When I was about 10 years old, I desperately wanted to become a doctor. While I was still in primary school, my father joined the Automobile Association and could choose a free gift from the AA. I insisted that he choose the first-aid kit. When it eventually arrived in the post I was elated: it had bandages, a wooden splint for fractures, and various creams for burns and other aches and pains.
In order not to waste any time on honing my skills for my future profession, I carried this kit to school every day for a year. My motives were altruistic: I wanted to help fellow classmates who became ill, and would also have been very happy to assist my Standard 3 teacher, who was rather attractive. If I must be completely honest, though, I was really hoping someone would break an arm so that I could use the wooden splint and the bandages in the first-aid kit. Unfortunately, no one did.
The lesson from my primary school medical stint is that I was waiting for an accident to happen. I was waiting for something to go wrong so that I could assist someone. It appears that medicine in South Africa today is mostly reactive: our healthcare system remains largely curative, with little or no scope for health promotion and disease prevention, which are essential for a comprehensive health system.
In the public service, the curative bias of our healthcare system stems from poor management and a lack of resources. In the private sector, medical aid companies are accused of limiting the doctor’s ability to adopt a health promotion model.
The inability to implement a health promotion model fully was one of the key issues raised by medical doctors I spoke to recently. I know little about the healthcare sector, so I took a list of questions to various healthcare practitioners, asking what the biggest challenges were in the sector.
The answers to my questions depended on the level of experience of the person I was interviewing.
Medical doctors who had been working in public health for less than 10 years indicated that staff shortages and a lack of resources and equipment were the major factors that impeded access to healthcare.
Doctors with more than 10 years’ experience, and who were in management positions, argued that the politicisation of healthcare, together with a bureaucratic public healthcare management system, remained the sector’s greatest challenges.
This anecdotal evidence is confirmed by a report released by prominent civil society organisations Section27 and the Treatment Action Campaign on the state of healthcare in Gauteng. It suggests three key reasons for the poor state of healthcare in the province: improper budgeting and financial management, poor supply chain management, and poor management generally.
The report also states that “the failures within the healthcare system must be addressed as a precursor to the implementation of the National Health Insurance (NHI). The NHI has the potential to improve equity and quality of healthcare in the country. However, high quality, functioning public facilities form the backbone of any national healthcare strategy. Acute crises in these facilities, left unaddressed, are likely to render ineffective any regulatory reforms aimed at improving care and have the potential to undermine the NHI reforms.”
The challenges identified and the solutions proposed in the report overlap to some extent with the recommendations made by the South African Human Rights Commission in its 2009 Report on Access to Health Care Services. The commission held public hearings on access to healthcare and made various recommendations in this regard. Yet, on the question of whether healthcare had improved or deteriorated between 1994 and 2009 – in other words, on the question of whether there had in fact been progressive realisation of the right to access healthcare – the report concluded that it was difficult to assess the situation with accuracy.
More recently, the commission held public hearings on access to water and sanitation across the country. This was largely in response to complaints we received about open toilets in Makhaza and Rammulotsi. I attended many of these hearings and was often struck by the level of anger towards the government.
From Bushbuckridge in Mpumalanga to Maboloka in North West, communities are angry. They are frustrated by the lack of delivery of basic services. They are tired of the excuses provided by their municipalities for failing to provide clean drinking water. And they are angry about the corruption in awarding contracts to provide sanitation services.
There is nothing like sitting in a town hall with hundreds of community members shouting at the local government officials addressing them to make you understand how the people are feeling.
Not that everyone shouts, of course. In Thaba Nchu in the Free State, an elderly man spoke calmly about the collapse of every single sanitation plant in the province. He had personally visited these sanitation plants.
Unfortunately, it appears that the government has not yet been able to make the link between access to water and other socioeconomic rights.
The commission has found that the government seems incapable of connecting the dots: without water, there is no proper sanitation. Without sanitation, there is an increase in illness and disease. An increase in illness places a burden on healthcare facilities and results in a loss of productivity. The loss of productivity in the workplace has an impact on the economy; the sick child cannot go to school.
Access to healthcare can, therefore, not be considered in isolation from access to other socioeconomic rights. This is what makes the progressive realisation of access to healthcare such a complex matter.
So, despite the commendable actions being taken by the minister of health, including the establishment of the National Health Insurance, his efforts need to be considered alongside the work of other government departments, including those of human settlements, water and environmental affairs, and basic education.
If our government fails to acknowledge that the right to dignity is connected to access to sufficient food and water – which in turn is connected to access to healthcare – it fails to recognise the interconnectedness and indivisibility of all human rights.
Kayum Ahmed is the chief executive of the South African Human Rights Commission. This is an edited extract from a speech he gave at the annual Steve Biko Centre for Bioethics Symposium at the University of the Witwatersrand