The Public Health Situation in South Africa

Although South Africa boasts a constitution considered amongst the most progressive in the world with a Bill of Rights that enshrines a range of rights to health and the conditions necessary for health, the practical realization of these rights remains elusive. For example, although the right of access to health care is one of a range of socio-economic rights to which all South Africans are entitled, there is abundant evidence that access to health care is limited by a range of institutional and poverty-related factors, such that the South African Human Rights Commission undertook an investigation into, and held a public hearing on the right to health in South Africa in 2007 (see Government Gazette of 16th February 2007, Notice 162 of 2007). There is a large gap between the human rights provisions in the constitution and what is happening on the ground, especially evident in rural & peri-urban areas where infant and young child mortality rates continue to climb, and where severe childhood undernutrition is being increasingly reported from health facilities. Additionally, levels of chronic undernutrition amongst young children have remained intractably high over the last decade. We know also that many incidents of the violation of people’s rights to health continue to occur in South Africa.

Yet, South Africa, as a signatory to the Millenium Development Goals (MDG’s) has committed itself to reducing under-5 child mortality by two thirds, reducing the maternal mortality ratio by 75% and halving the proportion of people who suffer from hunger. Far from meeting these goals, however, South Africa’s most recent health statistics suggest we are moving in the opposite direction. These ambitious goals will therefore not be realizable without a fundamental rethink in the way health is conceived, and practical commitment to policies and programmes that recognise health as a right consistent with international conventions and with the Alma Ata Declaration on Primary Health Care.   

However having a right to health in law is not the same as enjoying the right in practice.  Experience in South and Southern Africa¹ has shown the importance of civil society mobilization in realizing the right to health, particularly well illustrated in the success of the treatment access movement for HIV. Without civil society action for rights, reliance on the law or the goodwill of policy makers to adhere to a rights approach is unlikely to result in meaningful change. Indeed, pursuing rights in the absence of community mobilization loses any transformative potential² and is unlikely to effect meaningful and lasting changes in the underlying power relations that give rise to violations of human rights, such as those relating to health.

The Establishment of PHM-South Africa

In response to these challenges, a local chapter of the People’s Health Movement was established in South Africa in 2003. Consistent with the approach of the People’s Health Movement internationally³, which is a global umbrella network of civil society groups, researchers, activists and teachers involved in health, the local chapter of PHM was launched on the basis of operationalising health as a right, and reinvigorating civil society action for health that was characteristic of the anti-apartheid period. It is the position of PHM that only if civil society is well organized and active in pursuing health rights will the promise of constitutional rights to health be effectively realized.  PHM’s campaigning has also reaffirmed a global commitment to revitalizing Primary Health Care and a view of health that recognizes the social determinants of health as being much broader than just health care; rather socio-economic resources, such as adequate housing, clean water, provision of safe sanitation and access to basic nutrition are essential to good health. The right to health therefore embraces a wide range of claims to socio-economic entitlements beyond access to health care, notwithstanding the importance of health services.

To this end, PHM South Africa has worked carefully to build a network around a Campaign for the Right to Health and Health Care. This has involved a number of meetings with civil society groups over the past 3 years, the hosting of a workshop on the Right to Health at a joint inter-university seminar to mark Human Rights Day in March 2006, intensive media publicity on the right to health, culminating in the launch in September 2007 of the PHM’s Right to Health Campaign at a well attended public event in Khayelitsha near Cape Town .⁴

At present, current ‘membership’ of PHM in South Africa is over 500 people and approximately 75 organizations, mainly but not exclusively based in the Western Cape. PHM membership is drawn from academia, trade unions, social movements, non-governmental organisations and civil society (see Appendix 1 for member, affiliated and supporting organizations).  While the activities have primarily been located in the Western Cape, PHM has both a local and national focus, for example, in providing input to civil society lobbying on the Health Charter and labour action in the Health Sector in the past two years, as well as being increasingly acknowledged in the Southern Africa region as an important grouping in health civil society. Resource, including budgetary constraints, rather than restricted vision, have prevented PHM from expanding nationally, and interest in launching PHM in other regions, such as Gauteng and Kwazulu-Natal remains high. For example, a PHM contact working with the Valley Trust, a mass based community health worker organisation, has recently indicated an intention to facilitate the launching of PHM in Kwa Zulu-Natal and there are repeated enquiries from individuals in various centres about possible involvement in PHM activities.

Members of the PHM network in South Africa are organizations and individuals with a diverse range of skills and experiences that can be brought into the campaign, ranging from grassroots groups mobilizing around specific mandates (e.g. children’s rights, ARV access), specific constituencies (e.g. women farm workers, organized labour in the health sector, religious groups) and specific services (e.g. advice offices) to researchers and trainers, who can bring analysis and capacity building into the work of the campaign. In addition, PHM South Africa can draw on the experience and insights of PHM activists internationally through its global links, and has, for example, already done so in inviting a PHM India activist to South Africa to speak at its launch and through several members of PHM-SA participating in global PHM initiatives.

Broadly speaking, PHM sees itself providing a forum for mobilising progressive health professionals and advocating for the Primary Health Care approach, increasing information flows and knowledge on global and local issues impacting on health and health care and promoting participation in the development and monitoring of key health policies. This means that PHM will continue to actively engage in policy debates, and produce a regular newsletter, titled Critical Health Perspectives. For example, in 2005 PHM hosted a public panel on the crisis in the health system at the Public Health Association of South Africa conference in Midrand. PHM has also commented or made submissions on a range of health policy issues including the Health Charter, the Certificate of Need and supported other campaigns for basic services. Additionally PHM members have made invited presentations to academic, research trade union and civil society meetings and published prominent pieces in provincial and national print media. We anticipate these kinds of networking and advocacy activities will continue as PHM develops and builds ongoing partnerships in civil society. However, the RTH Campaign will be the flagship activity for PHM South Africa, given the urgency of the challenges facing the health system and the delivery of health-related basic services, and ongoing problems related to health inequalities. More so than any other PHM activities, the RTH campaign offers the opportunity to build CSO engagement in health issues most relevant to ensuring the realization of the right to health.

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¹  London L. Can Human rights serve as a tool for Equity? Equinet Discussion Paper 14.  Co-published by the Regional Network for Equity in Health in Southern Africa (EQUINET) and the University of Cape Town School of Public Health and Family Medicine, December 2003, Harare. Available at URL http://www.equinetafrica.org/bibl/docs/POL14rights.pdf
²  See for example, London L. ‘Issues of equity are also issues of rights’: Lessons from experiences in Southern Africa.  BMC Public Health 2007, 7:14. URL: http://www.biomedcentral.com/content/pdf/1471-2458-7-14.pdf and Haywood M, Altman D. Confronting AIDS: Human Rights, Law and Social Transformation. Health and Human Rights 2000; 5: 149-179
 ³ See URL: www.phmovement.org
 ⁴ See, for example, Wegerif M. Hundreds march for the right to health. Oxfam internal newsletter, 2007.