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Public Health in South Africa: AIDS and Child Welfare

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Public Health in South Africa:
AIDS and Child Welfare
Peter Barron and Marian Jacobs
I. Overview of Health in South Africa
A. Health Status
The life expectancy of South Africans is 62.8 years, with the West-
ern Cape and Gauteng both having life expectancy rates of over 65
years and most of the other provinces close to 60 years. The maternal
124
Figure 1 Provinces of South Africa
mortality rate is estimated at around 150 deaths per 100,000 births,
which is very high in relation to developed countries.
Infant mortality rates in 1998 (based on a household demographic
and health survey) were 45.4 deaths for every 1,000 live births. The
Eastern Cape had the highest infant mortality rate of 61.2 deaths per
1,000. For young children under one year of age, the major causes of
death remain preventable disorders such as perinatal conditions, infec-
tions including diarrheal disease, and respiratory problems.
In the last decade, there appears to have been a reversal in the child
mortality rates and this is illustrated in figure 2 below. The deteriora-
tion in these indicators is thought to be directly attributable to the
impact of the AIDS epidemic.
The household survey also showed that 80% of all children have
received measles immunization with nearly two thirds receiving their
full schedule of immunizations by the age of one year.
Other important health status data from this survey show that, on
average, the fertility rate is 2.9 children per fertile woman. However,
there is a gradient correlating with education. Women with higher
education have a fertility rate of 1.9 as opposed to women with no edu-
cation who have a fertility rate of 4.5. Nearly all women are aware of
Peter Barron and Marian Jacobs
125
Figure 2 Child Mortality Trends
methods of contraception and almost three-quarters of women have
used a contraceptive method.
Tuberculosis remains the single most important infectious disease.
More than 150 out of every 100,000 people in the general population
developed tuberculosis in 1996 and 1997. In some provinces, such as
the Northern and Western Cape, the rates were over 500 per 100,000
people. These are among the highest rates in the world. The two dis-
eases, tuberculosis and HIV infection, both affect the immune response
and more and more people are likely to be dually infected.
Other important aspects of health status include the large number of
non-natural deaths due largely to violence and traffic accidents. In par-
ticular, violence against women is an important cause of morbidity. In
the 1998 household survey, more than one in ten women reported
being beaten by their partner and nearly one in twenty reported hav-
ing been raped.
II. History of Health Policy in South Africa
A. Public Health Prior to 1994
The first phase, roughly the century prior to 1919, was characterized
by increasing organization, institutionalization, and professionaliza-
tion of health care, due to British influence. Before 1807, there was little
structure to the health care system in South Africa. British influence
resulted in the construction of numerous military and civilian hospi-
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Table 1 Socio-Demographic Indicators by Province
Population Proportion Population Population Population
1997 of less than 65 years Urbanized
Population 5 years and older
(millions) Percent (1996 %) (1996 %) (1996 %)
South Africa 43.1 100 10.9 4.8 53.7
Eastern Cape 7.0 15.5 12.0 5.8 36.6
Free State 3.0 6.5 9.5 4.5 68.6
Gauteng 7.2 18.1 8.9 4.1 97.0
KwaZulu-Natal 9.2 20.7 11.5 4.5 43.1
Mpumalanga 3.1 6.9 11.6 4.1 39.1
Northern Cape 0.8 2.1 10.6 5.0 70.1
Northern 5.5 12.1 13.1 5.2 11.0
North West 3.6 8.3 11.2 4.6 34.9
Western Cape 3.7 9.7 9.6 5.1 88.9
tals. A series of legislation was aimed at regulating the practice of
health care and containing the spread of epidemics. Despite these
developments, neither uniformity nor coordination of policy was
achieved until 1919. The international influenza epidemic of 1917 was
the main impetus to further change.
A second phase of health policy development, the period 1919 to
1940, began with the proclamation of the Public Health Act of 1919,
which established the first Department of Public Health in an attempt
to coordinate health care more effectively at the national level. How-
ever, this period saw little substantive and positive evolution in health
policy; developments favored exclusion and segregation of sectors of
the population and there was a reluctance to take active steps to solve
the increasing health problems of the time.
The third phase, the years 1940 to 1950, heralded an exciting period
in health care in South Africa. Attempts were made to redirect health
policy, to rid the prevailing system of its numerous structural deficien-
cies, and to restructure and reform it in every important respect. Dur-
ing this period, the vision of a unified, comprehensive, and
state-funded national health service based on primary care in the
form of a network of comprehensive health centers was cultivated
and even began to be realized. However, these progressive visions of
reform were stifled as a result of political change.
The fourth phase, spanning roughly the period 1950 to 1990, com-
menced with the victory of the National Party in the elections of 1948.
This phase was characterized by legislated racial discrimination and
segregation, which affected not only the way health services were
organized, but also the very health of the people. Health policy devel-
opment closely mirrored the ideology and social engineering of the
white minority government. By the end of this period, there were four-
teen national departments of health, one each for the ten
homelands/bantustans and another for each of the four “ethnic/popu-
lation” groups in the rest of South Africa.
The period 1990 to 1994 brought the first serious attempts to effect a
significant break with the past. Changes were initiated under increas-
ing pressure from a progressive health sector demanding fundamental
reform of the health sector and beyond. This phase was marked by
efforts to bring about “de-fragmentation” and deracialization of gov-
ernment structures and health care facilities by attempts to emphasize
primary health care; by a more sober and guarded approach to privati-
zation; and, with mounting intensity toward the end, by jockeying for
Peter Barron and Marian Jacobs
127
position in the future health service by health authorities, institutions,
and individuals alike. However, the steps toward reform originated
and were taken within the framework of a still racially segmented and
undemocratic society, which meant that reforms were cosmetic rather
than fundamental. Below are some more glaring points:
Prior to 1994, there was massive inequity in resources available to
the private and public sectors. Private sector spending was (and
remains) around 60% of total health expenditure while the users of
the private sector comprise around 20% of the population. This is
equivalent to a six-fold difference in spending. (The inequities of
resources between public and private have increased since 1994!)
The private sector operated almost totally independently, with little
government control.
The public health sector had a number of characteristics which
made it inequitable including:
Fragmentation of the organization of health services, i.e.,
between different homeland governments, provincial govern-
ments, central government, and local governments.
Fragmentation between curative and preventive services with
additional fragmentation of very centralized, vertically driven
programs (e.g., family planning).
Health services oriented toward hospital-based (especially acade-
mic/tertiary hospital) curative care.
Racial discrimination in access with many institutions having
duplicate facilities and separate entrances for whites and blacks.
Underfunding of services in certain geographic areas, especially
rural and peri-urban township areas where the vast majority of
blacks lived.
B. Developments since 1994
A number of accomplishments have been achieved since 1994. These
include:
The creation of a national health system, with cooperation between
the national and provincial health departments.
• A clearly stated policy of primary health care, accepted with
national support.
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The transformation of the public health system from a fragmented,
racially divided, hospital-centered service favoring the urban popu-
lation into an integrated, comprehensive national service driven by
the need to redress historical inequities and give priority to provid-
ing essential health care to disadvantaged people, especially those
living in rural areas.
Elimination of discriminatory practices and structures in the public
health system.
Expansion of the primary-care infrastructure through building and
upgrading clinics.
Making health care free at the point of delivery for all using the
public primary care system.
Launching a National Drugs Policy and introducing an Essential
Drugs List appropriate to the level of care.
Improving access to health services in disadvantaged communities
through the introduction of community service for new South
African graduates and employment of over 400 Cuban doctors.
Community service is planned to be extended to other health
worker categories, e.g., dentists and pharmacists, over the next few
years.
A more rational and equitable distribution of resources based on
increasingly sophisticated resource allocation formulas.
III. Some Challenges Facing the Health Sector
As a result of fiscal discipline and the Growth, Employment and Redis-
tribution (GEAR) strategy, there have been absolutely declining health
budgets per capita for the past few years. The key component of
expenditure, personnel cost, has not been under the control of health
services management. The only way to reduce staff costs in the short
term has been through voluntary severance packages. This has led to
unplanned reduction of services, which has had many negative conse-
quences. Indeed, the management of personnel in the civil service is
one of the key economic and social challenges facing the government
as a whole.
Another problem relating to the redistribution of resources and the
attainment of equity was that the rural and disadvantaged provinces,
Peter Barron and Marian Jacobs
129
which benefited from redistribution, did not have the capacity in the
short term to absorb the increases given to them.
The management of health services in the public sector has been
extremely centralized in the past. With the change in policy and an
emphasis on a decentralized, geographically based, district public
health system, there is a far greater need for well-trained, effective
health managers. Unfortunately, there is a dearth of such skills in the
country.
Planning for and training human resources are the most important
areas for a successful public health service. Human resource develop-
ment will need far greater attention in the future and the country is
still waiting for a coherent human resource policy for the health sector.
Further, the relationship between the public and private health sectors
needs to be better defined and there needs to be greater collaboration
between these sectors.
Within the public sector, the role of local government needs greater
definition and elaboration. However, the restructuring of local govern-
ment, culminating in elections for new structures at the end of 2000,
will give greater clarity to this unsolved problem.
A. HIV/AIDS and STDs
Estimates by the Joint United Nations Programme on HIV/AIDS
(UNAIDS) indicate that the epidemic of HIV in South Africa is one of
the fastest growing in the world. Unless a cure is found, the majority of
the 3.6 million South Africans already infected with HIV will die
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Figure 3 HIV Prevalence, Antenatal Clinic Attendees, 1990 to 1998
within the next ten years. If there is no success with interventions to
reduce the spread of HIV, an additional 550,000 persons will become
infected each year. This will have a major impact on all aspects of life
in South Africa.
The HIV prevalence determined in pregnant women attending ante-
natal services in the public sector is a good indicator of the progress of
the epidemic in the general population. Figure 3 shows the progres-
sion of the epidemic in South Africa since the inception of this annual
survey in 1990. Prevalence has increased from less than 1% in 1990 to
almost 23% in 1998.
Table 2 shows that:
The national HIV prevalence of women attending antenatal clinics
in 1998 was almost 23%. This represents an increase of 34% on 1997
figures.
Prevalence in the provinces continued to rise.
There is a gradient of infection in the provinces from the Western
Cape in the southwest to KwaZulu-Natal in the northeast.
Table 3 shows that:
HIV prevalence among pregnant women continues to rise, with
those age 2029 having the highest rates.
Prevalence among pregnant women under 20 years of age has risen
by 65%.
The exceptionally rapid increase of HIV infection in teenage women
is a serious cause for concern.
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Table 2 HIV Prevalence among Antenatal Attendees
by Province, 1997 and 1998
Province Est. HIV+ Est. HIV+ Rate of Increase
1998 1997 %
Eastern Cape 15.9 12.6 26.2
Free State 22.8 20.0 14.0
KwaZulu-Natal 32.61 26.9 20.8
Gauteng 22.5 17.1 31.6
Mpumalanga 30.0 22.6 32.8
Northern Cape 9.9 8.6 15.1
Northern Province 11.5 8.2 40.2
North West 21.3 18.1 17.7
Western Cape 5.2 6.3 0
South Africa 22.8 17.01 33.8
Levels of Infection among the General Population
It is estimated that:
Approximately 3.6 million South Africans were living with HIV at
the end of 1998, compared to 2.7 million in 1997.
One in eight adults (15 to 49 years of age) are infected with HIV, or
between 12 and 14 %.
• Current estimates suggest that over 1,500 South Africans are
infected with HIV each day or 550,000 per annum.
Projections into the 21st Century
Based on modeling of the data without effective interventions:
National adult infection levels will be at 5 million by 2002.
250,000 South Africans will die of AIDS each year by 2002.
500,000 South Africans will die of AIDS each year by 2008.
B. Impact of HIV/AIDS
It is estimated that:
Average life expectancy will fall from 60 years to 40 years between
1998 and 2008.
1
Infant mortality will rise from under 50 per 1,000 to over 60 per
1,000 in the same period.
Current estimates show that about 25% of children admitted to hos-
pitals for all reasons are HIV infected and in those areas with the
highest prevalence rates, this figure exceeds 50%.
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Table 3 HIV Prevalence by Age Group:
Antenatal Clinic Attendees, 1997 and 1998
Age group Est. (HIV+) Est. (HIV+) Rate of Increase
1998 1997 %
< 20 21.0 12.7 65.4
2024 26.1 19.7 32.5
2529 26.9 18.2 47.8
3032 19.1 14.5 31.7
3539 13.4 9.5 41.1
4044* 10.5 7.5 40.0
4549* 10.2 8.8 16.0
The epidemic will result in a large number of orphaned children. In
2005, it is estimated that a million children under the age of 15 years
will have lost their mothers to AIDS. The number of AIDS orphans will
increase to two million by the year 2010.
The impact of the AIDS epidemic will be most evident in the health
sector. In Gauteng, it has been estimated that adult hospital bed needs
will increase from 2,000 in 1998 to over 10,000 in 2010, a 600% increase
over the next ten years, unless more effective and efficient ways of car-
ing for people with HIV are implemented. There is anecdotal evidence
that currently acute medical hospital beds have between 30 and 50%
usage for AIDS-related conditions. There is no doubt that HIV will
consume a large proportion of future health budgets. In addition to the
health sector, the impact of HIV will be most marked in the educa-
tional and welfare sectors while it will have a significant impact on the
economy, development, and poverty, as well.
Levels of Infection with other Sexually Transmitted Diseases
The interaction between HIV and the other sexually transmitted dis-
eases (STDs) has been known for a number of years. The presence of an
STD in an HIV negative partner increases his/her susceptibility to HIV
during sexual intercourse with an HIV positive partner, while an HIV
positive partner is more infective when s/he has an STD.
As part of the Demographic and Health Survey undertaken by the
Department of Health in 1998, men were asked about the symptoms of
a STD. 12% of men over 15 years of age reported having the symptoms
of a discharge and/or an ulcer during the previous three months.
Prevalence was highest in the 15 to 44-year-old age group, although
prevalence for all age categories was over 10%. This prevalence is very
high.
Knowledge of AIDS and Behavioral Surveillance
Information from the 1998 South African Demographic and Health
Survey shows that 97% of women between 15 and 49 years of age have
heard of AIDS. However, their knowledge of ways to avoid AIDS was
limited, with up to 10% stating that staying with one partner and using
a condom during sexual intercourse would not protect them against
AIDS. 21% still believed that transmission could take place by sharing
public toilets while 38% felt mosquitoes could spread HIV. The impli-
Peter Barron and Marian Jacobs
133
cations of these data are that much more needs to be done in educating
the general public.
National AIDS Plan
The South African Nation AIDS plan has three primary objectives and
this section gives some details of these objectives and the strategies to
achieve them.
Prevent the Transmission of HIV
1. Prevent sexual transmission
2. Prevent transmission through blood
3. Prevent perinatal transmission
4. Promote policies and programs which address changes in the
socioeconomic conditions predisposing the population to the
spread of HIV
Reduce the Personal and Social Impact of HIV Infection
Mobilize and Unify National, Provincial, Local and International
Resources.
C. Prevent the Transmission of HIV
The prevention of HIV infection still remains the dominant response to
the epidemic in South Africa. There are four strategies associated with
this objective:
1. The Prevention of Sexual Transmission
In South Africa, as in most countries, the health care approach domi-
nates HIV prevention efforts. This response arises from the World
Health Organization’s (WHO) individual risk reduction strategy:
Correct and appropriate information/education
Health and social support services (such as counseling, testing, STD
management, and condom distribution)
Non-discrimination towards people living with HIV/AIDS.
This response to the epidemic is based on the assumption that risk
behavior must be minimized at the individual rather than at the com-
munity or societal level. The critical point about this approach is that
all three elements have to be accessible to individuals in order for them
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to sustain positive behavior change. The provision of information and
education is of little benefit if appropriate or accessible support ser-
vices are not available to facilitate behavior change.
a. Information/Education and Counseling (IEC)
Appropriate counseling remains a very important aspect of preven-
tion, particularly pre- and post-test counseling.
Life Skills Programs in Schools
Given the rapid increase in HIV infection among youth, life skills edu-
cation in schools is a priority. The National Life Skills Project Commit-
tee was established in 1995.
By the end of 1998, two teachers in every secondary school through-
out the country had been trained in life skills education.
The focus has now shifted to primary schools, with pilot training of
teachers in the Free State, Gauteng, North West and Northern
Provinces.
Most activities occur in “pockets” and are not generalized to the
whole province and the implementation of the program is slow in
rural areas.
Conservative elements in certain schools have delayed implementa-
tion. The question of condom promotion and availability in schools
continues to be controversial.
There are concerns that teachers are not ideally placed to conduct
life skills education and that it should be implemented through a
peer-based approach.
b. Barrier Methods
Access to and utilization of condoms is a critical factor in controlling
the spread of HIV.
There has been a rapid increase in demand for condoms from 1.2
million per month in 1995 to 15 million per month in early 1999.
In 1998, the government purchased 160 million condoms, up from
140 million in 1997.
Peter Barron and Marian Jacobs
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The single biggest challenge is persuading individuals to use con-
doms consistently. The survey conducted in 1998 suggests that adoles-
cents and adults have still not internalized the risks of unprotected
sexual intercourse. While gender programs have been very good at
persuading women to use condoms, their successes have been consid-
erably limited by the attitude of men toward condom use.
Figure 4 shows the availability of condoms in a sample of primary
care clinics in the nine provinces.
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Figure 4 Percent of clinics with condoms in their waiting rooms
Sexually Transmitted Disease (STD) Management and Control
STD management and control is the most advanced of all the HIV
prevention strategies.
Extensive training in STD management has taken place in all
provinces to implement policy guidelines.
All provinces surveyed reflected very few problems with service
delivery. In Gauteng, for example, over 80% of 300 clinics are deliv-
ering on policy.
This is not the case with private medical practitioners. Studies show
that the quality of care in the private sector and in the workplace is
poor.
A “best practice” model for STD control is the Lesedi Project, in a
mining community, where the presumptive treatment of STDs in
sex workers has led to a significant decrease in STDs among miners
who work in the area. The project estimates that the intervention
has reduced HIV infections by 46%.
c. Protection of the Rights of People with HIV/AIDS
In its approach to HIV prevention, the WHO has included non-dis-
crimination toward those most at risk and those infected. The deci-
sion was prompted by field experience showing that fear of
discrimination led those most likely to be infected to avoid partici-
pating in prevention programs. A number of laws that protect the
rights of people living with HIV/AIDS were enacted and promul-
gated during 1998/99. The Employment Equity Act (Act 55 of 1998)
eliminates unfair discrimination in any employment policy or prac-
tice. HIV is explicitly listed as a ground of non-discrimination. The
Medical Schemes Act prohibits discrimination against members or
prospective members on the grounds of pregnancy, disability, or
state of health.
Despite this progress in legal and policy formulation around human
rights, there is still discrimination and human rights abuse of
infected and affected persons. This is evidenced by the murder of
Gugu Dlamini in KwaZulu-Natal in December 1998 after she dis-
closed her HIV status on a public platform.
2. The Prevention of Transmission through Blood
Since the mid-1980s, the supply of blood products in South Africa has
been safe. With the rapid escalation of the epidemic placing pressure
on blood transfusion services to keep blood products safe, increasingly
stringent screening of donors has taken place.
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Between 25 and 35% of babies born to HIV positive mothers are
infected. A short course of AZT to pregnant mothers shortly before
birth and to the babies after birth reduces transmission by up to 50%.
However to provide AZT to every prospective mother would require a
great deal of logistical expertise and would also require extra staff time
over and above the cost of the medicine. The provision of drugs to
pregnant mothers has been one of the major public debates raging over
the past year and at the time of this writing the issue has not yet been
resolved.
There is, however, a growing ethical concern related to the health
care provider’s obligations to ensure the respective survival rights of
mother and baby, and this, coupled with the dilemmas of caring for
the orphan infants, is receiving considerable attention.
D. Reduce the Personal and Social Impact of HIV Infection
As the HIV epidemic develops in South Africa, there is a rapid increase
in the number of people who are becoming symptomatic and dying.
There are three main strategies to lessen the impact:
The provision of counseling, care, and social support for persons
with HIV/AIDS, their families, and the community
The provision of social welfare services for persons with
HIV/AIDS, their families, and the community
The reduction of the macro-social economic consequences of
HIV/AIDS.
1. The Provision of Counseling, Care, and Support
The appropriate treatment and support for people with HIV infection
have not been given priority in South Africa. There is a need for the
documentation of best practices and guidelines on implementation.
One controversial issue is the current move by government to make
AIDS a notifiable disease. This notification is to be anonymous and to
be used for tracking and planning purposes only. It is also to inform
caregivers. From a monitoring point of view, such notification infor-
mation is likely to be inaccurate, as persons with HIV will be reluctant
to divulge their status until there is a climate of nondiscrimination and
acceptance.
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Figure 5 shows the availability of HIV testing in primary care facili-
ties. That only around three out of every five clinics have testing facili-
ties is indicative of the great strides that still have to be taken in
coming to grips with this epidemic.
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139
Figure 5 Percent of clinics which offer HIV testing, 1998, by province
2. The Provision of Social Welfare Services
Many studies show the potential impact of the epidemic, particularly
in terms of social welfare services.
Two issues are particularly important at a local level:
The intensification of poverty as a result of AIDS-related mortality
and morbidity
The problem of how to cope with the increasing numbers of
orphans.
E. Mobilize and Unify National, Provincial, Local and International
Resources
This objective is the least developed of the three outlined in the AIDS
Plan.
The NACOSA Plan emphasizes three strategies to achieve this
objective:
1. Mobilize commitment, support, and resources
2. Strengthen national, provincial, and local capacities to respond to
HIV/AIDS
3. Strengthen international efforts in the Southern African region
1. Mobilize Commitment, Support, and Resources
There are three interventions associated with this strategy:
a. Promote common intersectoral strategies and coordination
b. Ensure financing through mobilizing provincial, national, and inter-
national funds
c. Promote community involvement and coordination with NGOs.
Intersectoral Strategies and Coordination
Intersectoral strategies and coordination are essential components in
mobilizing commitment, support, and resources. South Africa has not
mobilized on a scale sufficient to create a critical mass of action in the
face of the epidemic. There are, however, a number of encouraging
developments at a national level. One of these measures is the estab-
lishment of the Inter-Ministerial Committee (IMC) at the end of 1997,
which created a platform for ministries to strategize and mobilize col-
lectively. Early in 1998, the IMC developed the Government AIDS
Action Plan for South Africa (GAAP) to mobilize South Africans in
controlling the epidemic. This plan is intended to address two critical
weaknesses hindering the expanded response to the epidemic the
lack of political commitment and limited intersectoral collaboration.
The plan provides a strategic framework that is adaptable to different
regions, communities, and circumstances. Planning will happen on a
sectoral basis with consolidation of plans to be discussed at annual
National AIDS Summits. Deputy President Mbeki launched the plan in
October 1998 and called on all South Africans to join in a “Partnership
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against AIDS.” Sectoral pledges were made (e.g., from business, trade
unions, and youth). This has been followed by the mass mobilization
phase of the plan, using key calendar dates and activities to promote
partnership building. For example, on World AIDS Day, all cabinet
ministers were highly visible around the country pledging their sup-
port for the AIDS effort. There is strong evidence to suggest that the
mobilization campaign has caught the attention of South Africans and
that AIDS is widely spoken about.
One of the key roles of the Beyond Awareness Campaign in the
AIDS Action Plan is to provide tools for action that any program to
combat AIDS can use. Items such as the red ribbon and guidelines on
developing programs, pamphlets, and posters are readily obtainable
from a central AIDS Action office. In addition, the promotion of the
red ribbon has achieved much success in increasing the profile of the
program to combat the epidemic in South Africa.
Although the amount of funds mobilized and utilized in controlling
HIV in South Africa has never been quantified, it is known to be large.
Funds are mobilized from many different sources. It is, however, the
larger donor amounts (e.g., United States Agency for International
Development, the European Union, and the Department for Interna-
tional Development) that tend to be quantified. With the exception of
Gauteng, all provinces report very little financial support from their
respective governments. This reflects limited political commitment on
the part of most provinces.
2. Strengthen National, Provincial, and Local Capacities to Respond to
HIV/AIDS
This strategy poses many challenges. While the demands of the epi-
demic have increased substantially, there has not been a simultaneous
strengthening of the AIDS programs. The net result is an HIV/AIDS
response that is still relatively uncoordinated and lacking in vision,
strategy, and management.
The role of national and provincial AIDS programs is to coordinate
the implementation of the response. This is an extremely difficult task.
The difficulties of these programs include:
The low status of AIDS programs in many provinces and the subse-
quent absence of a visible presence at a district level.
Peter Barron and Marian Jacobs
141
The lack of human resources within programs. In some provinces,
there is only one person responsible for HIV/AIDS. In others, there
is a heavy reliance on secondary staff. This reflects a lack of true
commitment to control the epidemic.
• AIDS programs, both nationally and provincially, engaged in
implementation at the expense of coordination and management.
The inability of programs to advise politicians on appropriate pol-
icy.
The lack of planning for local implementation despite this being the
thrust of national health and development policy.
Provincial coordinators lacking management skills.
The AIDS program in Gauteng stands out in contrast to all the other
provincial programs. Political commitment in Gauteng started with an
impact assessment of the HIV/AIDS epidemic on Gauteng as a
province and on the government as an employer. This study was car-
ried out under the auspices of an interdepartmental committee. It was
a very effective way to begin the process of gaining political commit-
ment. Through this process, the AIDS program in Gauteng became an
interdepartmental initiative, with Health as the lead ministry. The ben-
efits to the program have been significant. The AIDS program reports
directly to the cabinet and derives its budget from an allocation from
each ministry. This is the reason for the budget of R40 million in 1998.
Despite its many challenges, the program is structured and funded in
such a way that it can provide strategic leadership to the HIV/AIDS
effort in the province. In large measure, this has been made possible by
political commitment that is translated into a strong resource base for
provincial action.
Little information is collected to measure and monitor the epidemic
in South Africa. Indicators used generally relate to input or output
such as number of condoms distributed, teachers trained in life skills
education, and number of HIV/AIDS events held. There are few mea-
sures that monitor the impact of programs and interventions. In addi-
tion, the prevalence of HIV will only begin to decline sometime after
interventions are successful. Thus, intermediate indicators are
required such as the prevalence of high-risk behavior and of STDs in
the general population and in sub-populations.
A number of conclusions can be drawn regarding the attempts at
combating HIV/AIDS.
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The first is to translate political commitment into strong national
and provincial AIDS programs.
The second is to harness the skills and expertise within civil society
through the establishment of intersectoral management committees
to work alongside government AIDS programs. Not only will this
provide an added dimension to strategic thinking, but it will also
broaden the response from a government to a country response.
The third is to learn from what has worked. The epidemic has
reached the stage where large numbers of people now have sympto-
matic HIV infection.
It is clear that South Africa is facing a catastrophic epidemic. The
window of opportunity to prevent a large-scale epidemic has passed.
The country now has to contend with the social and economic effects
of large numbers of HIV-infected and affected people. The control of
this epidemic will only be achieved through sustained action in a well
managed program that is based on interventions that have been shown
to work and in a programme in which all South Africans can partici-
pate.
IV. Child Health and Welfare
A large proportion of South Africa’s population is comprised of
infants, young people under the age of 18 years, and women of child-
bearing age. Many of these people live in the rural areas, where wide-
spread poverty still prevails. In these areas, poor maternal and child
health is exacerbated by inadequate social, economic, and physical
infrastructure, limited access to appropriate services, and a scarcity of
all those resources required to promote and maintain child well-being.
Until 1994, when the new democratic government came into power,
there was no comprehensive policy to promote and protect the overall
well-being of children. For child health in particular, there was no
explicit health policy for this large, vulnerable sector.
Recognizing that children need special consideration in social and
economic development policy, the new democratic government took
several steps to address the legacy of neglect. The Reconstruction and
Development Programme (RDP) made specific reference to policies
and programs for children, the most significant of which were declara-
tion of free basic health care for children under six years and pregnant
women, and an elementary school-based nutrition program. Although
Peter Barron and Marian Jacobs
143
subsequent evaluation revealed some limitations, these programs pro-
vided a firm foundation for development of child-focused activity by
government, while giving a clear indication of the seriousness of gov-
ernment’s intention to address the plight of children.
In 1995, the newly-elected parliament ratified the Convention on the
Rights of the Child, and, in the following year, included a dedicated
component entrenching child rights in the new South African Consti-
tution. Government followed this up by developing a National Plan of
Action for Children as a framework to guide the realization of child
rights by institutions of both the state and civil society.
Macalester International Vol. 9
144
Figure 6
Source: Statistics South Africa. 1996 Census in Brief (1999).
A. Framework for a National Program of Action for Children
The framework, based on the Convention on the Rights of the Child,
defined the policy areas related to promotion and protection of child
rights and child well-being, and identified the sectors (both govern-
mental and non-governmental) with responsibility for each policy
area. It was designed to guide child-focused actions by government
and civil society, while at the same time providing a basis for evaluat-
ing such actions with respect to their compliance with the dictates of
the Convention. Thus, within a period of less than two years, the new
government had created a rights-based framework with which every
governmental department was requested to comply through develop-
ment of child-oriented policies and programs.
Within this framework, civil society defined its own contribution to
implementation of child rights. Following years of advocacy for chil-
dren through activities such as campaigns for their release from deten-
tion in the apartheid repression, pressuring government to adopt the
Convention on the Rights of the Child in the face of widespread abuse
of their rights, and providing alternative services for children with
special needs when government failed to acknowledge such need, the
national child rights movement has now achieved recognized partner-
ship with the new government.
B. Response by the Health Sector
The fragmentation that characterized South Africa during the
apartheid years was very apparent in the health sector. This situation,
along with the failure to recognize children as a group worthy of spe-
cial consideration in comprehensive policy and programming, pre-
sented the new government with an opportunity for substantive
redress within the framework of its obligation to meet the require-
ments of the Convention on the Rights of the Child. Recognizing the
right to adequate health care as fundamental, policies for children pro-
moted equitable access through provision of free health care for young
children under six years old, and the development of a “package” of
essential health care services for every child in South Africa. Evalua-
tion of the free care policy showed broad appreciation for its intent,
but both health care providers and the beneficiaries expressed con-
cerns about its implementation. Key among these was the inappropri-
ate use of hospital services, seen to be aggravated by declaring free
Peter Barron and Marian Jacobs
145
access to this level of care. Since this time, the policy has been modi-
fied, enabling free care only at the primary level, and at other levels on
referral.
1. The Right to Basic Health Care
The draft Health Bill stipulates “the right of access of all South
Africans to a basic package of health care.” While the strategy of ensur-
ing health care for all children through a set of basic interventions is
Macalester International Vol. 9
146
Table 4 Summary of Sectors Responsible for Implementing the NPA
Policy Area Sector(s) with Lead Supporting Sectors
Responsibility
Nutrition Agriculture, Health Labor, Land Affairs, Posts, Telecommuni-
cations and Broadcasting, RDP, South
African Communication Services, Trade
and Industry, Water Affairs and Forestry,
Welfare and Population Development
Child and Maternal Health Agriculture, Education, Environmental
Health Affairs and Tourism, Housing, RDP,
South African Communication Services,
Water Affairs and Forestry and Welfare
and Population Development
Water and Sanitation Housing, Water Affairs and Agriculture, Environmental Affairs
Forestry, Constitutional and Tourism, Health, Home Affairs,
Development Education, Land Affairs, Public Works
and RDP
Early Childhood Education and Welfare and Agriculture, Arts and Culture, Environ-
Development and Population Development mental Affairs and Tourism, Health,
School Education Housing, Labor, Mineral and Energy
Affairs, Posts, Telecommunications and
Broadcasting, RDP, South African Com-
munication Services, Sports and Recre-
ation, and Water Affairs and Forestry
Social Welfare Welfare and Population Arts and Culture, Science and Technology,
Development (Family Development Education, Health, Justice, Labor, Posts,
Environment, Out-of- Telecommunications and Broadcasting,
Home Care and Social RDP, South African Communication
Security) Services, South African Police Services,
Sports and Recreation
Leisure and Cultural Arts and Culture, Science Education, Environmental Affairs and
Activities and Technology and Tourism, Housing and RDP
Sport and Recreation
Child Protection Correctional Services, Agriculture, Arts and Culture, Science
Measures Justice, South African and Technology, Education, Foreign
Police Service, Safety and Affairs, Health, Home Affairs, Labor,
Security and Welfare and RDP, Safety and Security, Sports and
Population Development Recreation and the President’s Office
worthy in its intent, careful consideration needs to be given to the
foundations of the chosen approach and its implementation in prac-
tice.
An example is the adoption of the World Health Organization initi-
ated program of Integrated Management of Childhood Illnesses. Based
on the assumption that the deaths and disease affecting the majority of
the world’s children are caused by a small number of preventable dis-
orders, viz., malnutrition, diarrhea, respiratory infections, and the
childhood diseases preventable by immunization, the program pro-
poses a core set of preventive and curative strategies to address these
conditions. Missing from the “basic package” are interventions to
address tuberculosis and HIV/AIDS a serious omission in a country
where both these conditions have reached epidemic proportions.
This has resulted in the development of complementary packages to
target these serious problems, and the approach could herald a cas-
cade of separate packageseach developed for a new priorityleav-
ing the children as vulnerable to piecemeal interventions as they were
before.
But the right to health care extends beyond the primary level and
beyond office hours, and an important consideration is finding a bal-
ance between ensuring essential services for all children and providing
special services for those who need additional care. The latter includes
after-hours care and care for children with chronic illnesses.
Providing Health Care “After-Hours”
A recent evaluation of after-hours health care services for children in
the public sector illustrates the pitfalls of ignoring the special needs of
children in a system of comprehensive primary care.
2
Focusing on the
primary care facilities in greater Cape Town, the study found that chil-
dren with common illnesses, like respiratory illness, had to share space
and a queuewith adults traumatized by gunshot and stab injuries.
These children also had difficulties of access when being referred to
another level for emergency or specialist care, a situation which was
further compromised in daytime hours by the contractual obligations
of their employed caregivers.
Comprehensive care should be available for 24 hours a day, and the
challenge of providing such services, to both adults and children,
remains a problem.
Peter Barron and Marian Jacobs
147
Care of Children with Chronic Diseases
Conditions like diabetes, epilepsy, and asthma constitute the second
component of the “double burden” of ill health borne by children in
developing countries. While the burden of the first component com-
prises the preventable conditions associated with poverty, the burden
of the second component is largely linked to societal transition, rapid
urbanization, and changes in lifestyle.
There are no national estimates of the burden of ill health associated
with chronic conditions, but estimates of some marker conditions pro-
vide an indication of the extent of the problem. In the Western Cape,
one in ten children is estimated to have asthma, and studies on deaths
from asthma also show that the proportion of child deaths is increas-
ing.
Another chronic condition that needs attention is mental illness.
Mental health care for children has been low on the national list of pri-
orities, with grossly inadequate services. Widespread under-diag-
nosed postnatal depression has serious implications for infant mental
health, while for older children, the burgeoning problem of substance
abuse is a major cause of morbidity and mortality.
In general, chronic illness of childhood is worthy of special consid-
eration in both budgetary allocations and service provision, and is an
area that is sorely in need of policies and plans.
Specialist Services
In the face of declining health care budgets, the services that have suf-
fered greatly are those delivered by expensive tertiary care institu-
tions. A case study from the Red Cross Children’s Hospital in the
Western Cape illustrates the dilemmas linked with finding the right
balance. This is the only hospital in the country solely dedicated to the
care of children. Serving more than 200,000 ambulatory patients and
25,000 in-patients per annum, the hospital provides unique specialist
and sub-specialist services to children at a provincial, national, and
regional level. Over the past five years, the number of beds has been
reduced by 22%, and in the past year, the budget has declined by 30%.
As the hospital has been affected by indiscriminate budget cuts to
tertiary hospitals across the board, those who advocate for children
and their rights regard the notion of children enjoying a “first call”
with serious skepticism.
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2. The Child Health Budget
To ensure realization, the basic right to health care has to be followed
by a basic set of resources, and crude estimates of health expenditure
in South Africa show that of the 10% of gross domestic product spent
on health, about 22% is dedicated to child health promotion and nutri-
tion. Within this pool of about R50m (1997 estimate), the bulk of the
money is concentrated in the urban areas of wealthier provinces, with
the larger proportion expended on tertiary care.
There have been proposals that expenditure be targeted at margin-
alized communities in greater need of care, and that priority funding
be given to primary and secondary level services. Such drastic action,
without any consideration for the overall funding of health care for
children at all levels, could have disastrous consequences.
3. The Right to Basic Nutrition
Malnutrition among South African children is still a serious problem.
A national survey of preschool children, undertaken in 1995, showed
that one in every four suffers from chronic undernutrition, which
results from lack of food. (See Table 5.)
This survey also showed that one in every three South Africans has
Vitamin A deficiency, increasing their vulnerability to serious compli-
cations of infections such as diarrhea and pneumonia. Provinces with
especially high rates of Vitamin A deficiency are the Northern
province and KwaZulu-Natal.
Peter Barron and Marian Jacobs
149
Table 5 Extent of Child Under-Nutrition by Province in South Africa:
Anthropometric Status of Children 672 months
Province % Wasting % Stunting %Underweight
Eastern Cape 3.2 28.8 11.4
Free State 4.5 28.7 13.6
Gauteng 1.2 11.5 5.6
Kwazulu-Natal 0.7 15.6 4.2
Mpumalanga 2.5 22.8 15.6
Northern Cape 1.7 34.2 12.6
Northern Province 3.8 20.4 7.3
North West 4.5 24.7 13.2
Western Cape 1.3 11.6 7.0
South Africa 2.6 22.9 9.3
Source: The South African Vitamin A Consultative Group, 1995
Widespread undernutrition is a major risk factor for child deaths
and disease, especially from infections. The introduction of an inte-
grated and comprehensive national nutrition policy and program was
a timely and essential response to ensuring a child’s right to adequate
nutrition, to survival, and to development. Underpinned by a radical
shift from addressing nutritional problems through a welfare
approach to one rooted in social and economic development, the pro-
gram includes a wide range of components, from ensuring household
food security and income generation to breastfeeding promotion to
food supplementation.
One important intervention to address this problem is the primary
school nutrition program, which has been in operation since 1994. By
1996, the former program reached nearly one million children in
schools in areas of need out of a target of 8 million. This example
illustrates the size of the task needed to make a real difference to child
nutrition.
4. The Right to Safety and Protection
The international media captured the flagrant violations of children’s
rights to safety and protection from abuse in the 1970s and 1980s.
While the climate has changed, the events of those years has resulted
in a culture of violence that is given expression through continued use
of corporal punishment in schools, sexual and other forms of physical
nonaccidental injury, and the burgeoning problem of firearm-related
injuries.
The reporting rate for crimes against children is increasing, and
from 1994 to 1998, the number of reported child rapes doubled from
7,559 to more than 15,000. In a twelve-month period between 1997 and
1998, the Red Cross Hospital recorded almost 7,000 admissions for
trauma-related injuries, most from falls, motor vehicle accidents, and
burns.
The health services are seriously engaged in efforts to address these
problems, and legislation has been given special attention by the pol-
icy-makers. The Child Care Act (being drafted at present) aims to pro-
vide equity of access to welfare support for children, while the national
child abuse protocol provides clear guidelines for the prevention and
management of the terrible problem. The Schools Act now prohibits
the use of corporal punishment but there have been calls for its rein-
Macalester International Vol. 9
150
statement, especially from crowded, under-resourced schools, where
alternative forms of discipline are difficult to implement.
Hence, the real solution lies in addressing the crux of the problem: a
culture of violence that is deeply entrenched in the psycho-social and
economic fabric of South African society.
Two other groups in need of special consideration are children in
prison, and those who are on the streets. For the former group, little
attention has been paid to development of policies or programs for
their general care in prison. Reports indicate that the situation is in
need of urgent attention. The extent of the problem of children on the
streets has defied assessment, but their large and increasing numbers
have drawn the attention of nongovernmental organizations and other
agents of civil society to their plight.
5. Children with Special Needs
Child disability is the most serious contributor to the burden of disease
for South African children. Based on crude measures of the extent of
the problem, an estimated half a million children are in need of disabil-
ity services. Ensuring children’s rights to protection in special circum-
stances includes development of strategies to prevent disabilities
arising from causes such as birth-related events, services to diagnose
and manage the medium-term health outcomes of disability, and a
coordinated rehabilitation response from health, welfare, and educa-
tion authorities.
The National Integrated Disability Strategy, launched by the Office
of the President in 1996, estimated that in 1997, almost 70% of disabled
children of school age were not at school. Today, for those who are at
school, very little budgetary provision has been made for special edu-
cation, with only 1% of all South African schools being equipped as
“special” schools. Policy for special education has shifted to encourage
mainstreaming, with variable results (and with particular problems
experienced in historically disadvantaged schools).
The disability strategy emphasizes a developmental and integrated
approach to the broader needs of the disabled child. Among these,
access to financial support remains a critical component, and one that
eludes many needy children. While caregivers are entitled to apply for
assistance, administrative inefficiency often obstructs the award of
social assistance.
Peter Barron and Marian Jacobs
151
One concern is that free health care has not been consistently
extended to include rehabilitation or assistive devices, and disabled
children who are unable to go to school are also denied other social
benefits, like school meals.
Child disability presents a special set of challenges for health, edu-
cation, and welfare authorities, and demands acceleration of the good
intentions proposed in national policies and plans.
6. Environment and Health
The scope of attention to ensuring the right of children to a healthy
environment has been expanded from a narrow focus on water and
sanitation to include other environmental threats such as tobacco
smoke, lead, and nuclear emissions.
More than 70% of South African unborn babies are exposed to envi-
ronmental tobacco smoke, more than 80% of young children in greater
Johannesburg have unacceptably high blood lead levels, and studies of
the impact of nuclear waste on birth defects have just commenced.
V. Future Challenges
A. Harmonizing Customary Law with National Legislation and the
Requirements of the Convention
In customary law, there is no clear definition of the end of childhood or
the start of adulthood. This progression is not determined by chrono-
logical age, but rather by maturity, initiation, marriage, and other tra-
ditional practices. This has implications for recognition of marriages,
as stipulated in national legislation, as well as for other legal transac-
tions involving adults (over the age of eighteen years). Other areas of
potential conflict reside in the areas of succession, legitimacy, custody,
and transfer of parental rights.
The definition of child in South African law needs more attention, as
various definitions are applied in different settings.
B. Reducing all Forms of Abuse of Children, including Corporal
Punishment and Humiliation
There is no doubt that the widespread flagrant physical and sexual
abuse of children needs attention, and plans for a national strategy are
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152
underway. More subtle expressions of abuse are of major concern, as
the greater proportion of South African society accepts smacking and
humiliating children as acceptable forms of discipline. Campaigns to
end such forms of abuse against children have had far less success than
the bigger campaigns against serious forms of abuse, but these need to
be encouraged as one facet of changing fundamental societal practices
that are prejudicial to children.
C. Ensuring that National Programs and Policies are in the Best
Interests of Children
Of increasing concern are the apparent contradictions between govern-
ment-initiated social development programs, such as the National Pro-
gramme of Action for Children (NPA), and the new macroeconomic
policies, which have resulted in decreased social spending.
The latter, the Growth, Employment and Redistribution Strategy
(GEAR), has placed significant strain on the safety net for children,
especially those who remain vulnerable to economic risk. Under these
circumstances, child advocates continue to focus on the need for the
best interests of the child to be given prime consideration in all areas of
governance, in national legislation, and in the national budget.
In the new government, coordination of the NPA is undertaken
from the President’s office, as a unit called the Office of the Status of
the Child. It reports directly to a Cabinet committee responsible for all
social issues. Although this has elevated the stature of the NPA, true
elevation can only be achieved when children get similar recognition
in the budget.
D. Introducing Comprehensive Child Legislation
The adoption of a single piece of legislation to promote and protect the
well-being of children is underway in South Africa. The new legisla-
tion being drafted by the South African Law Commission will include
defining children’s legal status, measures to protect them from abuse
and sexual offenses, incorporation of customary and religious law, and
protection of children in special circumstances (such as work, home-
lessness, provision of care).
Within each of these provisions, there are special considerations
related to the narrower responsibilities of the health sector, and these
need further elaboration.
Peter Barron and Marian Jacobs
153
E. Promoting Children’s Rights to Participation and Having their
Views Respected
One fundamental premise is children’s rights to participation. In coun-
tries such as the United Kingdom, special attention is being paid to
ensuring children’s rights in interactions with their health care
providers. Accelerating the realization of people’s right to participa-
tion in the health care process has been assisted by inclusion of a
patients’ Bill of Rights in the Draft Health Bill, and children need spe-
cial attention in this regard.
Acknowledging the importance of the views and opinions of chil-
drenin matters of their health, their education, their welfare, and the
state of society can go a long way to creating a society that truly
places the interests of children first.
The rights of children have been firmly entrenched in the South
African Constitution, and policies to give effect to these rights are also
well developed. Analysis of the status of children shows the multifac-
torial nature of their vulnerability, and highlights the needs for inter-
sectoral action, supported by adequate resources from central
government coffers.
Implementation of actions is underway, but is in danger of deterio-
rating once more into piecemeal interventions. Developing a better
understanding of children in poverty, and especially in the multicul-
tural South African society, could be an important step in the develop-
ment of holistic, effective interventions.
Monitoring the impact of these actions on the overall health and
well-being of the children will guide future efforts to close the loop in
meeting child health needs through a rights-based approach.
Notes
1. The trends in the AIDS epidemic continue to worsen with over four million people in
South Africa estimated to be currently infected with HIV. In the World Health Report
2000, “Health Systems: Improving Performance,” the World Health Organisation esti-
mates that the current life expectancy at birth is 47.3.
2. Mtambo, Child Health Unit, 1999.
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