Healing inequalities: The free health care policy

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Healing inequalities: The free health care policy
Healing inequalities:
The free health care policy
Annie Leatt, Maylene Shung-King and Jo Monson (Children’s Institute)
What is free health care?
hildren’s right to health care is expressed in two
sections of the South African Constitution.
Section 27 accords “the right to have access
In 1994, during his first hundred days in office, former
to health care services for all South Africans”. Section 28
President Nelson Mandela announced the provision of free
(1) (c), which is that portion of the Bill of Rights dealing
health care to children under six years and pregnant and
specifically with children’s rights, states that children have
lactating women as one of several programmes led by the
“the right to basic health care services”.
Presidency. This initiative was coupled with an extensive
This essay discusses the South African government’s free
clinic-building programme to ensure greater physical avail-
health care policy and the extent to which it meets children’s
ability of health care services to people in South Africa,
right to basic health care services, with a particular focus
especially for those who live in poverty. Free health care in
on the accessibility of services.
South Africa currently means that services at public sector
The information in this essay comes from The Means to
clinics and community health centres are free of charge for
Live: Targeting poverty alleviation to realise children’s rights,
all people, and public sector hospital services are free for
the forthcoming report on a three-year research project of
some groups of people. This policy was implemented in
the Child Poverty Programme at the Children’s Institute,
different stages since 1994.
University of Cape Town. The Means to Live Project aims to
Initially, free health care was offered to all children under
investigate how government poverty alleviation programmes
six and to pregnant and breastfeeding women making use
are targeted and the consequences of the targeting for
of public sector health facilities including clinics, community
children and their caregivers1 – particularly where it results
health centres and hospitals. The exceptions are those
in very poor children being excluded from programmes. This
children and women who are covered by medical aid or
essay is an abridged version of the more comprehensive
medical insurance and/or who live in households that earn
discussion of the free health care policy in the full Means to
more than R100,000 per year. Then, in 1996, free health
Live report, to be released in 2007. (See the essay starting
care was extended to all people using primary level public
on page 31 for more details on this research project.)
sector health care services. More recently, in 2003, free
This essay focuses on the following questions:
hospital care was further extended to include children older
than six with moderate and severe disabilities.
What is free health care?
What is basic health care?
ment must be made is public hospitals. The groups that have
Are children accessing free health care?
to pay for public sector hospital services are adults, children
What are the barriers to accessing health care?
older than six who do not have disabilities and anyone
What else impacts on health?
covered by medical aid or medical insurance and/or who
What are the conclusions?
live in households that earn more than R100,000 per year.
Caregivers are those who undertake the primary responsibility for parenting children from day to day. In most, but not all, cases, this is the child’s biological
mother. Many children are cared for by grandparents, siblings, other relatives, or non-relatives. In the Means to Live, specific criteria were used to define one primary
caregiver per child to replicate assessments of eligibility. In reality, however, care arrangements are often shared between parents or other household members.
The only type of public sector facility where some pay-
PART TWO: Children and Poverty
Are children accessing free
health care?
The amount that must be paid for hospital services is
determined according to a sliding scale, based on the annual
family income. If a family has no income at all, the service
is provided free of charge – but only if the family can prove
The Means to Live research team set out to discover if free
their “indigent” status.
health care was in fact free in its research sites – an urban
site in the Western Cape and a rural site in the Eastern Cape.
What is basic health care?
Primary level services always free
The free health care policy was, and remains, an important
On the whole, the application of free health care worked well
step towards realising children’s right to basic health care
as no fees were being charged at the primary level health
services. Many other child health policies and programmes
care facilities in both the rural and urban research sites of
help to give effect to this right. However, the effectiveness
the Means to Live Project. This is in keeping with reports
of all these measures in fulfilling children’s right to basic
from a few sites around the country that free health care at
health care services can only be assessed against a clear
the primary level facilities worked well and was applied as
definition of what ‘basic’ health care services for children
envisaged in the policy.
include. It is therefore important to note that a clear definition
Not all hospital services are free
of what constitutes basic health care, as outlined in the
Constitution, still has to be developed.
At the hospital level it was found that the free health care
Arriving at a definition of basic health care services for
policy is not always being applied consistently and correctly.
children in South Africa is a process that will require discus-
In the rural site in particular, some children who should not
sion with many role-players in the health and related sectors.
have been charged user fees were charged, although overall
It is reasonable to assume though that all services for chil-
it involved a small number of children.
dren currently rendered at primary level health care facilities,
including preventative health interventions and curative care
Access not just about fees
for common and uncomplicated childhood conditions, form
While it is clear that the free health care policy has largely
part of basic health care services.
delivered on the intention to make basic health services
The extent to which curative care for more complicated
health conditions and care for children with chronic (or
free, fees are not the only barrier to accessing health care.
long-term) health conditions are included in a definition of
The Means to Live also looked at the broader question of
basic health care services are some of the elements that
whether children who needed health care accessed it
require clarification. Project 28 at the Children’s Institute is
Just more than a quarter of children in the urban site
currently conducting research and legal analyses to define
the actual meaning of constitutional socio-economic rights
and about one third of children in the rural site were
provisions for children. This includes the right to “basic
identified by their caregivers as having needed health care
health care services”.
in the three months prior to the study. The study looked at
whether these children were able to access health care
In addition to supporting the advancement of children’s
right to basic health care services, the policy gives effect to
successfully in line with the policy. A successful health care
the three important principles of the Alma Ata declaration
interaction was defined as children getting to a public sector
of Primary Health Care of 1978 – which South Africa has
health care facility and obtaining the necessary medication.
adopted – namely ensuring that health services are available,
More detailed investigation into quality of care did not fall
accessible and affordable. One of the potential ways of
within the scope of the study.
About six out of 10 children who needed health care
making health services more affordable and accessible is
to remove or reduce health care fees. Free health care has
were found to access a public health care facility success-
been shown to improve utilisation of health care greatly in
fully. This means however that four out of 10 children who
other developing countries. The opposite is also true: the
needed health care did not successfully get it. The logis-
re-introduction of fees results in many people not being
tical and other challenges to accessing health care facilities
able to access much needed health care.
are described in the case study on page 53.
South African Child Gauge 2 0 0 6
CASE STUDY 3: Access to rural health services
The cluster of three villages that make up the Theko Springs administrative area in the Eastern Cape province includes
776 households across the villages of Nkelenkethe, Theko Springs and Krakrayo. The only health care service available
within the area is a mobile clinic, which arrives in the centre of Theko Springs for one day every six weeks – when the
roads are accessible.
For the rest of the time, whether it is an emergency, a regular visit to monitor an infant’s weight, or for a child who is
sick, parents and children need to travel long distances to access health care.
A previous temporary clinic at Theko Springs was closed after the building was deemed unsafe. The building of a
new clinic has since been contested, with different local leaders mooting different places for its location, and with the
local municipality prioritising a community hall over a clinic.
There are a number of primary health care facilities in adjacent areas. A long walk down the valley from Nkelenkethe,
across the Theko River and up the steep slopes of the next hill, is the Gcaleka clinic in Holela. However, the river is
impassable during the rainy season, and there is no footbridge.
From all three villages it is possible to walk to the taxi area in Theko Springs and take a ride to the T-junction where
the gravel road meets the main road to Butterworth. This of course requires money. From this junction it is possible to
walk to Tutura clinic, another 20 minutes at a good pace. Alternatively, one can continue by taxi to Butterworth where
there is a Gateway clinic 2 adjacent to Butterworth hospital. The taxi fare to Butterworth is extra, and the round trip costs
R18. A little further away, in the other direction, is the Community Health Centre in Centani.
Aside from these primary health care facilities, people in the three villages also use the two closest district hospitals.
Butterworth hospital is in the town with the same name, and Tafalofefe district hospital is further north from Theko
Springs towards the coast, and can be reached on foot in about two hours or by a taxi from Butterworth. Although there
is no official Gateway clinic at Tafalofefe, the hospital also offers primary level care because of the lack of alternative
clinics in the area. Physical access to the hospitals facilities cost money, and they are particularly hard to reach afterhours as there are few ambulances operating in the area.
2 Gateway clinics are attached to hospitals offering primary level of care.
Source: Hall K, Leatt A & Rosa S (forthcoming) The Means to Live: Targeting poverty alleviation to realise children's rights. Cape Town: Children's Institute, UCT.
What are the barriers to accessing
health care?
Mothers reported not being able to carry older or very sick
The Means to Live research underlined some of the reasons
hospital in serious cases. Where there is money for a taxi –
why children are not able to access health care services.
about R18 each way – they indicated that taxis returning
children the many kilometres to the clinic. They also reported
having no money for a taxi or to hire a car to get to the
from Butterworth (the nearest town) are sometimes too full
to pick up people returning from the rural clinic.
Distances too far
Distance to the nearest clinic made access to health care
difficult for many caregivers and their children, especially in
the rural site.
I have to get up early, and leave around four [am]
because I am going to walk, so that I should get
there at half past seven or eight; but when I get there
just before eight, then I am early. Then I know that at
half past or at nine I will be on my way back.
PART TWO: Children and Poverty
Medicines not available
Based on the General Household Survey 2004, Table 10
below shows the number and proportion of children across
As shown in Table 11, the Means to Live found that, even if
South Africa who are reported to be living ‘far’ or ‘not far’
children did reach the nearest health care facility, medicines
from their nearest clinic. A clinic is regarded as far when
were not always available.
more than half an hour of travel is needed to get there. The
table shows great provincial variation, with the Western and
Right now there are no pain tablets here in the clinic;
Eastern Cape provinces representing the best and worst
they are finished. [SISTER,
scenarios respectively. In the Western Cape, 92% of children
Medicines were reported as being unavailable by 24% of
are not far from a clinic, whereas in the Eastern Cape, only
caregivers who had taken a child to a clinic in the urban
43% of children do not need to travel far to access their
site and 17% of caregivers in the rural site. Health workers
nearest primary level facility.
cited delays between ordering medicine and it arriving,
and others referred to the insufficient number of vehicles
available to supply the clinics.
TABLE 10: Number and proportion of children living ‘far’ or ‘not far’ from nearest clinic in 2004
Number of
living far
Eastern Cape
Free State
Number of
living not far
not far
North West
Western Cape
Northern Cape
Source: Statistics South Africa (2005) General Household Survey 2004. Pretoria, Cape Town: Statistics South Africa. Analysis by Debbie Budlender, Centre for Actuarial Research, UCT.
TABLE 11: User satisfaction or quality of care at public health service points at Means to Live sites
(Base: Children who accessed public heath service points)
Problem (prompted)
Urban site
Rural site
Long waiting time (over an hour)
Opening times not convenient
Medicines not available
Facilities not clean
Rude staff/turning patients away
Incorrect diagnosis
Source: Hall K, Leatt A & Rosa S (forthcoming) The Means to Live: Targeting poverty alleviation to realise children's rights. Cape Town: Children's Institute, UCT.
South African Child Gauge 2 0 0 6
Staff under pressure
These challenges were also evident in earlier evaluations of
the introduction of free primary health care. Shung-King,
Very long waiting times at facilities sometimes resulted in
McIntyre and Jacobs discussed how the simultaneous intro-
patients being turned away as staff cannot always cope
duction of curative roles at clinic level led to the problem of
with the large numbers that turn up each day.
preventative services being crowded out by the drive to
Gone are the days when you would sit with the client
deliver curative services. This is of particular concern for
and you would know everything about the client; now
children’s health, as they need good preventative services.
we don’t have that time and for me it is important
and unfortunately I’m retiring quite soon, and I don’t
Use of private health care
feel good; I don’t know what I’m doing now. For me
it’s no longer caring. [SISTER,
The Means to Live established that 15% of all children in
need of health care in the research sites were taken to
The health sector workers interviewed in the Means to Live
private practitioners rather than public health services. The
study consistently identified staffing as a constraint to provi-
extent of the use of private health services is rather surprising,
ding high quality services. Although this was less of a problem
given the extent of poverty in the two research sites. The
in the urban areas, the negative effects of capacity constraints
decision to spend precious money on private health care
were found to impact on staff morale in the urban site too.
was found to be largely the result of dissatisfaction with the
public health service.
It’s a terrible cycle this thing of not enough staff, so
Although physical access to health services posed a
low morale, so more people feel too tired and they
get burnt out. [HEAD
greater barrier in the rural site than the urban site, the
quality of service received was less satisfactory to the
urban caregivers where, for instance, nearly half of those
This may explain another difficulty described by caregivers,
who attended a public health service experienced long
especially in the urban site: rude or unhelpful treatment
waiting periods before being attended to. Children in the
from nurses.
urban site were also slightly more likely to be taken to
I took Sibulelo 3 to the clinic but I was not treated well.
private practitioners rather than clinics.
I was scolded because I got there late – they said the
Caregivers in both sites reported that they were dealt with
time to get to the clinic is eight [am], and I had come
more seriously and with more respect by private doctors,
after eight. So I sat there and persevered and it was
and that better treatment was consistently available. When
like I would not be attended to but I sat on the chair
caregivers judged that they or their child was too sick to wait
and I didn’t leave until they attended to me.
at a clinic, they chose to go to a general practitioner instead.
Prevention and cure
What else impacts on health?
Some health care workers spoke of a shift from preventive
to curative services at the primary level since the intro-
The situation of living here is bad because it’s also
duction of the free health care policy.
dirty here in this area. This is where they threw all the
[Before,] I was able to go and do home visits, which I
rubbish. And the children are not safe because they
can’t do now. For instance our immunisation coverage
eat this sand and it’s dirty and we also put dirt on it,
has dropped because we are not visiting the crèches
and then again we dig it up and then the child takes
where most of the children are, and they are not immu-
that while playing and eats it … We have no toilets
nised because the mothers are working and they can’t
and no water here, the children are getting sick from
come to the clinic here. So you find … we have shifted
the area that we live in … And the children have
from preventive to more curative because you can’t leave
diarrhoea, the children from this area are filling up the
a sick child and go out there. [SISTER,
Red Cross [Children’s Hospital]. [CAREGIVER,
3 All names have been changed to protect identities.
PART TWO: Children and Poverty
Access to basic health care services must be seen as just
The major barriers to basic health care are not due to
one of many factors influencing the health and survival of
fees at health facilities, but are attributed to many other
children. Nutritious food, clean water, adequate housing and
factors such as transport to and from health care facilities
sanitation, a quality education, safe roads and safe, clean
and a shortage of nursing staff and medicines.
spaces for children to play are also very important to chil-
Overcoming these barriers requires an improved under-
dren’s health and well-being. Poverty has a negative impact
standing on the part of all duty-bearers as to what exactly
on the range of factors that contribute to child health. The
children’s right to basic health care entails. It also requires
association between poverty, poor health and health care
a better understanding of what duty-bearers’ specific contri-
outcomes for children and adults alike is very strong.
bution should be, whether in the health sector or the many
In South Africa, where inequality is a feature of society, the
other sectors and government departments that influence
differences in health and health care availability between
children’s health and survival.
rich and poor are very stark. One clear example of health
Nevertheless, the dedication and commitment of thou-
inequality is the infant mortality rate (IMR) – the death rate
sands of health workers throughout the health sector must
of children under one year old. The IMR is an indicator used
be commended and, with the required budget increases and
internationally to reflect access to health care as well as the
improvements in implementation, all children in South Africa
socio-economic status of communities. According to the
should be able to successfully access the quality health care
South African Health Review 2000, the IMR in a wealthy
that they require and are entitled to.
suburb of Cape Town was eight deaths per 1,000 live births.
Just 10 kilometers away, on the outskirts of the city in an
area where poverty is rife and access to services is more
difficult, the IMR was 64 deaths per 1,000 live births – eight
times as high.
Amatole Health District (2005) District Health Plan 2006 – 2007. Amatole
Health District, Eastern Cape province, November 2005.
Differences between regions and between provinces show
Bradshaw D, Nannan N, Laubscher R, Groenewald P, Joubert J, Nojilana B,
Norman R, Pieterse D & Schneider M (2004) South African National Burden
of Disease Study 2000 – Estimates of Provincial Mortality. Cape Town:
South African Medical Research Council, Burden of Disease Unit.
a similar IMR pattern. According to the South African Medical
Research Council’s National Burden of Disease Study for
2000, the relatively wealthy Western Cape province had an
Burger R & Swanepoel C (2006) Have pro-poor health policies improved the
targeting of spending and the effective delivery of health care in South
Africa? Stellenbosch Economic Working Papers: 12/06. University of
Stellenbosch: Department of Economics and Bureau for Economic Research.
average infant mortality rate of 32 per 1,000 live births,
while its poorer neighbour, the Eastern Cape province, had
double that rate: 71 deaths per 1,000 live births.
Chitha W, Cleary S, Davauid E, Jikwana S, Makan B, Masilela T, McIntyre D,
Pillay Y, Sebokedi L, Thomas S & Wilson T (2004) Financial resource requirements for a package of primary health care services in the South African
public health sector. Cape Town: Health Economics Unit, UCT, and national
Department of Health.
Given the multi-dimensional nature of health, as well as
the impact of poverty on health outcomes, promoting good
health and ensuring access to health care for children is not
Dangschat J & McIntyre D (1996) Patient fee collection: Is it worth it? A case
study of Groote Schuur hospital. Health Economics Unit Working Paper No.
22. Cape Town: University of Cape Town.
just the business of the Department of Health, but of all
government departments. Other government programmes
Free health services for pregnant women and children under the age of 6
years. Government Notice 657, Government Gazette 15817 of 1994.
that impact on poverty and a range of other deprivations are
discussed in the other essays of this PART TWO: Children
Hall K, Leatt A & Rosa S (forthcoming) The Means to Live: Targeting poverty
alleviation to realise children’s rights. Cape Town: Children's Institute, UCT.
and poverty section of the South African Child Gauge 2006.
Hirschowitz R & Orkin M (1995) A national household survey of health
inequalities in South Africa. Johannesburg: Community Agency for Social
Enquiry, for the Henry J. Kaiser Family Foundation.
What are the conclusions?
McCoy D (1996) Free health care for pregnant women and children under six
in South Africa. An impact assessment. Durban: Health Systems Trust.
The provision of free health care is an appropriate and
Shung-King M, Abrahams E, Giese S, Guthrie T, Hendricks M, Hussey G,
Irlam J, Jacobs M & Proudlock P (2002) Child health. In: Ntuli A (ed) South
African Health Review 2000. Durban: Health Systems Trust.
commendable policy objective, and it is working well as far
Shung-King M, McIntyre D & Jacobs M (2005) Healing Inequality: Targeting
health care for children. In: Leatt A & Rosa S (2005) Towards a Means to
Live: Targeting poverty alleviation to make children’s rights real. Cape Town:
Children’s Institute, UCT. [CD-ROM]
as correct application of the no-fee policy is concerned.
There are, however, some inconsistencies at hospital level
where people are sometimes charged user fees when they
Statistics South Africa (2005) General Household Survey 2004. Pretoria,
Cape Town: Statistics South Africa.
should not be.
South African Child Gauge 2 0 0 6
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