South Africa is a country of relative prosperity, with vast resources and a modern infrastructure. In contrast to this, it is plagued by persistent and widespread poverty and deep inequalities - the legacy of apartheid still casting a long shadow on the new democracy, after almost 5 decades of legitimised racial discrimination where the majority of communities were deprived of services and opportunities.
Although some progress has been made since 1994, the extent of poverty and inequality is still overwhelming - the worst affects are seen in communities in rural areas and informal settlements and amongst women.
According to the South African constitution, all people have the right to have access to health care services, including reproductive healthcare. (1) One has to evaluate the government policies and programs to alleviate the plight of women within the context of the constitution, stated policy of the government and how far it has met its own goals and the demands of the people and women in particular.
In 1994, the government introduced free health care to all children up to the age of six, and all pregnant and lactating women. Children are required to have seven points of contact with health services up to the age of 5 for immunisation purposes, and to establish if malnutrition or other developmental problems are present.
It is important to note that although the government aims to make healthcare accessible to all, it will be some time before remote areas in provinces like KwaZulu Natal are properly served - where there is only one doctor for every 4000 people.
The rapid increase in the number of AIDS infected patients in the country places and enormous strain on the health care infrastructure. After the introduction of a one year community service for qualified doctors, dentists and other medical professionals, a huge number of people from the health sector have left South Africa to work in other countries. This so-called "brain-drain" has had an increasingly negative impact on the healthcare system in the country. Healthcare givers who remain in South Africa are experiencing increased workloads - causing stress and burnout, higher absenteeism and lower staff morale. This has a negative impact on the quality and availability of healthcare in the country.
HIV: Extent
To determine the extent of HIV infection in South Africa, several studies have been done.
African women have the highest percentage of HIV infection, being in both the female category (with a higher rate of infection than the male category), and the African population (with a higher rate of infection than the other groups mentioned).
In an article: "Sexism, Youth and HIV in South Africa", Linn Hjort explains the reasons for this as follows: In South Africa, women make up a small part of the formal workforce. Men generally have more financial stability than women as they make up the majority of formal workers. When women work, they often have lower paying and less secure jobs. This has a direct impact on their ability to protect themselves from getting HIV. Women who are financially dependant on their men very often have to put up with a refusal to use condoms, afraid to insist on it for fear of being left destitute.
In a recent report, UNAIDS reports that the Aids epidemic in South Africa shows no evidence of decline, in contrast to other African countries (among which are Kenya and Zimbabwe) that have made major progress.
AIDS Orphans
A growing concern in South Africa is the increasing number of AIDS orphans.
One of the most disturbing consequences of the many AIDS-related deaths in the country is that of child-headed families. Because of the stigma attached to the disease, many relatives are reluctant to care for children of AIDS victims. It is not uncommon to find a teenage girl dropping out of school to take care of younger brothers and sisters. Child-headed families are in a continuous struggle for survival. To make matters worse, children (and child-headed families) are often evicted from their homes, because they cannot pay the mortgage on the house. These children have no one to take care of them and get no schooling, basic nutrition or hygiene.
In September 1999, "LoveLife", South Africa's national HIV prevention programme for youth, was launched. It is the combined effort of a group of leading South African public health organisations in partnership with a coalition of more that 100 community-based organisations, the Government, major South African media groups and private foundations.
LoveLife promotes abstinence, delayed initiation of sexual activity, reduction of sexual partners among already sexually active teenagers and condom usage. It builds on the optimism of the youth and promotes a holistic lifestyle approach aimed at encouraging young people to maintain an AIDS-free lifestyle and to achieve their dreams and aspirations through self-motivation and leadership.
The effectiveness of the LoveLife campaign cannot yet be judged. However, a national survey among the South African youth indicates that nearly 85% of young people have been exposed to LoveLife and more than two thirds of all youth have been exposed to at least three different LoveLife products.
Treatment
A lot of controversy arose when the South African Government refused to supply Antiretroviral (ARV) treatment to HIV positive South Africans who do not have private healthcare. The Government eventually agreed to supply ARV's to the public, but only after rigorous protest by the Treatment Action Campaign. Charges of culpable homicide were laid against the health minister and her trade and industry colleague, arguing that they were responsible for the deaths of 600 HIV-positive people a day in South Africa who had no access to ARV drugs. The Government's profile was further damaged by the Minister of Health's frequent mention of home-remedies for HIV infected people. An important factor contributing to the Health Ministry's change in attitude, was the result of a court battle in which GlaxoSmithKline and other pharmaceutical companies agreed to allow less costly generic versions of their drugs to be produced in South Africa, making South Africa one of the first African countries to produce its own AIDS drugs.
It is disconcerting to note that (according to a UNAIDS estimate) 79% of South Africans who needed ARV's were not receiving them at the end of 2005. In the poorer parts of the country, for instance Limpopo and Mpumalanga, the rollout is pitiful.
In an article "South Africa: HIV-Prevention Program Fails Rape Survivors," Rebecca Schleifer, Human Rights Watch researcher for the HIV/AIDS and Human Rights Program, reports that despite the South African Government's stated intention of providing rape survivors with post-exposure prophylaxis (PEP), the reality is that many can't get these drugs that are supposed to reduce the risk of contracting the HIV virus from the their attacker.
According to Schleifer, "Police and nurses who should have been helping rape survivors get anti-HIV drugs didn't do so, sometimes because they had no idea that the program even existed? and some service providers may not have offered these drugs even when they knew about them, because they thought that doing so was against government policy."
Traditional healers
Because most people in developing countries (including South Africa) still prefer traditional healers to Western medical practitioners, it became crucial that traditional healers be integrated into a holistic approach in the fight against HIV/AIDS.
In 2003, a former nurse and traditional healer, Patience Koloko, developed an HIV/AIDS training program for traditional healers in South Africa that combined traditional healing methods with modern medical practices. She says that most people living in rural areas are likely to visit a traditional healer before seeking other medical attention, when they discover that they are HIV positive. (11)
It is unfortunate that some traditional healers refuse to work together with health care professionals, often urging people to take remedies which impact negatively on the effectiveness of antiretroviral drugs taken by the patient.
Abortion
In apartheid-era South Africa, hundreds of women died yearly as a direct result of illegal abortion complications. This was due to the fact that abortions could not be done legally (except under extreme circumstances, for instance if the pregnancy endangered the life of the mother) by proper health care professionals.
Only in 1996 was abortion legalised in South Africa, with the implementation of the Choice on Termination of Pregnancy (CTOP) Act. The law allows for termination of pregnancy on request up to and including the 12th week of pregnancy, under specified circumstances from the 13th through the 20th weeks, and under very limited circumstances beyond that point. Since the passing of the CTOP act, abortion-related deaths among South African women dropped by 90 percent (South Africa Department of Health, 1999).
It would seem that access to abortion services is more readily available in the previously advantaged areas of South Africa.
In 2004 the Act was amended to allow registered nurses and midwives to perform abortions. Abortions can be legally performed only in designated facilities such as hospitals, a few community health centres and private clinics such as the Mary Stopes clinics (in Durban, Johannesburg and Cape Town).
Foetal alcohol syndrome
Foetal alcohol syndrome (FAS) is caused by maternal alcohol abuse during pregnancy. It is one of the leading causes of preventable birth defects and developmental disabilities. Children suffering from FAS are known to suffer from a combination of abnormal facial features, growth retardation, and central nervous system (CNS) abnormalities.
A recent report by the National Institutes of Alcoholism and Alcohol Abuse (NIAAA), states that the highest prevalence of FAS worldwide was reported among children in the wine-growing region of the Western Cape. In this region, the high incidence can be ascribed to the illegal "dop" or tot system, in which white-owned wine farms paid their black and coloured employees partly with low-grade wine as an alternative to cash. This left a legacy of alcohol abuse and dependency among the working community.
Foundation for Alcohol Related Research (FARR) founder Denis Viljoen, says that De Aar (in the Northern Cape) is the town with the highest prevalence of FAS in South Africa. He ascribes this to the high incidence of unemployment as a result of the closure of the town's railway junction. The entire community's economic existence was dependant on the railway junction. Another contributing factor to the high incidence of FAS can be traced to the "Shebeens" (informal bars selling mostly home-brewed beer) who are providing cheap liquor to the poor and unemployed.
It seems that education and treatment for FASD is pushed further down the list of priorities for government by the increasing attention required to the HIV/AIDS problem in the country.
Conclusion
While South Africa has come a long way towards providing healthcare for all its people, there is still much room for improvement - particularly in poverty-stricken rural areas where women and children are very vulnerable. The biggest obstacle the country is facing is the escalating incidence of AIDS-related illnesses and deaths (especially high among women), and until the HIV/AIDS pandemic stabilizes, it will continue to hamper the road to a better life for all South Africans.