Introduction: South Africa
For the last twenty years, South Africa has been transitioning from apartheid to constitutional democracy. Therefore, there are many considerable changes in all major spheres, directed mainly to alter discriminatory practices. However, the health care system faces significant problems associated with epidemics, inadequate health care, and poor access to medical facilities. Moreover, the country comprises diverse nations as well as the combination of the poor and affluent worlds. The aim of this paper is to analyze the main characteristics of South Africa and its healthcare system in terms of its main components, focusing on the role of nurses in addressing major medical issues.
South Africa occupies the southernmost part of the African continent. It covers an area of 1,219,090 km2, which equals to one-seventh of the United States area. It is the tenth largest country by land area in Africa. The location of the country has had a profound influence on its historical geography. In is situated at the junction of Indian and Atlantic oceans. The most significant relief feature is the Great Escarpment that runs southwards from the Limpopo river to Zimbabwe border and then to the south of Lesotho, twisting northwards to the Orange River. The Great Escarpment divides South Africa into two physiographic areas, including interior plateau and the marginal strips of low land between the plateau and the coastal region. Such combination of latitude and elevation has conditioned the emergence of natural environments that do not exist anywhere on the continent. Due to the fact that most of the territory lies outside the tropics, the country is Africa’s truly temperate state.
According to WHO, in South Africa there were 52.7 million people in 2013. This country is one of the most racially and ethnically diverse nations in the world, and comprises four broad groups: the Nguni, the Scotho-Tswana, the Tsonga, and the Venda. The white population includes Afrikaners, English-speaking people, descendants of British settlers, and immigrants from the rest of Europe. Africans amount to 79.2 percent of the population, whereas white people constitute 8.9 percent, and the Indian and Asian population represents 2.5 percent. Moreover, the Khoisans, derogatorily known as Bushmen and Hottentots are the first and earliest inhabitants of the country. Gauteng province is geographically the smallest, but the most densely populated area with 22.3 percent of the total population living there. Northern Cape is the largest province with the smallest population of 2.1 percent. The population annual growth rate equals to 1.06 percent, and 88.6 percent of the total residents live in urban areas.
South Africa is a constitutional democracy with three-tier system of government, namely national, provincial, and local. National government has three levels, such as legislative with the capital in Cape Town, executive with the center in Pretoria, and judiciary in Bloemfontein. There are two houses of Parliament: the National Assembly, which passes laws for the whole country, and the National Council of Provinces, which is entitled to implement those laws in accordance with the needs of each province. The National Assembly elects the president, who performs the executive functions as a head of the state, and is in charge of the Cabinet. Moreover, each province has its own legislature that elects the Premier who will be the head of the provincial government and who can appoint an Executive Council.
South Africa is an economic powerhouse of Africa due to the large proportion of electricity generation, industrial capabilities, and mineral production. Minerals and energy have traditionally dominated the exports. In contrast to other African countries, South Africa has a well-developed manufacturing capacity that amounts to 25 percent of the GDP mainly in the industries of iron, steel, and heavy chemicals mining and processing. Although agriculture, forestry, and fishing provide considerable employment, the contributions of these sectors to GDP have been declining. Moreover, the country is notorious for the wide disparity between the rich who earn 58 percent of total national income, and the poor who receive a mere 17 percent.
State of Health
South Africa faces the quadruple burden of diseases, violence, and accidents due to concurrent epidemics, poverty-related illnesses, and non-communicable diseases. According to WHO, South Africa has the lowest life expectancy. For men, it is 57 years, and women live seven years longer. The infant mortality rate is 33.6 per 1000 live births, which is expected to increase due to the HIV/AIDs epidemic. Forty children per 1000 die before their fifth birthday mainly because of diseases related to unsafe water and inadequate sanitation and hygiene conditions.
In South Africa, around 5.54 million people live with HIV/AIDs with 18.8 percent of the adult population aged 15-49 infected. Geographically, the province of KwaZulu-Natal is the most affected by the disease. In urban informal settlements, people face a higher risk of contracting HIV/AIDs. By contrast, rural populations are less subject to epidemic due to its relative remoteness. The disease is not confined to homosexual men, drug users, and sex workers; it is rather a generalized heterosexual epidemic. In general, women are more vulnerable than man. Women 25-29 years old are affected disproportionally and comprise 40 percent of the total. The rate of HIV prevalence among females under 20 years old seems to become stable and amounts to around 16 percent.
All-cause mortality was in its peak in 2006 and thereafter the rate started to decline. For example, the decreasing trend in HIV/AIDs deaths is the result of the extensive application of antiretroviral therapy. As a result, the rate of deaths related to stroke, diabetes mellitus and chronic kidney disease has sharply declined, as these non-communicable diseases are related to AIDs.
Cheap and effective vaccines can prevent diseases associated with poverty, but they are the leading cause of infant mortality. For example, children in rural areas are less likely to be vaccinated than those in the urban areas. Moreover, poverty leads to under-nutrition that has resulted in the increased rate of cardiovascular disease and non-insulin dependent diabetes mellitus.
Another important problem is tuberculosis (TB). In South Africa, 380 000 people suffered from this disease, and 24 000 people died in 2014. This figure excludes HIV/AIDs-related deaths linked to TB, as many AIDs fatalities are caused by TB infection. The treatment success rate is over 80 percent, and immunization of babies with the Bacillus Calmette-Guerin vaccine has increased up to 85 percent in 2010. Nevertheless, it is estimated that 50 percent of HIV infected people will be infected with TB, and thus fourfold increase the rate in the next ten years.
Although malaria has been effectively eradicated in most of the world, there were 8654 reported cases in South Africa. The rate reached its maximum in 2004, and since has decreased by 20 percent. South Africa aims to eradicate malaria completely in the next few years by distributing the insecticide-treated mosquito nets. However, the use of these nets can induce the rise of insecticide-resistant mosquitoes, which can lead to recurrent epidemic outburst.
Violence and injuries occupy the second place after HIV/AIDs for causing premature deaths and disability. Violence directed against women poses another serious issue. For example, 13 percent of women experienced incidents of abuse from their partners. It has been reported that every six hours a woman is murdered by her partner. Furthermore, 8.2 percent of women reported to be raped and sexually assaulted. Annually, an estimated 3.5 million people refer to medical facilities with non-fatal injuries. Injuries from traffic accidents constitute three-quarters of death from external factors. Moreover, the rate continues to increase with 18 and 16 fatalities per 100,000 men and women, respectively. The most notable risk factor associated with injuries is alcohol abuse, which causes more than half of deaths due to violence and traffic accidents.
Due to its colonial past, the culture of South Africa is diverse. For this reason, this country is called “Rainbow Nation”. African black culture is famous for its art, dance, and music. Songs reflect the attributes of such styles as gospel, jazz, and rock with distinctive local attributes. House music, or kwaito, Zulu vocal (mbube), and jazzy street music (kwela) are based on indigenous sounds. Artists incorporate masks, statues, and figurines of tribal culture into their works. Art forms are linked tightly to traditional culture that reveals identity and shared history. The most renowned dance is gumboot, it originates from the time when in the mines black Africans slapped and thudded their Wellingtons in the dark in order to communicate with each other. In addition, beadwork adornment is an inseparable element of culture for both men and women. It has a symbolic meaning, as well as conveys individual’s history and experience through patterns and colors and determines a person’s ethnic group: Xhosa, Zulu or Ndebele.
In South Africa, alongside with the Westernized medical providers, traditional healers are involved in the treatment of people. There are estimated 150 000 to 200 000 healers in the country. A healer called an isangoma tries to help sick people by talking to their ancestors about the reasons why they are unhappy. After this, isangoma tells the ill to perform certain rituals to satisfy their ancestors, what in turn will heal him/her. Moreover, people may refer to inyanga, or herbalist that uses plants to cure aches and pains. Another group of healers is represented by umthakatis. They have an inherited skill to set bones, heal snakebites, and help deliver babies.
Healthcare System and Delivery
Governmental Health-Related Agencies
Governance of healthcare services encompasses control, accountability, transparency, and management of the services. The public health care is regulated on the national, provincial, and district levels. The three levels cooperate with each other and share plans and reports that complement one another. The national Health Council is subordinate to the Minister of Health and is entitled to advice on guidelines and format of national health plans. The National Consultative Health Forum facilitates the cooperation between the health department and national organizations. The National Health Department coordinates the public and private health sectors, provides a contact with the international community and the World Health Organization, adopts national policy and regulations, and monitors the work of provinces.
Each of nine provinces has a provincial department of health whose aim is to regulate the spending of the national health budget, identify health needs, implement national polices, and monitor the work of health services. District health level consists of health authorities, management teams, and multi-disciplinary groups. The latter ensures that the basic needs are met, working with other public service sectors, such as departments of Housing, Water, Affairs, and Agriculture. A district management team is responsible for assessing services in terms of its cost effectiveness, guaranteeing that people receive high-quality health services. Finally, a district health authority oversees the application of national and provincial policies and standards, identification of the health needs, and allocation of the budget and resources.
South Africa has mainly nurse-based healthcare system. In brief, the number of doctors is only seven percent of the requirement, whereas the rate of nurses amounts to 94 percent. According to OECD, there are only 0.8 physicians per 1000 people. The number of nurses is higher, amounting to 1.2 nurses per 1000 patients, but still it does not meet the demand. They play a pivotal role in providing healthcare that is not limited to traditional facilities and long-term care but also critical in primary care and home care settings. In 2010, among 231,000 nurses in South Africa, there was 49.9 percent of registered, 22.7 percent of enrolled and 27.5 percent of enrolled auxiliaries. The proportion of foreign-trained nurses is considerably lower in comparison with doctors. Lack of career opportunities, poor provision of service benefits, insecure working environment, and low salaries influenced the decision of both physicians and nurses to migrate. For example, over 23 000 healthcare workers left the country within one year. Accordingly, 30 percent of doctors have left the country, and 58 percent have intended to move to Western countries.
Nursing Education System and Accrediting Organizations
Universities and University of Technologies offer nursing education and provide a Generic Bachelor Degree or B. Tech., respectively. It is also possible to enroll in postgraduate programs, with a chance to receive clinical specialties, the honors, masters, and doctoral degrees. The Department of Health manages and funds the nursing colleges. Nursing training can be performed in both public and private institutions and private hospitals. Many private hospital groups organize their own nursing training due to the critical staff shortage and the government’s inability to provide the required number of medical workers in healthcare facilities.
The South African Nursing Council (SANC) is entitled to provide nursing training, examinations, certification, regulation, registration, and licensure. In particular, the SANC controls nursing education through its accreditation and quality assurance. Thus, Nursing Education Institutions (NEI) should meet the certain number of requirements to receive accreditation to commence any nursing program. At first, the SANC accredits the documentation on the curriculum and the associated clinical facilities, and then this procedure is followed by a site visit. All NEI accredited can be found on the SANC website. Moreover, NEIs are obliged to meet criteria for registration in accordance with the requirements of the Department of Higher or Further Education, the Council on Higher Education (CHE), and Umalusi. In addition, the Democratic Nursing Organization of South Africa (DENOSA) was founded to unify various units.
A nursing association strives to facilitate the progress of nurses throughout their careers and promote the interests of the profession. The Nursing Act of 1978, which was enforced in 1982, established the SANA. Nowadays, all practicing nurses and midwives and some non-practicing nurses are members of this association. The SANA aims to promote the development of effective and competent nursing service, to raise the status and guarantee the rights of the nurses, and strive for better remuneration, working and training conditions.
SANC is an autonomous and financially independent body that has been created by the Nursing Act, 1944, to preserve the standards of nursing education and practice. The main objectives of the organization are to protect the public, improve the health standards in the country, and control the training in connection with curriculum and examinations. SANC keeps an up-to-date list of all professional nurses, midwives, staff nurses, auxiliary nurses, and students to eliminate the possibility of illegal nursing practices.
In 1995, the South African Nursing Association has been merged with other smaller separate associations into one organization known as the Democratic Nursing Organization of South Africa (DENOSA). The latter is the country’s only professional nursing organization. It is an affiliate of the Congress of South African Trade Unions (COSATU) and is a member of the International Council of Nurses since 1997. Apart from fulfilling functions of a labor union, this organization seeks to enhance the professional growth of nurses and protect their rights.
According to Mayosi and Benatar, it is vital to enhance the functioning of the multi-drug resistant tuberculosis (MDR-TB) program and increase access to MDR-TB treatment. The WHO stated that by using affordable and sustainable course of primary preventive actions, it is possible to prevent serious chronic diseases. Therefore, the first and foremost priority is to promote a healthy lifestyle and concentrate on early detection of risk factors and symptoms of medical conditions. This includes increasing access to the information and health facilities. Furthermore, it is important to implement different treatment guidelines to handle the spread of sexually transmitted infections and HIV/AIDS. In addition, there should be special attention to the vaccination campaigns focused mainly on rural areas to restrain the spread of infectious diseases.
Nurses can assist in implementing intervention programs and promoting health awareness and adopting healthy lifestyle through corresponding programs and initiatives. They can also help to adopt a health-service approach for the early diagnosis and cost-effective management of chronic diseases. Nurses can increase the level of vaccinated children by reaching distant areas and performing necessary procedures. Moreover, healthcare workers can participate more actively in providing support for people with HIV, TB, and sexually transmitted infections.
Most importantly, nurses can be trained to perform MDR-TB treatment. Because of such training, nurses will be able to diagnose MDR-TB specifically in HIV patients and refer them to a corresponding facility. There the patients can receive a qualified primary health care provided by nurses under the supervision of physicians. Consequently, this initiative can partially solve the problem of the deficiency of physicians and improve access to healthcare for many people. Moreover, more nurses can be trained to participate in the Nurse Initiated management of Antiretroviral Therapy Program. It will be possible to open new facilities that will specialize in providing antiretroviral treatment. Consequently, it will help to preempt the spread of HIV/AIDS.
In summary, South Africa is a diverse country not only from ethnical perspective but also governmental, economic, environmental, and medical ones. Although there have been some minor positive changes in handling major epidemics, the lack of access to health facilities, economic and cultural barriers, the insufficient number of physicians and nurses significantly prevent the country from more sustainable development. Nevertheless, several associations regulate the work and training of healthcare providers and strive to develop the healthcare system. As nurses constitute a considerable part of medical workers, they should continue to provide basic care on the curative, preventive, promotional, and rehabilitation levels.