Primary healthcare barely exists outside our urban centres, and apartheid-ordained inequality is stark.
Last week the Health Systems Trust, an independent not-for-profit research institution, published the ninth edition of its annual District Health Barometer. The Barometer is a publication that provides a snapshot – using a range of primary healthcare indicators – of how well districts within and between provinces are doing in terms of delivering health services.
For organisations such as the Rural Health Advocacy Project, which advocates for better access to healthcare services for rural communities, it is an important tool for assessing how far the health system has come in addressing structural inequities in relation to the need for services and access to healthcare.
Healthcare need is difficult to measure directly, so the Barometer makes use of relative deprivation as a proxy measure. Relative deprivation provides an aggregated measure of the social determinants of health such as access to basic services (water, sanitation and electricity) and socioeconomic status (employment, education and levels of poverty) in a district.
In short, people who have less access to the social and material conditions necessary for remaining healthy will have a greater need for healthcare services.
As the Barometer points out, there are distinct patterns in the geographic and historical spread of deprivation in South Africa.
The 10 most deprived districts in the country are all rural and, not coincidentally, fit neatly into the borders of the former homelands. On the other hand, the 10 least deprived districts fall within either the Western Cape or Gauteng, or are metro districts, which have historically well-developed health infrastructure and systems.
Apartheid social engineering is persistent. The Barometer confirms the relationship between health and deprivation. Burden of disease indicators reveal that communicable diseases – such as HIV, tuberculosis, diarrhoeal diseases and pneumonia – disproportionately continue to affect the most deprived districts.
Noncommunicable diseases – such as diabetes, hypertension, heart disease and cancers – although still far more prevalent in urban settings, are rapidly increasing in rural areas.
Research evidence suggests these increases in both urban and rural settings are driven by a combination of factors relating to high fat intake, physical inactivity, and alcohol and tobacco use. Although these factors are not unique to deprived settings, their impact is often greatest in these contexts because of the absence of alternatives or responsive public health interventions.
Poor access to services
In terms of other indicators of access, the Barometer confirms that people living in the most deprived rural districts are dependent on services provided at under-resourced primary healthcare facilities. Residents in comparatively well-off urban districts, on the other hand, have greater access to care at hospitals and many benefit from services in a relatively well-resourced private sector.
The unfortunate reality in South Africa is that inequities are sustained because investment in healthcare is not based on any assessment of need for services. For example, countrywide increases in primary healthcare expenditure over the past decade have not resulted in equitable resourcing of services between districts.
Health expenditure data from the Barometer reveals that primary healthcare expenditure in the least deprived districts still outstrips expenditure in the most deprived districts by at least 10% a year.
Superficially this disparity may seem insignificant, but when understood in terms of backlogs in health infrastructure, a chronic shortage of personnel and an ever-increasing demand for services, 10% is unjust.
Health services in deprived and rural districts are simply inadequate to meet the need. For instance, immunisation coverage, one of the most cost-effective interventions available, is highest in the least deprived districts (89%) and lowest in the most deprived districts (74%).
Poor access to the most basic services, such as immunisation, places an increased burden on poorly resourced health facilities and contributes to worse outcomes at these facilities.
For example, the average number of child deaths from pneumonia for South Africa has almost halved since 2009-2010 (dropping from 6.6% to 3.5%). There has, however, only been marginal benefit in the most deprived districts. Mortality rates in these districts (6.1%) are nearly double the national average and three times higher than the least deprived districts.
Even in instances where there appears to be no relationship between deprivation and health outcomes, it is important to consider indicators in context. An example is maternal mortality ratios in health facilities (only including inpatient mortality). These ratios are significantly lower than the national average of (133 per 100 000 live births) in both the most deprived (105 per 100 000) and least deprived districts (79 per 100 000).
But this does not necessarily point to any real improvements in outcomes. Rather, as these are health facility measures, it is most likely more an indication of a lack of access to facilities and emergency obstetric care. The reality is that in rural settings many pregnant women in need of emergency care simply never make it to a health facility.
Decline in mother-to-child-transmission of HIV
High levels of deprivation do not automatically result in poor access to services and worse health outcomes though. An important trend highlighted in this year’s Barometer is the continued decline in rates of mother-to-baby transmission of HIV to infants. The average number of infants born to women with HIV who also tested positive for HIV dropped from 8.4% in 2008-2009 to 2.2% in 2013-2014.
Some measure of success in HIV, particularly with regard to the expansion of access to antiretrovirals to more than 2.8-million people, has demonstrated that, with political will, sustained investment in interventions and an active citizenry, significant change in a relatively short space of time is certainly possible.
Unfortunately, the underlying message from this year’s Barometer has been that the public health system has largely been unable to overcome disparities in access to care and improve health outcomes in contexts with high levels of relative deprivation, particularly in rural settings. Deprivation need not be a significant factor in determining access to healthcare.
Equity in access is a function of how and where the government invests in the health system. This does not necessarily mean privileging rural over urban, but rather involves proper planning and investment in health systems that work in context. At present this does not happen and apartheid era structural inequities are allowed to persist in healthcare.