Adverse or acceptable: negotiating access to a post-apartheid health care contract

Globalization and Health

Jane Goudge³  Liz Thomas³  Loveday Penn-Kekana²  John Eyles¹  Bronwyn Harris³ 

[1] School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada;Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK;Health Policy Research Group, Medical Research Council of South Africa, Johannesburg, Gauteng, South Africa

关键词: Post-apartheid South Africa;    Defaulting;    Suffering;    Health care access;    Social contract theory;   

Others  :  802348
DOI  :  10.1186/1744-8603-10-35

 received in 2013-10-29, accepted in 2014-02-06,  发布年份 2014

【 摘 要 】

Background

As in many fragile and post-conflict countries, South Africa’s social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting.

Methods

Using in-depth interviews with 45 patients and 67 providers, and field observations from twelve health facilities in one rural and two urban sub-districts, we explore access narratives of those seeking and delivering – negotiating - maternal health, tuberculosis and antiretroviral services in South Africa.

Results

Although South Africa’s right to access to health care is constitutionally guaranteed, in practice, a post-apartheid health care contract is not automatically or unconditionally inclusive. Access barriers, including poverty, an under-resourced, hierarchical health system, the nature of illness and treatment, and negative attitudes and actions, create conditions for insecure or adverse incorporation into this contract, or even exclusion (sometimes temporary) from health care services. Such barriers are exacerbated by differences in the expectations that patients and providers have of each other and the contract, leading to differing, potentially conflicting, identities of inclusion and exclusion: defaulting versus suffering patients, uncaring versus overstretched providers. Conversely, caring, respectful communication, individual acts of kindness, and institutional flexibility and leadership may mitigate key access barriers and limit threats to the contract, fostering more positive forms of inclusion and facilitating easier access to health care.

Conclusions

Building health in fragile and post-conflict societies requires the negotiation of a new social contract. Surfacing and engaging with differences in patient and provider expectations of this contract may contribute to more acceptable, accessible health care services. Additionally, the health system is well positioned to highlight and connect the political economy, institutions and social relationships that create and sustain identities of exclusion and inclusion – (re)politicise suffering - and co-ordinate and lead intersectoral action for overcoming affordability and availability barriers to inclusive and equitable health care services.

【 授权许可】

   
2014 Harris et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Frenz P, Vega J: Universal health coverage with equity: what we know, don’t know and need to know. In Background paper for the First Global Symposium on Health Systems Research: 16–19 November 2010. Montreux; 2010. http://www.hsr-symposium.org/images/stories/9coverage_with_equity.pdf webcite
• [2]Dixon-Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Harvey J, Hsu R, Katbamna S, Olsen R, Smith L, et al.: Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol 2006, 6:35. BioMed Central Full Text
• [3]Thiede M, Akweongo P, McIntyre D: Exploring the dimensions of access. In The economics of health equity. Edited by McIntyre D, Mooney G. Cambridge: Cambridge University Press; 2007:103-123.
• [4]Laplante LJ, Working Group on Peace and Development (FriEnt): Linking peacebuilding and health in post-conflict settings. Bonn: FriEnt; 2011. http://www.medicusmundi.org/en/contributions/events/2012/health-systems-strengthening-in-fragile-states.-mmi-ntwork-meeting/collection-of-case-studies/frient-peacebuilding-and-health-in-postconflict.pdf webcite
• [5]Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D: Health in South Africa 1: The health and health system of South Africa: historical roots of current public health challenges. Lancet 2009, 374:817.
• [6]Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, Chersich M: Inequities in access to health care in South Africa. J Public Health Pol 2011, 32:S102-S123.
• [7]Veary J: Challenging urban health: towards an improved local government response to migration, informal settlements, and HIV in Johannesburg. 4 2011. http://www.globalhealthaction.net/index.php/gha/article/view/5898/8646 webcite
• [8]Weirich P: Exclusion from the social contract. Polit Philos Econs 2011, 10:148-169.
• [9]Statutes of the Republic of South Africa: Constitution of the Republic of South Africa. (No. 108 of 1996). Pretoria: Constitution of the Republic of South Africa. (No. 108 of 1996); 1996.
• [10]Veitch K: Social Solidarity and the Power of Contract. J Law Soc 2011, 38:189-214.
• [11]Gilson L, McIntyre D: Post-apartheid challenges: household access and use of health care in South Africa. Int J Health Serv 2007, 37:673-691.
• [12]McIntyre D, Gilson L: Redressing dis-advantage: Promoting vertical equity within South Africa. Health Care Anal 2000, 8:235-258.
• [13]Hassim A, Heywood M, Berger J (Eds): Health & Democracy: a guide to human rights, health law and policy in post-apartheid South Africa. 1st edition. Cape Town: Siber Ink; 2007.
• [14]Friedman S: Another elephant? Prospects for a South African social contract. In Policy, Issues and Actors. Johannesburg: Centre for Policy Studies; 1991:19.
• [15]Mills CW: The Domination Contract. Cambridge: Polity Press; 2007.
• [16]O’Brien K, Hayward B, Berkes F: Rethinking social contracts: building resilience in a changing climate. Ecol Soc 2009, 14(2):12. [online] http://www.ecologyandsociety.org/vol14/iss2/art12/ webcite
• [17]Solomon RC: A passion for justice: Emotion and the origins of the social contract. Reading, Massachusetts: Addison-Weslet; 1990.
• [18]Mills CW: The racial contract. Ithaca, New York: Cornell University Press; 1997.
• [19]Pateman C: The sexual contract. Stanford, California: Stanford University Press; 1988.
• [20]Charmaz K: ‘Discovering’ chronic illness: Using grounded theory. Soc Sci Med 1990, 30:1161-1172.
• [21]Kleinman A: The illness narratives: suffering, healing and the human condition. New York: Basic Books; 1998.
• [22]Barolsky V: Transitioning out of violence: snapshots from Kathorus. Centre for the Study of Violence and Reconciliation: Braamfontein; 2006.
• [23]Mayosi BM, Lawn JE, van Niekerk A, Bradshaw D, Abdool Karim SS, Coovadia HM: Health in South Africa: changes and challenges since 2009. Lancet 2012, 380:2029-2043.
• [24]Cleary S, Birch S, Chimbindi N, Silal S, McIntyre D: Investigating the affordability of key health services in South Africa. Soc Sci Med 2013, 80:37-46.
• [25]McIntyre D: Private sector involvement in funding and providing health services in South Africa: implications for equity and access to health care. Regional Network for Equity in Health in Southern Africa.: Harare; 2010.
• [26]Jewkes R, Abrahams N, Mvo Z: Why do nurses abuse patients? Reflections from South African obstetric services. Soc Sci Med 1998, 47:1781-1795.
• [27]Silal S, Penn-Kekana L, Harris B, Birch S, McIntyre D: Exploring inequalities in access to and use of maternal health services in South Africa. BMC Health Serv Res 2012, 12:120. BioMed Central Full Text
• [28]Von Holdt K: The South African Post-Apartheid Bureaucracy: Inner Workings, Contradictory Rationales and the Developmental State. In Constructing a Democratic Developmental State in South Africa: Potentials and Challenges. Edited by Edigheji O. Cape Town: HSRC Press; 2010.
• [29]Blaauw D, Penn-Kekana L: Maternal Health. In South African Health Review. Edited by Padarath A, Fonn S. Durban: Health Systems Trust; 2010.
• [30]National Committee on Confidential Enquiries into Maternal Deaths: Saving Mothers 2008–2010: The Fifth Report on Confidential Enquiries into Maternal Deaths in South Africa. Pretoria: Government Printer; 2012.
• [31]UNAIDS: Update. Special Report. UNAIDS; 2013. http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2013/20130521_Update_Africa.pdf webcite
• [32]Chase SE: Narrative Inquiry: Still a field in the Making. In The SAGE Handbook of Qualitative Research. 4th edition. Edited by Denzin NK, Lincoln YS. Los Angeles: SAGE Publications; 2011:421-434.
• [33]Freeman M: Life “on holiday”? In defense of big stories. Narrat Inq 2006, 16:131-138.
• [34]Georgakopoulou A: Thinking big with small stories in narrative and identity analysis. Narrat Inq 2006, 16:122-130.
• [35]Scollon R, Scollon S: Nexus Analyis: Discourse and the Emerging Internet. London: Routledge; 2004.
• [36]Fried J, Harris B, Eyles J: Hopes interrupted: accessing and experiences of antiretroviral therapy in South Africa. Sex Transm Infect 2012, 88:147-151.
• [37]Schneider H, Govender V, Harris B, Cleary S, Moshabela M, Birch S: Gender differences in experiences of ART services in South Africa: a mixed methods study. Trop Med Int Health 2012, 7:820-826.
• [38]Taylor-Powell E, Steele S: Collecting evaluation data - direct observation. In Program Development and Evaluation (G3658-5). Madison: University of Wisconsin-Extension; 1996.
• [39]Fox NJ, Ward KJ, O’Rourke AJ: The ‘expert patient’: empowerment or medical dominance? The case of weight loss, pharmaceutical drugs and the Internet. Soc Sci Med 2005, 60:1299-1309.
• [40]Foucault M: Discipline and Punish: the Birth of the Prison. New York: Random House; 1975.
• [41]Butchart A: The “Bantu Clinic”: A Genealogy of the African Patient as Object and Effect of South African Clinical Medicine, 1930–1990. Cult Med Psychiatry 1997, 21:405-447.
• [42]Schneider H, le Marcis F, Grard J, Penn-Kekana L, Blaauw D, Didier F: Negotiating care: patient tactics at an urban South African hospital. J Health Serv Res Policy 2010, 15:137-142.
• [43]Marks S: Divided sisterhood: race, class and gender in the South African nursing profession. Basingstoke: St Martin’s Press; 1994.
• [44]McIntyre D, Goudge J, Harris B, Nxumalo N, Nkosi M: Pre-requisites for National Health Insurance in South Africa: Results of a national household survey. S Afr Med J 2009, 99:725-729.
• [45]Pooran A, Pieterson E, Davids M, Theron G, Dheda K: What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLoS ONE 2013, 8:e54587.
• [46]Foucault M: The History of Sexuality vol. 1: An Introduction. New York: Vintage; 1990.
• [47]Lewin S, Green J: Ritual and the organisation of care in primary care clinics in Cape Town, South Africa. Soc Sci Med 2009, 68:1464-1471.
• [48]Penn-Kekana L, Blaauw D, Schneider H: ‘It makes me want to run away to Saudi Arabia’: management and implementation challenges for public financing reforms from a maternity ward perspective. Health Policy Plan 2004, 19:i71-i77.
• [49]du Toit A: Living on the margins: the social dynamics of economic marginalisation. Dev South Afr 2008, 25:135-150.
• [50]Charmaz K: Stories of Suffering: Subjective Tales and Research Narratives. Qual Health Res 1999, 9:362-382.
• [51]Soskolne T, Stein J, Gibson K: Working With Ambivalence: Finding a Positive Identity for HIV/AIDS in South Africa. Cape Town: Centre for Social Science Research, University of Cape Town; 2003.
• [52]Gilson L: Acceptability, trust and equity. In The economics of health equity. Edited by McIntyre D, Mooney G. Cambridge: Cambridge University Press; 2007:124-147.
• [53]Boulle T: A review of the functioning of Health Committees in Nelson Mandela Bay Health District - with particular emphasis on identifying key challenges. Health care users’ experience as a focus for unlocking opportunities for quality health care. Cape Town: School of Public Health and Family Medicine, University of Cape Town; 2013.
• [54]Padarath A, Friedman I: The status of clinic committees in primary level public health sector facilities in South Africa. Health Systems Trust: Durban; 2008.
• [55]Republic of South Africa: Green paper on National Health Insurance (Government Gazette no 34523). Pretoria: National Department of Health; 2011.
• [56]Pham PN, Vinck P, Weinstein HM: Human rights, transitional justice, public health and social reconstruction. Soc Sci Med 2010, 70:98-105.