harmful effect on the physical, mental and social health of the peoples... Apartheid runs counter to the social objective of health for all by the year 2000 and to the Alma-Ata Declaration. Health for all cannot be achieved in South Africa without negation of apartheid which is itself a negation of health.

The homelands lacked financial and economic resources to establish or maintain autonomic independent nations, and despite ostensible commitment from the Bantustan governments to offer PHC and improved health care services, the lack of budget was crippling (Baldwin-Ragaven et al. 1999). Lack of resources resulted in compromised health care that was inaccessible to people living in the Bantustans due to shortage of transport, but also, in shown in Figure 12, to poorly equipped, understaffed, as well as severely overcrowded hospitals. In the first half of 1981, only a third (34%) of vacant positions for doctors in Lebowa hospitals were filled full-time (Mphahlele 1981). Also in 1981, there were vacancies for more than seventy doctors in KwaZulu, while Bophuthatswana had an estimated 2.2 doctors per 100,000 of the population. In Lebowa, only one doctor was available for 20,000 to 30,000 residents, compared to one doctor for every 875 white South African citizens (de Beer 1986). This inequality was aggravated by a severe shortage of nurses, which spilt over into the white hospital sector. The Health System in South Africa 177

Box 3. The history of homelands

Before 1994, the South African health system was characterised by political, economical, and land restriction policies based on geographical and racial disparity. In seeking to segregate all aspects of society, the Government developed so-called ethnic ‘homelands’, which were semi-autonomous and administrative entities charged with the provision of health and public health services. The health system was then fragmented among fourteen Departments of Health, with ten homeland departments, three 'own affairs' departments, and another 'general' affairs department. This resulted in a health system that was vastly inefficient and also cost ineffective. The health system lacked coordination, decreased access to services, and provided different quality of care for the separated population groups. The homelands quickly became dumping grounds for the black African population. Between 1960 and 1980, nearly 2 million people were forced into the homelands to clear ‘black spots’ in urban areas and rural villages, comprising blacks whose labour-tenant contracts on white farms were hence cancelled (Rogerson and Letsoalo 1981). The homelands soon became increasingly populated and quasi-urban communities emerged on homeland borders as the labour force commuting to urban industrial complexes grew rapidly in the 70’s. Other black workers lived in single-sex hostels near industry too far for daily commuting, but the remainder of the black population, who were employed in the industry, mines, or as domestic labourers, was still restricted to legally defined ‘townships’ outside white urban areas.

Figure 13. Mass protest against apartheid, South Africa 1970s.

Although services for whites in rural areas were relatively neglected, services for the black African population were severely neglected. In urban areas, in 1970 there were 109 blacks for each hospital bed, but in rural areas there were 191 blacks for each hospital bed (McGrath 1979). In 1961, South African government declared itself a Republic and formally withdrew from the British common wealth. At the same time, the ANC and South African Communist Party formed a people’s army to fight the government after years of failed diplomacy. The township revolt of 1976 forced the government onto the defensive side, and economic changes coupled with rapid urbanization paved the way for reform, including in the health sector. Through the 1977 Health Act, the roles of national, provincial, and local authorities in the health care system were again defined. The Act and subsequent policy statements by the 178 Peter Delobelle

Department of Health reopened the debate on prevention rather than cure, and the 1980 National Plan for Health Service Facilities even suggested the development of a network of community health centres aimed at providing accessible care to the entire population, but the policy was never fully implemented (de Beer 1986). In the early 1970s, Government decided to nationalise all mission hospitals, mainly to get rid of foreign influences and philosophies inimical to apartheid (Jaques and Fehrsen 2007). As a result, in 1983 less than 10% of hospitals in the homelands were run by missions, whereas the rest had been taken over by government and subsequently handed over to the homeland health departments in order to enhance their political respectability (Price 1986). At the same time, a new ‘Comprehensive Hospital Centric Health Service’ was adopted, attempting to provide health care for the population by allocating geographic areas equivalent to the size of a district under the control and administration of hospital chief medical officers in so-called ‘hospital wards.’ These wards included the hospital itself and some satellite clinics, and aimed at integrating all health services under one authority. The policy was gradually introduced during the 1970’s, but met with severe resistance from provinces and eventually vanished without major successes. The end of the 1970’s welcomed some improvements in laws governing the life of urban black Africans, in order to suit the need for a more skilled workforce and respond to rapid urbanization and economic downturn. Greater freedom of personal movement, relaxation of trading control, home ownership and building, and the increased participation of black Africans in municipal affairs and administration boards intended to foster expansion of a politically stable middle class, albeit to the detriment of excluded blacks living in the 'resettlement villages' inside the homelands (Rogerson and Letsoalo 1981). The settlements had become real dumping grounds for black Africans and were characterized by underdevelopment and appalling poverty rates, as a consequence of overcrowding and unemployment due to the lack of opportunities for subsistence farming. At the same time, the 1970s also witnessed the rise of mass resistance, with strikes from unionized workers and, after the strikes were crushed, by a growing urbanized proletariat (Chopra and Sanders 2004). The increasing militancy and mobilisation on behalf of the African majority placed the regime under constant pressure, which led to adopting more sophisticated strategies to maintain white privilege and supremacy, such as an unfettered enthusiasm for privatisation and creation of the tricameral racially exclusive parliaments in 1983.6 The result was, in turn, increased fragmentation of health care services, which were at one point coordinated by fourteen different departments of health, together with the National Department of Public Health (Jaques and Fehrsen 2007). The Browne Commission (1986) made a detailed study of conditions at the time, identifying previously known problems which had never been addressed (Jaques and Fehrsen 2007). The White Paper on the Report of the Commission, known as the Browne Report, advocated the formulation of a national health policy; the prioritisation of preventive and primary health services and the privatisation and deregulation of health care services, which the government could no longer afford because of spiralling costs. The recommendations were to be regarded within the widespread shift from welfarism to monetarist policies emerging in the 1970s, related to the economic decline in industrialized countries (Price

6 The Tricameral Constitution of 1983 introduced three separate chambers of parliament which were responsible for the ‘own affairs’ of separate race groups, excluding Africans whose needs were regarded as ‘general affairs’. The Health System in South Africa 179

1989), and the broad and so-called ‘reform’ strategy pursued by government, which aimed at co-opting middle-class urban black Africans to depoliticise the issue of state support for segregated health services (Price 1986). The drive towards privatization was, paradoxically, also inspired by an increased demand for private care, as shown by the six-fold increase in the coverage of black Africans by medical aid schemes from 1977 to 1986 (Price 1989). This increase was attributed to the undignified conditions faced in public sector facilities; the increasing availability of private practitioners in the townships; the rise in real black wages; the policy of some large employers; and the growth of black trade unions. The deliberate attempt to increase accessibility to private health care, however, also meant sustaining wide gaps in health status among different population groups. Substantial health inequities between racial groups and provinces, and inequities in resource distributions between and within provinces and among different socio-economic groups were hence rife in this era (McIntyre and Gilson 2002). In the period 1981-1985, the infant mortality rate (IMR) for black Africans was estimated to be 9 – 10 times higher than that experienced by the white population (Yach 1988). Regional estimates of the IMR for black Africans were known to vary from 35/1,000 in Soweto (1982) to 130/1,000 in rural Transkei (1980) (Yach and Botha 1986).

Table 2. Profile of selected health indicators, South Africa 1980

South African Population Group US/UK Asian African Coloured White No. (x103) (%) 821 (3) 20,692 (71) 2,613 (9) 4,528 (17) Growth rate (%)* 2.68 3.04 2.42 1.84 Birthrate (per 24 40 28 17 17 1000) Mortality Infant (per 1000) 25 95 65 17 16 Total (per 1000) 5.9 11.0 9.2 8.3 8 % < 5 yr (1970) – 55 49 7 % > 65 yr – 12 18 52 Life expectancy Men 62 54 55 67 Women 67 58 60 73 Source: adapted from Benatar (1986); * trends are calculated for the period 1970-1980.

Marked ranges in the IMR among other population groups, in particular coloureds, were systematically found in rural areas of the Cape Province and contiguous areas of the Orange Free State and the Transvaal (Rip and Bourne 1988). The disease profile and mortality patterns of the white population, on the other hand, resembled those in developed countries, as shown in Table 2, while those of black Africans and coloureds approximated those in developing countries (Benatar 1986). Although decreases in IMR were achieved in a few rural areas through the implementation of selective PHC, the maldistribution in health needs and services brought about by apartheid policies indicated that fundamental political change was required in order to address the situation (Botha et al. 1988). A final commission of inquiry, named the Second 180 Peter Delobelle

Carnegie Inquiry into Poverty and Development (Wilson and Ramphele 1989), which was launched in 1982 and centred around black poverty, clearly pointed to the link between poverty and health and advocated a multi-faceted strategy, which included a redistribution of political power, in order to address the fundamental social injustice and inequity of apartheid policies, thereby contributing to the government blueprint for restructuring society after political transition (Pick et al. 2008). In keeping with the general climate of social and political reform between 1990 and 1994, a number of changes to the health care system were made which required no legislation, such as the desegregation of hospitals. Although the National Department of Health attempted to implement elements of PHC in government policy in the late 1980s and early 1990s, the efforts were profoundly flawed and achieved little due to the fundamental inability of the apartheid state to accommodate the inherently egalitarian and pro-poor principles of PHC (Kautzky and Tollman 2008). The National Health Service Delivery Plan for South Africa, published in 1991, also paid lip service to change, but the official policy remained oriented towards privatisation (Jaques and Fehrsen 2007).

1.2.4. The New Democracy (1994-2011) In 1994, when the Government of National Unity was installed through South Africa’s first democratic elections, the health sector was extremely fragmented, racially discriminatory and poorly coordinated. The country possessed a well developed system of hospital and community-based tertiary care, but public health care was severely damaged by the lack of regulation of the health sector and by economic stagnation in South Africa throughout the last decades. Immediately after the election of the new ANC government, a range of pro-equity policies and programmes were initiated through the public sector, many of which were part of the famed Reconstruction and Development Programme (RDP),7 based on the policy formulated by the National Health Plan (ANC 1994a):

The health of all South Africans will be secured and improved mainly through the achievement of equitable social and economic development such as the level of employment, the standards of education, and the provision of housing, clean water, sanitation and electricity (ANC 1994a).

The ANC National Health Plan (1994a) was one of the first comprehensive sectoral plans for post-apartheid South Africa that firmly entrenched the principles of social justice and equity (Chetty 2007). The Plan outlined its belief in the fundamental right to health care for all, and envisioned a fundamental restructuring of the health system based on the PHC approach. As such, the Plan sought to eliminate the fragmentation and duplication of health care services existing under the previous regime by integrating all the health services in a single Ministry of Health, by decentralising the organisation and management of services through a well-coordinated district health system, and rendering comprehensive, community- based health care accessible to all by establishing PHC centres at the basis of the national health system. The Plan was largely influenced by the COPC experience pioneered at the

7 The Reconstruction and Development Programme (RDP) is a South African socioeconomic policy framework implemented by the African National Congress (ANC) in 1994 after consultations among the ANC, the Congress of South African Trade Unions, the South African Communist Party, and civil society organizations. The Health System in South Africa 181

Pholela Health Centre, and by the recommendations emanating from the Gluckman Commission (Kautzky and Tollman 2008). Key health sector goals arising from the Plan were integrated in the RDP, which proposed a package of socio-economic measures aimed at redressing the massive inequities of the past. Many of the broader social sector policies (e.g. improved access to water and sanitation) were thus largely motivated by their likely impact on health status, as it was conceived that meeting targets could be more rapidly achieved through health service reform in comparison with other sectors (Chetty 2007, ANC 1994b). In addition to a dynamic building program for PHC units, the RDP hence introduced free health care for mothers and children at PHC level, which was subsequently expanded to free PHC for all; a comprehensive extension of social welfare grants for previously disadvantaged population groups; and a national school nutrition program. Efforts were also made to address problems arising from the social determinants of health, such as poverty, inequality, inadequate housing and poor education. With many members of the progressive PHC movement in the new National Department of Health (NDoH), and a relatively clear policy direction detailed in the National Health Plan, enthusiasm for the transformation of the national health system was very high (Kautzky and Tollman 2008).

Figure 14. Mass rally in support of Nelson Mandela, 1994.

Translating these progressive national health policies into effective local and provincial practices was, however, fraught with unexpected obstacles, such as the sudden inundation of PHC clinics which were required to offer free maternal and child care, and the difficulties in structurally integrating the highly fragmented health departments at provincial and local level in alignment with the new legislation. For example, the Northern Province was confronted 182 Peter Delobelle with the task of uniting three previous homelands and parts of the old Transvaal Province, all of which had different health administrations (Jaques and Fehrsen 2007). At the same time, under the direction of the NDoH, a team of officials from the nine newly founded provinces drafted a detailed implementation strategy for the development of a decentralised, district based health system. The report, entitled 'A policy for the development of the district health system for South Africa', informed the subsequent 'White Paper on the Transformation of the Health System', which was formally endorsed by Parliament in 1997 (Department of Health 1997). The White Paper highlighted the objective of promoting equity in health by developing a unified national health system, and advocated forging partnerships between state, non-governmental organisations (NGOs) and the private sector, delineating three tiers of health policy (national, provincial and district), and focusing on integrated PHC services. The White Paper was used as basis for the drafting of the National Health Act No 61 of 2003, which aim was to ‘establish a health system based on decentralised management, on principles of equity, efficiency and sound governance, on internationally recognized research standards, and on a spirit of enquiry and advocacy that encourages participation (Department of Health 2003a). The National Health Act hence provided the basis for a legal environment for promoting equity and also established a framework for administration of the health care system, including the delineation of powers and functions among national, provincial and district health authorities; protecting the rights of health users; addressing the establishment and operation of private and public health facilities; regulating public health programs, services and health laboratories; and implementing health surveillance. Although these political intentions hence put health equity initially high on the agenda, achievement was severely compromised by adopting a neoliberal macroeconomic policy favoured by the International Monetary Fund (IMF) and The World Bank (Baker 2010). This policy, named the Growth, Employment and Redistribution (GEAR) strategy, introduced more orthodox development economics, espousing fiscal constraint, reduction of budget deficits, and promotion of international competitiveness (McIntyre and Gilson 2002), which made the achievement of redistribution and equity goals, as set out by the RDP and National Health Plan, nearly impossible. The effect of GEAR was neither growth nor redistribution, but a significant growth in unemployment, from 16% in 1995 to 30% by 2003, with a concomitant drop in average black African household income by 19% in the period 1995- 2000 (Bond 2004). Although the health sector was relatively saved from budgetary cuts, the public-private mix of provision in health care maintained the pre-democratic inequity in access to health which was now based on social class and income rather than race (van Niekerk 2003). Racial apartheid in health care was hence seen to be transforming into a two-tier system of economic apartheid, with the upper and middle income classes of all races being deflected towards the rapidly growing and expensive private sector backed by private insurance, while the under-resourced public health sector catering for the poor was relatively neglected (Benatar and Vanrensburg 1995). As a result, in 2004, sixty percent of the national health budget was spent on less than 20% of the population covered by private insurance, and the percentage of physicians working in the private sector had increased from 40% in the 1970s to 66% in 2004 (Benatar 2004). The Health System in South Africa 183

In addition to the continued tension with the private health sector and to developing a more equitable system of public health care, there were also tensions within the public health sector itself. Allocation of resources was focused on national redistribution, including shifting resources from tertiary care towards primary care and community-based care (Mbatsha and McIntyre 2001), and from wealthier provinces towards historically disadvantaged areas. Despite increases in the population of Gauteng and Western Cape, the national health budget allocated to each was hence reduced after 1995, leading to a reduction of the highly specialized tertiary care for the poor and uninsured offered at academic medical complexes as a result of downsizing and budget cuts, and a concomitant loss in postgraduate training potential of medical students (Benatar 2004). Redistribution of resources in the public sector included building tertiary care hospitals in the previously disadvantaged areas of Eastern Cape and Kwazulu-Natal, but shifting medical personnel towards these areas appeared more difficult. Introduction of a compulsory one-year community service for medical graduates in rural areas, which was established in 1998 in order to ensure an improved distribution of health services nationwide, indicated positive experiences, although early investigation did not show any effect on the retention of physicians (Reid 2001). The challenge of retaining health care workers in the country seemed even more daunting given the freeing up of international trade markets, with a resultant outmigration of health workers towards more developed countries due to dissatisfaction with the quality of working conditions, pay, and career opportunities (Mooney and McIntyre 2008).

1.3. Current Challenges

1.3.1. Human Resources for Health In South Africa, an estimated 250,000 skilled health workers left the country between 1989 and 1997 for New Zealand, Canada, Australia, the UK and USA (Padarath et al. 2004), and in 2001, more than 4,000 vacancies for doctors and upwards of 32,000 vacancies for nurses were found (Hall and Erasmus 2003). The impact on the public health sector was clearly enormous and still aggravated by the loss of training investments, which equalled US$5 billion due to the outflow of doctors between 1989 and 1997 alone (Padarath et al. 2003). The number of South African health workers practicing overseas was found to be substantial, as shown in Table 3 presenting statistics of South African-born workers practicing a medical profession in selected OECD member countries in 2001 (Dumont and Meyer 2004). The brain drain is associated with the migration of health care workers to more developed countries on a global scale, driven by so-called ‘push’ and ‘pull’ factors which emanate from ‘source’ and ‘destination’ countries, respectively. ‘Push’ factors are inherent to the health system, such as low remuneration and salaries, inadequate working conditions, lack of opportunities for professional development and personal safety (Awases et al. 2003, Padarath et al. 2003, Kingma 2001), or external to the health system, such as quality of life, social and political security, and education opportunities. ‘Pull’ factors include improved standards of living, working conditions, nurse staffing ratios, and career prospects (Kline 2003, Dovlo 2007). In South Africa, migration has not only been attributed to the prospects of higher pay and better work conditions overseas, but 184 Peter Delobelle also to dissatisfaction with the socio-economic climate, in particular crime (Lehmann and Sanders 2003). In a six country study conducted by the WHO Regional Office for Africa in 2002 looking into the issue of migration among health care professionals, over a third of South African respondents cited a general decline in health services as a reason for emigration, especially among those aged 20-29 years. Violence and crime were found to be reasons for emigration by an equally high proportion of respondents, while a quarter of all respondents mentioned financial reasons (Awases et al. 2003). More than three quarters of the interviewed professionals argued that better salaries would motivate them to stay in their country, followed by a healthy work environment, fringe benefits, and a reasonable workload. Financial and non-financial incentives were hence explored as a means to motivate health care workers and increase their retention, in South Africa and in less developed countries in general (Vujicic et al. 2004, Mathauer and Imhoff 2006, Willis-Shattuck et al. 2008).

Table 3. Number of South African health professionals working in OECD member countries, 2001

Practitioners$ Nurses / midwives Other health Total professionals* Australia 1114 1085 1297 3496 Canada 1345 330 685 2360 New Zealand 555 423 618 1596 United Kingdom 3625 2923 2451 8999 United States 2282 2083 2591 6956 Total 8921 6844 7642 23407 Source: Organisation for Economic Co-Operation and Development (2004). $ Doctors, dentists, veterinarians, pharmacists and other diagnostic practitioners. * Including assistants.

Migration of health care workers also occurs within the country itself, following a pattern from rural to urban, public to private and primary to higher levels of health care (Padarath et al. 2003). This migration results in a highly uneven skills distribution, affecting the equitable provision of health services, but also the workload and morale of remaining staff, in turn leading to stress, burnout, lower quality of care and further attrition (Liese and Dussault 2004). The relatively favourable population health worker ratios in South Africa compared with neighbouring countries hence hide substantial internal disparities, between provinces and between the public and private sector (Lehmann 2008). While geographical distribution of health professionals has gradually improved between 1994 and 2007, the number of health care workers working in the public sector dropped significantly over the same time period. Several policy measures, including the recruitment of health professionals from outside the country, the extension of community service for other health professional groups and the introduction of a certificate of need clause for establishing, extending or expanding health facilities, faced severe resistance from some health worker categories and only had limited success in increasing the supply of health personnel in underserved areas (Padarath et al. 2004). The introduction of rural and scarce skills allowances for designated categories of health workers, implemented through the National Health Bill in 2004, offered high The Health System in South Africa 185 expectations, but a preliminary evaluation of the community service program indicated that only a minority of the affected health professionals was influenced by the rural allowance to change their short-term career plans (Reid 2003). In order to cope with the rising demand placed on the public health system due to the increased burden of disease and population growth, training of sufficient numbers of health workers with adequate skills is therefore clearly needed. However, between 2000 and 2004/05, the output of enrolled and professional nurses dropped significantly at public training institutions, while the output increased sharply at private institutions (Lehmann 2008). Nurses constitute the majority of health care workers in the country and form the backbone of the district based PHC system, guided by a set of norms and standards articulated in the PHC Package for South Africa (Department of Health 2000). Increased output of nurses is hence strongly indicated, given the accelerating attrition rate and the impact of task shifting in view of the need to cope with the devastating HIV/AIDS epidemic. The use of new cadres of health workers to fill the human resources gap was also discussed extensively, as they could play an important role in PHC implementation and ensure service delivery in underserved areas (Hugo 2005, Van Niekerk 2006). The concept of mid-level workers was already advocated by the National Health Plan (ANC 1994a), but progress had been slow and only renewed by a Ministerial Task Team on Human Resources (Pick et al. 2001). In 2004, the National Department of Health decided to develop a new cadre of mid-level medical workers or so-called Clinical Associates, who were conceived to assist doctors in district hospitals. The strategy was incorporated in the national planning framework for human resources for health launched in 2006 (Department of Health 2006), which also discussed the revitalisation of community health workers and which presented detailed guidelines for human resources management and development planning at Provincial level. Although the plan was driven by strong human resource leadership and significant progress was made in terms of training and retention policies for health care professionals, disparities between provinces and the public and private sector continued to grow (Lehmann 2008). The increasing human resources crisis, particularly in the nursing profession, attracted a lot of media attention and resulted in some nationwide strikes that were especially prominent in the hospital sector. Development of mid-level cadres meantime remained slow, and implementation of the community health worker program was patchy and uneven. In addition, although training curricula had been reformed in many medical schools, no fundamental shift in the orientation and resourcing of health professions was done. The introduction of Occupation Specific Dispensations for specific categories of health care workers in 2007 which included improved salary scales, frequency of pay progression and career pathing, moreover resulted in budget overdrafts with a concomitant inability to fill vacancies for financial reasons. As such, findings indicated continued maldistribution and shortages of health care workers, in particular in rural areas (Daviaud and Chopra 2008), which were exacerbated by poor monitoring and management skills within the public health sector (Pillay 2008, Pillay 2011a). In addition, production and growth rates of health care workers were insufficient to deal with the demographic changes and impact of HIV/AIDS (George et al. 2009), and further compounded by the lack of absorption of new graduates in the public health sector in the last decade. 186 Peter Delobelle

Figure 15. Doctors on strike, May 2009.

In order to face the human resources crisis head-on, a new strategic framework was published in 2011, aimed at ensuring the required capacity for implementing national health reform (Department of Health 2011a). The strategy advocates improved production and retention of health care workers as critical to a successful outcome, in particular regarding accessibility in rural and remote areas, based on revitalised education, training, and research, including development of Academic Health Complexes; creating an adequate infrastructure for workforce and service development; improving human resources management; improving workforce flexibility, planning and information; ensuring professional quality care; and implementing sound leadership, governance, and accountability. The framework is determined by epidemiological indicators, which include child and maternal mortality, and by national health policy priorities, and includes refinement of the human resources plan, the re- opening of nursing schools and colleges, human resources recruitment and retention, a focus on the training of PHC personnel and mid-level workers, assessment and review of related grants, and integrating and standardising community health worker categories. The priorities are embedded in the recently launched national health policy to comprehensively overhaul the health system through PHC re-engineering and development of a National Health Insurance (NHI) as the primary financing mechanism.

1.3.2. Health Systems Strengthening The new policies are in accordance with the overall government strategy of ‘A long and healthy life for all South Africans,’ to which the Minister of Health has signed a negotiated service delivery agreement with the President, whereby formal commitment was made with respect to four main outputs: increasing life expectancy, decreasing maternal and child mortality, combating HIV/AIDS and tuberculosis, and strengthening health system effectiveness. These goals need to be achieved by strengthening the DHS, the institutional The Health System in South Africa 187 vehicle for the delivery of PHC and district hospital services in accordance with national legislation. Strengthening of PHC services is in line with the international trend towards tackling health inequity by addressing the social determinants of health (WHO 2008a), and builds on the community based primary care approach developed in South Africa in the late 1930s and early 1940s (see above). The strategy consists of a three pronged priority approach towards re-engineering PHC, which include the deployment of ward based PHC outreach teams, implementation of school health services, and development of district based clinical specialist teams that initially focus on maternal and child health. The policy entails holding District, sub-District Management Teams, and hospital CEOs, accountable for these priorities by strengthening management and monitoring capacity, including the strengthening of planning and budgeting at district level, community participation and intersectoral collaboration, district hospital performance, and implementation support, including supervision and monitoring. The approach clearly benefits from the acknowledgment of past achievements, but also from the recognition of the need to guarantee successful NHI implementation. The ward based PHC outreach teams build largely on existing community health worker (CHW) cadres, which total around 72,000 in South Africa, including lay counsellors, TB supporters, home based carers, volunteers, and CHW receiving stipends through NGOs contracted by Provincial Departments of Health and other development partners. Each team is envisaged to comprise a professional nurse, environmental health and health promotion practitioners, and six CHW, whose main task includes promoting health and preventing disease through integrated health care services delivery, based on the mapping of household demographics and epidemiology. Challenges of this model include the need for appropriate selection and training, adequate supervision support, and community participation (Lehmann and Sanders 2007). Further objectives include improved geographical spread and coverage, established links with fixed PHC services, improved accountability of funding organizations, and established monitoring mechanisms. With regard to school health services, an intersectoral task team has reviewed the 2002 National School Health Policy and its implementation guidelines in order to address unequal distribution of school health services between and within Provinces. Due to resource constraints schools in the poorest districts will be first prioritized and a selected range of services provided, including screening of learners for a variety of developmental conditions, dentistry and optometry, control of vaccination, and health education and promotion in selected grades, including sexual and reproductive health, in order to supplement the life skills programme. As more resources become available, services will be expanded and additional nurses deployed in order to provide the full package of services as outlined in the revised policy (Pillay 2011b). In addition to the above, district based clinical specialist teams will be established to improve the quality of care at district level, initially focusing and maternal and child health, by supervising, supporting and mentoring existing personnel. The teams will include a gynaecologist, a paediatrician, an anaesthetist, a family physician, an advanced midwife and a paediatric nurse, and a PHC nurse (Department of Health 2011a). The approach includes formalising composition and functionality of existing teams and ensuring equal distribution, and aims at strengthening the clinical governance through monitoring of treatment guidelines and protocols, ensuring the availability and use of essential equipment, providing supportive supervision, and monitoring of health outcomes. These teams will collaborate with PHC 188 Peter Delobelle outreach teams, and districts without specialist support will be prioritized by recruiting specialists on a rotational basis. Strengthening the district based PHC system and implementing the human resources for health strategic framework are located within the policy initiative to implement National Health Insurance (NHI) as the primary financing mechanism for the health system, aimed at providing more equitable access to health care in South Africa (Department of Health 2011a). Although the issue has been discussed since the late 1980s, the debate on implementation has continued in the last decade with proposals varying from social health insurance to focusing on providing health care without regard to contribution (Ncayiyana 2008). Concerns have been raised regarding the cost and administrative complexity of implementing NHI and with the demand pressure that is likely to be unleashed by introducing a comprehensive benefit package without co-payments (Keeton 2010). With the release of the Green Paper in August 2011 (Department of Health 2011b), the country has now formally opened the discussion on the proposed NHI, based on the premise of providing universal health coverage by offering a defined comprehensive package of health services, with an emphasis on disease prevention and health promotion. The quality of public health sector services will be addressed through the establishment of an Office of Health Standards Compliance in order to monitor adherence to a set of core standards, by investing in health infrastructure and equipment, and by standardizing hospital care in line with the policy towards improved management in the public health care system. Implementation will occur through a phased approach over a fifteen year time period, with the first five years dedicated to piloting the strategy in selected districts based on an audit of public health facilities countrywide, and to strengthening the public health system with regard to the proposed objectives. The second five-year phase aims to focus on NHI financing and includes establishing a pooled NHI fund which will integrate the administration of all public health funds, including the road accident fund and compensation for occupational injuries and diseases. The NHI also aims to mobilise additional resources for health through the implementation of a health tax, and while the Green Paper suggests that primary care services will be paid on a per capita basis, diagnosis-related groups will be used to pay for hospital services. Purchasing of services from public and private providers will also be introduced in this phase, based on the establishment of a single public pooling and purchasing entity. The third phase will include similar goals but focus on accreditation of private sector providers, capacity building, and infrastructure improvement (Department of Health 2011b). Although the draft policy is clearly based on the goal of achieving universal coverage in order to address the problems inherent in the health sector, the Green Paper remains vague on aspects of implementation and feasibility and has been criticized for its lack of evidence-base, transparency and public consultation at the proposal stage. Some stakeholders are critical of the potential role the private sector could play in a state-funded multi-payer and provider scheme, and fear mismanagement of public funds, while health lobbyists and taxpayers worry about NHI autonomy (Austin-Evelyn 2011). Others are concerned by the impact of additional tax funding and the loss of tax incentives for medical scheme membership, which indirectly subsidises the private health sector through a loss of public revenue. Civil society, on the other hand, favours a progressive taxation in order to narrow the equity gap. The case for re-engineering the functionality of the DHS and the capacity of PHC services arises from NHI planning on the one hand, and analysis of health outcomes on the The Health System in South Africa 189 other hand. Several reports have indeed shown that South Africa, as a middle income country, performs poorly in terms of maternal and child mortality, and is off track for achieving the Millennium Development Goals (MDG). Data indicate, for example, that under-five mortality has risen from an estimated 59 per 1,000 live births in 1998 to 104 per 1,000 live births in 2007, while the 2015 MDG target is 20 (Department of Health 2011a). Maternal mortality has dramatically increased from 369 per 100,000 live births in 2001 to over 600 per 100,000 in 2007, and, although the rise has been largely associated with health system failures (Moszynski 2011), nearly half of the reported deaths can be attributed to HIV/AIDS.

1.3.3. The Dual HIV/AIDS/TB Epidemic In South Africa, the HIV/AIDS epidemic has had a devastating impact, with an estimated 5.7 million people living with HIV in 2008 (UNAIDS/WHO 2008), representing the highest level of HIV infection in sub-Saharan Africa (SSA). AIDS-related illnesses accounted for 43% of all deaths in the last decade, taking away the economically productive population and leaving nearly two million children orphaned (Statistics South Africa 2010). Although the epidemic has stabilized over the last four years, the country continues to bear a large share of the burden of disease.

Figure 16. AIDS orphan and its grandma.

In 2008, HIV prevalence among people aged two years and above was estimated at 11%, with prevalence rates increasing from 2.5% among children aged 2-14 years to 16.9% among 190 Peter Delobelle adults aged 15-49 (Shisana et al. 2009). Prevalence is higher in women than in men and peaks in the 25-29 year age category, and of those infected with HIV in South Africa, one in two is a woman of child-bearing age (SAIRR 2011). As in most other SSA countries, HIV is transmitted through heterosexual sex, fuelled by multiple concurrent partnerships and intergenerational sex, which typically occurs between younger women and older men (Katz and Low-Beer 2008). This health risk behaviour has been motivated by subsistence needs, materialism, but also by consumerism (Hunter 2002, Leclerc-Madlala 2008), and has been associated with a higher HIV incidence in women aged 15-24 years old in comparison with men (Shisana et al. 2005). Studies on the burden of HIV among men who have sex with men also indicate a high prevalence (Shisana et al. 2009), but injecting drug use is rather uncommon as source of infection. Blood donors and donated blood are screened for infection and the safety of blood derivatives is on a par with international standards leading to very rare transfusion-related infections. The second most important HIV transmission route in South Africa is from mother to child, occurring during pregnancy, in the perinatal period, and during breastfeeding. In 2008, mother-to-child transmission of HIV (MTCT) accounted for an estimated 64,000 new infections among children (ASSA 2005). Prevention of mother-to-child-transmission was only initiated after prolonged battle with civil society over the free provision of antiretroviral treatment (ART) in 2002. The debate was highly politicized and indicated weak governmental HIV/AIDS leadership in the period following democratic transition and beyond, influenced by a denialist attitude towards HIV/AIDS under the government of former president Thabo Mbeki.8 The impact on the health sector is clearly substantial, with a large increase in the number of HIV/AIDS admissions and nearly half of all patients admitted to public hospital wards testing positive (Shisana et al. 2003). The epidemic also affects the health sector through loss of staff due to illness and absenteeism, with an estimated 16% of public health care workers testing positive for HIV (Shisana et al. 2004). The health of health professionals themselves has hence become a matter of concern, since indications are that health care workers are not always adequately protected from occupational HIV infection, in turn compromising the quality of care and decreasing staff morale (Unger et al. 2002, Zelnick and O'Donnell 2005, Delobelle et al. 2009). In South Africa, HIV/AIDS has indeed been shown to affect the ability to provide quality care and occupational safety among PHC nurses (Lehmann and Zulu 2005) and hospital nurses (Unger et al. 2002). It was not until 2004 when universal access to ART became available in the public health sector, guided by the Operational Plan for Comprehensive HIV/AIDS Care, Management and Treatment (Department of Health 2003b). The number of people treated with highly active antiretroviral therapy (HAART) quickly rose from less than 2,000 in 2003 to nearly 200,000 in late 2005, but coverage remained poor compared with other countries and with the targets set out in the Operational Plan (Nattrass 2006). By mid-2006, nearly a quarter million people were on treatment and an estimated 711,000 were in need of it (Dorrington et al. 2006). In the

8 The political attitude of HIV/AIDS denialism of the Mbeki administration should be seen in its socio-political and historical context where biomedical characterizations of the epidemic were interpreted as instruments of a continuing racist conspiracy (Butler 2005). The widespread disbelief of ART efficacy, for example, was rooted in the belief that AIDS was introduced by whites in order to control black population growth (Kalichman 2009), which in turn could be attributed to the highly attested racialised character of public health under the former apartheid regime (Fassin and Schneider 2003). The Health System in South Africa 191 same year, however, nearly half a million people developed AIDS, and more than 70% of deaths among those aged 15-49 years old were estimated to be due to AIDS (Dorrington et al. 2006). In 2007, after widespread consultation with civil society and other stakeholders, South Africa bolstered its national response by revamping the national AIDS council into a multisectoral body and released the ‘HIV & AIDS and STI Strategic Plan (NSP) for South Africa, 2007-2011’ (Department of Health 2007a). The aim was to reduce the incidence of HIV in South Africa by half by 2011, and to ensure that at least 80% of those eligible for ART would be able to access it. The NSP flowed from the National Strategic Plan of 2000- 2005, and from the Operational Plan for Comprehensive HIV and AIDS Care, Management, and Treatment, thereby constituting the long-awaited response to dealing with the challenges of HIV and the wide-ranging impacts of AIDS. ART coverage continued to expand in the ensuing years, turning the national program into the most costly public health program ever introduced in the country.9 Although the short-term results of the ART program are promising, many barriers still remain for providing universal access (Wouters et al. 2011). The lack of horizontal integration of ART in district-based PHC services; the higher need for comprehensive HIV/AIDS care addressing the psychosocial and economic dynamics of HIV/AIDS; the increasing cost associated with maintaining growing numbers of patients on ART; and, the severe human resources shortages, are all cited as potential barriers to implementing ART scale-up (Wouters et al. 2011). Since the program only serves just over half of the population in need of treatment (UNAIDS et al. 2010), and coverage varies considerably between Provinces, the challenges to reach universal implementation remain considerable. Introducing nurse-initiated ART and decentralizing service delivery to PHC facilities, as stipulated by the Department of Health, constitute an important first step towards delivering integrated HIV/AIDS care and treatment. In order to address the backlog of undiagnosed HIV infections, in 2010 a national HIV counselling and testing (HCT) campaign was also launched, aiming to test 15 million people by mid-2011. Remarkably, the program nearly achieved its goal with 14.8 million counselling sessions and 13 million tests of HIV conducted as of June 2011 (Day et al. 2011). At the same time, nearly one quarter million medical male circumcisions had been carried out, a procedure shown to decrease the risk of HIV infection among men with approximately 60% (Wamai et al. 2011, Brooks et al. 2010). In addition, the number of male and female condoms distributed between 2007 and 2010 increased substantially, and the nearly universal implementation of prevention of mother-to-child HIV transmission (PMTCT) resulted in a reduction of new HIV infections at six weeks postpartum to under 4%, albeit with substantial provincial differences. In December 2011, the South African National AIDS Council (SANAC) launched a new HIV/AIDS NSP for the period 2012-2016, aimed at informing national, provincial, district, and community-level stakeholders on strategic directions to be considered when developing implementation plans, and to be used as a framework for monitoring and evaluation (SANAC 2011). The NSP was, contrary to previous strategic plans, informed by an unprecedented level of civil society and government consultation, and is based on the UNAIDS 20-year vision of zero new infections, zero deaths associated with HIV/TB, and zero discrimination (UNAIDS

9 South Africa claims to have the largest ART program worldwide, with an estimated 1.4 million patients initiated on ART by the end of June 2011 (Department of Health 2011c). 192 Peter Delobelle

2011). The plan has been partly costed prior to introduction and for the first time specifically includes reducing the number of TB-related deaths, which is important given the high rate of HIV/AIDS and TB co-infection in the country. South Africa is one of twenty-two high burden TB countries and has the third highest number of TB cases in the world (WHO 2011). The number of reported cases has grown significantly in the last decade, in parallel to the increase in prevalence of HIV among the adult population (Figure 17). It is estimated that 80% of the population is infected with TB, with vulnerable population groups showing a higher risk of developing active TB disease.10 Nationally, TB has become the leading cause of death, constituting the most frequent cause of death in people living with HIV/AIDS, and accounting for more than 10% of deaths in 2007 (Statistics South Africa 2009). The proportion of TB deaths is higher among black and coloured people and further aggravated by the increasing occurrence of multi-drug resistant (MDR) TB and, more recently, extensively drug-resistant (XDR) forms of TB (Andrews et al. 2007).11 The TB burden in South Africa is mainly due to historical neglect and poor management systems, compounded by the legacy of fragmented health care services. Although a national TB control program was in place from 1979 under the previous health system, attempts to coordinate the vertically controlled services for eighteen different health departments proved inefficient (Edginton 2000). Nnational TB review conducted in 1996 with support from WHO indicated that, despite a theoretical commitment and the availability of an excellent health infrastructure and resources, national and provincial departments had failed to adequately respond to the TB epidemic (Edginton 2000). A lack of management systems was identified at all levels and the available resources, including a TB register and microscopy services, were inadequately used.

Source: Statistics South Africa (2009), Department of Health (2007b), and Department of Health (2009).

Figure 17. The burden of HIV/AIDS/TB on all-cause mortality, South Africa, 1997-2006.

In addition, incomplete treatment resulted in development of MDR-TB, with an estimated 2,500 new MDR-TB cases in 1999 alone (Rawlinson 2000). The high rates of TB resistance

10 The lifetime risk of developing active TB among HIV-negative individuals is 10%, while persons living with HIV/TB have a 10% annual risk of TB disease (SANAC 2011). 11 XDR-TB refers to a strain of MDR-TB that is also resistant to three or more classes of second-line TB drugs. The Health System in South Africa 193 pointed to a failure of control programmes, as evidenced by the fact that in 1997 a cure rate of only 54% was recorded (Fourie 2000). Based on a reported notification rate of 382 per 100,000 population, TB was declared a national epidemic (van Zyl 2001), and the newly established National TB Control Programme recommended that the country adopt the Directly Observed Treatment Short Course (DOTS) strategy to fight TB. In 1997, Demonstration and Training Districts (DTDs) were established nationwide in order to adopt the strategy, but although performance improved, TB cure rates remained far beneath the WHO target of 85% and treatment defaulters created an ever increasing problem of drug resistance. In March 2000, the National Department of Health signed the Declaration of Amsterdam to Stop TB, as one of 22 high burden TB countries (DOH 2001). The Declaration called for an accelerated expansion of control measures for TB and for increased political commitment and financial resources to reach the targets for global TB control by 2005, which was restated for WHO member states by the World Health Assembly in May 2000 (Lee et al. 2002). As a result, implementation of the DOTS strategy was rapidly expanded, and in 2003 complete coverage was achieved in all districts of the nine provinces (Weyer 2007). Comprehensive programmatic management of patients with MDR-TB consequently became national policy in 2000, and gradually implemented through a network of provincial MDR-TB referral centres. Despite these efforts, TB incidence increased nearly threefold from 269 per 100,000 in 1996 to 720 per 100,000 in 2006 (Department of Health 2007b). At the same time, mortality rates due to TB nearly doubled, and although a favourable outcome is achieved in more than 80% of patients who complete full treatment, defaulting and treatment failure reduce overall program effectiveness to less than 50%. In addition, the lack of adequate infection control in public health care settings, coupled with poor treatment outcomes and the large group of HIV-infected persons, provides ideal conditions for an MDR- and XDR-TB epidemic of unparalleled magnitude (Andrews et al. 2007). Data from the Medical Research Council show an incidence of MDR-TB of about 10,000 cases annually, which represent the largest burden of MDR-TB in Africa and clearly indicate the failure of TB program control (Weyer 2007). In addition, the outbreak of XDR-TB in Kwazulu-Natal in 2005-2006 has created an even larger problem, in particular among HIV infected persons (Gandhi et al. 2006). XDR-TB is an important cause of death in TB/HIV co-infected patients, and although initially thought to be localised, the outbreak has now taken on epidemic characteristics. The combination of a large population of HIV infected hosts with poor TB treatment success rates, associated with a lack of infection control, limited drug-resistance testing, and an overburdened MDR-TB treatment program, all provide ideal conditions for an XDR-TB epidemic of unprecedented magnitude (Andrews et al. 2007). Given the intertwined TB/HIV epidemics, the integration of HIV/TB services is hence crucial, as well as HIV testing of TB patients and early initiation on ART, as envisaged by the latest National Strategic Plan on HIV, STIs and TB (Department of Health 2011c).

1.3.4. A Quadruple Burden of Disease In addition to the dual HIV/AIDS and TB epidemic, South Africa also faces a large burden of disease as a result of its protracted health transition from poverty associated diseases, including infectious diseases, high child and maternal mortality, and malnutrition, to a predominance of chronic diseases due to lifestyle changes and to socio-economic, cultural 194 Peter Delobelle and environmental risk factors. This disease pattern, which is characteristic for developing countries, is not only aggravated by HIV/AIDS in South Africa, but also by a high burden of injuries (Norman et al. 2007), in turn constituting a quadruple burden of disease (Bradshaw et al. 2002), as shown in Table 4. In 2000, HIV/AIDS accounted for one quarter of all deaths, and chronic diseases accounted for four out of ten deaths. In addition, WHO estimates suggest that chronic diseases caused 28% of the total burden of disability-adjusted life years (DALY) in 2004 (WHO 2008b). The rise in chronic or non-communicable diseases (NCDs), which include cardiovascular diseases, diabetes, cancer, chronic respiratory disease, and mental illness, affects the quality of life and increases health care expenses both at personal and community level, affecting the workforce and productivity of the population (Bradshaw et al. 2011). In South Africa, higher mortality from NCDs has been found among the urban poor (Vorster 2002), and people in poor communities have been found to be at greater risk of being exposed to defined NCD risk factors, such as second-hand smoke, excessive alcohol use, and indoor air pollution, as well as suffering from asthma (Bradshaw and Steyn 2001). The NCD burden is predicted to increase substantially over the next few decades and is also driving the demand for chronic disease care. The changing pattern of disease associated with health transition was already documented in the early 1980s (Walker 1982), but a clear picture did not emerge because of low quality of routinely collected data and inadequate death registration, particularly in the rural areas and former ‘homelands’ (Botha and Bradshaw 1985). Data derived from different sources, however, showed that adult mortality was rising at an accelerating rate since the early 1990s (Bradshaw et al. 2000), while data from validated verbal autopsies highlighted the social and demographic transition in a rural, underdeveloped population in this time period (Kahn et al. 1999). Results also indicated a change in mortality from infectious diseases and malnutrition toward an increased number of deaths due to violence, HIV/AIDS and TB, as well as NCD, with vascular diseases in particular (Kahn et al. 1999).

Table 4. Estimated cause of death by sex, SA 2000

Broad Group12 Male Female Total pop (N = 274,084) (N = 246,998) (N = 521,082) HIV/AIDS 23.5% 27.8% 25.5% Pre-transitional diseases (Group I) 22.9% 21.4% 22.2% Non-communicable diseases (Group II) 37.1% 44.9% 40.8% Injuries (Group III) 16.5% 6.0% 11.5% Source: adapted from Norman et al. (2006).

A comparison of mortality rates in this rural population for the period 1992-93 and 2002- 2003 showed a significant increase of deaths for both sexes since the mid-1990s, with a rapid decline in life expectancy of 12 years for females and 14 years for males (Kahn et al. 2007). The increases were most prominent in children aged 0-4 years old and adults aged 20-49 and were more marked in adult females. Further data showed an almost double change in female

12 Adaptation of the Global Burden of Disease list of causes of death developed by WHO (Murray and Lopez 1996), based on the disease profile for South Africa and excluding HIV/AIDS from Group I due to the large burden attributed to HIV/AIDS. The Health System in South Africa 195 risk of death from HIV/TB in this period compared with the risk for males, while the burden of disease requiring chronic care increased disproportionately compared with that requiring acute care (Tollman et al. 2008). The mortality reversal found at this time was hence closely related to the growing burden of HIV/TB, which continued to spread relentlessly throughout South Africa in the following years. Together with the sustained increase in deaths from HIV/AIDS, among older adults a growing burden of NCD was found (Kahn et al. 2007). In 2004, WHO estimates placed the burden of NCD in South Africa two to three times higher than in developed countries (WHO 2008b). Cardiovascular disease, diabetes, respiratory disease and cancers constituted twelve percent of the burden of disease, and neuropsychiatric disorders accounted for six percent. Chronic diseases continued to emerge as a growing threat due to the ongoing industrialization and adaptation of western lifestyles, resulting in a range of diseases with a number of shared risk factors, such as smoking, unhealthy diets, physical inactivity, and stress. The trend still continues to increase and disproportionately affects the poor living in rural communities and urban areas due to relative lack of access to NCD treatment (Mayosi et al. 2009, Schneider et al. 2009). With regard to NCDs, however, the South African government was the first government worldwide to set time bound NCD targets ahead of the UN High-Level Meeting on NCDs in September 2011, and issued a Declaration with time bound targets for reducing premature mortality from NCDs by 25%. The announcement was made at the South African Summit for the Prevention and Control of NCDs in September 2011, where additional targets were made, including a 20% reduction in tobacco use, 10% reduction in the number of people who are overweight or obese, and 20% reduction in the number of people with high blood pressure. In addition, South Africa also plans to reduce daily salt intake from current levels of 8-10 g/day to less than 5 g/day through public health initiatives and regulation of the food industry; to reform legislation on alcohol; and to establish an inter-ministerial NCD Committee to oversee the whole of government approach towards tackling the increasing burden of NCDs (Mungal- Singh 2011). In addition, injuries are an important public health problem in South Africa, consisting of intentional injuries largely due to interpersonal violence, and unintentional injuries related to road traffic and other accidents. Injuries were the second leading cause of loss of healthy life years in 2000, accounting for 14 percent of disability adjusted life years (DALY) (Norman et al. 2007). Age-standardized death rates for interpersonal violence were seven times the global rate, whereas road traffic fatality rates (40/100,000) were higher than in any other WHO region in 2000, and almost twice the global average. Although death rates due to interpersonal violence have more than halved since 1994, they remain exceedingly high, and in 2010/11 still exceeded road accident fatality rates (32/100,000 resp. 28/100,000 population) (SAIRR 2011). Traffic fatalities are mostly related to unsafe road conditions and aggressive driving associated with alcohol abuse, and compounded by poor law enforcement. Violence and injuries are also profoundly gendered with young men aged 15-29 years old disproportionately involved in violent acts both as victims and perpetrators. Half of all female homicide victims are killed by their intimate male partner and South Africa has an alarmingly high rate of female rape (Seedat et al. 2009). The social determinants include poverty and unemployment, patriarchal notions of masculinity, vulnerabilities within families, exposure to violence during childhood, widespread access to firearms, alcohol, and drug abuse, in turn contributing to the burden of serious health problems, such as HIV and sexually transmitted 196 Peter Delobelle infections (STI), substance abuse, and common mental disorders, including post-traumatic stress disorder, depression, and suicidal behaviour (Seedat et al. 2009). Violence is high on the political agenda, and prevention of violence and injuries remains a national public health priority. Taken together, the above described factors constitute the quadruple burden of disease, which requires a broad range of interventions, including improved access to health care and promotion of healthy lifestyles, and ensuring that basic needs, including water, sanitation, and safety, are met. In addition, interventions are needed to stem the impact of the HIV/AIDS and TB epidemic, whereas collaborative care, which engages the interconnectedness of TB/HIV, is critical to controlling the epidemics (Grimwood et al. 2006, Abdool Karim et al. 2009). The burden caused by HIV/AIDS also leads to additional spending and efforts to sustain funding for comprehensive HIV/AIDS care, treatment and prevention, while improving efficiency and quality of care, will require new formulas such as those envisaged by the introduction of a National Health Insurance (Harrison 2009). In addition, efforts to address the increasing burden of NCDs and its risk factors are urgently needed to mitigate the impact on the health system (Mayosi et al. 2009). In summary, although the restructuring of the public health sector post-1994 has achieved substantial improvements in terms of access, health management rationalisation and equitable health expenditure, the early gains have gradually eroded by the increasing burden of disease due to HIV/AIDS, weak health systems management, and consistently low health staff morale (Harrison 2009). The challenges are hence to show improvements in the quality of health care services delivery, whilst simultaneously addressing the intractable health management issues that bedevil efficiency and drive up the costs. Given the large burden of disease affecting the health system and the fact that HIV/AIDS has now become a chronic disease, a horizontal approach to health systems strengthening at primary care level needs serious consideration (Levitt et al. 2011). The decision taken by government to implement the ambitious process of PHC re-engineering may prove to be both timely and crucial in this regard.

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