OVERVIEW OF ACHIEVEMENTS IN HEALTH

1. Introduction

The ushering of the new dispensation in South Africa provided the nation with a number of positive and far-reaching benefits. One of these remarkable achievements has been the inclusion of gender equality and equity in the transformation agenda. From the outset, integration of the fragmented health facilities and administrations presented an immense challenge. With such integration came a need to improve access to health services to the majority of people whose needs were not catered for during the apartheid era. Other challenges included ensuring that resources were allocated equitably to provinces. Included in that was a shift of resources to primary health care as well as the management of expenditure to ensure that the budget was effectively utilised. A vision for health care was set out by theHealth Sector Strategic Framework 1999-2004:

A caring and humane society in which all South Africans have access to affordable, good quality health care.

In line with this vision, Gender Policy Guidelines were initiated so that an effective framework is in place to develop, implement and monitor laws, policies, programmes, procedures and practices to ensure:

Through initiatives such as the Gender Policy Guidelines and Batho Pele: White Paper on the Transformation of Public Service Delivery, Government has sought to ensure that legislation, policies and programmes are more responsive to gender-specific issues such as violence against women. The challenge was taken up not only to promote transformation in how and who the department of health and supporting agencies serve but also to ensure transformation and gender equity amongst those who serve in the quest to provide access to affordable, good quality health care. Transformation has been underpinned by the introduction of legislation as a first step to dealing with institutional discrimination against women.

2. Legislating equality

A ground-breaking Constitution and over 780 pieces of legislation have created a framework to reshape South Africa and correct the imbalances of the past. Policy and implementation are more integrated thanks to government's cluster approach, provincial co-ordination, Integrated Development Plans in local government and the recently introduced National Planning Framework. Finalized in February 1996, the Constitution has entrenched a number of rights that are significant for women. These rights include:

Building on legislative reform, Government has also shown a policy commitment to addressing historical gender imbalances. Among the policies adopted - the health needs of women are recognised and contribute to reducing the burdens women face every day. These policies include:

2a) Universal access to Primary Health Care

Apartheid-entrenched inequalities have left a legacy of poverty particularly among rural communities. Women carry additional burdens and research in 1995 found that 49% of women-headed households were among the poorest compared to 31% of male-headed households. This feminisation of poverty, in turn, impacts on women's health and the health of their children. In April 1996 theMinister of Health announced a policy on universal access to primary health care. Linked to this was a departmental programme to upgrade and build new clinics. From September 1995 until the end of 1998, 495 new clinics were built and 249 clinics upgraded while some had maternity sections added to them. There are now over 4 350 primary health care access points available to the nation. This strategy improved access to health care for people who had never had access before.

Women and children under six now receive free healthcare in public health fascilities. One of the major successes has been the increase in the immunisation programme, from 63% in 1994 to 72% nationally in 2002, and through this, the elimination of deaths from measles and reducing incidences of polio. Those who have received antenatal treatment increased from 89% to 94% between 1994 and 1998, a level at which the decline in births that have received no antenatal care has been from 12% to 3%. Infant mortality has not yet declined, however, although deliveries at healthcare facilities have increased from 78% to 83%. The provision of clean water is an important contributing factor to a healthy nation. Lack of electricity or piped water affects women more than men since, in most cases, women have to fetch wood and water. By 2001, 85% of households had access to clean water at a cost to the Government of approximately R5 billion, an increase of 25% since 1996. Access to sanitation has increased at a slightly slower rate, from 49% in 1994 to 63% in 2003.

This has resulted in a decline in the rate of cholera infection. Women, particularly those in rural areas, continue to bear the brunt of poverty. Their health status impacts not only on themselves but on those who depend on them such as their children and extended families. The Department's Integrated Nutrition Programme acknowledges extreme inequities in our society and targets the most disadvantaged groups. It includes school feeding programmes, community nutrition projects and income generation projects. Since 1994/5 when 13 167 schools consisting of 5 628 320 learners were reached, the Primary School Nutrition Programme has increased school feeding coverage to a budgeted programme of R489,6-m in 2001/2, reaching 15 428 schools with 4 719 489 learners out of a total of 9 900 000 learners. A programme to fortify a basic staple, mealie meal, with a range of micronutrients is in place - to the benefit of poor.

2b) Access to Reproductive Health Care

The Constitution makes provision for the right to access to reproductive healthcare. This includes family planning advice, access to contraceptives and the choice of termination of pregnancy (Choice on Termination of Pregnancy Act of 1996). Although much education is still required to drive broader understanding of options related to reproductive health among South African women, 216 718 pregnancies had been terminated during the first four years since the Act was passed, with a 7.2% decrease in the incidence of severemorbidity associated with this procedure.

2c) Tobacco

Research indicates that there are currently about five million smokers in South Africa and this smoking population has been steadily reduced through Tobacco Control Legislation and tax policies. The number of adult smokers has declined from 34% in 1992 to 24% in 1998. About 42% of men and 11% of women smoke cigarettes. Snuff use is more common among women than men. African women are twice as likely to use snuff daily (12%) as to smoke cigarettes daily (5%). Coloured women (52%) are ten times more likely to smoke cigarettes than African women. Cigarette smoking prevalence rates are higher in urban than in rural settings, especially for women where the difference is two fold (13.2% urban vs. 6.6% rural). The benefits in reducing the number of smokers will be continue to be felt in years to come.

3. Implementing policy&programmes

3a) HIV and AIDS

Women's role in society is reflected in their health status and in their ability to access relevant health services. The HIV and AIDS pandemic remains one of themost critical health and development challenges facing South Africa, with women bearing the brunt of the onslaught. Government's HIV, AIDS and STD Strategic Plan for South Africa was launched early in 2000 and underpins a comprehensive prevention, treatment, support and care campaign. More than 59% of the 4.2 million HIV-infected persons in South Africa are women. In 1999, women of the age group 20-29 had the highest prevalence of HIV infection. By 2000, an estimated 2.3 million women and 95 000 children (0-14 years) are living with HIV and AIDS in South Africa.

Women in South Africa are especially vulnerable to the AIDS epidemic. Firstly, the risk of becoming infected with HIV during unprotected vaginal intercourse is as much as 2-4 times higher for women than men. Secondly, due to social inequalities that often lead to their disempowerment, women are often unable to negotiate within a relationship.

For this reason, there have been calls for government to engender the South African response to the HIV and AIDS pandemic in order to address the epidemic at the level of case, effect and manifestations. Women are usually infected during childbearing and productive years and are impacted not only by their own infection but of that of their partner and spouses and even children. Particularly older women are stepping in as caregivers within their extended families in caring for their children and grandchildren who are dying of AIDS. Women affected and infected with HIV need access to health care, information, counselling and wellness. Fighting the spread of HIV and AIDS has been one of the greatest challenges faced by government during this decade.

Government spending on HIV and AIDS has increased from R342 million in 1994 to a projected R3,6 billion in the 2005/06 financial year. Government has implemented various programmes, including life skills training through the South African AIDS Youth Programme and building partnerships with a wide range of organisations including faith-based, business, government, labour, media, traditional healers, the disabled and women's organisations. The Women In Partnership Against Aids (WIPAA) and Men in Partnership Against Aids (MIPAA) are two forums established under the umbrella of the South African National AIDS Council (SANAC) with the aim of addressing gender related aspects of HIV and AIDS.WIPAA addresses specific issues of women infected and affected by HIV and AIDS .

Other interventions include guidelines on opportunistic infections and improved district co-ordination, together with capacity building for primary healthcare workers. Mass media campaigns were also implemented. South Africa has begun the rollout of what is likely to be the world's largest comprehensive AIDS treatment plan which includes prevention, treatment, support, care and nutrition. The rollout of anti-retroviral treatment in the country's public health sector will involve a massive training and infrastructure overhaul and will cost in the region of R12-billion over the next three years.

3b) TB Control

South Africa has one of the highest recorded incidence rates of TB in the world and, although more men than women are diagnosed with TB, it remains a leading cause of death for women. Some studies indicate that women may have higher rates of progression from infection to disease and a higher case fatality in their early reproductive ages. In 1996, South Africa declared tuberculosis as the country's top health priorities and committed itself to reversing the infection trends. The DOTS (Directly-Observed Treatment Short-course) approach has now been adopted in more than 70% of all health districts with improvements in detection and cure rates in both DOTS and non-DOTS areas. High rates of treatment interruption and transfers, however, mean that treatment rates remain below the targeted 85%. This lower rate also indicates the compounding effect of drug-resistant TB, elements of which can be related to HIV and AIDS.

3c) Malaria

A total of 88 million Southern Africans live in malaria transmission areas including 14 million children under five and four million pregnant women, the latter groups considered to be at high risk from mortality if they contract the disease. TheWorld Health Organisation estimates that 19 to 22 million people get malaria in Southern Africa each year. Of these, 500 000 die of the disease. Efforts in South Africa to distribute chemically treated mosquito netting, combined with aerial spraying of mosquito breeding areas and, on the ground, the spraying of homes and yards, and the stocking of malarial medicines in the nation's healthcare facilities, reduced the number of malaria cases by 59 percent in 2001 and a further 42 percent last year. Malaria deaths in 2001 declined by an impressive 74 percent, and a further 21 percent in 2002, compared to the 2000 malaria season. Malaria case trends for the 2002-2003 season how shown a continued decline. Achievements of the malaria control programme in South Africa include the review and update of the National malaria treatment guidelines and prophylaxis guidelines, capacity development through training of environmental health officers, case management and community mobilisation. Together with the malaria programmes of Mozambique and Swaziland, South Africa successfully secured funding from the Global Fund to Fight AIDS, TB and Malaria for the trilateral Lubombo Spatial Development Initiative (LSDI) Project for five years. South Africa is in the process of initiating and strengthening cross border malaria and intercountry collaboration with Zimbabwe and Angola. The South African malaria programme successfully spearheaded the Race Against Malaria Rally campaign the largest health promotion campaign ever undertaken in southern African. All these initiatives have ensured that women in the region have been direct beneficiaries of this war againstmalaria.

3d) Cancer Control

Breast cancer and cancer of the cervix remain the most common forms of cancer among South African women. Breast cancer statistics show the largest incidence of cancers in women in South Africa, but it is argued that this could be due to fewer cervical cancer screening taking place. The department's National Guidelines for Cervical Cancer Screening were launched in November 2000 with the aim of facilitating comprehensive and systematic cervical cancer screening for all South African women. It aims to reduce the incidence of and mortality due to cervical cancer by more than 60% - with the ultimate goal of screening at least 70% of women nationally within 10 years of implementing the programme. About one in every 41 women will, within their lifetime, develop this form of cancer. It is the most common cancer in African (31%) and Coloured (22.9%) women, and second most common in Indian (8.9%) and fourth most common in White (2.7%) women. The success of screening programmes is dependent on good attendance rates by women at high risk. National Breast Cancer Awareness Month has developed into a significant annual collaboration between government, civil society and the private sector in a combined
effort to counter this form of cancer.

3e) Violence against Women

Gender based violence remains and continues to pose a challenge to our young democracy and is an obstacle to the achievement of the objectives of equality, development and peace. Gender-based violence represents a critical area for state intervention. Violence against women affects all spheres of women's lives, their autonomy, productivity and capacity to care for themselves and their children. It increases women's exposure to a wide range of negative health risks including HIV and AIDS. It carries great costs to the victim and many sectors of the society including the health care system, which has to respond to the consequences. South Africa has recognised violence as a health issue and has instituted a number of programmes to combat the scourge. Additional programmes have been put in place following the release of theWorld Report on Violence and Health - a report that came about as a result of a motion tabled by South Africa in 1996 at the world health assembly.

Non-natural causes remain the highest single cause of death with a significant proportion of the health budget spent on emergency services due to a high number of violence-related injuries. A central team, consisting of representatives from all major sectors responsible for violence prevention, was being set up, and an intersectoral plan put in place. The National Conference of Commitments on the Implementation of the SADC Addendum on the Prevention and Eradication of Violence Against Women and Children held in 1998, constituted the first year of the 16 days campaign. The lack of a comprehensive approach in the provision of care and collecting evidence in cases of rape and sexual assault negatively affects women and it constitutes another dimension of inequality in the provision of services. The department of Health therefore started with the preliminary programme for the Sexual Assault Care Practitioners Training Project that is aimed at providing skills for effective management and support for the survivors of violence, rape and abuse. The Department of Health also recently finalised the "Sexual Assault Policy", completed the Management Guidelines for Sexual Assault, and put in place a case record policy to help health workers assisting women survivors of violence.

4. Transforming the department

South Africa boasts the highest number of women at the highest level of political representation Cabinet - in Africa. There are now 16 men and 12 omen ministers in South Africa's executive, with 11 men and 10 women deputy ministers bringing the total to 43% of South African's cabinet. This commitment to gender representation at all levels is also being felt in the provinces where four of the nine premiers are female. There are ongoing initiatives within the Department of Health to change the gender and race balance for senior management appointments. The department is creating an enabling environment for its women staff members as well as women decision-makers. Institutional commitment is a pre-requisite for implementation and the Gender Policy Guidelines helps create an enabling environment to translate the commitment into reality. It establishes an institutional framework for the advancement of the status of women as well as the achievement of equality. The guide also aims to integrate the empowerment of women and transformation of gender relations into policies and programmes at all levels of the public health system. Finally, it aims to promote new attitudes, values and behaviour and a culture of respect throughout the health system. A representivity audit completed in 2001 showed that the National Department of Health had surpassed all of the original targets set by the Department of Public Service and Administration (DPSA) for government institutions:

At that stage, 58% of the national department's employees were female, and 42% male. Overall, female managers occupy substantial (and in some instances commanding) positions in proportional representation of post categories: Top Management (44%), Middle Management (59%), Junior Management (66%) and Low Level Supervision and Production (56%). The DPSA's target of 30% female managers in 1999 was surpassed with an average of 58% female managers in the national department. "In terms of gender equity, it is clear that the DoH has made major strides in building a balanced employee profile, despite the weight of patriarchy (male dominance) in broader South African society and institutions," said the report which noted that there were already processes underway to mainstream gender issues.

5. Global Involvement

After years of isolation, South Africa has, during the past ten years, emerged as an active player in the global health arena. South African delegations have participated in international conferences in Beijing, Dakar and the United Nations conference in 1995 leading to the ratification of the Eliminations of all Forms of Discrimination Against Women. South Africa was a signatory to the Gender and Development SADC Declaration signed in Malawi in 1997 and the SADC Declaration on the Prevention of Violence Against Women and Children in Mauritius in 1998. The basic components of sexual and reproductive health were policy in South Africa before they were articulated as international policy at the International Conference on Population Development (ICPD) in Cairo, 1994 and the Fourth World Conference on Women in Beijing, 1995. South Africa is a member of the board of the Global Fund to Fight AIDS, TB and Malaria where it represents the Southern and Eastern Africa Region. South Africa also chairs the African Regional Committee of theWorld Health Organization.

6. Conclusion

During the past 10 years, the focus has been on achieving amore equitable distribution of resources, most of which contribute to the quality of health care of the nation. Simultaneously there has been a focus on empowerment of the people, through wide ranging programmes including Batho Pele and gender equality initiatives. There is still much to be done before South Africa achieves a society in which all of our women and children have an equal chance at a healthy lifestyle. The foundation is in place, however, and the women honoured in this book are among the thousands who continue to build towards that goal with the loyal and tireless support of our community health workers.We honour all the women, known and unknown, who have made the health of our nation their life's work.