Challenges of Health Inequality between the Private and Public Sectors

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Challenges of Health Inequality between the Private and Public Sectors Powered By Docstoc
					      Towards a National Dialogue: The State of the Nation Truth Conference

       Health and Health Care in Post
               Apartheid SA

1. Introduction
2. Inherited Inequalities
3. South Africa‟s Burden of Disease
4. Financing Health Care
5. Private Public Sector Inequalities
6. HIV/AIDS in South Africa
7. Primary Health Care
8. Occupation Health in SA
9. Health: Right or Privilege
10. Campaigning for free quality health for all

   1. Introduction
Fifteen years after our first elections, health in South Africa remains a sobering
reflection of our levels of employment, education, social security, women‟s
emancipation and safety. Symptoms of a society in distress are found among those
seeking healthcare: gangster related stabbings and gunshots; ulcers from drug abuse;
shack dwellers burnt by exploding paraffin stoves; young children dying of
malnutrition; gangrene from disease and personal neglect; cancers from smoking,
asbestos and gold mining dust; rape and domestic violence. Health workers in
hospitals and clinics are literally picking up the broken pieces of a ravaged society.

In this paper we hope to arm activists with some facts and insights into health in
South Africa so that we can empower ourselves to campaign for its improvement. We
aim to look briefly at the inherited health problems from Apartheid, the positive
changes that have taken place after 1994 and the funding issues and mal-distribution
of resources in health that have made many well meaning policies from government
essentially ineffective. We will also briefly look at a few sectors within health
although some important areas have not been addressed such as women in health and
traditional and complementary medicine. Hopefully others will add in sections as the
document is circulated and developed. Towards the end of the document, we will look
at the idea of health as a right and some of the discussions around a better health

   2. South Africa – Inherited Inequalities
Apartheid as a system of oppression and exploitation denied people healthy lives on
several levels. The systematic impoverishment of the black majority directly
contributed to the development of diseases such as tuberculosis, malnutrition and
dysentery but also indirectly caused ill health by denying people access to adequate

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

housing, education and job security. This direct racial discrimination was
complimented by the exploitative practises of corporations such as the gold, asbestos
and diamond mines which took young men from their rural homes and crowded them
into the inhumane compounds of the migrant labour system. These large companies
made enormous profits from the sweat of this labour while their workers suffered
from mining injuries, asbestosis, silicosis and tuberculosis (2). Differences in
employment and wealth meant that black and white South Africans were not equally
exposed to these health threats. The greatest health burden was born by the poor,
black majority. Those who could least afford to be sick.

Post 1994 we inherited a fragmented health system. A total of 14 separate
departments of health had been set up to serve different Bantustans and artificially
created racial and ethnic groups. This was an expensive administrative nightmare. The
strong private sector catered mainly to white South Africans. Within the public sector,
the Apartheid government created a few centres of excellence for white South
Africans. World-class health services for a small minority flourished in the major
cities. The phrase „islands of excellence in a sea of need‟ sums up this phenomenon.
For huge numbers of South Africans, particularly those living in rural areas, there was
virtually no access to health care. The health care, when available, was of poor quality
and racially segregated.

Health rights formed an important part of political programmes during the struggle for
liberation. As early as 1955 with the Freedom Charter, the principles of a free and
inclusive health service were put forward:

       „A preventative health scheme should be run by the state.
       Free medical care and hospitalisation shall be provided for all, with special care for
       mothers and young children.
       Slums shall be demolished, and new suburbs built where all have transport, roads,
       lighting, playing fields, crèches and social centres.
       The aged, the orphans, the disabled and the sick shall be cared for by the state.‟ (10)

With sweeping political changes in 1994, there was an expectation that health services
would be improved and the disease burden reduced as economic disparities decreased.
The ANC Health Desk discussed and produced papers on progressive health reforms
such as National Health Insurance or National Health Service. The Reconstruction
and Development Programme (RDP) promised overarching social welfare reforms
which would alleviate poverty and suffering for the majority:

       „The government will develop a national health system offering affordable health
       care. The focus will be on primary health care to prevent disease and promote health,
       as well as to cure illness.‟ (11)

There have been important changes and gains in health since 1994. We have a single
Department of Health. 13000 new clinics and 18 new hospitals were built by 2004.
New legislature has given pregnant women and children under six free access to
health care. The Termination of Pregnancy Act allowed women access to safe
abortion. After a prolonged struggle by civil society, people living with HIV now
have access to ARV‟s in the public sector. Progressive changes such as the

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

introduction of community service for categories of health workers, brings human
resources to distant rural areas that are in desperate need. The recently finalised
Patient Charter sets out the rights of all patients laying the foundation for the
empowerment of users of the health system. There is also now a greater equality
between provinces with regards to health expenditure and a stated emphasis on
primary health care.

These positive steps have unfortunately had little real impact on the health status of
our people.

   3. South Africa: Burden of Disease
As a reflection of the ongoing socioeconomic inequalities in South Africa, the burden
of disease remains enormous.

The life expectancy in South Africa in 2003 was 48 years. The health expectancy in
Canada is 80 years, and Brazil, a more comparable country, 71 years. Infant mortality
rate (IMR) is a good marker of health service delivery and poverty. In Canada the
IMR is 5/1000, Cuba 6/1000, in Brazil 33/1000 and in South Africa a staggering
53/1000. In South Africa, under-five mortality is 87/1000 for those in the lowest
wealth percentile and 21/1000 for those in highest wealth percentile (9). This means
that the child of a poor family is four times more likely to die before their fifth
birthday than a child from a rich family.

Other markers of social development remain poor: only 63% of the population are in
formal housing, only 51% use electricity for cooking, and 16% of the population still
have no access to piped water(12). The Western Cape has one of the highest rates of
tuberculosis in the world.

Tragically, post 1994, South Africa was plunged into its greatest health crisis in recent
times. The HIV/AIDS epidemic swept through the country, affecting tens of
thousands. A weak, fragmented and under funded health service was faced with the
full force of this epidemic without political or financial support from the government.
Already strained health workers became increasingly demoralised. HIV has emerged
as the biggest single cause of death in South Africa.

These numbers only confirm what we already know. That people in South Africa still
suffer an unacceptable burden of disease and that the important indicators of health
status have mostly not improved and in some cases become worse. There are many
reasons for this: the HIV epidemic, incompetent administrations, a huge backlog from
the past, lack of infrastructure etc. More fundamentally, the reasons for this
spectacular failure to deliver in health is related to: chronic underfunding of public
health care, huge inequalities between public and private health care and the lack of a
commitment to a unitary, free, health system.

   4. Financing of Health Care

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

Despite the euphoria of 1994 and the promises of the RDP to deliver to the poor, the
new government, in 1996, implemented the Growth Employment and Redistribution
(GEAR) strategy, a stringent, anti-poor economic policy. GEAR ushered in a period
of tight fiscal discipline. For health this meant an effective per capital cut for several
years. The decreased health expenditure was accompanied by an aggressive period of
retrenchment of health personnel. Experienced nursing staff were systematically given
voluntary retrenchment packages and several nursing training colleges were closed.
Many hospitals experienced crippling budget cuts and bed closures with no visible
primary level development to compensate for this.

The per capita spending on public sector patients for the last 15 years has been
stagnant, remaining at R1000 – R1300 per year. The total population dependent on
the public sector has increased by 7 million from 1995 to 2005, effectively
eliminating any real increase in expenditure on health. The percentage of the budget
spent on health also decreased from 11.5% in 2000 to 10.9% in 2007/8. While the
government has been speaking about improving health care, it has not been putting
any money behind these promises. This is starting to correct with a small, real
increase in expenditure since the 2005/6. This slight increase does not even begin to
balance out the chronic backlog of underfunding over the last 15 years.

Fiscal constraints in the 1990‟s, an expanding population, a huge burden of disease
backlog, inadequate infrastructure and the explosion of the AIDS epidemic has meant
that public health is hopelessly and chronically under-funded.

The Statistics of Inequality

There are few areas where the discrimination on the basis of wealth is more startling
or more morally outrageous than in health care.

South Africa spends approximately 8.6% of its GDP on health care. This is higher
than many other middle income countries and only slightly less than Canada (9.6%).
Yet we are saying that healthcare is underfunded. The reason for this is the gross mal-
distribution of health finances. About 60% of all money spent on health care in South
Africa is spent in the private sector. The private sector only serves about 14-15% of
the population. While spending on every patient in the state sector has not increased
for more than ten years, private sector spending has spiralled out of control. The per
capita spending on a patient in the private sector is R9500 per year, versus R1300 on a
patient in the public sector. This inequality has increased, not decreased since 1994.

Human Resources

The backbone of any health service is it health workers. In South Africa, the
inequalities in health are not only financial. 34 324 doctors work in SA, yet only
9959 (<30%) work in the state sector. When looking at specialists, the numbers are
even worse with more than 75% working in the private sector. Only 43% of nurses are
in the public sector. The majority of pharmacists are also in the private sector, making
ARV rollout for HIV even more of a challenge. In 1980, approximately 40% of
doctors worked in the private sector, now more than 60% are in private yet the
population covered by private healthcare is decreasing. This is clearly an
unsustainable situation.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

Health workers migrate out of the public service and the country continuously, with
salaries being only part of the problem. Working conditions in many state hospitals
are appalling with nurses and doctors working unacceptably long hours, being
subjected to threats of violence at the workplace and working under enormous
pressure to try to deliver some kind of service to their patients with insufficient beds,
medicines and staff. There are approximately 42 000 unfilled nursing posts in the
Department of Health. An unbelievable 31.2% of all health professional posts in the
public sector are vacant. This means that those health workers left behind are
constantly doing extra to fill this gap. Yet at the same time, the majority of health
workers are working in a sector that only looks after 15% of the population.

Ordinary users of the public health system don‟t need these numbers to tell them there
is inequality in the system. In the public sector, patients wait days, weeks and months
for out-patient appointments, for elective surgery, for specialist visits, they wait in
long queues outside clinics for hours often to be turned away when the patient quota
is full. When admitted, many patients suffer the indignity of lying for hours or days
on casualty trolley‟s waiting for a bed in the ward, or get to the end of a long
pharmacy queue to find that the medication is out of stock. These delays cause
unnecessary suffering and in the more critical cases, preventable deaths. With two
parallel systems of health care, your ability to pay can literally determine whether you
live or die.

The Private Sector undermines Public Health Care

Current government policy reflects a misguided belief that the private sector and
public sectors are completely separate and solutions should be found internally for
both. It then follows that there should be an increase in the number patients in the
private sector to „relieve the burden‟ on the public sector.

However, the private sector is not independent and self-contained. There is a constant
flow of resources from public to private. The most glaring is the human resource drift.
The high vacancy rate, poor working conditions and poor remuneration in the public
sector results in a constant flow of health professionals from public to private. The
majority of health professionals work in the private sector and many of those in the
public sector do substantial amounts of private work. Yet it is the state that funds the
training for all health professionals. Nursing staff often work in both sectors,
„moonlighting‟ to improve their remuneration. This results in overworked, tired health
workers who are able to contribute less in their daily work.

Medical aid contributions are tax deductable. This decreases the total tax contribution
to the state (public funds) and encourages expenditure on medical packages (private
funds). The total loss to the government from these tax deductions is estimated at R8
billion! Hundreds of thousands of public sector workers receive government subsidies
to buy private medical care, a direct subsidisation of the private sector. This is
particularly ironic for public sector health workers who are encouraged not to use the
very system in which they should be providing a quality service.
The final and most direct way in which the private sector uses the public sector is by
the „dumping‟ of patients on the public sector. Medical aid patients are allowed to
access the services of the private sector until their medical funds have run dry. They

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

are then shunted to state hospitals which bear the cost of completing treatment
without the benefit of the medical funds already spent. Because the private sector has
no ongoing responsibility to its patients, every patient in the country, in particular
those on cheaper medical packages, is ultimately the responsibility of the state. Thus
having more patients in the private sector does not lighten the public sector burden.

4. Primary Health Care
2008 marked the 30th anniversary of the Alma Ata Declaration on Primary Health
Care (PHC). This conference took place in Alma Ata in the former USSR under the
banners of UNESCO and WHO. Primary health care is a broad philosophy that
recognises the social and economic factors that determine the health a community and
a nation. The primary health care philosophy means that water, sanitation,
immunisation, equity and social and economic justice are vital to health. These ideas
informed the demands and proposed programmes of liberation organisations during
the anti apartheid struggle. In 1994, the ANC Health Plan included many of the PHC
concepts with the view that a District Health System would be the platform from
which PHC could be implemented. The plan also promoted school nutrition
programmes, the building of clinics and an increase in social welfare grants.

The broad philosophy of PHC has deep socioeconomic implications. Over time, the
philosophy of PHC as a comprehensive health plan with appropriate care at all levels
and a focus on prevention, has been narrowed down to mean health care at the first
point of contact (clinic or general practitioner). The well meaning policies born of the
PHC vision in South Africa have been rendered ineffective by the tight fiscal financial
policies of the 1990‟s and the inequalities in the health sector. Primary health care in a
society like South Africa requires a massive redistribution of resources at all levels of
society. It requires job creation, housing, proper access to piped water and electricity.
It also means equal access to all appropriate levels of health care (primary, secondary
or tertiary). In other words it is not a cheap option. On the contrary, in a society with
such an enormous health burden, preventative care will only result in health savings in
the long term (20 – 30 years) but in the interim, health expenditure must increase.

There has been a concerted effort to set up District Health Systems. As in other areas
of health service delivery, the success is largely dependent on existing infrastructure
and the enthusiasm and commitment of people working at ground level. Unfortunately
markers of population health such as life expectancy, infant mortality and under-five
mortality are all worsening, demonstrating a fundamental failure to implement broad
based primary health care. South Africa remains one of the most unequal countries in
the world with a GINI coefficient of 0.68. A large part of the population still lives in
informal housing (14.5%). Food security remains an issue for many with up to 28% of
the population at risk of hunger (National Food Consumption Survey).

Prior to 1994, the Apartheid health system emphasised hospital based health care at
the expense of community clinic and preventative health care. The new government
as part of its progressive health plan tried to shift this focus. Unfortunately, this
happened in the context of real term per capital health cuts for many years. Hospital
budgets were cut and staff retrenched from functional secondary and tertiary hospitals

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

to stay within these financial constraints. Cynically, this was done in the name of
primary health care. In the form of a race to the bottom in healthcare, functioning
institutions came under attack with the idea that the little money we have must be
shifted. Redistribution did not occur from the wealthy private sector hospitals to
primary level clinics but rather from stretched public sector hospitals. Many of the
experienced nurses retrenched at hospital level were never replaced at primary level
and just represented a net loss in human resources.

The shocking idea that we can only afford clinic level health care for the majority of
people is inherently elitist and must be fought. Our health needs are so great that no
health facility should be closed or health worker retrenched. To build primary health
care we must add to and strengthen what exists. No person should be denied access to
lifesaving specialist care such as drainage of a lung abscess or a cancer operation.
Weakening tertiary hospitals is also a form of privatisation. As specialist centres are
closed in the public sector, more and more specialists and specialist care moves into
private, having nowhere else to go.

Primary health care does not mean cheap medicine for poor people but holistic
appropriate care at all levels.

   5. The HIV/AIDS Epidemic
The first person known to be HIV positive was diagnosed in 1982. In 1990, only 0.8%
of all women attending antenatal clinics were HIV positive, this percentage went up to
12 % in 1996, 24 % in 2001 and 28% in 2003. Within the space of a few years, South
Africa became a country with one of the highest rates of new infections. It was in the
mid to late 1990‟s while the country was just emerging from Apartheid that the virus
spread like wild fire. For a fledgling democracy with poverty, a fragmented health
system, a multitude of social problems, the epidemic has proved catastrophic.

On the issue of HIV, the ANC led government has made arguably its greatest
mistakes. The spoken and unspoken doubts cast by senior government officials and
the former President, Thabo Mbeki, on the existence of HIV and it‟s relation to AIDS
contributed to the ongoing denialism and stigmatisation of the virus. In a misguided
attempt at defending Africa‟s pride and engaging in intellectual curiosities, such as
the dissident theories around HIV, Thabo Mbeki threw the country into confusion.
Very few ANC leaders or other political leaders openly challenged these dangerous

The practical implication of this vacillation in the highest offices of government was
devastating. Thousands died without access to appropriate Anti-retroviral treatment.
Many patients, when found to be HIV positive were not given any kind of treatment
as it was considered an untreatable disease with a universally fatal outcome. Health
workers became demoralised by their ineffectiveness. Hospital wards were rapidly
filled with AIDS patients, paralysing the systems‟s ability to deal with other illnesses.
Young people started attending more funerals than weddings and the grave yards
overflowed with the numbers needing burial. Still, the government took no action.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

This will surely go down as one of the most incomprehensible and costly errors of the
Mbeki era.

It was the Treatment Action Campaign, founded and led by Zaki Achmat in 1998, that
started to mobilise ordinary citizens affected by the virus. With a brilliant
combination of legal challenges, street demonstrations and community mobilisation,
the TAC put the issue of treatment for AIDS firmly on the South African political
landscape. However, AIDS activists were vilified and accused of being
pharmaceutical company agents or spies. The then Minister of Health, Mantu
Tshabalala-Msimang, rejected antiretroviral treatment and promoted nutrition and
vegetables as an alternative. Only in August 2003, after years of struggle and a
relentless campaign, did the government finally agreed to roll out anti-retrovirals.
With a crumbling public health system and a reluctant department of health, this was
to prove a struggle in itself.

Anti-retroviral roll out began in 2004. The pace of rollout was not uniform throughout
the country. Areas with more infrastructure, health workers and AIDS activists tended
to rollout faster. In other areas, the pace was slow and hesitant. By the end of 2006
over 100 000 patients were on treatment and by the end of 2007 almost one third of
those in need were on anti-retrovirals. This level of rollout was possible is only due to
the tremendous energy and effort of health workers, AIDS activists, communities and
people living with HIV themselves.

Anti-retroviral treatment is difficult in our context. Firstly, patients need to be willing
to be counselled and tested and disclose their status to a supportive family member or
friend. Many people still find the stigmatisation in communities too daunting and
refuse to know their status. Treatment centres need more counsellors, social workers
and nurses to effect the rollout. Health workers, already stretched to the limit, need to
add this service to their work load. Anti-retroviral treatment is life-long and requires
one hundred percent adherence. This is not always easy. Clinics need to have a
consistent and reliable supply of drugs as well as qualified pharmacists to dispense
them. Despite these enormous challenges, ARV rollout in South Africa is established,
growing and saving the lives of thousands. The fact that this epidemic is now being
treated in a medically rational, humane and open manner has helped decrease the
secrecy and stigma that has surrounded it for so long.

The appointment in 2008 of a new minister of health, Barbara Hogan, who openly and
publicly stated that HIV causes AIDS and has made a clear commitment to an
integrated prevention and treatment programme has given health workers and AIDS
activists some hope. The successful management of HIV/AIDS, however, can only
occur through a working and properly funded public health system.

   6. Occupation Health Care
An overview of the Political Economy and Historical Development of
Occupational Health in South Africa

             Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

The development of occupational health in South Africa closely tracks the
development of the South African economy, and can be traced to the transition of
South Africa from a dominant agricultural-pastoral economy to that driven by
capitalist mining economy. The origins of occupational health in South Africa dates
back to the late 1800‟s with the discovery of gold on the Witwatersrand. With the
indigenous population self-sufficient on their farms throughout the country, the mine
owners were forced to import labour from the European countries. Unfortunately,
these workers also brought with them the historically endemic scourge of Southern
Africa, tuberculosis (TB). Working deep underground, these workers were exposed to
some of the highest levels of silica worldwide. More than eighty years later,
researchers understood that exposure to silica is one of the leading risk factors for the
development of this debilitating disease. These immigrant workers began dying in
their hundreds, posing a tremendous waste of human resources for the growing
mining capitalist in South Africa.

These labour immigrants arrived in South Africa from worker organisations with
strong traditions in craft unions, and protection of the rights of workers, and together
with the need by the mining capitalists to protect their investment in the immigrant
workforce, a number of interventions to protect the health of these workers. In 1902
the Milner Commission of Enquiry into Phthisis identified prevalence rates of TB
among mineworkers was approximately 15%, with a further 8% having suspected
disease. In 1910, the passage of the Miners‟ Phthisis Act was the first set of
compulsory compensation for occupational diseases in the country (and amongst the
first internationally). The death rate reported for African workers around 1912 was
5.65 per 1000 workers. Although this rate was between 4-5 fold the rate seen in other
countries, some reports actually argued this was more likely to be 10.9 per 1000
workers.. The Factories Act of 1918 and shortly after, the Mines and Works Act
which controlled working conditions on the mines was also promulgated. In addition,
the establishment of a research unit, the Medical Committee on Tuberculosis by the
Chamber of Mines and the South African Institute for Medical Research in May 1925,
allowed for investigation of TB as an occupational disease. These developments
placed South Africa as one of the leaders in occupational health internationally.

After the white mineworkers uprising in 1922, and the subsequent white worker
support for governments since, destruction of the rural economy forcing indigenous
people to seek work on the mines, white workers enjoyed a privileged status within
the South African economy. However, with the rapidly increasing numbers of black
mineworkers, without the biological resistance to TB, large numbers began
succumbing to the disease. The death rate reported for African workers around 1912
was 5.65 per 1000 workers. Although this rate was between 4-5 fold the rate seen in
other countries, some reports actually argued this was more likely to be 10.9 per 1000
workers. By the late 1920‟s, workers from the labour sending areas such as the
Eastern Cape were seeing high death rates among returning miners. For example, in
1926, 58% of repatriated miners to the Eastern Cape were dead within 3 years.

           "Two hundred thousand subterranean heroes who, by day and by
           night, for a mere pittance lay down their lives to the familiar 'fall
           of rock' and who, at deep levels, ranging from 1,000 to 3,000 feet
           in the bowels of the earth, sacrifice their lungs to the rock dust
           which develops miners' phthisis and pneumonia." (Sol Plaatjie, first

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     Towards a National Dialogue: The State of the Nation Truth Conference

           Secretary of the African National Congress, describing the lives of
           black miners in 1914)

The laws to protect African workers were not as strictly enforced. Occupational health
took a lower priority on the developmental agenda, until the worker uprisings of 1972
with the rapid organisation of black workers into large worker federations. In order to
better understand the implications of this new economy and this organised militant
workforce, the state established a number of Commission‟s of Enquiry to review
employment practices and labour disputes, the Weihahn Commission (1977); control
of movement of Black workers, the Riekert Commission (1977) and occupational
health and safety (the Erasmus Commission) and workers‟ compensation, the
Niewenhuizen Commission. These latter two commissions resulted in the Machinery
Occupational Safety Act, Basic Conditions of Employment Act, Occupational
Diseases in Mines and Works Act (ODMWA).

In the early to mid-1990‟s two sentinel studies investigated the prevalence of disease
among ex-mineworkers from two key labour sending areas, the Transkei and
Botswana. These studies provide some of the most stark realities of work related
diseases exported by the mining industry to the poorest areas in our region. Among
the ex-workers from Botswana, the TB prevalence was 13.5 per 1000, with
pneumoconiosis rates of between 26-31%. Similarly, the prevalence of TB among the
ex-miners from Libode, Transkei was 33%, while pneumoconiosis was 26%. Only a
small percentage of these workers received their compensation for an occupational
disease. It was estimated that if all those in these areas were appropriately
compensated according to our legislation, the Compensation Fund would become

At the time of the close of the apartheid era, all occupational health legislation
contained varying degrees of racism – overt examples were to be found in the
ODMWA. In 1993, 242 424 occupational accidents were reported to the
Compensation Fund - an accident rate of 33.4 accidents per 1000 workers. Despite the
information above, suggesting high prevalence of occupational diseases among South
African workers, very few cases were being reported to the Compensation Fund. In
1990, only 128 cases were compensated. These statistics exclude mining related
occupational lung diseases, which are compensated under separate legislation

The extent of occupational health services provided by industry was consistently low.
According to studies from the late eighties to early nineties indicating that only 11-
18% of companies in the private sector provided some form of worker health service.
Occupational health service provision was completely absent in the public sector.

The New Democracy and Expectations for Workers’ Health

The early 1990‟s saw a resurgence in occupational health activism on several fronts.
Trade unions felt confident to engage the state in the drafting of new legislation in
occupational health, including the drafting of new legislation, the Compensation for
Occupational Injuries and Diseases Act (replacing the old Workmens‟ Compensation
Act) and the Occupational Health and Safety Act (replacing the old Machinery

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

Occupational Safety Act). In the mid-nineties, the Mine Health and Safety Act and the
Hazardous Chemical Substances Regulations made significant strides in creating a
legal framework for occupational health that was of similar standards as the most
developed industrial nations worldwide.

Probably the most important development for the health and safety of mineworkers
was the establishment of the Leon Commission into Mining Health and Safety
following a series of serious mining accidents which claimed the lives of large
numbers of workers. The Leon Commission identified fundamental shortcomings in
the management of health and safety by the mining companies, inadequate health and
safety legislation and enforcement by government. The trade union movement, led by
the National Union of Mineworkers played a significant role in tabling the workers‟
position to the Commission. This led to NUM making substantial contributions to the
development of the Mine Health and Safety Act, which is one of the most progressive
pieces of health and safety legislation internationally.

The promulgation of the new legislation, which made provision for considerably more
worker rights in protecting their health at work (for example, the right to know;
elected health and safety representatives; right to training, the right to stop dangerous
work etc) promised to make dramatic changes to occupational health in workplaces.
Non-governmental organisations in health and safety, established to provide technical
support to the trade union movement strengthened workers‟ ability to engage
management on the shopfloor. This, coupled with renewed vigour in academic
programmes in occupational health at the major universities in the country, began
producing a new cadre of occupational health practitioners, doctors, nurses and

It was hoped that these initiatives would result in companies recognising the need to
invest in the health and safety of their employees, establish hazard control
programmes and medical surveillance services, introduce health and safety training,
develop policies, health and safety management structures and health and safety

Unfulfilled Expectations

However, this changed environment for occupational health has yet to deliver a
working environment that protects the health and safety of all workers. There have
been a multitude of reasons for this inadequate response. The rapid globalisation of
the late nineties and the entry of South Africa into the global economy had marked
socio-economic consequences for this country. Companies, forced to become
competitive on a world scale, began a systematic process of outsourcing non-core
activities within their businesses. Overnight, large numbers of workers became
casualised, employed by labour brokers, but doing the same work on the same
premises that they had done since their employment at the same company. There was
a rapid growth in the small and medium enterprises, encouraged on by the state
through the provision of finance for such entrepreneurship. Trade unions had to go on
the defensive – job and wage security was paramount, while other worker issues took
on secondary importance.

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      Towards a National Dialogue: The State of the Nation Truth Conference

Activities such as occupational health services generally fell to the same outsourcing
fate. Even though a small percentage of companies actually provided comprehensive
occupational health services in the past, this number was reduced even further.
Occupational health management at companies was placed in the hands of private
managed care organisations, working strictly to achieve legal compliance. Worker
organisations were incapable of agitating for health and safety to be higher up on the
agenda, as they sought to defend the jobs and wages of their members.

Despite promulgating some of the best occupational health legislation in the world,
the state has been completely ineffective in enforcing the laws. Companies
recognising this ineffectiveness respond by placing less emphasis on creating
healthier and safer working environment.

Current Situation

The numbers of cases of occupational diseases have been increasing over the years,
with the number of occupational injuries presenting within a narrow band. In 1990 the
total number of injuries and diseases compensated by the Compensation
Commissioner was 225 178 (with 1618 work related deaths) and 128 respectively. In
2002, this number increased to 280 631 and 3 226, while in 2007, this was 213 226
and 3720 for injuries and diseases respectively. The increase in the number of
occupational diseases compensated is reassuring because this means that more doctors
are diagnosing workers with such diseases, but occupational diseases are still
considerably underdiagnosed in this country. Under ODMWA, in the 1996-7 period
the number of certifications for occupational lung diseases was reported to be 10 425.
This is almost double the figure reported for the previous period of 5 730. Because
ODMWA falls under the responsibility of the Department of Health, there has been a
concerted effort on the part of the Department to harness the institutional resources in
the public health system to conduct benefit examinations. There has been an 88%
increase in the number of benefit examination cases reviewed by the Certification
Committee of the Medical Bureau of Occupational Diseases (MBOD) – an increase
from 11 248 in 1995/6 to 21 169 in 1996/7.

A hangover from the apartheid era has been the consistent inefficiency of the
compensation systems. In the event that workers do manage to get diagnosed with an
occupational disease, and have their documents submitted to either the Medical
Bureau for Occupational Diseases (mining related respiratory diseases) or the
Compensation Fund (all other diseases and injuries), the bureaucracy within the
system frustrates workers who have little recourse to resources to challenge decisions
or expedite the process. Turnaround times for the acceptance of claims frequently take
more than a year, sometimes much longer to finalise. Ex-miners (and other workers),
living in distant former homelands, either do not enter into the compensation system,
of if they do, are forced to invest considerable resources to obtain clinical services to
ensure that they are properly investigated to arrive at a work-related diagnosis. If they
succeed in having their documents submitted into the system, the waiting for the
Commissioners to decide on their case requires additional resources on the part of the
worker to determine case progress – either travelling to the centre that made the
diagnosis or making contacting with the relevant compensating authority. In many
instances workers give up, and are denied their rightful compensation.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

Evidence of the risks that workers face on a daily basis is found when there is total
collapse of health and safety at workplaces. These have been happening with
regularity in South Africa. Mining and industrial accidents instantly claim the lives of
hundreds of workers, or cause permanent disabling injury. These normally receive
widespread media attention. The popular media is less focused on the exposures that
workers face on a daily basis, causing slow and often debilitating disease or even
death. These conditions are exposed when large numbers of workers are diagnosed
within a short space of time, and usually brought to the public‟s attention by non-
governmental organisations, activists or trade unions. In 1991, a German
multinational, Beier Chemicals‟ tannery factory, Chrome Chemicals, in Merebank,
Durban was exposed has having a large number of its workers suffering from adverse
health effects as a result of workplace exposure to hexavalent chrome, a known
human carcinogen. About the same time, dozens of workers at a British multinational
company, Thor Chemicals, a mercury recycling plant in the rural KwaZulu-Natal
midlands, were diagnosed as having mercury toxicity. The latter story made headlines
when three workers became severely poisoned and were admitted to hospital in
varying states of neurological disease. Two of these workers subsequently died, one
after a prolonged period of coma. More recently, in 2007, another company, literally
the neighbour of Thor Chemicals, Assmang, a manganese smelter was reported to
have had large numbers of workers with features of manganese toxicity. The company
and its medical advisors contested the findings of worker representatives by claiming
these workers were presenting with Parkinson‟s Disease, a disease affecting the brain,
which closely resembles manganese toxicity. Interestingly very few of the workers
from these companies had been either submitted or received compensation from the
state compensation fund.

Improving and Protecting the Health of Workers

Protecting the health and safety of workers in South Africa requires a multipronged
approach with all stakeholders, particularly the state and employers.

1. Rationalisation of the management of OH in South Africa
   The legal framework and statutory management of occupational health in South
   Africa is fragmented with poor structure, resource allocation and direction. Recent
   developments has seen progress made on this front. In 2005/6 Cabinet made a
   decision for the establishment of a single entity to manage occupational health, and
   mandated the Department of Labour to drive this process. Recently, the
   Occupational Health and Safety Bill was released which proposes such a national
   framework, integrating the enforcement agencies of the Department of Labour and
   Department of Minerals and Energy and establishing a National Health and Safety
   Authority. However, since the publication of the Bill, there has been no further

2. Integration of the system of Compensation into the SA Social Security Agency
   Workers diagnosed with occupational diseases need a system which recognises
   their predicament and facilitates the payment of their compensation, which in some
   instances, may be their only means of survival.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

3. Provision of comprehensive OHS in the private sector
   Currently, companies are focused on meeting their legal requirements. This is
   easily achieved by outsourcing medical services to private managed occupational
   health care organisations. The latter work according to strict contracts – a pre-
   engagement list of services to be provided, but should there be any problems
   detected, and further investigations required, then these are outside the terms of
   agreement. Managed care organisation and employer both deny responsibility in
   further investigations of the worker, and refer these workers to public sector
   services. Companies should assume responsibility for the management of workers
   with suspected occupational diseases. This implies that workers must have access
   to comprehensive health care, fully paid for by the employer. In the instance this is
   diagnosed as an occupational disease, and liability is accepted by the Compensation
   Commissioner, the company can claim back from the Fund. Consideration for the
   development of legal imperatives to drive this action by companies may be
   necessary. Discussion at the level of NEDLAC should be commenced.

4. Investment by the state in occupational health support for the informal sector and
   The state has developed a clear policy of economic development which encourages
   the growth of the informal sector as well as small and medium enterprises. These
   workers are amongst the most vulnerable – casual, temporary jobs, generally not
   registered, no benefits beyond the day‟s wages, and very little health and safety
   protection. This sector has no resources to invest either in environmental
   monitoring, hazard control or medical surveillance. It becomes the responsibility of
   the state to provide resources to ensure the protection of these workers.

5. Structured public health sector provision of occupational health services
   Occupational health services in the public sector is almost non-existent. The state
   has a legal responsibility to protect the health of the workers in the public sector.
   This means the provision of comprehensive occupational health services, including
   environmental monitoring, hazard control and medical surveillance. In addition, the
   state has a responsibility to workers in the informal sector, as well as the SME
   sector. In addition, through some form of taxation of the private sector, the state has
   to provide occupational health services for ex-workers from industry. These public
   sector occupational health services needs to be integrated into a district health
   service, with clinic based identification, secondary and specialist level diagnostic
   and management of workers.


   7. Health: Right or Privilege
We have shown that the crisis in our health system is related to fiscal and budgetary
planning which does not prioritise social spending, and a private/public divide which
is underpinned by the philosophy that we should pay for our health care. This

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

philosophy has been challenged by many over the last few hundred years. In fact, the
idea that people have the right to health and health care has a long history.

The first recorded writings of a physician are those from an Egyptian genius Imhotep
who lived 2600BC in the 3rd dynasty. This polymath was also a brilliant architect,
politician, priest and adviser to the king. He designed the first pyramid Saqqares. His
medical contribution was the documentation 200 diseases, several operations and the
treatment for various forms of trauma.

Imhotep preceeded Hippocrates (400BC), the conventionally recognised father of
medicine by more than 2000 years (2). Hippocrates was the first Western physician to
apply the scientific method to the management of disease. He is best remembered for
the „Hippocratic Oath‟. This is the first formal recognition of the responsibilities of
the doctor and the rights of the patient: to adequate care, confidentiality and respect.
The „Hippocratic Oath‟ (in a modern version which does not make reference to
ancient Greek Gods) is still made by medical students all over the world when
entering the medical profession. It outlines our responsibility to the individual.

At the time of the French Revolution, philosophers such as Jean Rousseau popularised
the then new idea that „every man naturally had a right to everything he needs for his
subsistence‟(3). This implied collective responsibility on the part of society for
providing for minimum needs. The last few centuries have seen the expansion of the
recognition of what it is to be human. This is evidenced by the abolition of serfdom
with the French Revolution, the abolition of slavery, the right to vote for men, the
right to vote for women. In 1870, the US, after a hard fought public campaign,
granted the recognition of the universal right to education.

After the second world-war these ideas were consolidated through a number of
international declarations:

In the 1948 United Nations Universal Declaration of Human Rights:

       „Everyone has the right to a standard of living adequate for the health and well-being
       of himself and of his family, including food, clothing, housing and medical care and
       necessary social services‟. (4)

The specific right to health is reiterated by the WHO 1948 in the preamble to its
Constitution :

       „The enjoyment of the highest attainable standard of health is one of the fundamental
       rights of every human being without distinction of race, religion, political belief,
       economic or social condition.‟

1966 International Convenant on Economic, Social and Cultural Rights mandated
governments to:

       1. The provision for the reduction of the stillbirth-rate and of infant mortality and
          for the healthy development of the child.
       2. The improvement of all aspects of environmental and industrial hygiene.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

       3. The prevention, treatment and control of epidemic, endemic, occupational and
          other diseases.
       4. The creation of conditions which would assure to all, medical service and
          medical attention in the event of sickness. (5)

And the WHO definition of health:

       „A state of complete physical, mental and social wellbeing‟ (6)

This means not just access to hospitals, doctors and medicines but also clean water,
sanitation, adequate housing, a safe working environment.

The WHO Alma Ata Declaration of Primary Health Care in the USSR, 1978:

       „An acceptable level of health for all the people of the world by the year 2000 can be
       attained through a fuller and better use of the world‟s resources, a considerable part of
       which is now spent on armaments and military conflicts.‟ (7)

Our South African Constitution 1996 ‘enshrines the rights of all people in our country
and affirms the democratic values of human dignity, equality and freedom’

       Everyone has the right of access to:
          1. Health care services, including reproductive health care
          2. Sufficient food and water, and
          3. Social security, including, if they are unable to support themselves and their
              dependents, appropriate social assistance. (8)

These socio-economic rights however, do not have the same status as civil and
political rights. Within a capitalist context, these „rights‟ are subject to availability of
state resources, in other words, fiscal policy and the budgetary process. In the South
African context, these rights, though broadly accepted as guiding principles, are
continuously violated.

Health as a Commodity

Juxtaposed to these ideas is the concept of health as a commodity, that is, a willing
buyer, willing seller basis for the transaction. The US is probably the best example of
this form of privatised health care. Everyone in the US must have health insurance to
access medical care, unless it is emergency care. In 2004, 45 million US citizens
were uninsured. At least the same number had inadequate insurance. Over any two
year period up to 3 in 10 US citizens are uninsured. (3)

In the USA, the right to health as a principle is hotly contested. Many vehemently
oppose the concept that every human being has the right to health care. In 2005, the
UN Commission for Human Rights resolved „the right of everyone to the enjoyment
of the highest attainable standard of physical and mental health.‟ Member states were
encouraged to invest the necessary human and material resources towards the
progressive achievement of this goal. 52 countries voted for this resolution, only the
United States voted against (3). The US spends 15% of its GDP on health yet still has
a higher infant mortality rate than Cuba. Cuba, a small, relatively poor country spends

             Prepared by the Health Focus Group led by Dr Lydia Cairncross
     Towards a National Dialogue: The State of the Nation Truth Conference

6.3% of its GDP on health and yet has some of the best health statistics in the world.
They have a unitary system based on a primary health care model (9).

South Africa: Which road are we taking...

While the immediate implementation of a unitary free and equitable health system
may have been difficult, steps taken thus far, post 1994, have not put us on the road
towards this vision. On the contrary, a number of government policies have
encouraged the growth of the private sector:

   1. The tax deductability of medical aid contributions means that about R8 billion
      rand is lost to the private sector
   2. All public health officials have their medical aid contributions heavily
   3. State hospital fees are exorbitant for higher income earners discouraging them
      from using the state services. This means that resources remain locked in the
      private sector.

Private-Public Partnerships (PPP):

The stated aim with PPP‟s is to harness the efficiency and resources of the private
sector to provide a better service in the state sector. There are a number of potential
problems with this. Crucially, the philosophy of running a health service as a business
is accepted. The private partner has an interest in making a profit through access to
state resources. The public partner has primarily an interest in service delivery.
Perceived efficiencies in the private sector are not measured against health outcomes,
but rather against monetary outcomes. Also, the state partner usually takes most of the
financial liability.

PPP initiatives in practise often mean a wing or ward within the state hospital which
is “private”. These interactions are a form of insidious privatisation. Within state
hospitals where these PPP‟s are functioning, private/semi-private patients may use the
same resources e.g. CT scan, theatre staff and radiotherapy equipment etc as state
patients. This directly increases the waiting time for these scarce resources. Also,
many public sector doctors and nurses cross over and spend a large portion of their
time working in these facilities.

User Fees

With the exception of pregnant women and children under six, state patients are
expected to pay when they seek treatment at a health facility. In recent years there
have been increasing attempts to recover this fee from patients. Hospital fees are also
charged for admissions and procedures according to a salary scale. In real terms, these
fees are an added burden on already impoverished communities. Most worrying is the
fee charge for low income workers. Unable to afford a medical aid, these workers can
receive huge hospital bills if admitted for any major procedure. For example, a mother
of three working at a supermarket and earning R3500/month was charged R2500 for
her in hospital treatment. She self discharged early fearing the escalating bill.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

User fees at public hospitals are not a reliable or sustainable source of funds in our
context. They tend to discriminate against low paid workers who are not exempt from
fees, cannot afford medial aid and are already living just within their means. There is
a danger that some members of society will fall between the cracks and not be
covered by either the public or the private sector.

Mandatory Health Insurance (SHI and NHI)

Social Health Insurance was proposed by the government before the 2009 elections.
SHI is a form of mandatory health insurance where all people in formal employment
will be obliged to buy health insurance. The state will support/own one of these funds.
Patients can then use this fund either in the private or public sector. There will be
„semi-private‟ sections in state hospitals where the fund could also be used. The idea
behind this is to increase the number of people who have access to medical aid cover
and gain revenue for the state.

There are a number of problems with SHI. The proposed 5% will become an extra tax
burden on already strained working people. This system will not challenge but
strengthen the commercialisation of health services. Health care will still bought, but
through the state owned medical scheme. There are also a number of problems for
SHI as a long-term solution. South Africa has a very high unemployment rate which
will exclude many from this scheme. Job insecurity, contract work and work in the
informal sector will mean many workers will not have stable and secure access to
medical aid. Lower cost medical schemes will run out sooner, with patients once
again being dumped on the state sector. It also does not encourage the unification of
private and public health sectors.

The ANC 2009 election manifesto includes the promise to form a National Health
Insurance. This is mandatory health insurance for everyone and will cover every
member of the population. In this way it is better that SHI. If all funds are contributed
towards a common pool it will go a long way towards bringing the public and private
sectors closer in terms of access and quality. The detailed plan for NHI is not clear but
if it is implemented, it may be a significant shift away for the pro private health
policies that have marred health policies thus far.

10. Campaigning for free quality health for all
The evidence in the health sector is damning. Even within a capitalist framework, the
current government has performed abysmally. Health inequality is widening, the
burden of disease is increasing, the response to the HIV epidemic remains half
hearted, there is up to the present moment, ongoing privatisation and movement
towards a user pays philosophy. Public hospitals which may be functioning well are
being undermined. The small funding increases in health in recent years do not even
begin to address the huge chronic underfunding of public health care. The false
division of the health resources of the nation into public and private leaves the
majority as second class citizens whose lack of money may literally mean the
difference between life and death. This two tier system of health care entrenches
social Apartheid.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

Health care should not be a business. The health of the nation should not be held to
ransom by the profit motive. We must continue to uphold our vision of a single health
system and the ideal of a free national health service which is funded from a single tax
base. This will give every person the security that they will be cared for if they are ill
or injured. This can be achieved if we correctly harness and merge the considerable
resources already spent on health care in this country.

For us to effect this change, we need both a vision and interim demands for reforms.
These are some ideas for campaigns around healthcare.

Alternatives and Interim Demands:

   1. Free single health system funded from a single tax base

   2. Abolish ALL user fees at health centres

   3. Stop privatisation:
         a. End to subsidies for medical aid
         b. Reject Social Health Insurance, we want free health for all
         c. Abolish Private Public Partnerships which prey on the public sector

   4. Health Funding
         a. Stop the tax deductibility of medical aid contributions (freeing up
             billions for health care)
         b. Divide the Defence Budget between health, education, housing and
             social welfare
         c. Increase corporate taxation

   5. Human Resources
        a. Fill all vacant posts in the public sector
        b. Open previously closed nursing colleges with a generous bursary
           scheme to encourage new nurses
        c. Improve working conditions for health workers
        d. Improve salaries for all health workers

   6. Share Public/Private resources

           a. Encourage community general practitioners to become part of the
              public health system by contracting them in
           b. Cluster hospitals geographically. Make each private hospital legally
              required to donate a percentage of their human and material resources
              to a neighbouring poor hospital
           c. Legislate that no patient should die for want of emergency treatment
              e.g. intensive care, when that resource is available in the private sector

   7. All Parliamentarians and Cabinet ministers and their families should use
      public health facilities. What they, as civil servants, provide for the people
      should be good enough for them too.

            Prepared by the Health Focus Group led by Dr Lydia Cairncross
      Towards a National Dialogue: The State of the Nation Truth Conference

   8. Schools and workplaces can become centres for Health Care. These are places
      with large numbers of people where health education, screening and treatment
      can take place.

   9. Community Mobilisation around Health
        a. Community health forums involved in running clinics/day hospitals
        b. Youth volunteer programme at health centres
        c. Recognise home based care as paid work

   10. Implement the true holist principles of primary health care based on the Alma
       Ata Declaration 1978

Virchow, a brilliant 19th century doctor, pathologist and anthropologist said: „Health
is a social science and politics is nothing more than medicine on a large scale.‟ By
challenging the commercialisation of health care, we challenge the profit motive of
capitalist society where it takes it‟s most brutal form. If we can change the way we
treat our ill and vulnerable, we can begin to change the very essence of our society.

We need to first know the principle: the right to health for all, imagine the ideal as
possible: a single, free health system, then develop the policies and strategies that put
us on the path towards that goal.

Forward to free quality health for all!
Written by Lydia Cairncross (public sector doctor)
April 2009


   1. South African Health Review 2005/6 Health Systems Trust
   2. Health and Democracy 2007 Edited by Adila Hassim, Mark Heywood,
       Jonathan Berger.
   3. Universal Right to Health Care Organisation USA 2007
   4. United Nations Declaration on Human Rights 1948.
   5. United Nations International Convention on Economic, Social and Cultural
       Rights 1966.
   6. World Health Organisation Constitution Preamble 1948.
   7. WHO Conference in Alma Ata Declaration on Primary Health Care 1978.
   8. Constitution of the Republic of South Africa 1996.
   9. World Health Organisation International Health Indicators 2006.
   10. The South African Freedom Charter 1955.
   11. The South African Reconstruction and Development Programme 1994.
   12. South African Health Review 2003/4 Health Systems Trust.

Special acknowledgement for insights and statistics to the South African Health
Systems Trust and to the authors and editors of the book Health and Democracy. Also
to Di McIntyre of the UCT Health Economics unit for most of the statistics in this

            Prepared by the Health Focus Group led by Dr Lydia Cairncross

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