AN ALTERNATIVE ANALYSIS OF HEALTH CARE IN SOUTH AFRICA

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AN ALTERNATIVE ANALYSIS OF HEALTH CARE IN SOUTH AFRICA

The following article is based on a series of

lectures sucessfully used in workshops involving medical students. It provides an introductory

approach to an analysis of health care in South Africa. We have decided to include this article on the basis of it's accessability to people

who might be approaching an alternate analysis of health care for the first time.

INTRODUCTION

This article will discuss some aspects of how health services are organised in South Africa and why they are organised in this way.

It is important for health workers to understand the system in which they work and to realise how closely the health

system is linked to other systems in South African society.

HOW ARE HEALTH SERVICES ORGANISED IN SOUTH AFRICA?

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There are;.two major features under t h i s heading;

-the d i s t r i b u t i o n of health services - p r i v a t e p r a c t i c e .

DISTRIBUTION OF HEALTH SERVICES Rural areas have been neglected.

Many r u r a l people have to travel very long distances to the nearest c l i n i c or h o s p i t a l . When they get there the treatment i s often inadequate due to s t a f f shortages and the inadequate t r a i n i n g of health workers.For example, i n most c l i n i c s , a nursing s i s t e r i s l e f t i n charge

and he or she has to cope w i t h a l l the diseases w i t h which the patients present. When the s i s t e r goes o f f duty,

a nursing assistant (a person w i t h only 6 months of hospital t r a i n i n g ) may be l e f t i n charge.

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Althougn services f o r whites i n rural areas are also r e l a t i v e l y neglected (McGrath 1979.134), i t i s the

services f o r blacks which suffer most. In the urban areas, there were 109 blacks f o r each hospital bed in 1970, while

in the rural areas there 191 blacks f o r each bed ( McGrathi).

In addition to the shortage of beds, doctors are also maldistributed. In the major urban areas there are 10.3

doctors per 10 000 people. In "homeland" areas there are only 0.43 per 10 000 people (McGrath 1979 134)

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Thus we see t h a t i n rural areas health services have been neglected when compared with urban areas. Health services are only one aspect of t h i s urban b i a s - the same pattern

can be seen i n the provision of water supplies, s a n i t a t i o n , roads, education.

IN URBAN AREAS SERVICES FOR BLACKS ARE NEGLECTED.

Health services can be provided by p r i v a t e p r a c t i t i o n e r s and i n s t i t u t i o n s or through p u b l i c , government subsidised channels. Private services f o r blacks i n the urban areas are very neglected, as shown in the table below.

DISTRIBUTION OF GENERAL PRACTITIONERS IN CAPE TOWN

NEWLANDS WYNBERG

MITCHELLS' PLAIN ELSIES RIVER

LANGA

1:600 1:650 1:3300 1:64000 1:19000

white areas black areas

This m a l d i s t r i b u t i o n of p r i v a t e services i s understandable because most black people cannot a f f o r d the high costs

of private medicine. In f a c t whites spend 94% of the

t o t a l expenditure on private services (McGrath 1979 128) In the public sector services are also maldistributed.

For example* an analysis o f two Durban hospitals showed t h a t the white hospital had 64% of i t s beds occupied

against 93% i n the black h o s p i t a l . There were only 7.2 d a i l y patients per doctor i n the white hospital compared witn 13.5 in the black hospital (McGrath 1979 132).

although i t i s d i f f i c u l t to assess what constitutes

"adequate" health c a r e , these comparisons do show t h a t

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whites i n urban areas are receiving more services.

I t may be useful to think about whether more services always means b e t t e r or relevant s e r v i c e s .

McGrath (1979 128 129) also mentions another i n t e r e s t i n g f a c t . In a study of c e r t a i n urban areas, i t was found

that white f a m i l i e s spend only 6% of t h e i r t o t a l health budget on patent medicines ( i e medicines not prescribed by a doctor, but bought i n a shop), while black families spent 49% of t h e i r health budget on these medicines.

He concludes. "Indeed, the r e l a t i v e l y high level of expenditure on patent medicines by Africans in urban areas might be an i n d i c a t i o n of the d i f f i c u l t i e s i n

obtaining subsidised medical treatment at hospitals or c l i n i c s " .

PREVENTIVE AND PROMOTIVE SERVICES ARE NEGLECTED.

In South A f r i c a about 97% of the health budget goes to curative services. I f a l l people get adequate preventive and promotive services on only 3% of the budget, t h i s

would not be an issue. But the examples t h a t surround us prove t h a t many people do not get adequate services.

For example, i f our health education campaigns were adequate - would mothers use dangerous and expensive

b o t t l e f e e d when they could breastfeed

- would the p o l i o epidemic have struck l a s t year

- would cholera and typhoid be a problem - would children s t i l l die from measles

PRIVATE PRACTICE AS A FEATURE OF HEALTH SERVICE ORGANISATION.

The m a j o r i t y of South African doctors (59%) work i n

p r i v a t e practice (McGrath 1979 120), and approximately one t h i r d of a l l beds i n the country are i n p r i v a t e l y owned hospitals (McGrath 1979 120).

A f t e r t h i s b r i e f study of how health services are organised, we must ask ourselves why are they organised i n t h i s way

in South Africa? We know t h a t there are other ways of organising services. For example, p r i v a t e practice has been banned i n the Soviet Union (Ryan 1978 32-33). In

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Once we see how health services are bought and s o l d

j u s t l i k e other goods (food) and services (plumbing) then we begin t o understand why health services are organised

the way they a r e .

I t was noted previously t h a t p r i v a t e p r a c t i t i o n e r s are allowed. In a c a p i t a l i s t s o c i e t y which encourages free e n t e r p r i s e and the formation of new businesses, a doctor

i s seen as another shopkeeper. The doctor s e l l s his or

her s k i l l s and makes a p r o f i t of the patients (customers) i l l n e s s .

Another p o i n t noted was t h a t preventive medicine i s

neglected i n favour of c u r a t i v e medicine. This i s understandable i n a s o c i e t y where the emphasis i s on s e l l i n g health care. When people are sick they w i l l do anything

to f i n d help and so sick people are eager customers.

When people are w e l l however they are not always i n t e r e s t e d i n learning about health education of other preventive

measures.

I t was also noted t h a t r u r a l areas are neglected. I f you were a shopkeeper would you r a t h e r open a shop i n Soweto or Johannesburg where there are many people l i v i n g close t o the shop or i n a r u r a l area where your cu-stomers are poorer and l i v e f u t h e r from the shop.

Of course you w i l l make more p r o f i t i n the c i t y . This i s one reasonwhy health services are more p l e n t i f u l i n the urban areas. Other reasons include the f a c t t h a t most health workers p r e f e r l i v i n g i n the c i t i e s , t h a t urban dwellers are usually b e t t e r organised to demand services

than scattered r u r a l d w e l l e r s , and t h a t the workers

who l i v e i n the c i t i e s must be kept f i t enough t o work.

(The influence of the homeland system on the d i s t r i b u t i o n of resources i s dealth w i t h i n a separate a r t i c l e i n

t h i s e d i t i o n )

In a d d i t i o n to these influences of the c a p i t a l i s t economic system, which would apply i n most c a p i t a l i s t c o u n t r i e s ,

South A f r i c a has some p o l i t i c a l issues which complicate the p i c t u r e . The system of r a c i a l separation and the

development of homelands accounts f o r the l a s t item noted e a r l i e r ; services t o r blacks are neglected. As w e l l as

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the differences i n q u a l i t y and q u a n t i t y of services mentioned b e f o r e , these r a c i a l p o l i c i e s account f o r - separate black and white hospitals

- separate t r a i n i n g i n s t i t u t i o n s f o r black and white nurses - the formation of a black medical school at MEDUNSA

2 the South African Nursing Association asking f o r a l l

"~ "homelands" to form t h e i r "own" nursing associations - separate Departments o f Health being formed i n each

"homeland"

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some countries, special attempts are being made to upgrade services i n the rural areas. I t is important to ask why these attempts are not being made in South Africa?

WHY ARE HEALTH SERVICES ORGANISED THIS WAY IN SOUTH AFRICA?

Different people have suggested d i f f e r e n t answers to t h i s question.

Do you believe t h i s professor?

Even i f he were r i g h t how many features does his explanation account for? Does t h i s explain

why we s t i l l allow p r i v a t e practice or why preventative services

are neglected?

Do you believe t i ' i s doctor?

Even i f he were r i g h t , does his explanation account for a l l the features o f health service organisation l i s t e d

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Each of these examples explains only a part of the whole story (with exclusion of the f i r s t example which has

been shown t o be s t a t i s t i c a l l y i n c o r r e c t ) . The f o l l o w i n g i s an alternate explanation as to why services are

organised the way they are.

INTRODUCTION TO A POLITICAL ANALYSIS OF HEALTH SERVICES.

A political-economic analysis begins by recognising

that d i f f e r e n t societies are structured in d i f f e r e n t ways, f o r example* America i s a c a p i t a l i s t country characterised by mcney and power being concentrated in the hands o f

a few while the majority of people work for the "owners", s e l l i n g t h e i r labour.

In a communist country everything i s owned by the

government which represents the people, there are no

"owners" and everyone works f o r a wage.

The economy and p o l i t i c a l system influences a l l the

smaller parts of the society such as the education system, the legal system and the medical system. In c a p i t a l i s t

countries i n d i v i d u a l s are expected to made t h e i r own

provision f o r health care. They must pay a p r i v a t e doctor or pay a hospital or get an insurance scheme. In China

nowever the government feels responsible f o r providing free medical care t o a l l c i t i z e n s . Health care i s seen as a basic human r i g h t which the government must provide.

In South A f r i c a the features of capitalism are r e f l e c t e d i n the health services. Health care i s bought and sold - by p r i v a t e p r a c t i t i o n e r s , hospitals and c l i n i c s i n the same way t h a t one buys and s e l l s c l o t h i n g , f u r n i t u r e ,

and food.

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II.

Another p o l i t i c a l influence on the organisation of

health care is that because South Africa has a system of government with three levels (state,provincial and local authority) health services are fragmented. This causes unnecessary expense and e f f o r t . . ( T h i s issue is

dealt with in the a r t i c l e e n t i t l e d Who Cares i n this issue) CONCLUSION..

In order to understand why health services are organised the way they are in South Africa and in other countries, i t is important to use a political-economic analysis.

In the same way one could analyse the education or legal system. Each of these systems is a part of the South

African society and are influenced by the p o l i t i c a l and economic organisation of South A f r i c a . The problems

in the South African health system cannot therefore be

separated from the broader problems found in the p o l i t i c a l and economic policies of this country.

Merry! Hammond

References

McGrath , D(1979) Health Expenditure in South A f r i c a .

Economics of Health in South Africa Vol 1 Westcott 7 Wilson(eds) Ravan Press JHB.

Ryan, M The Organisation of Soviet Medical Care. Blackwell,

Oxford.

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