Laetitia Rispel, Boitumelo Molomo & Sellinah Dumela South African case study on social exclusion Free download from www.hsrcpress.ac.za This work was made possible through funding provided by the World Health Organization (WHO) via Lancaster University. It was undertaken as work for the SEKN established as part of the WHO Commission on the Social Determinants of Health (CSDH). The views presented in this report are those of the authors and do not necessarily represent the decisions, policy or views of WHO or CSDH Commissioners. Published by HSRC Press Private Bag X9182, Cape Town, 8000, South Africa www.hsrcpress.ac.za First published 2008 ISBN 978-0-7969-2231-1 © 2008 Human Sciences Research Council Print management by GREYMATTER & FINCH Printed by RSA Litho Distributed in Africa by Blue Weaver Tel: +27 (0) 21 701 4477; Fax: +27 (0) 21 701 7302 www.oneworldbooks.com Distributed in Europe and the United Kingdom by Eurospan Distribution Services (EDS) Tel: +44 (0) 20 7240 0856; Fax: +44 (0) 20 7379 0609 www.eurospanbookstore.com Distributed in North America by Independent Publishers Group (IPG) Call toll-free: (800) 888 4741; Fax: +1 (312) 337 5985 www.ipgbook.com Free download from www.hsrcpress.ac.za List of tables, figures and boxes iv Acknowledgements v Acronyms and abbreviations vi Executive summary vii Chapter 1 The global and national context 1 Global response to health inequities 1 South African case study 2 Country profile 2 The current context 6 Chapter 2 Aims and methodology 15 Aims and focus 15 Methodology 16 Chapter 3 Social exclusion: constructs and policies 19 Constructs of social exclusion 19 Affected groups 22 The impact of social exclusion 23 Social inclusion policies 25 Chapter 4 Appraising South African policies 29 Free healthcare 29 Cash transfers and support grants 31 Bana Pele 33 Summary 38 Chapter 5 Key issues and recommendations 41 Key issues 41 Recommendations 41 References 43 CONTENTS Free download from www.hsrcpress.ac.za iv Tables Table 1.1: Health inequalities in South Africa by race (1994) 5 Table 1.2: Selected indicators for South Africa from HDR (2006) 9 Table 1.3: Selected maternal and child health indicators for South Africa (1998) 12 Table 1.4: The ten leading underlying causes of death (2004) 12 Table 1.5: Rank comparison of the five leading causes of death by race (2004) 13 Table 2.1: Key informant interview topics 16 Table 3.1: Health inequities in South Africa (1998) 22 Table 3.2: Categories of policies addressing social exclusion or its proxies 26 Table 4.1: Types of CSGs and eligibility criteria 32 Table 4.2: Bana Pele principles 35 Table 4.3: Summary of policies appraised 38 Table 4.4: Enabling factors for policy implementation 38 Figures Figure 1.1: South Africa and its provinces 3 Figure 1.2: South Africa’s population pyramid – percentage of the total South African population in each five-year age group by sex (October 2001) 3 Figure 1.3: Official unemployment rate among those aged 15–65 years by province (October 1996 and October 2001) 8 Figure 1.4: Burden of disease by province (2005) 10 Figure 1.5: The HIV epidemic among South African antenatal clinic attendees (1990–2002) 10 Figure 1.6: HIV prevalence by age and sex, HSRC household survey of HIV (2005) 11 Figure 4.1: Bana Pele identification and referral form 36 Boxes Box 1.1: The legacy of apartheid health services 4 Box 1.2: Summary of the National Household Survey of Health Inequalities in South Africa (1995) 5 Box 1.3: Trends for social determinants of health (1996–2001) 7 Box 3.1: Constructs of social exlusion 19 LIST OF TABLES, FIGURES AND BOXES Free download from www.hsrcpress.ac.za v This case study was funded by the World Health Organization (WHO) via Lancaster University . Nico Jacobs is thanked for his excellent administrative and logistical support. We wish to acknowledge the support of Professor Jennie Popay, the overall Social Exclusion Knowledge Network (SEKN) coordinator. We also want to thank Karl Peltzer for his input and comments on drafts of the report. We have greatly benefited from the input and contributions of the 22 key informants, and other network members. Marijke van Vuuren is thanked for editorial assistance. We are grateful to the South African Human Sciences Research Council (HSRC) for giving home to the sub-regional hub. Lastly, we thank Mary Ralphs and her production team at the HSRC Press. ACKNOWLEDGEMENTS Free download from www.hsrcpress.ac.za vi AIDS Acquired Immune Deficiency Syndrome ANC African National Congress CASE Community Agency for Social Enquiry CBO community-based organisation CCT conditional cash transfer CSDH Commission on Social Determinants of Health CSG child support grant DoH Department of Health DSD Department of Social Development GDP gross domestic product GPG Gauteng Provincial Government (South Africa) HDI Human Development Index HDR Human Development Report HIV Human Immuno-deficiency Virus HSRC Human Sciences Research Council (South Africa) IMR infant mortality rate IRIF Inter-Regional Inequality Facility KN knowledge network MDG Millennium Development Goal PIMD provincial indices of multiple deprivation PMTCT prevention of mother-to-child transmission of HIV RDP Reconstruction and Development Programme RSA Republic of South Africa SASSA South African Social Security Agency SD social determinants SDH social determinants of health SEKN Social Exclusion Knowledge Network SSA sub-Saharan Africa StatsSA Statistics South Africa TB Tuberculosis UNDP United Nations Development Programme WHO World Health Organization ACRONYMS AND ABBREVIATIONS Free download from www.hsrcpress.ac.za vii The World Health Organization (WHO) has established a Commission on Social Determinants of Health (CSDH) to suppor t countries and global health partners in addressing the social factors leading to ill health and health inequities. The most important objective of the Commission is to leverage policy change by turning existing social determinants of health (SDH) public health knowledge into actionable global and national agendas. The Social Exclusion Knowledge Network (SEKN) was established as part of the work of the Commission. The scope of the SEKN is to focus on and examine the relational processes excluding groups of people in particular contexts from engaging fully in community and social life. South African case study The aims of the South African case study were to: Explore the various constructs of social exclusion and its impact on health and • well-being; Examine the relational processes that serve to exclude groups of people in particular • contexts from engaging fully in community and social life, at both macro and micro levels; Identify and appraise examples of policies, programmes, actions and institutional • arrangements that have the potential to address exclusionary processes and ultimately reduce the impact of health inequalities; and Explore factors that enable and/or constrain the implementation and scaling up of • policies and actions to address social exclusion. This South African case study is based primarily on a review of published literature and key informant interviews. The document is not intended to provide a comprehensive overview or scientific analysis of social exclusion experiences or activities. Rather, its aim is to draw on available knowledge and experience, to highlight lessons learned, and to contribute to the development of key recommendations of the SEKN. Chapter 1 gives a high-level overview of the Republic of South Africa (RSA), describes key aspects of the current policy landscape relevant to promoting health equity, and summarises available baseline indicators of the scale of inequality. In 2006 the RSA, had an estimated mid-year population of 47.4 million, of which 51 per cent were female. Life expectancy at birth was estimated at approximately 49 years for males and 53 years for females. The 2006 Human Development Report (UNDP 2006) ranks the RSA at 121 out of 177 countries. The overall Human Development Index (HDI) decreased from 0.691 in 2000 to 0.653 in 2004, mainly due to the HIV and AIDS epidemic. South Africa has a quadruple burden of diseases, consisting of HIV and AIDS, poverty-related diseases, chronic lifestyle diseases, and high injury rates. The country’s legacy of apartheid is also reflected in racially-based health status inequalities, many of which persist more than a decade after democracy. The black African majority continue to bear the greatest burden of ill-health in the country. Health inequities are also influenced by levels of wealth, geography, and the educational level achieved by mothers. Access to health services is lowest for those in the poorest 20 per cent of the population, with 51 per cent immunisation coverage of children in the poorest 20 per cent, compared with 70 per cent for those in the richest 20 per cent. Similarly, infants and children under five in the poorest 20 per cent are more likely to die, compared with those in the richest 20 per cent. Chapter 2 summarises the conceptual approach to and methods used in the case study, including limitations. In addition to the literature review, 22 key informants in South Africa EXECUTIVE SUMMARY Free download from www.hsrcpress.ac.za South African case study on social exclusion viii were interviewed, representing senior officials in national ministries, academics and members of civil society. A semi-structured interview schedule consisting of 30 questions was used to collect information from key informants. The project was constrained by time limitations and numerous competing priorities. Although a small group was interviewed and no generalisations can be made, the views expressed present rich perspectives on and insights into the various aspects of social exclusion and inclusion, and the pathways to health inequalities. Chapter 3 describes the key issues and themes arising from the South African case study, comments on informants’ perceptions of affected groups, and the impact of social exclusion on health and well-being, and concludes with the identification of policies and programmes with the potential to reduce social exclusion and reduce health inequalities. The social exclusion discourse has been more extensive in the north and alternative discourses of poverty, marginalisation and vulnerability have received much more attention in South Africa. The key informants’ constructs of social exclusion include four main categories, although these tend to overlap in practice. The contextual construct includes proxy terms and/or alternative discourses of poverty, marginalisation and disadvantage. The relational perspective includes political and social systems and processes, and emphasises the multi- dimensional nature of social exclusion. Extreme marginalisation focuses on categories of excluded people. The paradox of exclusion/inclusion incorporates the notion of the adverse incorporation of certain groups of people. The pathways between social exclusion and health are complex, but four main mechanisms are useful in explaining some of the complexity. The pathways are social stratification, differential exposure, differential susceptibility and differential consequences. Chapter 4 presents an appraisal of three of the policies or actions identified as part of the South Africa case study: free healthcare policy; social transfers, with a particular emphasis on the child support grant, and the Bana Pele (‘children first’) Programme, a Gauteng provincial programme for integrated child care. The free healthcare policy has been effective in removing barriers to access. Positive effects include an increased utilisation of primary healthcare services, and an increased use of preventive services such as antenatal care and family planning. The policy has not had an impact on health status, but that was not its primary intention. However, there have been unintended consequences, the most important of which has been negative health-worker attitudes because of inadequate communication and their lack of involvement in policy design and discussions on implementation. With regard to the child support grant, the number of beneficiaries has been rising rapidly, reaching in excess of six million children in South Africa. Studies have shown that social grants are the most pro-poor item of government expenditure and provide households with income, and support second-order effects that further reduce poverty. These include sending young children to school, providing better nutrition for children, and looking for work more intensively. The grants have been plagued by implementation difficulties including fraud, delays in approving grant applications, and difficulties in accessing payment, with great inequities across provinces. Relatively little is known about the link between government social grants and the private social safety net, or about the differential impacts of social grants, by gender and by geographical areas, or their effects on health or labour migration. It has been argued that the use of a means test and different interpretations of means testing may act as a significant barrier to the greater Free download from www.hsrcpress.ac.za ix take-up of social grants among poor households, particularly in rural areas, where the poor hav e the least access to the official identification documents necessary to access social grants. A rapid appraisal of the provincial Bana Pele Programme shows that many of the services are not new in the current South Africa social assistance system. The Bana Pele Programme is implemented through an integrated approach, by identifying, referring and tracking beneficiaries, and through the establishment of a common database of children in need within the province. While Bana Pele shows promise and appears to be a worthwhile endeavour, a formal impact assessment of the programme has not been done. Many of the current indicators are output-focused (number of beneficiaries) rather than impact-focused (reduction in vulnerability). Factors enabling policy implementation include research evidence; political support; community or civil society support, advocacy and lobbying; public consultation and debate about policy and programmes; as well as the ability to enforce policy through legislation, a functioning accountability system, economic growth and cultural support. The main barriers identified to policy implementation were wide-ranging, and include political and fiscal constraints, a lack of skills and human resources, the attitudes of public servants, vested interests of the private sector, misuse or default by consumers, and inadequate policy communication strategies. The conclusion highlights that many of the policies in post-apartheid South Africa have been directed at correcting historical injustices and redressing the wrongs of the past. However, after more than a decade of democracy, many of the historical and intractable inequalities remain at both macro and micro levels. The rapid review also shows that greater attention is needed to ensure the effective implementation of these policies. Recommendations Measurement of health inequalities More attention needs to be paid to the measurement of heath inequalities, including the extent, degree and gradient of these inequalities. Policy design, and development A broader country-wide framework is needed to recognise and address health inequalities, which includes the social context, sustainable development, health-worker attitudes and decisive action against HIV and AIDS. The New Strategic Plan on HIV and AIDS provides hope, but the challenge is in its implementation and communication Implementation The following steps are required to address health inequalities: Raising implementers’ consciousness of the steps necessary to address health • inequalities; Reviewing and/or evaluating approaches to the training of policy implementers;• Ensuring the dissemination of information on good practices; and• Encouraging networking and the sharing of good practices.• Executive summary Free download from www.hsrcpress.ac.za South African case study on social exclusion x Community responses and advocacy The following is required in terms of community respose and advocacy: There is a need for greater advocacy and for increased attention to be paid to • addressing health inequalities at an intra-country and inter-group level; Communities need to be sensitised and involved with actions to address health • inequalities and their causes; and Advocate for public ministries and civil- society (including private sector) cooperation • and coordination to reduce health inequalities. Monitoring and evaluation The overall monitoring and evaluation system requires strengthening, with sufficient attention paid to funding, human resources, user-friendly systems and implementation issues. The involvement of implementing agencies is once again critical, as is capacity building. Free download from www.hsrcpress.ac.za [...]... appropriate concept? Most of the informants emphasised the importance of context in understanding definitions and terms The relational perspective emphasised the multi-dimensional nature of social exclusion and the political and social systems and processes that may lead to exclusion 19 South African case study on social exclusion A selection of views is highlighted below There is disease-based exclusion, class-based... actions and institutional arrangements that have the potential to address exclusionary processes and ultimately reduce health inequalities and their impact; and 1 South African case study on social exclusion • Conduct selected-country case studies to explore factors that enable and/or constrain the implementation and scaling up of policies and actions to address social exclusion or to promote social. .. categories of excluded people • The paradox of exclusion and inclusion and the notion of adverse incorporation In the theme, which we have termed a contextual construct of social exclusion, key informants questioned the ‘importing’ of the notion of social exclusion into South Africa, as illustrated by the quotations below: This concept has been exported to South Africa where the problem is not a small... the conceptual approach to, and the methods used in, the case study, including limitations Chapter 3 describes the key issues and themes arising from the South African case study, comments on informants’ perceptions of affected groups and the impact of social exclusion on health and wellbeing, and concludes with the identification of policies or programmes with the potential to reduce social exclusion. .. potential to reduce social exclusion and ultimately reduce health inequalities Fortuitously, two of the members of the SEKN in SSA also attended a conference on socioeconomic exclusion that was held in Cape Town, South Africa, and useful insights were gleaned from this conference Aims and focus The aims of the South African case study were to: • Explore the various constructs of social exclusion in the country... schedule, consisting of 30 questions, was used to collect information from key informants The questions focused on the areas highlighted in Table 2.1 Table 2.1: Key informant interview topics Category Areas explored Free download from www.hsrcpress.ac.za Constructs of social exclusion and its effects/impact on health/well-being, including views on social exclusion • Views on understanding social exclusion. .. class-based exclusion, the exclusion drawn out of the behaviour of health workers, and the issue of marginalised and displaced people and refugees Quite often there is a pattern of social exclusion of rural and informal settlement areas, and there is social exclusion on the basis of religion Social exclusion is very broad-based in terms of how it manifests There are certain pathways to social exclusion: some... and inclusion and on health inequalities 17 Free download from www.hsrcpress.ac.za CHAPTER 3 Social exclusion: constructs and policies This chapter describes the key issues and themes arising from the South African case study, comments on informants’ perceptions of the most affected groups, the impact of social exclusion on health and well-being, and concludes with the identification of policies and... The concept of social exclusion also includes exclusion from healthcare, water supply, social grants as well as access to education We know that education is one of the most powerful sectors that can impact on women’s health Social exclusion starts working at the village and local community level, at the town and city level, region or province level, the national level, at the level of Africa Beyond... society 25 South African case study on social exclusion Table 3.2: Categories of policies addressing social exclusion or its proxies Category Enabling framework or value system Examples Brief description Reconstruction • Developed by the ANC and alliance partners and through extensive community consultations and Development • An important development strategy, which became the Programme blueprint for social . implementation and scaling up of policies and actions to address social exclusion or to promote social inclusion. South African case study The South African case. African National Congress CASE Community Agency for Social Enquiry CBO community-based organisation CCT conditional cash transfer CSDH Commission on Social