Lancet Seriesch1for First Years
Transcript of Lancet Seriesch1for First Years
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Historical Roots of current public
health challenges
Dr T. Naidu
Dept of Public Health MedicineUKZN
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Lancet Series
Health in South AfricaAugust 2009www.thelancet.com
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Outline of Lecture
1. Social, Political and economic contexts of health (historical
perspective)
2. Health system through colonialism and apartheid
3. Post apartheid health system
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Historical perspective..
The roots of a dysfunctional health system and the collision of
the epidemics can be found in policies from periods of the
countries history.
Colonial subjugation Apartheid dispossession
Post apartheid period
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South Africa has 4 concurrent epidemics
Poverty related illnesses (infectious diseases, maternal
death, malnutrition)
Non-communicable diseases HIV/AIDS
Violence and injuries
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THETROUBLED PAST
Racial and gender discrimination
Migrant labour system
Destruction of family life
Vast income inequalities
Extreme violence
IMPACT ON HEALTH AND HEALTH SERVICES
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Social context gender and violence
History of war and violence shaped the dominant forms SouthAfricas racially defined masculinities
White masculinity
Colonial natal
School and sport participation inculcated values of racialsuperiority, gender hierachy and class chavunism
Boer republic
Afrikaner boys organised from a young age into a form of militaryorganisation known as the Boer commando.
Black population
Socialisation of boys included childhood training in indigenous martialarts such as stick fighting which instilled discipline, courage and adefence of honour
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Social context cont.
Control of women
Central part of present day constructions of South African masculinity
Violence against women legitimated when the goal is to secure
control or to punish resistance against it
Sexual entitlement exaggerated in gang culture, violence in urban
areas, labour migration ( Gangsters seeing women living in their
territory as belonging to them)
Gang culture
Explanation for many black and coloured men being involved Apartheid rendered many traditional aspects of adult manhood
unattainable, including fulfilling the role of provider.
Manhood refashioned to draw on resources that were available
This meant the application of courage strength, strategy and male
camaraderie to the criminal pursuits of gangs
This provided ways of generating income through crime.
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Families and sexual socialisation
Two competing discourses on sexuality
Christianity
Sex is for procreation and marriage and not a topic for discussion with
young people.
Traditional black ideas
Sex is normal, healthy essential feature of life for all ages and something
about which there should be openess and communication.
The effect of migrant labour
Male migrants had sexual partners in towns as well as their rural homes.
Men often established second families. Apartheid and migrant lanour system had major effect of the structure of the
black family.
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Effect on the structure of the black family
Increasing poverty made marriage unaffordable to groom ( lobola)
Co-habiting
Median age of marriage for black people incr.
40% of household female headed in 2003
Children raised without fathers
Magnified childhood poverty
Undermined the process of socialisation in children esp boys
Children often raised by social and not biological mother
Important implications for adult and child health High levels of sexual, physical and emotional abuse and neglect of children.
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Macroeconomic and socioeconomic context
Poverty and income inequality
One of the most important influences on the Health of South Africans
has been the impoverishment of the black population in the face of
general white affluence.
In the late 19th and 20th century low wages, overcrowding, inadequate
sanitation, malnutrition and stress caused health of black population
to deteriorate.
Had major effect on crime and violence.
Roots of poverty and income inequality lie in unfree black labour
Despite generating great wealth for the mines, mine owners paid black
workers less than a living wage.
The plight of black South Africans exacerbated by legislation on racially
based job reservation, education and wage variation.
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Macroeconomic and socioeconomic cont
Expenditure on education
In 1980/81 expenditure per head on education for white children was
double that for Indian children and 5 times that for black children.
This was caused by policy of deliberate undereducation of black
people.
Low educational attainment, dysfunctional education system worsens
unemployment
Current rate of unemployment
25% with narrow definition that includes only those actively seeking work
37% with the broader definition that includes all unemployed
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National system ofsocial grants provides some relief from the impact of
poverty and unemployment
One of the successes of the post apartheid years has been to unify the
national state pension system and disability grants and introduce new grants.
Bet 1996/07 and 2007/8 beneficiaries of social grants incr. from 2.4 million to12.4 million
New child support grant 8.2 mill beneficiaries
Disability grant payable to people with AIDS 1.4 million
Old age pensioners 1.6 million to 2.2 million
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South African constitution binds the state to work towards the
progressive realistaion of the right to health.
STILL GRAPPLINGWITH:
racial differences in mortality rates and rates of diseases
Inequities between provinces
Mortality rates for children under 5 46 per 1000 live births in
Western Cape to 116 per 1000 in KZN.
Differences between the sexes
Mortality 1.38 times higher for men than women.
Urban rural differences
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The health system through colonialism and
apartheid
Fragmented system
Within the public health sector and between the public and privatesectors
The 1919 Health Act gave responsibility for hospital curative care tothe 4 provinces and preventive promotive health to the local
authorities. 14 separate health departments (by then end of the apartheid era)
Growth of the Private Sector Expansion fostered by government policy of privatisation
1980s 40% doctors in private sector
1
0 yrs later 62% generalists and 66% specialists Main cost drivers are private hospitals(>35% of med schemes exp),
specialists(21% of med scheme exp
Driven by fee for service payment
Quality of care ( no mechanism for oversight of quality of care)
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Key challenges facing the health system in 1994
The health system inherited by 1994 government was well resourced
compared to other middle income countries.
More than half the financial and human resources in the private sector
Public sector
Inequalities in distribution of infrastructure and financial and humanresources, between provinces and between levels of care (80% going to
hospitals)
Academic and tertairy hospitals accounted for 44% of total public sector
health care spending
Only 11% to non hospital primary care services
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Post Apartheid system
14 administrations consolidated into one national and 9 provincial health
dept
Primary Health care delivered via district health system made the
cornerstone of health policy
Clinic infrastructure programme
1345 new clinics built and 263 upgraded
Improved availability and access to services
Primary Health care came at no cost
Mass immunisation campaigns
Essential Drug List and standard treatment guidelines developed
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Legislation passes to transform the health proffesional councils to
make it more representative
Public health legistation
TOP
Control of firearms
Cigarette smoking
Strengthen post rape care
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Progress made in redistributing resources
Gap in spending per person dependent on the public
sector , between best and worst resourced provinces
declined from 5 fold difference in1
992/3 to 2 folddifference in 2005/6
Spending in primary health care incr to over 22% of tot.
public health expenditure.
Major constraints to implementation
Confusion and delays incurred in defining geographical
boundaries and governance responsibilities
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Structure of South African health sector
1. NDoH responsible for health policy
2. Nine provincial DOHresponsible for developing provincial policy within
the framework of national policy and public health service delivery.
3. Three tiers of hospital: tertiary, regional, and district
4. The primary health care system a mainly nurse driven service inclinics- includes the district hospital and community health centres.
5. Local government is responsible for preventive and promotive services
6. The private health system consists of GPs and private hospitals, care in
private hospitals mostly funded through medical schemes. In 2008 70%
of private hospitals lay in 3 of the 9 provinces 38% in gauteng alone.
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Key challenges of current system
Inadequate human resource capacity and planning
Poor stewardship, leadership and management
Stress on system by AIDS epidemic
Restricted spending in public health sector
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Human Resource capacity
Challenges
60% health budget spent on human resources
Decrease in Nurse to population ratio from 149 per 100 000 pop in1998 to 110 per 100 000 in 2007
Decline in numbers of nurses graduating due to closure of nursingcolleges in 1990s
Migration to the private sector and to jobs abroad
Retirement and HIV/AIDSm(affects 16% of nurses)
% doctors in private sector rose from 40% in 1980s to 79% in 2007
Important policies Incr uptake medical schools
Legislated community service
Introduction of mid level health workers
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Community healthworker programmes
Little standardization in their work, training supervision
Disagreement on whether they should be paid
Issues
Inexperienced managers
Insufficient political will and leadership to manage undeperformance
and incompetence
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Poor stewardship, leadership and management
Evident in highly variable quality of Care delivered in public sector
TB programme
In 1996-2004 key outcome indicators deteriorated
HIVmanagement
HIV/AIDS epidemic allowed to spread
Annual antenatal surveillance prevalence rate increased from 0.7% in 1990 to
8% in 1994 and 20% in 2005
Aids denialism by the countries president at the time resulted in a great cost
to the south African people.
Inability to deliver intersectoral programmes Primary School NutritionProgramme (no clear designation of responsibilities between Dept of
Education and DOH)
Need to change national thinking on accountability
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Without concerted efforts to change National
thinking on accountability, South Africa will
become a country that is not just a product of
its past, but one that is continually unable to
either address the health problems of the
present or to prepare for the futureThe Lancet 2009
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conclusions
Distinctive features of South African history that account for
current health problems
Racial and gender discrimination
Income inequalities Migrant labour
Destruction of family life
Persisting violence
Lack of progress in implementing core policies
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To meet the Millenium Development Goals
Address the unacceptable levels of income inequality
Improve access to the broad range of social services
Introduce broad ranging development policy
Promote gender equality Macroeconomic policy that centres on redistributive growth
Intervention to treat major problems HIV/AIDS, TB, other
communicable and non communicable diseases, sexual and
reproductive disorders, substance abuse, crime, interpersonalviolence and trauma