Health workers, government officials, vigilante groups, and even patients themselves, may mistreat those deemed undeserving of care
Despite stated ideals of equitable care, health service delivery in South Africa remains suboptimal, especially for socially marginalised people — from sex workers to members of the LGBTQ+ community to the unhoused — who may be deemed unworthy of scarce resources to promote health and treat illness.
Disadvantaged patients are often blamed for both systemic challenges and their own medical conditions, especially if they are considered to have self-induced illnesses that result from behaviour perceived as deviant or immoral such as drinking, injection drug use or promiscuity.
Perceptions of patients’ relative worthiness impact health-seeking behaviour and outcomes — those deemed unworthy may receive inferior care or be denied health services altogether. If unaddressed, vulnerable patients will not obtain essential primary healthcare services, which increases the risk of complications related to poor management of acute and chronic conditions, thus placing further strain on an overstretched health system.
Triaging patients by perceived worthiness is learned behaviour. Since the problem is often considered a lack of awareness, it is presumed that “sensitisation” or “awareness-raising” workshops are the solution. The assumption is that problematic attitudes and behaviour will disappear once clinicians undergo training on the Constitution and the Patients’ Rights Charter and memorise the definition of stigma.
Yet, in-service learning does not take place in a vacuum. Although it is tempting to seek simple solutions to intractable problems, entrenched sociocultural and operational challenges inherent in the South African health system are not easily remedied through discrete interventions.
There is a disconnect between the egalitarian principle of “health for all” espoused in the classroom and clinicians’ attitudes and behaviour. The stratification of patients by perceived worthiness does not align with the way clinicians are taught to behave during formal training; however, the practice may be conveyed implicitly.
Though content regarding patients’ rights is embedded in the formal curriculum, some educators and health facility staff demonstrate stigmatising and prejudicial behaviour towards “unworthy” patients, as do high-ranking government officials and members of nativist vigilante groups. This includes the then Limpopo MEC for health, Dr Phophi Ramathuba, whose 2022 rant at the bedside of a hospitalised foreigner was widely circulated on social media.
To address the gap in knowledge regarding perceptions of patient worthiness, examine the factors that underlie such perceptions and explore learning strategies to minimise the practice of triaging socially marginalised patients, a group of nurses and cross-border migrants — a socially marginalised population in South Africa — engaged in critical reflection and dialogue with me in Cape Town for one year as part of a doctoral research project. This study helps explain why perceptions of patient (un)worthiness persist in South Africa and describes an alternative approach to traditional in-service training that may address this issue.
Findings
Stereotypes ascribed to the socially marginalised shape perceptions of their relative deservingness which, in turn, maintain hierarchies and shift blame for systemic failures onto individuals. Worthiness determinations on the part of clinicians, support staff and patients from the general population justify dehumanising actions that harm socially marginalised patients, bolster social and institutional hierarchies and preserve the unequal status quo.
A strict and inflexible hierarchy pervades the public health system, including the Primary Health Care facility, where doctors rank higher than nurses, operational managers (who are themselves nurses) rank higher than front-line nurses, clinicians and support staff rank higher than patients and patients from the general population rank higher than those from socially marginalised groups.
The rigid hierarchy within the Primary Health Care facility precludes nurses from speaking freely to their supervisors for fear of being disciplined. Frustration with the rigid organisational structure can cause overworked clinicians to direct their anger towards those who occupy lower positions in this stratified system, resulting in patient mistreatment. Socially marginalised patients on the receiving end of mistreatment might, in turn, be reluctant to share their concerns for fear of repercussions.
Socially marginalised patients are perceived as competitors for scarce health resources, including the clinician’s time, and are therefore considered a threat to the health system. Likewise, nurses in South Africa are often blamed for a range of systemic health challenges beyond their control.
Rather than criticise a government that allocates insufficient funds and personnel to the health system, vigilante groups perpetuate the misconception that cross-border migrants are to blame for systemic problems such as long waiting times and medication stockouts.
Instead of questioning a system that requires them to queue for hours, frustrated patients may blame socially marginalised people who, like them, are seeking health services. The tendency for patients from the general population to stereotype and blame fellow socially marginalised patients illustrates how historical hierarchies are maintained, both in institutions and communities, and how apartheid-era divide-and-conquer strategies that pit Africans against Africans continue in the present day.
Challenging the system
It is easier and safer to blame patients and clinicians for systemic failures than to challenge the system itself. Stand-alone ‘sensitisation’ workshops have failed to shift negative perceptions of socially marginalised people that result in determinations of (un)worthiness. The assumption that a single workshop will solve entrenched sociocultural and systemic problems does a disservice to both learners and patients.
In-service training is unlikely to change problematic attitudes and behaviour if systemic challenges remain unaddressed. Moreover, the traditional didactic approach can exacerbate systemic issues by conveying the demotivating message that all clinicians in the primary Health Care Facility mistreat patients. In contrast, counter-narratives that encourage health workers, government officials and patients to question their assumptions about the underlying causes of health system challenges might diminish the practice of shifting blame for systemic failure onto socially marginalised patients and the clinicians who care for them.
The research project described here brought people on disparate sides of a contentious issue together to collaborate. Encouraging individuals who might not typically interact to critically reflect on assumptions and beliefs that perpetuate misperceptions, and to consider the perspectives of others over time, provides an alternative to the traditional training approach and holds promise as a strategy to deter worthiness determinations.
Fostering opportunities for dialogue, in tandem with steps to resolve entrenched operational issues within the health system, increases the likelihood that any resulting perspective shifts will endure.
Sara Ilyse Jacobson is a global health specialist, instructional designer and registered nurse with a background in health workforce capacity development. She recently completed a PhD in Health Sciences Education at the University of Cape Town.