South African Healthcare System Elizabeth Chester Lecture 15 HSCI 609 Comparative International Health Systems

South Africa Republic of South Africa Capital: Pretoria Style of Government: Republic Administrative divisions: 9 provinces Middle-income, emerging market, vast natural resources, high unemployment

Population Statistics 44.1 million (2006, CIA) Poverty levels: 71% rural/ 50% urban Unemployment: 38% People living with AIDS: 23.5% More than 6 million HIV/AIDS deaths expected by 2012

Macro Health Statistics Total health expenditure as % GDP: 8.4 (2003) Life expectancy: male/ female Infant Mortality: 60.6 per 1000 Population >65 yrs: 5.3% The impact of AIDS cannot be ignored –Higher infant mortality –Lower life expectancy –Negative population growth rate (-0.4%)

Organization Decentralized and participatory at the lowest levels Department of Health—Federal level –Sets user fee schedule, nation legislation (i.e. free health care for certain groups: women, children, AIDS, TB) Provincial Departments of Health— –maintain operational decision-making authority in health care delivery and finance –provide hospital and primary healthcare Further divisions into Health Regions & Districts

Funding the System 18% of population has private insurance Private health expenditures per person are 7.1 times higher than public health expenditures per person (2003) ( Federal gov’t contributes 40% of total health expenditures for 80% of population Public health consumes 11% of federal budget

From the South Africa home page “Aids and other poverty-related diseases like tuberculosis and cholera are placing a tremendous strain on South Africa's health care system, eroding attempts to improve the general health of South Africa's people.” Accessed 26 May

Social and Historical Impact on Health and the Health System Under Apartheid hospitals were assigned to particular racial groups & concentrated in white areas. When Apartheid ended in 1994, the country had to overhaul its entire healthcare system So many separate systems led to duplication of services No emphasis to meet the needs of the majority Black population The health sector was largely focused around hospitals Lack of facilities in the rural regions

District-based primary care Promotes local control of public health services Promotes access and affordability to all citizens 42 health regions and 162 health districts Primary health care clinics are controlled by district authorities Hospitals are controlled by provincial authorities.

District-based Primary Care Since the end of Apartheid in 1994, there has been a tremendous effort to build and upgrade clinics Now there are greater than 3,500 clinics in the public sector. Free health care at the clinics for children under six, for pregnant or breastfeeding mothers Source: South Africa home page accessed 26 May

Physician Issues To fill the long-standing shortage of doctors in rural areas, 450 foreign doctors, mainly from Cuba, were employed in the late 1990s. Simplified regulations encourage foreign doctors to practice in SA New South African MDs and Pharmacists must do a year of work in an underserved area/sector. There is a "brain drain" of South African doctors to the UK and Canada 29,788 doctors in 2000

Provider Issues and Changes Decentralization has led to change and disparity Most physicians work in the private sector Public emphasis on primary care has driven all acute, secondary & tertiary care into the private sector Physicians, hospitals and pharmacists are concentrated in the wealthier provinces

Traditional Medicine Photos: /sa_glance/health/traditional- healersbill.htm and /sa_glance/health/traditional- healersbill.htm

Deep Cultural Roots N’debele Sepedi Sesotho Shangan Swati Tsonga Tswana Venda Xhosa Zulu Photo:

STRUCTURE Divined as Traditional Healer Study under a mentor (individual or group) Work out of hut, house or office Associate with other traditional healers Formally recognized by the SA government in 2004 Estimated 200,000 indigenous traditional healers in SA 60% South Africans consult them Retrieved 06/04/06 from:

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VOCABULARY Traditional Healers or Doctors Ngoma or Izangoma = Diviner (not witch doctor) Inyanga or Izinyanga = Herbalist Umuthi (muti) = medicine (tree, bark) Retrieved 6/4/06 from:

HOW TRADITIONAL MEDICINE SYSTEM.WORKS Photo:

Balance or harmony of your life is disturbed bringing misfortune. Causes: Ancestral Wrath Witchcraft Pollution Natural causes (Ngubane 1977)

For diseases and other medical complaints, patients resort to both western doctors and traditional healers. Minor ailments are treated with home remedies More serious complaints are taken to western doctors, traditional healers or faith healers. VISITING TRADITIONAL HEALERS

VISITING TRADITIONAL HEALERS continued Choice of healer based on patients belief system, money available or the seriousness of illness. More than 60% go to primary health care institutions like clinics or public hospitals. If looking for health maintenance, patients often just buy muti from the healers or muti markets. Visit cost is approximately R20 – R40 (treatment or muti costs additional)

Izangoma (Sangoma) Photos: and

INYANGA (Herbalist) Photo: chimages/mutusellers.jpg

IMITHI (Muti) The majority of substances I have seen on the Faraday market in Johannesburg are of vegetable origin. The herbalist or diviner administers imithi (medicines) which are usually of vegetable origin to treat diseases or ailments. Raw herbs are ground into powders to be taken with water, or are boiled as barks or roots that are drunk as decoctions. Other imuthi are bathed with, rubbed into incisions (ukuchaza), inhaled as smoke (ukuqhumisa) or nibbled on, especially roots, or also licked from ones fingers (ukuncinda) (Hunter, 1936)

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WESTERN / TRADITIONAL MEDICINE ARE NOT MUTUALLY EXCLUSIVE Belief can be a powerful healer Traditional remedies can and do often work Traditional Healers see the benefit of clinical medicine (vice versa?) Trad. healers play an important role in teaching good health on the grassroots level