In this article, we consider the conduct of post-apartheid health care in a policy context direct... more In this article, we consider the conduct of post-apartheid health care in a policy context directed toward entrenching democracy, ensuring treatment-adherent patients, and creating a healthy populace actively responsible for their own health. We ask how tuberculosis treatment, antiretroviral therapy, and maternal services are delivered within South Africa's health system, an institutional site of colonial and apartheid injustice, and democratic reform. Using Foucauldian and post-Foucauldian notions of governmentality, we explore provider ways of doing to, for, and with patients in three health subdistricts. Although restorative provider engagements are expected in policy, older authoritarian and paternalistic norms persist in practice. These challenge and reshape, even 'undo' democratic assertions of citizenship, while producing compliant, self-responsible patients. Alongside the need to address pervasive structural barriers to health care, a restorative approach require...
South Africa is at present undertaking a series of reforms to transform public health services to... more South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.
Community health workers (CHWs) are an integral resource in many health systems, particularly in ... more Community health workers (CHWs) are an integral resource in many health systems, particularly in resource-poor settings. Their identities--'who' they are--play an important role in their hiring, training, and retention. We explore the perceptions, experiences, and identities of CHWs as they adopt a CHW role in rural South Africa, using 'role identity theory'. From April to December 2010, we conducted 18 semi-structured interviews with CHWs volunteering in non-governmental home-based care (HBC) organisations in one rural sub-district in South Africa. The role identity theory framework was used to understand the work of CHWs within their communities, addressing themes, such as entry into, and nature of, caring roles, organisational support, state resourcing, and community acceptability. A thematic content analysis was used to analyse the collected data. The study found that CHWs usually begin their 'caring work' before they formally join HBC organisations, by caring for children, neighbours, mothers, fathers, friends, and the community in some way. CHWs felt that becoming a health worker provided an elevated status within the community, but that it often led community members to believe they were able to control resources. The key role identities assumed by CHWs, as they sought to meet patients' and their own needs, were a complex mix of community 'insider', 'outsider', and 'broker'. Each of these role identities served as a unique way to position, from the CHW's perspective, themselves and the community, given the diversity of needs and expectations. These role identities reveal the tensions CHWs face as 'insider' members of the community and yet at times being treated as 'outsiders', who might be regarded with suspicion, and at the same time, appreciated for the resources that they might possess. Understanding role identities, and how best to support them, may contribute to strategies of retention and sustainability of CHW programmes, as their formalisation in different contexts continues to grow.
This paper examines elements of mistrust, blame and suspicion among patients and providers in the... more This paper examines elements of mistrust, blame and suspicion among patients and providers in the South African health system which affect practice and policy development. Using stories told by patients and providers in Cape Town, Johannesburg and Bushbuckridge, it examines how suspicion is constructed and how others are blamed for adverse outcomes. This paper sets a conceptual framework which examines the attribution of blame in contemporary social and political life, the narratives of 45 patients receiving HIV/AIDS, TB or maternal delivery services and those of 63 providers dealing with similar treatments and arranged across a series of facilities, clinics, hospitals and mobile vans were constructed and shared with participants. These narratives form the basis of the results sections which examines suspicions among both providers and patients with the former seeing the latter as having no respect and regard and providing poor care and access to grants. Providers saw themselves as highly stressed but diligent with service challenges being blamed on patient ignorance, unreasonable demands and failure to follow medical advice. The paper ends with a discussion on how to limit mistrust and reduce suspicion through more cooperative provider-patient relations and what this kind of evidence means for decision-makers.
Achieving equitable access to health care is an important policy goal, with access influenced by ... more Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas-conversely-these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and ref...
South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2009
National Health Insurance (NHI) is currently high on the health policy agenda. The intention of t... more National Health Insurance (NHI) is currently high on the health policy agenda. The intention of this financing system is to promote efficiency and the equitable distribution of financial and human resources, improving health outcomes for the majority. However, there are some key prerequisites that need to be in place before an NHI can achieve these goals. To explore public perceptions on what changes in the public health system are necessary to ensure acceptability and sustainability of an NHI, and whether South Africans are ready for a change in the health system. A cross-sectional nationally representative survey of 4 800 households was undertaken, using a structured questionnaire. Data were analysed in STATA IC10. There is dissatisfaction with both public and private sectors, suggesting South Africans are ready for health system change. Concerns about the quality of public sector services relate primarily to patient-provider engagements (empathic staff attitudes, communication an...
Background: As in many fragile and post-conflict countries, South Africa's social contract has fo... more Background: As in many fragile and post-conflict countries, South Africa's social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting.
Background Universal coverage of health care is now receiving substantial worldwide and national ... more Background Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of fi nancing mechanisms, especially to protect people outside the formal employment sector. Crucial issues are the equity implications of diff erent fi nancing mechanisms, and patterns of service use. We report a whole-system analysis-integrating both public and private sectors-of the equity of health-system fi nancing and service use in Ghana, South Africa, and Tanzania.
objectives A mixed methods study exploring gender differences in patient profiles and experiences... more objectives A mixed methods study exploring gender differences in patient profiles and experiences of ART services, along the access dimensions of availability, affordability and acceptability, in two rural and two urban areas of South Africa.
Using the example of South Africa, this study aimed to examine and obtain a better understanding ... more Using the example of South Africa, this study aimed to examine and obtain a better understanding of the experiences and challenges of urban and rural patients on antiretroviral therapy (ART) in accessing this complex treatment in a resource-limited setting. Following a narrative approach, in-depth interviews were conducted with 20 patients successfully and unsuccessfully (ie, with interruptions) receiving ART in urban Johannesburg and rural Bushbuckridge, using a detailed interview guide structured to illuminate interviewees' life circumstances and contextualise illness and treatment trajectories. Participants were interviewed by trained fieldworkers in their local languages. The translated and transcribed interviews were coded by several team members. Codes were cross-examined and showed good congruence. All interviewees emphasised the positive aspects of receiving ART, the lifeline and hope it provided by improving health, increasing their ability to live actively and reducing visible signs of (stigmatised) illness. Important factors supporting continuing adherence included social and economic support by individuals, role models and networks as well as positive experiences within the healthcare system and of the treatment itself. The main challenges were linked to patients' difficult life circumstances, especially those related to poverty (eg, transport and food costs) and health system constraints, including perceived lack of compassion and flexibility by healthcare workers. While there are many challenges for the sustainability of ART on an individual and health system level, this study emphasised the need for a patient-centric focus to continue to provide and increase the number of HIV-positive people receiving this lifeline, receiving hope.
The use of traditional medicine is widespread in developing countries. We report on the utilizati... more The use of traditional medicine is widespread in developing countries. We report on the utilization of traditional healers, using data obtained in a 2008 national survey of 4762 households in South Africa. Only 1.2 per cent of survey participants reported utilization of traditional healers. Respondents' reasons for visiting traditional healers included continuity of care and a belief in their effectiveness. Traditional healer utilization rates (0.02 visits per month) were considerably lower compared to utilization rates of public sector clinics (0.18 visits per month) or hospitals (0.09 visits per month). Almost three-quarters of the poorest quintile spent more than 10 per cent of their household expenditure in the previous month on traditional healers. Given the use of two parallel health-care systems, policy-makers should develop strategies to protect poor South Africans from out-of-pocket payments for health care. Simultaneous utilization of these systems evidently absorbs expenditure from low-income households significantly.
Achieving equitable universal health coverage requires the provision of accessible, necessary ser... more Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n = 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.
We present qualitative data from a 2005 exploratory study, recently published studies, and an ana... more We present qualitative data from a 2005 exploratory study, recently published studies, and an analysis of the Department of Health's strategic plan to highlight the need for a broader policy debate on health-care access for migrants in South Africa. We conducted in-depth interviews with 15 Zimbabwean women living in inner-city Johannesburg to document the special characteristics of this group of migrants, enquiring about their perceptions of HIV risk, and experiences of health services in South Africa. We identified access barriers, namely perceptions of relatively low HIV risk, severely constrained financial circumstances, uncertain legal status, and experiences of unresponsive health workers. We recommend that migranthealth rights be placed on South Africa's policy agenda, migrants be included in HIV prevention programs and that health workers be sensitized to the needs of migrants.
In South Africa, anticipated health sector reforms aim to achieve universal health coverage for a... more In South Africa, anticipated health sector reforms aim to achieve universal health coverage for all citizens. Success will depend on social solidarity and willingness to pay for health care according to means, while benefitting on the basis of their need. In this study, we interviewed 1330 health and education sector civil servants in four South African provinces, about potential income cross-subsidies and financing mechanisms for a National Health Insurance. One third was willing to cross-subsidize others and half favored a progressive financing system, with senior managers, black Africans, or those with tertiary education more likely to choose these options than lower-skilled staff, white, Indian or Asian respondents, or those with primary or less education. Insurance- and health-status were not associated with willingness to pay or preferred type of financing system. Understanding social relationships, identities, and shared meanings is important for any reform striving toward universal coverage.
International Journal of Transitional Justice, 2014
ABSTRACT Transforming repressive institutions into respected instruments of justice is necessary ... more ABSTRACT Transforming repressive institutions into respected instruments of justice is necessary for the social reconstruction of fragile and postconflict states. Yet, little attention has been given to the role of health systems in facilitating such change. We situate South Africa’s right to access health care as part of a broader sociopolitical endeavour to ‘bring justice’ in the aftermath of apartheid and argue that street-level bureaucrats tasked with delivering health services are a gauge of both individual and institutional transformation. Using cases from two urban areas, we consider responses to inaccessible antiretroviral therapy, tuberculosis treatment and maternal deliveries and ask whether these ameliorate or compound access barriers. We also explore some conditions for bringing justice to street-level interactions. Our cases suggest that, if left unchallenged, negative street-level bureaucracy may compound inaccessible care for patients and perpetuate a wider culture of disempowerment, deprivation and poverty – ongoing structural violence – for citizens, while positive provider practices may be ameliorative. Strengthening street-level accountability and engendering respectful, empathetic provider practices is consequently vital to improving access to services and contributing more generally to the restoration of justice and health in society.
In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-o... more In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.
The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the ... more The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the damaging downward spiral of poverty and illness, there is a need for a greater level of social protection, with greater cross-subsidization between the poor and wealthy, and the healthy and those with ill-health.
Background: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a... more Background: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Methods: A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. Results: Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. Conclusions: To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.
Background: In 2005, the South African government introduced a voluntary, subsidised health insur... more Background: In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. Objectives: This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. Methods: Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. Results: Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. Conclusion: Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.
In this article, we consider the conduct of post-apartheid health care in a policy context direct... more In this article, we consider the conduct of post-apartheid health care in a policy context directed toward entrenching democracy, ensuring treatment-adherent patients, and creating a healthy populace actively responsible for their own health. We ask how tuberculosis treatment, antiretroviral therapy, and maternal services are delivered within South Africa's health system, an institutional site of colonial and apartheid injustice, and democratic reform. Using Foucauldian and post-Foucauldian notions of governmentality, we explore provider ways of doing to, for, and with patients in three health subdistricts. Although restorative provider engagements are expected in policy, older authoritarian and paternalistic norms persist in practice. These challenge and reshape, even 'undo' democratic assertions of citizenship, while producing compliant, self-responsible patients. Alongside the need to address pervasive structural barriers to health care, a restorative approach require...
South Africa is at present undertaking a series of reforms to transform public health services to... more South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.
Community health workers (CHWs) are an integral resource in many health systems, particularly in ... more Community health workers (CHWs) are an integral resource in many health systems, particularly in resource-poor settings. Their identities--'who' they are--play an important role in their hiring, training, and retention. We explore the perceptions, experiences, and identities of CHWs as they adopt a CHW role in rural South Africa, using 'role identity theory'. From April to December 2010, we conducted 18 semi-structured interviews with CHWs volunteering in non-governmental home-based care (HBC) organisations in one rural sub-district in South Africa. The role identity theory framework was used to understand the work of CHWs within their communities, addressing themes, such as entry into, and nature of, caring roles, organisational support, state resourcing, and community acceptability. A thematic content analysis was used to analyse the collected data. The study found that CHWs usually begin their 'caring work' before they formally join HBC organisations, by caring for children, neighbours, mothers, fathers, friends, and the community in some way. CHWs felt that becoming a health worker provided an elevated status within the community, but that it often led community members to believe they were able to control resources. The key role identities assumed by CHWs, as they sought to meet patients' and their own needs, were a complex mix of community 'insider', 'outsider', and 'broker'. Each of these role identities served as a unique way to position, from the CHW's perspective, themselves and the community, given the diversity of needs and expectations. These role identities reveal the tensions CHWs face as 'insider' members of the community and yet at times being treated as 'outsiders', who might be regarded with suspicion, and at the same time, appreciated for the resources that they might possess. Understanding role identities, and how best to support them, may contribute to strategies of retention and sustainability of CHW programmes, as their formalisation in different contexts continues to grow.
This paper examines elements of mistrust, blame and suspicion among patients and providers in the... more This paper examines elements of mistrust, blame and suspicion among patients and providers in the South African health system which affect practice and policy development. Using stories told by patients and providers in Cape Town, Johannesburg and Bushbuckridge, it examines how suspicion is constructed and how others are blamed for adverse outcomes. This paper sets a conceptual framework which examines the attribution of blame in contemporary social and political life, the narratives of 45 patients receiving HIV/AIDS, TB or maternal delivery services and those of 63 providers dealing with similar treatments and arranged across a series of facilities, clinics, hospitals and mobile vans were constructed and shared with participants. These narratives form the basis of the results sections which examines suspicions among both providers and patients with the former seeing the latter as having no respect and regard and providing poor care and access to grants. Providers saw themselves as highly stressed but diligent with service challenges being blamed on patient ignorance, unreasonable demands and failure to follow medical advice. The paper ends with a discussion on how to limit mistrust and reduce suspicion through more cooperative provider-patient relations and what this kind of evidence means for decision-makers.
Achieving equitable access to health care is an important policy goal, with access influenced by ... more Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas-conversely-these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and ref...
South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2009
National Health Insurance (NHI) is currently high on the health policy agenda. The intention of t... more National Health Insurance (NHI) is currently high on the health policy agenda. The intention of this financing system is to promote efficiency and the equitable distribution of financial and human resources, improving health outcomes for the majority. However, there are some key prerequisites that need to be in place before an NHI can achieve these goals. To explore public perceptions on what changes in the public health system are necessary to ensure acceptability and sustainability of an NHI, and whether South Africans are ready for a change in the health system. A cross-sectional nationally representative survey of 4 800 households was undertaken, using a structured questionnaire. Data were analysed in STATA IC10. There is dissatisfaction with both public and private sectors, suggesting South Africans are ready for health system change. Concerns about the quality of public sector services relate primarily to patient-provider engagements (empathic staff attitudes, communication an...
Background: As in many fragile and post-conflict countries, South Africa's social contract has fo... more Background: As in many fragile and post-conflict countries, South Africa's social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting.
Background Universal coverage of health care is now receiving substantial worldwide and national ... more Background Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of fi nancing mechanisms, especially to protect people outside the formal employment sector. Crucial issues are the equity implications of diff erent fi nancing mechanisms, and patterns of service use. We report a whole-system analysis-integrating both public and private sectors-of the equity of health-system fi nancing and service use in Ghana, South Africa, and Tanzania.
objectives A mixed methods study exploring gender differences in patient profiles and experiences... more objectives A mixed methods study exploring gender differences in patient profiles and experiences of ART services, along the access dimensions of availability, affordability and acceptability, in two rural and two urban areas of South Africa.
Using the example of South Africa, this study aimed to examine and obtain a better understanding ... more Using the example of South Africa, this study aimed to examine and obtain a better understanding of the experiences and challenges of urban and rural patients on antiretroviral therapy (ART) in accessing this complex treatment in a resource-limited setting. Following a narrative approach, in-depth interviews were conducted with 20 patients successfully and unsuccessfully (ie, with interruptions) receiving ART in urban Johannesburg and rural Bushbuckridge, using a detailed interview guide structured to illuminate interviewees' life circumstances and contextualise illness and treatment trajectories. Participants were interviewed by trained fieldworkers in their local languages. The translated and transcribed interviews were coded by several team members. Codes were cross-examined and showed good congruence. All interviewees emphasised the positive aspects of receiving ART, the lifeline and hope it provided by improving health, increasing their ability to live actively and reducing visible signs of (stigmatised) illness. Important factors supporting continuing adherence included social and economic support by individuals, role models and networks as well as positive experiences within the healthcare system and of the treatment itself. The main challenges were linked to patients' difficult life circumstances, especially those related to poverty (eg, transport and food costs) and health system constraints, including perceived lack of compassion and flexibility by healthcare workers. While there are many challenges for the sustainability of ART on an individual and health system level, this study emphasised the need for a patient-centric focus to continue to provide and increase the number of HIV-positive people receiving this lifeline, receiving hope.
The use of traditional medicine is widespread in developing countries. We report on the utilizati... more The use of traditional medicine is widespread in developing countries. We report on the utilization of traditional healers, using data obtained in a 2008 national survey of 4762 households in South Africa. Only 1.2 per cent of survey participants reported utilization of traditional healers. Respondents' reasons for visiting traditional healers included continuity of care and a belief in their effectiveness. Traditional healer utilization rates (0.02 visits per month) were considerably lower compared to utilization rates of public sector clinics (0.18 visits per month) or hospitals (0.09 visits per month). Almost three-quarters of the poorest quintile spent more than 10 per cent of their household expenditure in the previous month on traditional healers. Given the use of two parallel health-care systems, policy-makers should develop strategies to protect poor South Africans from out-of-pocket payments for health care. Simultaneous utilization of these systems evidently absorbs expenditure from low-income households significantly.
Achieving equitable universal health coverage requires the provision of accessible, necessary ser... more Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n = 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.
We present qualitative data from a 2005 exploratory study, recently published studies, and an ana... more We present qualitative data from a 2005 exploratory study, recently published studies, and an analysis of the Department of Health's strategic plan to highlight the need for a broader policy debate on health-care access for migrants in South Africa. We conducted in-depth interviews with 15 Zimbabwean women living in inner-city Johannesburg to document the special characteristics of this group of migrants, enquiring about their perceptions of HIV risk, and experiences of health services in South Africa. We identified access barriers, namely perceptions of relatively low HIV risk, severely constrained financial circumstances, uncertain legal status, and experiences of unresponsive health workers. We recommend that migranthealth rights be placed on South Africa's policy agenda, migrants be included in HIV prevention programs and that health workers be sensitized to the needs of migrants.
In South Africa, anticipated health sector reforms aim to achieve universal health coverage for a... more In South Africa, anticipated health sector reforms aim to achieve universal health coverage for all citizens. Success will depend on social solidarity and willingness to pay for health care according to means, while benefitting on the basis of their need. In this study, we interviewed 1330 health and education sector civil servants in four South African provinces, about potential income cross-subsidies and financing mechanisms for a National Health Insurance. One third was willing to cross-subsidize others and half favored a progressive financing system, with senior managers, black Africans, or those with tertiary education more likely to choose these options than lower-skilled staff, white, Indian or Asian respondents, or those with primary or less education. Insurance- and health-status were not associated with willingness to pay or preferred type of financing system. Understanding social relationships, identities, and shared meanings is important for any reform striving toward universal coverage.
International Journal of Transitional Justice, 2014
ABSTRACT Transforming repressive institutions into respected instruments of justice is necessary ... more ABSTRACT Transforming repressive institutions into respected instruments of justice is necessary for the social reconstruction of fragile and postconflict states. Yet, little attention has been given to the role of health systems in facilitating such change. We situate South Africa’s right to access health care as part of a broader sociopolitical endeavour to ‘bring justice’ in the aftermath of apartheid and argue that street-level bureaucrats tasked with delivering health services are a gauge of both individual and institutional transformation. Using cases from two urban areas, we consider responses to inaccessible antiretroviral therapy, tuberculosis treatment and maternal deliveries and ask whether these ameliorate or compound access barriers. We also explore some conditions for bringing justice to street-level interactions. Our cases suggest that, if left unchallenged, negative street-level bureaucracy may compound inaccessible care for patients and perpetuate a wider culture of disempowerment, deprivation and poverty – ongoing structural violence – for citizens, while positive provider practices may be ameliorative. Strengthening street-level accountability and engendering respectful, empathetic provider practices is consequently vital to improving access to services and contributing more generally to the restoration of justice and health in society.
In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-o... more In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.
The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the ... more The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the damaging downward spiral of poverty and illness, there is a need for a greater level of social protection, with greater cross-subsidization between the poor and wealthy, and the healthy and those with ill-health.
Background: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a... more Background: South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Methods: A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers. Results: Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care. Conclusions: To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.
Background: In 2005, the South African government introduced a voluntary, subsidised health insur... more Background: In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. Objectives: This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. Methods: Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. Results: Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. Conclusion: Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.
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Papers by Bronwyn Harris