SAHR 2007 - Health Systems Trust

Socio-economic indicators
As long as poverty remains a key determinant of health,
indicators of socio-economic status will remain important
inputs for health policy-making and management. Measures
of poverty are thus important, but also highly contested.
The Treasury has announced that Government intends to
develop an official “poverty line” for South Africa, “to assist in
measuring the extent of household poverty and monitoring
progress in poverty reduction” [Poverty line]. The proposal is
to base this poverty line on minimum food needs for daily
energy requirements, plus essential non-food items. In addition
to the official poverty line, two additional thresholds
have been proposed. One, below the poverty line, will be
used to measure extreme poverty. The other, above the
poverty line, will measure a broader level of household
income adequacy. Starting with a pilot period, Statistics SA
expects to publish the new series before the end of 2007,
update the poverty line and the lower and upper thresholds
annually (based on a basket of goods and the consumer
price index), and review the measure every 5 years.
Depicting poverty at a district level has been accomplished
using various indices, such as the multiple deprivation index
cited in the District Health Barometer report [DHB 2005/06].
Alternative indices have been proposed, such as that used
in the “Baseline survey of the 21 ISRDP and URP nodes” [ISRDP
& URP Baseline] prepared for the Department of Social
Development in November 2006. This report was based on
8 387 individual interviews conducted in the 13 Integrated
Sustainable Rural Development Programme nodes and the
8 Urban Renewal Programme nodes, at the halfway mark of
these 10-year programmes. While the results are not easily
incorporated into this chapter, some are highlighted here
as indicative of the more nuanced and in-depth data that
are becoming available. The rate of unemployment averaged
79.1% in the rural and 62.6% in the urban nodes.
Not surprisingly, government grants were described as the
“mainstay of many households” in these settings. Across
all 21 nodes, 50.4% of households were female-headed.
While access to sanitation had improved in every urban
node compared to the 2002 baseline, the situation in rural
nodes was mixed. While 77% of URP households had a flush
toilet inside the house or yard, only 20% of ISRDP households
enjoyed the same access. In the rural nodes, 28% of
respondents obtained their water from a source other than
a “piped” one (e.g. a borehole, river, dam or truck), a source
likely to be of poor quality. Although the specific health question
used (proportion of household infected by malaria in
the past 12 months) was of limited use, except in particular
provinces, other questions posed were instructive. Half of
all respondents described their health as “poor” (53% in
the rural nodes and 43% in the urban nodes). The health
problem perceived to be most significant varied, but the four
main problems identified were HIV/AIDS, alcohol, TB and
drug abuse. Of relevance to the discussion on the extent
of use of the private sector, while 72% of all respondents
reported using public clinics and 11% reported using public
hospitals, 14% reported using private medical practitioners.
This last proportion varied considerably, from 31% in urban
Mitchell’s Plain to 3% in rural Sekhukhune district. Interestingly,
2% or less reported using private hospitals, pharmacies or
traditional healers. The report called for qualitative research
into the reasons for patient choices, beyond the predictable
factors of cost, location and convenience, in order to understand
why patients with access to free PHC services chose
to use private medical practitioners or secondary / tertiary
hospitals.
Another new secondary source of socio-economic data is
the Development Indicators Mid-term Review [Development
Indicators 2007], issued by the Presidency in 2006, midway
through the government’s term of office. Using a poverty
line based on an income of R3 000 per capita per annum
(expressed in constant 2000 Rands), it showed that fewer
people were living in poverty in 2006 (43.2%) than was the
case in 1993 (50.1%). However, the report did note that “the
rate of improvement of income for the poor has not matched
that of the rich” and that “while income poverty is declining,
inequality has not been reduced”. This was also shown by
the increase in the Gini coefficient, which measures income
inequality. The value of this measure rose from 0.672 in 1993
to 0.685 in 2006. The report also contains data on the population
in each of 10 Living Standards Measure groups from
2001/02 to 2005/06. The number of people in the poorest
category (LSM 1) dropped substantially from 2001/02
(3 456 000) to 2005/06 (1 895 000). There was evidence of
a growing “middle class”, as represented by those in LSM
4-10. The Theil index is another measure of inequality. While
inequality by this measure has been rising, it has changed
in nature. Inequality between races has declined, while
inequality within race groups has grown. In 1993, 61 per cent
of inequality was between race groups, however, by 2006
inequality between race groups had declined to 40 per
cent. Over the same period, inequality within race groups
has become much more prominent.
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