Ensure the NHI is fit for women

Deputy Health Minister Gwen Ramokgoba held a national video conference with feminist activists and researchers last Thursday on the crisis in women's sexual and reproductive health. The conference was held to launch a special issue of the feminist journal Agenda, titled The Politics of Women's Health in South Africa, which we co-edited.

The meeting was held at a time when the introduction of national health insurance (NHI) is imminent, which will entail far-reaching reforms to our health system. As we told the deputy minister, the NHI could be vital in comprehensively improving women's health, but only if it is designed to do so from the outset.  

What are the major elements of the crisis that could be addressed by the NHI?

HIV is the leading cause of maternal mortality. According to the 2010 South African Health Review of the Health Systems Trust, the number of women who die while pregnant or shortly after being pregnant has doubled since 1990. High rates of sexual assault and domestic violence also have adverse implications for women's health and has been amply documented. Less prominent  HIV-related women's health issues are also emerging, such as the serious and largely unaddressed issue of coerced sterilisations of women living with HIV. Another critical issue is cervical cancer, a preventable and treatable Aids-defining condition especially common among women living with HIV. The human papillomavirus causes cervical cancer, the leading cause of cancer deaths in South African women. According to the Cancer Association of South Africa, nine women die from cancer every day in our country.

The women's health crisis has two main causes.

First, we are living through one of the worst HIV epidemics in the world. HIV has a disproportionately adverse effect on women. More are living with the virus and they bear a greater burden of care for those rendered sick or orphaned by it, tasks generally deemed "women's work".

Second, our public health facilities are underfinanced, which means poor women not only get health services of a lower quality, but also have to do much additional care work themselves.

The crisis in women's health highlights the important work ahead in creating a gender-equal developmental state. Several proposals in the NHI green paper could realise women's constitutional right to access to health services. As part of the introduction of the NHI, an office of health-standards compliance will be created to deal with patients' complaints, among other things, and could help patients who have experienced unethical and unprofessional practices to seek redress.

Improving maternal and child health is, and should be, a central goal of NHI financing. At the same time, not all women are mothers and some are past their child-bearing years. They also have a right of access to health services such as those to prevent and treat cervical cancer.

We urge the treasury and the department of health to work together to cost and ring-fence NHI funds for evidence-based women's health interventions aligned with international best practice.   

Medical advances
In the arena of cervical cancer, for instance, increasing service provision could have dramatic long-term effects. There have been substantial medical advances in prevention and diagnosis recently, on which the government has yet to capitalise. Vaccines could prevent 70% of cervical cancer cases and visual inspection with acetic acid (vinegar) is a promising diagnostic technique.

Janine Hicks of the Commission for Gender Equality agreed at our launch to convey our recommendation for public hearings on the crisis in women's health. The deputy minister was open to the idea of a national summit on how the NHI could improve women's health.

Men and women have different sexual and reproductive-health needs and a one-size-fits-all approach cannot suit women – or men, for that matter. The NHI will enhance women's status only if it reflects this reality. The system can dramatically improve women's health if the best interventions are carefully assessed, costed and ­provided on a universal basis from the outset.  

Mandisa Mbali is a lecturer in social anthropology at Stellenbosch ­University. Sethembiso Mthembu is the executive director of the Her Rights Initiative. The Agenda special issue is available for free for two weeks at tandfonline.com/r/unisa14

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