Just in time for National Women’s Day in South Africa, Human Rights Watch published a report last week on failing maternal care in the country. South Africa has seen its maternal mortality ratio quadruple in the last ten years. The report focuses on the Eastern Cape, one of the least developed provinces in the country, and discusses the lack of accountability, unsuccessful implementation of existing health policies and systems, and verbal and physical abuse by nurses and health workers that have led to increased maternal mortality and other poor outcomes for maternal, infant, and child health. These failures are ugly reminders of the persistent effects of Apartheid and indicative of a vastly unequal society. They are also disappointing, given South Africa’s good economic status and strong constitution–one of the most progressive in the world–which includes provisions for the right to health. And, ever omnipresent for low- and middle-income countries, are the usual issues around overburdened health systems and human resources for health. In this context, the South African government just released a proposal for a national health insurance (read: universal health care) program.
“We cannot say that these things are not happening; we know they are.”
HRW reports that a lack of oversight and accountability has failed to address recurrent problems in the public health system and that risky and negligent practices, including refusal to examine or treat patients who are in labor, pain, and/or other distress, discrimination against pregnant patients based on HIV or migrant/refugee status, and physical and verbal abuse by nurses and health workers are pervasive in the Eastern Cape (and presumably, South Africa as a whole). In some of the interviews conducted by HRW, women described their reluctance to go to health facilities for delivery, citing concerns about low quality of care and poor treatment by nurses. Women reported being turned away without examinations while they were in labor, being ignored when requesting help, waiting hours for treatment or examination, and being forced to carry their babies, make their beds, and clean up their own blood even after undergoing Cesarean sections. Others described being pinched or hit, insulted, and mocked for saying they were in pain. Despite the alarming anecdotal evidence about negligent, uncaring, and cruel practices by nurses, HRW points out that the main problem is that there is virtually no oversight or actions by the government to correct the problems. The government, however, is aware of the abuses and even collects information about maternal deaths that could help inform solutions. Without implementation of the laws that are in place and analysis of the information the health system is already collecting, South Africa cannot decrease its high maternal mortality rate, which is currently estimated at 625 deaths per 100,000 live births. Furthermore, the system for lodging complaints is completely broken. A senior official with the national Department of Health quoted by HRW acknowledged the problems: “We cannot say that these things are not happening; we know they are.” As HRW writes, the human rights of pregnant women and new mothers in South Africa are systematically violated, including: the right to life, to health, and to freedom from cruel, inhuman, and degrading treatment, as well as the right to a remedy if a person’s rights are violated.
South Africa is a deeply unequal society, where some live in shacks and others in mega-mansions overlooking the ocean. This is a remnant of Apartheid, one that has been extremely difficult to overcome. Under Apartheid, parts of the Eastern Cape (the subject of the HRW report) were designated independent “Bantustans,” or homelands, in which !Xhosa people were forced to live, migrating across “borders” to the more-developed South Africa to work for white-owned mines and farms. Little investment was made in infrastructure, and the province remains poor and less developed than much of modern South Africa and has some of the worst health indicators in the country. Today, the Eastern Cape is a reminder, in its poor maternal health records and infrastructure, of the legacy of Apartheid and of the extreme wealth disparity and unemployment that plagues the new South Africa. It is not, unfortunately, the only part of South Africa with disparity and inequality problems. Furthermore, South Africa faces discrimination and violence against immigrants, migrants, and refugees and stigma against people with HIV/AIDS is high, despite the country’s high prevalence of the virus. HRW writes that 4,500 women die each year in South Africa as a result of preventable and treatable causes during pregnancy and birth. While the public health system is deeply flawed, the private system can be world-class (as I can attest). One Somali woman interviewed by HRW explained that after being ignored and denied treatment at a public facility while she was in labor, the Somali community collected money to send her to a private hospital. She said: “Here I got help and was treated with respect.”
At the same time, South Africa has the strongest economy in Africa, a progressive constitution and laws that guarantee the right to health and reproductive rights, and some success in addressing its health-related shortcomings. South Africa was recently admitted to the BRIC (now BRICS) group of emerging economies and is the only African county in the G20. The South African Constitution guarantees the right to health, there is a public health system in place with free maternity care, and the nation spends $748 per capita on health, the highest expenditure in sub-Saharan Africa. Legislation and public health outreach, as HRW outlines, have led to some successes: 92% of women attend antenatal care and almost 87% deliver in health facilities. Given this context, HRW’s report is especially disappointing. As Agnes Odhiambo, an HRW researcher, details: “Internationally, we have tended to see maternal mortality as an issue of resources. But in South Africa, reducing maternal mortality requires looking at the human rights abuses that are taking place.” The South African government must do much, much more.
Despite its economic successes and robust health care legislation, South Africa is just as subject to the problems of overburdened health systems and sparse human resources for health that one reads about across the developing world. In the HRW report, many health workers in the public system blame their actions on low pay, high job stress, and lack of support, both in numbers of co-workers and in management. Anthony Butler, professor of politics at the University of Witswatersrand in Johannesburg, argued in an opinion piece in South Africa’s Business Day for the need for more nurses in South Africa. As he points out, 45% of nurses working today are over age 50, and 1 in 6 has passed the retirement age. There are no easy solutions to overburdened health systems; though, as I’ve argued in the past, to address some of the human resource shortages in the health sector, governments must train and pay community health workers.
In the midst of these health system problems, the South African government has released a plan for a universal health care/national insurance program, as I mentioned above. It proposes a 14-year phase-in, with an estimated initial cost of $18 billion that will be raised through taxation above a certain income level. Health Minister Aaron Motsoaledi says: “The central challenge to the stability and well-being of our nation is reducing the deep inequality between rich and poor, between privilege and deprivation. This goes to the heart of South Africa’s future.” With more than 80% of South Africans unable to afford private medical insurance, this is certainly welcome news. However, without significant reforms to South Africa’s health system, universal health care will not succeed. Better training of nurses, more recruitment and retention programs, and implementation of existing legislation and already-gathered data are key to improved maternal and overall health. Addressing discrimination against foreigners and people with HIV is a more difficult issue, as is reversing decades of Apartheid inequalities. Before South Africa guarantees health care for all, it must make its health delivery system work well enough to deal with not just the patients it currently has, but those it will have. First and foremost, however, South Africa must eradicate the human rights violations that are causing needless and preventable maternal deaths.
Header photo here, by USAID Southern Africa, CC BY.
