Health and Health Care in South Africa 2nd Edition

H.C.J. Van Rensburg (Ed.) download pdf

https://ebookfinal.com/download/health-and-health-care-in-south-
africa-2nd-edition-h-c-j-van-rensburg-ed/

Visit ebookfinal.com today to download the complete set of

ebook or textbook!
Here are some recommended products that we believe you will be
interested in. You can click the link to download.

Managing in Health and Social Care 2nd Edition Vivien

Martin

https://ebookfinal.com/download/managing-in-health-and-social-
care-2nd-edition-vivien-martin/

Child and Adolescent Health and Health Care Quality

Measuring What Matters Committee On Pediatric Health And
Health Care Quality Measures
https://ebookfinal.com/download/child-and-adolescent-health-and-
health-care-quality-measuring-what-matters-committee-on-pediatric-
health-and-health-care-quality-measures/

Critical Reflection In Health And Social Care White

https://ebookfinal.com/download/critical-reflection-in-health-and-
social-care-white/

Speech and Automata in Health Care 2014. Edition Neustein

https://ebookfinal.com/download/speech-and-automata-in-health-
care-2014-edition-neustein/
Chaos and Organization in Health Care Thomas H. Lee

https://ebookfinal.com/download/chaos-and-organization-in-health-care-
thomas-h-lee/

Systematic Reviews in Health Care Meta Analysis in Context

2nd Edition Matthias Egger

https://ebookfinal.com/download/systematic-reviews-in-health-care-
meta-analysis-in-context-2nd-edition-matthias-egger/

Quantit Methods in Health Care Management Techniques and

Applications J B Public Health Health Services Text 1st
Edition Yasar A.
https://ebookfinal.com/download/quantit-methods-in-health-care-
management-techniques-and-applications-j-b-public-health-health-
services-text-1st-edition-yasar-a/

Llama and alpaca care Medicine surgery reproduction

nutrition and herd health 1st Edition Robert J. Van Saun

https://ebookfinal.com/download/llama-and-alpaca-care-medicine-
surgery-reproduction-nutrition-and-herd-health-1st-edition-robert-j-
van-saun/

Delivering Health Care in America A Systems Approach Third

Edition Delivering Health Care in America A System
Approach Leiyu Shi
https://ebookfinal.com/download/delivering-health-care-in-america-a-
systems-approach-third-edition-delivering-health-care-in-america-a-
system-approach-leiyu-shi/
Health and Health Care in South Africa 2nd Edition
H.C.J. Van Rensburg (Ed.) Digital Instant Download
Author(s): H.C.J. van Rensburg (ed.)
ISBN(s): 9780627030130, 0627030130
Edition: 2nd
File Details: PDF, 17.37 MB
Year: 2012
Language: english
 Health and
Health Care
in South Africa
Second edition

HC J van Rensburg
EDITOR

JE Ataguba • S R Benatar • JE Doherty • MC Engelbrecht

• J C Heunis • AP Janse van Rensburg • NG Kigozi
• DE McIntyre • A J Pelser • E Pretorius
• N Redelinghuys • F Steyn • E Wouters

Van Schaik
PUBLISHERS
Published by Van Schaik Publishers
1059 Francis Baard Street, Hatfield, Pretoria
All rights reserved
Copyright © 2012 Van Schaik Publishers

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in

any form or by any means – electronic, mechanical, photocopying, recording or otherwise –
without the written permission from the publisher, except in accordance with the provisions
of the Copyright Act, 98 of 1978.

First edition 2004

Second edition 2012
Converted to EBook 2012

Print ISBN 978 0 627 03013 0

WebPdf ISBN 9780627030369

Commissioning editor Lydia Reid

Production manager Werner von Gruenewaldt
Editorial coordinator Estian Behrens
Copy editor Dineke Ehlers
Proofreaders Lee-Ann Ashcroft & Chrisna Nel
Cover design by Werner von Gruenewaldt
Typeset in 9.5 on 11.5 ITCCentury Book pt by Pace-Setting & Graphics, Pretoria
EBook conversion by Pace-Setting and Gesina Retief

Every effort has been made to obtain copyright permission for material used in this book.
Please contact the publisher with any queries in this regard.
Please note that reference to one gender includes reference to the other.
Website addresses and links were correct at time of publication.

This book has been reviewed by independent peer reviewers.

Please contact DALRO for information regarding copyright clearance for this publication.
Any unauthorised copying could lead to civil liability and/or criminal sanctions.
Tel: 086 12 DALRO (from within South Africa) or +27 (0)11 712 8000
Fax: +27 (0)11 403 9094
Postal address: PO Box 31627, Braamfontein, 2017, South Africa
http://www.dalro.co.za

Website addresses and links were correct at time of original publication

 PREFACE

RATIONALE FOR THIS BOOK

For both those inside and those outside the South African health care system, the
changes that have taken place (and are still taking place) in the post-1994 health
sphere are often difficult to comprehend. Often these reforms are confusing, even
bewildering. What is the essence of the transformation? Where are the reforms head-
ing? This book portrays a coherent “big picture” of health and health care in the coun-
try. Chapter by chapter, Health and health care in South Africa is taking stock of the
evolving health system, along with the ensuing changes and challenges in the health
sector. Throughout, it attempts to contextualise these developments historically and
globally, and to critically assess them.
The book has its origin in the early 1980s with the publication of Profiles of disease
and health care in South Africa (Van Rensburg & Mans 1982). Ten years later, just
before the country’s transition to full democracy, Health care in South Africa –
structure and dynamics (Van Rensburg, Fourie & Pretorius 1992) was published.
Then followed the first edition of Health and health care in South Africa (Van Rens-
burg (Ed) 2004) – a book that retained the historical perspective of its predecessors,
but at the time focused specifically on the nature, accomplishments and failures of
the first decade of health reforms. This 2012 edition of Health and health care in
South Africa builds further on the work and developments of the past three decades
in this field.

PURPOSE AND AIMS OF THE BOOK

The general purpose of the book is to present a coherent picture of the current state
of health and health care in the country, and of how these nestle in the larger histori-
cal, societal and global contexts. More specific aims are, first, to construe a sociohis-
torical perspective of the recent and long-term developments in the health system
with a view to better understand current and future developments and challenges;
second, to analyse post-1994 reform policies and legislation, and the ensuing new
structures and directions in South African health care, and; third, to review progress
and achievements, but also to better comprehend contemporary constraints and defi-
ciencies in health performance. Over and above these aims, the book strives to be an
authoritative reference source on health and health care in South Africa and as these
relate to the global context.

FOR WHOM THE BOOK IS MEANT

The book serves as a reference source on health and health care in South Africa for
diverse interest and stakeholder groups. Firstly, it is meant for researchers and lec-
turers in the domains of the history of health care, public and community health,
health policy and systems, health economics, medical sociology and other health-
related social sciences, social epidemiology, and bioethics. Secondly, the book tar-
gets managing and practising health professionals (nurses, doctors, dentists, pharma-
cists, supplementary and allied health professionals), as well as health planners, poli-
cy makers and managers. Thirdly, it is meant for senior and postgraduate students in
the health and health-related professions, the social sciences, and those studying in
the health planning, policy and management-related disciplines.

v
 THE INDIVIDUAL CHAPTERS, THEIR SEQUENCE AND
INTERRELATEDNESS
Although all the chapters can be approached as stand-alone entities – and thus may
be read separately and independently from one another – the sequence of the chap-
ters nevertheless follows a particular logic. Together the chapters form a coherent
whole that portrays the complexity and diversity of South African health and health
care. As the title suggests, the chapters focus on two broad themes: the health care
system and the health of the population. Apart from Chapter 1 (a conceptual and
global framework) and Chapter 12 (on bioethics), seven chapters deal – from various
angles – with the South African health care system, its composition, operation,
dynamics and recent reform. The remaining three chapters cover the health and
health status of the South African population and its subpopulations, and the sur-
rounding environment as the ultimate source of determinants that affect the health,
disease and ill-health of its inhabitants.

South African health care in global context

Chapter 1 presents a conceptual framework and the tools for analysing and inter-
preting the nature, functioning and dynamics of health systems. Specifically, the com-
ponents of health care systems, the environments in which they function, and the
clientele they serve, are described. It then reviews the nature and diverse types of
health systems of countries and the ensuing typologies of national health systems.
Attention is also paid to the global and international health system, globalising, con-
verging and diverging trends in health care, the two main thrusts in health care (high-
tech medicine and primary health care), reforms of national health care systems on
the globe, and the main propellers driving change and reform. A special focus is the
nature, dynamics, mixes and reforms of health care systems in Africa.

The South African health care system and its transformation

Chapter 2 has a historical focus: it reconstructs the evolution of the South African
health care system from its earliest documented origins, through the colonial and
apartheid phases, and up to the prelude to the reforms that commenced in 1994.
Attention is paid to the evolving nature of the health system, the rise of the health
professions and health institutions, the policies and legislation that shaped the health
system, and that eventually instigated the trends and contours responsible for the
notorious policies of exclusion and discrimination clearly reflected in grave race and
class disparities and inequities in health care and in the health status of the different
population groups. Also documented are the sporadic official and non-official reform-
minded attempts to redirect the system with a view to manage structural and func-
tional inefficiencies.
Chapter 3 takes the development of the South African health care system further
by reconstructing its transformation since 1994. It reviews the rationale for reform,
the post-apartheid reform policies and legislation in the health sphere, the reorganisa-
tion of the spheres of government in health, and the rise of the district-based PHC
system as the post-apartheid government’s solution to past inequities, inaccessibility
and inefficiencies in health care delivery. Despite remarkable progress in restructur-
ing the health care system and services, the transformation has still a long and diffi-
cult way to negotiate in order to overcome the many unresolved issues and to deal
with new challenges, inter alia, persisting disparities and inequities, poor steward-
ship, policy–implementation gaps, a growing burden of disease, and poor perfor-
mance of the health system.

vi
The health conditions, health and health status of South Africans
Three chapters of Health and health care in South Africa (Chapters 4, 5, 6) focus
on the health, health conditions and “ill health” of the population – a population in
numerous respects under serious and increasing stress. The analyses are done
against the backdrop of the broader South African environment and the unique so-
cietal context with its compounding conditions of unequal distribution of develop-
ment and wealth. These directly and indirectly lead to unequal exposure and to grave
disparities in human development, health status and life expectancy. In turn, amid
gross discrepancies in the provision for basic needs, significant differences in suscep-
tibility to disease and death prevail.
Chapter 4 explores the links between health, environment and development as
well as strategies to manage ensuing challenges, both globally and in South Africa.
Three main dimensions form the crux of the analysis. The first is the structure and
dynamics (size, composition, distribution, growth, migration) of the population and
the diverse implications of these for human development and health. The second is
the changing biophysical or “green” environment (climatic changes, deteriorating
fresh water resources, soil degradation, pollution, loss of biodiversity) and its impact
on the health of the population. The third dimension is the social or “brown” environ-
ment (the socioeconomic landscape, social inequalities, poverty, unemployment) that
poses conditions that profoundly affect the health and well-being of people.
Chapter 5 explains the variety of indicators used to measure health, ill-health and
the health status of populations. It describes the health status of the world population
and the propellers of the health transition, and analyses the morbidity and mortality
patterns in developed and developing nations. Against this global background, the
health and health status of South Africans are reconstructed in terms of the current
trends in morbidity, mortality, fertility and life expectancy. Prevailing disease and
death profiles are reconstructed according to the prevalence of prominent infectious
diseases and chronic diseases of lifestyle, especially as these conditions and risks
result in a quadruple burden of disease which has serious ramifications for health
care in the country. Specific attention is also paid the health and vulnerability of
women in South Africa.
Chapter 6 deals with the origins, growth and burdens of the HIV and AIDS and TB
epidemics globally, in sub-Saharan Africa and especially in South Africa. In recent
years, these diseases have become major threats to human development, health and
wellbeing. Attention is given to the social epidemiology of the diseases, factors
fuelling them, and the manifestation of these epidemics according to geographic and
social differentials. Past and current HIV and AIDS and TB policies and strategies to
control the epidemics are reconstructed and appraised. The recent confluence of the
two diseases into the TB-HIV and AIDS co-epidemic considerably aggravates the dev-
astating effects of both epidemics. The disruptive impacts of the epidemics on broad-
er society, societal sectors and social institutions, and on communities, families and
individuals are reviewed.

Main components of South African health care and their

transformation
Several chapters (especially Chapters 7, 8, 9, 10) deal with specific components of
the South African health care system, including the composition and dynamics of
these components, the challenges to these components posed by the new dispensa-
tion, and efforts to reform the legislation and policies that govern and guide the struc-
ture and operation of these components.

vii
 Chapter 7 reviews human resources for health in South Africa against a global and
historical backdrop. Attention is given to human resource shortages and their
inequitable distribution along geographic, sectoral and socioeconomic lines, as well
as to post-1994 reform strategies to redress disparities and inequities. The organisa-
tion and regulation of the health professions are analysed, along with recent trends in
the supply of health professionals. Four hard-core issues persist in South Africa’s
human resources for health: geographical shortages and distributional disparities;
private–public disparities and inequities; loss of large numbers of health profession-
als via emigration; and low worker morale and suboptimal productivity. The chapter
concludes with the demands that the planned re-engineering of PHC will place on the
human resource corps.
Chapter 8 describes the nature of health care financing and expenditure in South
Africa, and past and present strategies to deal with challenges in this domain. The dif-
ferent sources of health care funding, the relative contributions of these sources as
well as allocation mechanisms are analysed. Special focus is placed on health care
expenditure, and on post-1994 progress in addressing previous inequities and ineffi-
ciencies in the distribution of resources among provinces, at different levels of care,
within public sector facilities, in the private sector and in the public–private mix.
Challenges requiring urgent attention are the sustainability of health care financing,
the expenditure spiral in the private sector, and the inequitable public–private mix.
Lastly, the planned NHI is analysed in terms of funding requirements and as a mecha-
nism to secure universal access to health care.
Chapter 9 deals with the nature and status of PHC, both as an international thrust
since Alma-Ata and as a strategy ardently pursued by the post-1994 government. PHC
in South Africa is explored, from its relative neglect by previous governments up to
its rise to centre stage in health care. The essence of the 2001 Service Package for
PHC facilities and the contents of the subsequently revised 2010 PHC Package are
reconstructed, and so are the types, numbers, distribution and trends regarding pub-
lic PHC facilities. Post-1994 achievements and gains in service delivery and in equi-
table care are recorded, but amid successes, the approach to PHC remains selective
and many backlogs and inequities at various levels still prevail. To address these
remaining shortcomings, a major effort is currently under way to revitalise PHC as
part of a comprehensive re-engineering of the entire health care system.
Chapter 10 portrays the development of hospitals, globally and locally, and docu-
ments hospital reforms and reform strategies in post-1994 South Africa. The supply of
hospitals – in both the public and private sectors – is analysed in terms of their
nature, numbers and trends. Persistent inequities and the dominance of commer-
cialised, private-for-profit hospitals are depicted. Strategies to improve hospital ser-
vices, the essential linkages between hospitals, PHC, the DHS and the crucial role of
district hospitals in the public service chain, expenditure on district hospitals, and
the District Hospital Service Package are duly considered. In addition, the social
dynamics of hospitals are covered, also as manifested in the role of hospital man-
agers, industrial action in hospitals, patients’ experiences of hospitalisation, and the
say of communities in the governance of hospitals.
Chapter 11 describes the divergent modes, principles, methods, and use of com-
plementary and alternative healing globally, and specifically their rise, status and
coexistence with Western allopathic medicine in South Africa. The advantages of
these healing forms are appraised and so are prospects of integrating these forms of
medicine with biomedicine. Subsequently, extensive attention is devoted to the
nature and extent of African ethnomedicine in South Africa, the types and training of
traditional practitioners, and the methods and means of diagnosis and treatment.
Contemporary challenges are discussed; inter alia, the position of African traditional
healers vis-à-vis Western counterparts; organisation and control in own ranks; intel-

viii
lectual property rights, as well as developments in legalisation, legislation, profes-
sionalisation, and closer collaboration.

Ethical perspectives on health care in South Africa

Chapter 12 is a contribution in its own right. It explains what ethics in health care at
different levels and in different spheres mean and require. From a different angle, it
spans most of what has been presented in the preceding chapters. In a different man-
ner, it again touches on the key questions and issues raised in the foregoing chapters,
and takes a step-back stance to appraise – through the ethics lens – what is happen-
ing around, within and to South African health care. It does so against the backdrop
of global developments and culturally diverse contexts. The author identifies the key
challenges, unsettling dilemmas, and topical choices that confront health profession-
als, managers, policy makers and politicians, and that they should come to terms with
in order to remain humane and to secure fairness in administering, allocating and dis-
tributing health and health care.

THE AUTHORS
Various authors from diverse backgrounds and disciplines wrote the different chap-
ters of the book. Among them count seasoned and prolific academic writers, but
upcoming researchers in the domains of health and health systems research were
also deliberately involved. All these authors contributed in significant ways to the
production of this publication.

ACKNOWLEDGEMENTS AND APPRECIATION

I owe a debt of gratitude to the various contributors who made the book possible and
who ensured its quality and value. First and foremost, sincere gratitude needs to be
conveyed to all the authors and co-authors, in particular for their willingness to make
an indispensable contribution, and, then, for the time and energy they devoted with
such remarkable dedication to completing the task.
I also want to warmly thank those people who took care of the linguistic, artistic,
editorial and secretarial aspects that formed and formatted the book in these essen-
tial respects: Marius Pretorius, for investing so much time, energy and patience over
a protracted period of time in the linguistic editing and for securing acceptable levels
of uniformity amid the obviously diverse writing styles and skills of the authors in the
2004 edition; Belinda Jacobs, for taking care of editing and controlling the vast num-
ber of references and the bibliographies of the twelve chapters in an effort to secure
correctness, uniformity, consistency and completeness. In similar vein I convey my
sincere gratitude to all those dedicated people at Van Schaik Publishers who ren-
dered the publication of this book a reality. The following need to be mentioned by
name: Lydia Reid, Daleen Venter, Werner von Gruenewaldt, Estian Behrens and Ron-
nie Dombai for their expertise and enthusiasm in different domains of this endeav-
our.
In conclusion, I gratefully acknowledge and appreciate the understanding, support
and sacrifices of those people in the close surroundings of the authors during the
writing of the book.

Dingie van Rensburg

Bloemfontein
August 2012

ix
BACK TO 1&2
CONTENTS

Chapter 1 National health care systems: structure, dynamics and

types
HCJ VAN RENSBURG
1 Health systems and health care systems: conceptual clarification . . 1
1.1 Definitions and clarification of concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 The components of national health care systems: internal determinants . . . 4
1.3 The environments of health care systems: external determinants . . . . . . . . . 6
1.4 The clientele/target population of health care systems . . . . . . . . . . . . . . . . . . 8
2 National health care systems: types and typologie . . . . . . . . . . . . . . . . . 10
2.1 The typology of Mark G Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2 The typology of Milton I Roemer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.3 The typology of William C Cockerham . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3 National health care systems: trends, changes and reforms . . . . . . . . 16
3.1 Health sector reform and the propellers of change and reform . . . . . . . . . . . 16
3.2 Converging and diverging trends in national health systems . . . . . . . . . . . . . 18
4 Towards global health and a global health system . . . . . . . . . . . . . . . . . 24
4.1 Globalisation trends in health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4.2 The global health system: logical extension of national health systems . . . . 25
4.3 Two main thrusts in health care: high-tech medicine and primary health care 27
4.4 Millennium Development Goals (MDGs) and health systems strengthening 34
5 Health systems in Africa: nature, variety and dynamics . . . . . . . . . . . . 37
5.1 African traditional systems and influences of Islam, Christianity and
colonialism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5.2 Western health care in Africa: private–public mixes and partnerships . . . . . 40
5.3 Models of financing and provisioning Western health care in Africa . . . . . . . 42
5.4 Challenges confronting African health care systems . . . . . . . . . . . . . . . . . . . . 45
5.5 Reform of African health care systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Chapter 2 A history of health and health care in South Africa:

1652–1994
HCJ VAN RENSBURG
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
2 The settlement period: 1652–1795 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3 The period of expansion, consolidation and control: 1795–1910 . . . . 66
3.1 Health care legislation and official control structures . . . . . . . . . . . . . . . . . . . 66
3.2 Developments in the healing professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.3 Development of hospitals and institutional care . . . . . . . . . . . . . . . . . . . . . . . 71

x
BACK TO 3
3.4 Folk medicine, quackery and traditional practices: health care among
the Voortrekkers and the indigenous peoples . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.5 Morbidity and mortality in South Africa during the 19th century . . . . . . . . . 75
4 Early South African health care: summary of trends and features . . 77
5 South African health care after 1910: overview of trends and
features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6 Health legislation under Union government: the Public Health Act 36
of 1919 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
7 Reform-minded thinking, official inquiries and the Gluckman Report
of 1944 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
8 The era of apartheid in South African health care . . . . . . . . . . . . . . . . . 87
8.1 The homelands policy and the creation of ten departments of health . . . . . . 91
8.2 The nationalisation of mission hospitals and their transfer to homeland
governments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
8.3 The tricameral parliament and three “own affairs” departments of health . . 96
9 Health reform in the 1970s and the Health Act of 1977 . . . . . . . . . . . . 97
10 Developments in the 1980s: strides towards PHC and privatisation . 100
10.1 The Browne Commission of 1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
10.2 The National Health Plan of 1986 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
10.3 The privatisation of South African health care . . . . . . . . . . . . . . . . . . . . . . . . . 104
10.4 The close of the 1980s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
11 Restructuring of South African health care in the early 1990s . . . . . . 108
12 Calls for fundamental reform by oppositional political and labour
movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
13 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Chapter 3 Transformation of the South African health system:

post-1994
HCJ VAN RENSBURG & MC ENGELBRECHT
1 Rationale and aims of the post-1994 health reforms . . . . . . . . . . . . . . . 121
2 Preparing for reform: three core reform documents . . . . . . . . . . . . . . . 123
2.1 Interim Constitution of the Republic of South Africa (1993) . . . . . . . . . . . . . 123
2.2 Reconstruction and Development Programme (1994) . . . . . . . . . . . . . . . . . . . 123
2.3 National Health Plan for South Africa (1994) . . . . . . . . . . . . . . . . . . . . . . . . . . 125
3 Policy and legal reforms of the health sector: 1994 and after . . . . . . . 126
3.1 Policy, legislation and implementation: necessary distinctions . . . . . . . . . . . 126
3.2 Constitution of the Republic of South Africa (1996) . . . . . . . . . . . . . . . . . . . . 126
3.3 Important post-1994 health policies (strategies/plans) for reforming the
health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
3.4 Important post-1994 legislation for reforming the health system and health
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
4 Reorganising the spheres of health governance: structures, powers
and functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
4.1 National sphere of government: governance and management bodies . . . . . 138
4.2 Provincial sphere of government: governance and management bodies . . . 139

xi
BACK TO 4
4.3 Spheres of district and local governments: governance and management
bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
5 Rise of the district-based PHC system . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
5.1 Moves towards PHC and the DHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
5.2 DHS in South Africa: defining, describing and demarcating health districts 145
5.3 Municipal health services: defining and demarcating the scope . . . . . . . . . . . 149
5.4 Essentials of a district-based PHC system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
5.5 Key challenges and issues in establishing the district-based PHC service . . 156
6 Persistent and emerging challenges to health reforms . . . . . . . . . . . . . 162
6.1 Remaining and deepening disparities, inequalities and inequities in health
and health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
6.2 Poor, inadequate and deficient stewardship, leadership and management
capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
6.3 Gaps or disconnects between policy and implementationof policy . . . . . . . . 167
6.4 PHC: lacking and neglected essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
6.5 Inadequate human resources and lack of strategic planning in the health
human resource sphere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
6.6 Predominance of HIV and AIDS . . . . . . and the growing burden of disease:
persistent stress on the health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
6.7 Poor performance of the health system: deteriorating service delivery,
deteriorating health outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
6.8 The public–private divide: continued fragmentation, lack of national
health system unity, and huge disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Chapter 4 The health, environment and development nexus in

South Africa
AJ PELSER
1 The relationship between health, environment and development . . . 189
2 The South African population: demographic structure and changes . 191
2.1 Current trends and projected changes of the South African population . . . . 193
2.2 South African and worldwide demographic trends compared . . . . . . . . . . . . 201
2.3 The Population Policy for South Africa (1998) . . . . . . . . . . . . . . . . . . . . . . . . . 202
3 The changing biophysical environment: impact on health and health
conditions in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
3.1 Climate change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
3.2 Deteriorating and unsafe fresh water resources . . . . . . . . . . . . . . . . . . . . . . . . 210
3.3 Soil degradation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
3.4 Pollution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
3.5 Loss of biodiversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
4 The changing social environment: impact on health and health
conditions in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
4.1 The global context of health and socioeconomic development . . . . . . . . . . . 226
4.2 The socioeconomic landscape of health in South Africa . . . . . . . . . . . . . . . . . 227
4.3 Disparities in health indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

xii
BACK TO 5&6
4.4 Teenage pregnancies, poverty and development . . . . . . . . . . . . . . . . . . . . . . . 230
4.5 Poverty, mortality and reproductive health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Chapter 5 Health and health status of the South African population

N REDELINGHUYS
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
2 Measuring the health and health status of populations . . . . . . . . . . . . 238
2.1 Morbidity and mortality: indicators of health, ill-health and health status . . 239
2.2 Indicators of health expectancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
2.3 Indicators of socioeconomicwellbeing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
2.4 Millennium Development Goals: enhancing population health and wellbeing 245
3 Health of the world population: status and trends . . . . . . . . . . . . . . . . . 247
3.1 Health transition and main propellers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
3.2 Trends in global morbidity and mortality: developed and developing nations 251
4 Health of the South African population: context, status and trends 265
4.1 General observations on the health status of South Africans . . . . . . . . . . . . . 265
4.2 Mortality trends in the South African population . . . . . . . . . . . . . . . . . . . . . . . 266
4.3 Diseases associated with underdevelopment and poverty in South Africa . . 269
4.4 Prominent infectious diseases in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . 273
4.5 Prominent chronic diseases of lifestyle in South Africa . . . . . . . . . . . . . . . . . 276
4.6 Health status of women in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Chapter 6 HIV, AIDS and tuberculosis inSouth Africa: trends,

challenges and responses
JC HEUNIS, E WOUTERS & NG KIGOZI
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
2 The global HIV and AIDS epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
3 South Africa’s HIV and AIDS epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
3.1 Evolution of the epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
3.2 Disproportional burdens of HIV and AIDS in South Africa . . . . . . . . . . . . . . . 298
4 Factors fuelling the HIV and AIDS epidemic in South Africa . . . . . . . 302
5 Impact of the HIV and AIDS epidemic in South Africa . . . . . . . . . . . . . 304
5.1 Demographic impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
5.2 Impact on health, morbidity and mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
5.3 Impact on health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
5.4 Macroeconomic impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
5.5 Microeconomic impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
5.6 Impact on households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
5.7 Impact on communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
6 HIV and AIDS policies in South Africa: pre-1994 and post-1994 . . . . 310
6.1 Pre-1994 HIV and AIDS policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

xiii
BACK TO 7
6.2 Post-1994 HIV and AIDS policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
6.3 South Africa’s ART programme: outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
7 Future HIV and AIDS policy requirements and challenges . . . . . . . . . 319
8 The global TB epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
9 South Africa’s TB epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
9.1 History of TB in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
9.2 Nature and forms of TB in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
10 TB control efforts and challenges in South Africa . . . . . . . . . . . . . . . . . 331
10.1 Early TB control measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
10.2 TB control during apartheid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
10.3 TB control post-1994 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
11 TB treatment outcomes in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
11.1 New smear-positive cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
11.2 Re-treatment cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
11.3 TB-related mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
12 Failures in TB control: multiple explanations . . . . . . . . . . . . . . . . . . . . . 331
13 The global TB-HIV co-epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
13.1 Extent of the global TB-HIV and AIDS co-epidemic . . . . . . . . . . . . . . . . . . . . 331
13.2 Collaborative TB/HIV activities: globally (with reference to South Africa) . 331
14 South Africa’s TB-HIV co-epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
14.1 Extent of the TB-HIV co-epidemic in South Africa . . . . . . . . . . . . . . . . . . . . . . 331
14.2 Collaborative TB/HIV activities: South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . 331
14.3 NSP 2012–2016: South Africa’s integrated strategy to combat the
co-epidemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
15 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Chapter 7 Human resources for health and the health

professions in South Africa
HCJ VAN RENSBURG, JC HEUNIS & F STEYN
1 Human resources for health: global challenges . . . . . . . . . . . . . . . . . . . . 361
2 Human resources for health: South Africa’s legacy, challenges and
responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
2.1 In brief – pre-1994 legacy of human resources . . . . . . . . . . . . . . . . . . . . . . . . . 363
2.2 Post-1994 record of responses to human resource challenges: policies
and plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
3 Post-1994 strategies for reforming human resources in the public
health sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
3.1 Amalgamating fragmented public sector staff establishments . . . . . . . . . . . . 368
3.2 Creating race and gender representativeness . . . . . . . . . . . . . . . . . . . . . . . . . . 368
3.3 Redirecting health provider education and training towards priority
needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
3.4 Recruiting and employing foreign health professionals . . . . . . . . . . . . . . . . . 370
3.5 Phasing in compulsory community service . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
3.6 Task shifting and utilising community cadres as service providers . . . . . . . . 373
3.7 Introducing incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376

xiv
BACK TO 8
3.8 Forming public–private partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
4 The health professions in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
4.1 The rise of the health professions in South Africa . . . . . . . . . . . . . . . . . . . . . . 378
4.2 Post-1994 reform of the organisation and regulation of the health
professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
4.3 Supply of health professionals: overview of numbers and trends . . . . . . . . . 383
5 The medical profession: development, status and challenges . . . . . . . 385
5.1 A brief history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
5.2 South African Medical and Dental Council (later Medical and Dental
Professions Board) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
5.3 MASA, NAMDA and SAMA: professional associations for doctors . . . . . . . . 386
5.4 Medical doctors: numbers, trends, issues and future scenarios . . . . . . . . . . . 387
6 The nursing profession: development, status and challenges . . . . . . . 391
6.1 A brief history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
6.2 Post-1994 statutory and regulatory reforms of the nursing profession . . . . . 394
6.3 SANA and DENOSA: new professional associations . . . . . . . . . . . . . . . . . . . . 395
6.4 Other post-1994 developments in nursing and the nursing profession . . . . . 396
6.5 Nurses: training, supply and trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
6.6 Enrolled nurses and nurse auxiliaries (nurses on rolls): supply, trends
and concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
7 Other health professions: past, present and future . . . . . . . . . . . . . . . . 405
7.1 Pharmacists and pharmacist assistants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
7.2 The dental profession and supplementary dental occupations . . . . . . . . . . . 407
7.3 The allied or supplementary health professions . . . . . . . . . . . . . . . . . . . . . . . . 409
8 Hard-core issues in South Africa’s health human resources . . . . . . . . 409
8.1 Geographical shortages and disparities: inter- and intraprovincial . . . . . . . . 410
8.2 Private–public disparities and maldistribution . . . . . . . . . . . . . . . . . . . . . . . . . 414
8.3 Loss of health professionals by overseas migration . . . . . . . . . . . . . . . . . . . . . 417
8.4 Worker morale and productivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
9 Re-engineering PHC: new human resource requirements and
challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
10 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424

Chapter 8 Health care financing and expenditure:post-1994

progress and remaining challenges
DE MCINTYRE, JE DOHERTY & JE ATAGUBA
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
1.1 Pre-1994 efficiency challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
1.2 Pre-1994 equity challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
1.3 Focus of this chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
2 Overview and trends in health care financing . . . . . . . . . . . . . . . . . . . . . 435
2.1 Health care funding from government tax revenue . . . . . . . . . . . . . . . . . . . . . 436
2.2 Health care funding via medical schemes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
2.3 Direct health care funding by households (“out of pocket” payments) . . . . . 440

xv
BACK TO 9
2.4 Distribution of the burden of health care funding across socioeconomic
groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
3 Pooling of funds and key allocation mechanisms . . . . . . . . . . . . . . . . . . 441
3.1 Pooling through private health insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
3.2 Pooling through general tax funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
3.3 Distribution of financial resources across public and private funding
pools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
4 Health care expenditure: using resources efficiently and equitably . 447
4.1 Progress in addressing inequities in distribution of public sector
resources between provinces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
4.2 Progress in addressing public sector inefficiencies related to relative
expenditure at different levels of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
4.3 Progress in addressing inefficiencies within public sector facilities . . . . . . . 450
4.4 Progress in addressing private sector inefficiencies . . . . . . . . . . . . . . . . . . . . 450
4.5 Progress in addressing public–private mix inequities . . . . . . . . . . . . . . . . . . . 450
4.6 Implications of efficiency and equity challenges for distribution of
benefits from using health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
5 Key health policy challenges for the future . . . . . . . . . . . . . . . . . . . . . . . 450
5.1 Core concerns about the sustainability of health care financing . . . . . . . . . . 450
5.2 Addressing the expenditure spiral in the private sector . . . . . . . . . . . . . . . . . 450
5.3 Addressing the inequitable public–private mix . . . . . . . . . . . . . . . . . . . . . . . . . 450
6 Overview of efforts to fundamentally reform health care financing . 450
6.1 Early attempts to fundamentally reform health care financing . . . . . . . . . . . 450
6.2 Reform efforts in the 1990s to 2004: proposals for social health
insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
7 National health insurance: policy in search of universal coverage . . 450
7.1 Ideal of universal coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
7.2 The Green Paper on National Health Insurance in South Africa . . . . . . . . . . 450
7.3 NHI and earlier health financing reform proposals compared . . . . . . . . . . . . 450
7.4 Funding requirements for the proposed NHI . . . . . . . . . . . . . . . . . . . . . . . . . . 450
7.5 Potential for proposed NHI to address health system challenges in
South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450

Chapter 9 Primary health care: nature and state in South Africa

MC ENGELBRECHT & HCJ VAN RENSBURG
1 Primary health care: concept, philosophy and strategy . . . . . . . . . . . . . 483
1.1 Primary health care: different meanings, different approaches . . . . . . . . . . . 483
1.2 Manifestations of PHC in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
2 Nature and state of PHC in pre-1994 South Africa . . . . . . . . . . . . . . . . . 486
2.1 PHC versus curative care: signs of emerging multiple fragmentation . . . . . . 486
2.2 Early experimentation with PHC and the golden era of PHC . . . . . . . . . . . . . 487
2.3 Sporadic government attempts to revive PHC: 1970s, 1980s and early 1990s 489
3 PHC in post-1994 South Africa: building a district-based PHC
system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492

xvi
BACK TO 10
3.1 First strides towards PHC as predominant policy in health care . . . . . . . . . . 492
3.2 Apartheid legacy and early reforms: further strides towards implementing
PHC policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
4 PHC delivery in South Africa: service packages and programmes . . . 497
4.1 The first service package for PHC facilities (2001) . . . . . . . . . . . . . . . . . . . . . 497
4.2 Revising the PHC Package (2010) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
5 Supply of PHC services in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
5.1 Public PHC facilities: spectrum, types and authority . . . . . . . . . . . . . . . . . . . . 504
5.2 Public PHC facilities: numbers and trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506
5.3 Role of private and non-govern-mental organisations in PHC . . . . . . . . . . . . 508
6 Current state of public PHC services in South Africa . . . . . . . . . . . . . . 510
6.1 Milestones of achievements, successes and gains . . . . . . . . . . . . . . . . . . . . . . 510
6.2 Remaining issues and emerging challenges in the delivery of PHC services 512
6.3 Progress in PHC: indicators of success and failure . . . . . . . . . . . . . . . . . . . . . 516
7 Revitalisation and re-engineering of PHC in South Africa . . . . . . . . . . 524
8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529

Chapter 10 Hospitals andhospital reform in South Africa

JC HEUNIS & AP JANSE VAN RENSBURG
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
2 Hospital history: globally and in South Africa . . . . . . . . . . . . . . . . . . . . . 537
2.1 Hospitals: global developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
2.2 Hospitals: developments in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
3 Post-1994 developments and reforms of hospitals in South Africa . . 543
3.1 The reform challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543
3.2 The reform policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
4 Provision of hospital care in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . 551
4.1 Hospitals in the public sector: nature, numbers and trends . . . . . . . . . . . . . . 551
4.2 Hospitals in the private sector: nature, numbers and trends . . . . . . . . . . . . . 554
4.3 Strategies to improve the sustainability of the hospital sector . . . . . . . . . . . . 560
5 The district hospital, PHC and the DHS in South Africa . . . . . . . . . . . . 561
5.1 District hospitals and PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
5.2 DHS development and thedistrict hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
5.3 The District Hospital Service Package: norms and standards . . . . . . . . . . . . 564
5.4 Proportion of DHS expenditure on district hospitals . . . . . . . . . . . . . . . . . . . . 567
6 Social dynamics of hospitals in South Africa . . . . . . . . . . . . . . . . . . . . . . 568
6.1 Hospitals and managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
6.2 Industrial action and the right to strike in hospitals . . . . . . . . . . . . . . . . . . . . 571
6.3 The “human” dimensions of human resources for health . . . . . . . . . . . . . . . . 575
6.4 The hospital patient experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
6.5 Hospitals and communities:the hospital board . . . . . . . . . . . . . . . . . . . . . . . . . 581
7 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 584
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

xvii
BACK TO 11
Chapter 11 Complementary and alternative medicine and
traditional health care in South Africa
E PRETORIUS
1 Health care pluralism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
1.1 Biomedicine or allopathic medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 594
1.2 Non-biomedical or non-allopathic healing systems . . . . . . . . . . . . . . . . . . . . . 595
2 Complementary and alternative medicine (CAM) . . . . . . . . . . . . . . . . . 596
2.1 Complementary and alternative medicine: diversity and principles . . . . . . . 596
2.2 Classifying complementary and alternative healing systems . . . . . . . . . . . . . 598
3 Complementary and alternative medicine: diversity of therapeutic and
diagnostic methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
3.1 Therapeutic methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
3.2 Diagnostic methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 602
3.3 Complementary and alternative healing systems . . . . . . . . . . . . . . . . . . . . . . . 602
3.4 Choosing complementary and alternative therapies . . . . . . . . . . . . . . . . . . . . 607
4 Assessing complementary and alternative medicine . . . . . . . . . . . . . . . 608
4.1 Gauging consumer demand and utilisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609
4.2 Gauging medical practitioners’ attitudes regarding CAM . . . . . . . . . . . . . . . . 609
5 Integrating biomedicine and complementary and alternative
medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610
6 Complementary and alternative medicine inSouth Africa . . . . . . . . . . 611
6.1 The legitimisation of complementary and alternative health care . . . . . . . . . 611
6.2 Present status of complementary and alternative therapies . . . . . . . . . . . . . . 612
7 Parochial health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
7.1 The folk medicine of the white settlers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
7.2 The folk medicine of other cultural groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
8 African traditional healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
8.1 Traditional healing: a brief historical overview . . . . . . . . . . . . . . . . . . . . . . . . 617
8.2 The premises of traditional healing: African cosmological views . . . . . . . . . 618
8.3 African views on health, disease and disease causation . . . . . . . . . . . . . . . . . 621
8.4 Types of traditional healers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624
8.5 Traditional treatment of disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
9 Traditional health care systems vis-à-vis national health care systems:
the global scene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630
9.1 Policy options for determining the status of traditional health care systems 630
9.2 The role of global organisations in promoting traditional health care . . . . . 631
9.3 The role of organisations on the African continent in promoting traditional
health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
10 The current position of traditional health care . . . . . . . . . . . . . . . . . . . . 634
10.1 Assessing traditional health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634
10.2 Legitimisation and professionalisation of traditional health care . . . . . . . . . 638
11 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646

xviii
BACK TO 12
Chapter 12 Perspectives from bioethics on health care
challenges for South Africa
SR BENATAR
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
2 Health in South Africa within a world of which it is a microcosm . . . 654
3 History of medical ethics in South Africa . . . . . . . . . . . . . . . . . . . . . . . . . 657
3.1 Early markers of medical ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657
3.2 Growth and transformation of medical ethics . . . . . . . . . . . . . . . . . . . . . . . . . 658
4 Medical ethics and human rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662
5 Ethical dilemmas at the interpersonal level: the health
professional–patient relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
5.1 Confidentiality and trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
5.2 Informed consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
5.3 Dual loyalty, conflicts of interest and advertising . . . . . . . . . . . . . . . . . . . . . . 671
6 Ethical dilemmas at the levels of nations, health systems and
institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
6.1 In search of equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
6.2 Resource allocation, priority setting and rationing . . . . . . . . . . . . . . . . . . . . . 674
6.3 Withholding and withdrawing treatment: the concept of futility . . . . . . . . . . 676
6.4 Institutional governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
6.5 Balancing clinical services, teaching and research . . . . . . . . . . . . . . . . . . . . . 677
6.6 Maintaining professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677
7 Ethical dilemmas at the national level . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
7.1 Dealing with the HIV and AIDS pandemic: a major challenge . . . . . . . . . . . . 679
7.2 HIV transmission preventionand treatment programmes:the controversies 680
7.3 The health budget: ethical implications of decisions . . . . . . . . . . . . . . . . . . . . 682
7.4 Expanding the health budget in the face of the HIV and AIDS national
emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683
7.5 Universal access to health care: the public–private divide . . . . . . . . . . . . . . . 683
7.6 Public health ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685
8 Ethical issues at the level of international collaboration . . . . . . . . . . 686
8.1 International collaborative research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
8.2 Development: different connotations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 688
9 Building national capacity to deal with social and ethical dilemmas 689
9.1 Transdisciplinarity in health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
9.2 Promoting global health ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
9.3 Teaching health care ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
10 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701

xix
Random documents with unrelated
content Scribd suggests to you:
 He was not used to dealing with women of her class, and though he was
ready to bully or bluster, he found nothing in her self-possessed, impersonal
manner which he could take hold of. Besides, he reflected, it was far better
not to frighten her. If he did, she might produce lawyers, or such other
undesired persons, to take part in the proceedings. He knew, far better than
she, the flimsiness of his own claims. He was not the girl's legal guardian,
and never had been. A moral claim was all that he could urge, joined to a
cunning by means of which he hoped to attain his end, for he was
convinced that it would be well worth his while to get hold of Rona. She
had grown into just such a woman as he had foreseen. He did not feel any
doubt of being able, with little difficulty, to reconcile her to the way of life
he had in view for her, when once she realized her own power, and what a
splendid time she could have if she were but sensible. But he knew well that
the tactics he had formerly adopted were woefully mistaken. Of all things
now, he must not scare her. As his mind flew rapidly over his intended
course, he felt that he could not do better than accept this dinner invitation.
He helped the two ladies into the carriage, little dreaming how the heart of
the haughty-looking Miss Rawson was knocking against her side.

"If you would kindly give me the address," he said.

Miss Rawson was seated in the victoria. She opened her card-case.
"Home," said she to the coachman, in the act of handing the card to Mr.
Leigh, with a bow and a condescending smile. The man touched his hat,
and started. They glided away, leaving Mr. Leigh staring fixedly at the card,
with a face suddenly crimson.

"Normansgrave!" he repeated over and over to himself. "Why, that's the

Vanstons' place! His brother's place! Well, of all the fools, that detective of
mine, Burnett, was the worst! And yet, of all the places that I should have
thought he would not have taken her to, his brother's place was certainly the
one." He was so thoroughly disconcerted that he actually grinned. "I
thought they had slipped through his fingers somewhere," he reflected. "He
said he was certain that he sent her across from Plymouth—such stuff! I
told him. I said, 'He left her somewhere between London and Basingstoke,
or my name's not Rankin Leigh.' But they always think they know best,
these blooming detectives! Well, it's a queer thing! Young Vanston must
have brought her here, yet I'll swear that he never went near the place
himself, and, what's more, I can swear that his brother didn't know where he
was, unless Denzil Vanston, Esq., is the most finished liar on the face of the
earth. Why, at that very time, he was paying the police a pretty penny to
find the ticket-of-leaver—or his corpse! Humph! Well, I thought I had only
a woman to deal with, but if the two Vanstons are in it the difficulties will
be greater than I had foreseen. What did become of the other one, after all?
Well, there may be some information to be got up at the hotel yonder, that's
one thing."

He hurried back to the second-rate inn where he had put up, and, in the
course of an hour or two, had found out something of some importance. The
Squire had just gone abroad—very unexpectedly. It was even known at the
post-office that he had had a cable from Siberia. This was good news. Leigh
determined upon his plan of action. He would ask humbly, but with
firmness, so as to imply that he could enforce obedience if he chose—he
would ask that his niece be allowed to come and stay with him in his flat in
London, to show that all was right between them. He would speculate; he
would hire a furnished flat in a good position for a month, no matter at what
cost. And he would take the girl about—give her clothes and a few jewels;
take her to the theater and to race-meetings—he believed that the men to
whom he could introduce her would do the rest.

For all the latter part of his life, the man had been a hanger-on at stage
doors, a theatrical agent, a go-between of the profession. He believed all
women to be like those with whom he was in daily contact—greedy,
grasping, pleasure-loving, non-moral. To him, the life he found Rona living
—going to church with a maiden lady—was a life from which any
handsome young girl would escape, if she could.

If she once found that her beauty would bring to her—and incidentally
to him—diamonds, motors, life on the champagne standard, he literally
could not conceive that she could hesitate. What was the good of having a
girl like that in your power if you could not make her keep you? He was
determined to have an old age of comfort, as a result of the earnings of
Rona. He knew all the ropes. He knew all there was to know about the
"Profession." He knew that, given material of the quality of that girl,
success, with the right steps taken, the right course adopted, was quite
certain.

He sat smoking, and thinking it over, with his whisky on the table
beside him. He considered what, or how much, he could or should tell Rona
of what he suspected of her parentage. He was himself the son of a solicitor,
and had received a good education. But there was a bad strain in the blood.
Both he and his brother had gone to the bad, and his brother had died
young, leaving an orphan girl, whose early associations were those of a life
of discreditable shifts, but who had developed the backbone lacking in her
father and uncle, had insisted upon qualifying to teach, and when her
education was complete, had obtained a post as governess in the family of
Mauleverer, a well-known old house of the Roman faith in the North of
England. But it seemed as if this girl, too, were infected by the obliquity of
the family morals, for, after a time, she disappeared from her uncle's view,
his letters being returned to him marked "Gone away. Address unknown."
One day he received a letter with a London postmark, written at her
dictation. It said that she was married, that she had just become a mother,
that she was dying. The letter, which bore no address, was only to be posted
in case of her actual death, and then not until after a month had elapsed. She
did not reveal the name of her husband, but said that her tiny daughter was
to be brought up in a certain convent—the address of which she gave him—
under the name of Leigh. She begged him to inquire from time to time of
the child's health.

Her uncle and she had never been in sympathy. Evidently she had
nobody else at all to whom she could appeal for her baby's sake to take
some interest in her. She had always been a good and very quiet, steady girl,
yet her uncle found it a little hard to believe in the story of her marriage.

There was a young man at Vane Abbey—John Mauleverer, the eldest

son. But he was a shy, retiring, delicate youth, by no means the kind of man
whom one suspects of making love to the governess. Rankin Leigh had
made a few inquiries at the time, but had learnt nothing to confirm such a
suspicion.

Other young men had come and gone, visitors at the Abbey; and as all
these were Roman Catholics, the fact of the baby's being sent to a convent
was not of much significance. Young Mauleverer married, a wife of his own
rank, not long after the death of Veronica's mother. If he were the man, this
gave some color to the dead girl's solemn assertion that she had been
actually married. The fact that the supplies for Veronica's maintenance
stopped upon John Mauleverer's death made Rankin Leigh morally certain
that he was, after all, the father. He left a family of several children. Had
Veronica been a boy, it would have been worth her uncle's while to incur the
expense and trouble of hunting up evidence, and establishing her claims on
the property. But since she was a girl, and her father had sons, he did not
care to follow up the clew. And when, summoned to the convent by a letter
from the solicitors explaining that the supplies had ceased, he saw his niece,
he felt that she would be a more lucrative and less risky source of income
than the levying of blackmail.

But what he had not cared to set on foot, he had little doubt that the
Vanstons might be willing to undertake, if he told them the truth. Should
he? He was still meditating on the subject, when the waiter looked in.

"Mr. Leigh! Gentleman of the name of Burnett to see you, sir."

"Burnett! Well, that's a coincidence! Burnett, by all that's wonderful!

The very man!"

Burnett, the detective, came in with a twinkle. He sat down, and when
he had refreshed himself at his host's invitation, he produced a letter from
his pocket. "You're wanted, Leigh, seemin'ly," he remarked, with humor.

"I'm wanted, am I?" said Rankin, with a stare. "And who wants me?"

"No less a person than Squire Vanston, of Normansgrave, has written to

me to trace you out."

"Well, I'm——" remarked Leigh, in amazement.

"Here's the letter, if you don't believe me. Got it yesterday. So I've come
to ask—do you want to be traced or don't you?"
 "No need, my dear friend," said Leigh, in an off-hand way. "I introduced
myself this morning to Mr. Vanston's aunt, and to my own niece, who has
lived with them ever since I had the pleasure of putting you on her track. If
ever there was a confounded fool, it is you, Burnett, if you'll give me leave
to pass the remark. I'm dining there Tuesday," he added, with nonchalance.

CHAPTER XXIII

THE ESCAPE OF AUNT BEE

I should have cleaved to her who did not dwell
In splendor, was not hostess unto kings,
But lived contented among simple things,
And had a heart, and loved me long and well.
—WILLIAM WATSON.

The victoria fled swiftly along the pretty country road for some
moments without either occupant saying a word. Rona sat as if the falling
of the long-expected blow had stunned her. Aunt Bee, watching her set lips
and tragic eyes, felt vaguely alarmed.

"Rona," she said, in low tones, almost a whisper, "had you any sort of
idea that he was in the neighborhood—before we set out for church?"

The girl hesitated. At last—"I thought I saw him," she said, reluctantly,
"at the station the other day, when we went to see Denzil off. A race train
came in from Virginia Water, and I turned, glancing idly along the carriage
windows, and felt almost sure that I saw his face. I had the idea that he had
suddenly risen from his seat, and was looking at me. But at that moment the
train moved, and I—I could not be sure. But he must have been sure, and he
must have spent all these days searching the neighborhood for me. It was a
clever idea to go to church, wasn't it?"

Aunt Bee remained silent for a swift moment or two. Then she turned
suddenly, stooping, her lips close to the girl's ear. "Rona—how long shall
you take to pack?"

The girl started, a light came into her eyes and color into her cheeks.
"For how long?" she rejoined, with bated breath.

"For a journey,—one hardly knows how long. One trunk, a hat-box, a

hand-bag."

"Two hours, if there is time. Twenty minutes if there isn't."

"Good girl. I expect we can have our two hours. But I must study a
time-table. I see nothing for it but flight, and before he can suspect us of
anything of the sort. I cannot deal with him in Denzil's absence."

"No," said Rona, her eyes glowing. "You are simply splendid! Oh, what
a relief! I have been so sick with fear. I am not a coward, really, but my
nerves cannot bear the sight of him. If you could know the things he recalls!
I feel like a thrashed slave when you show her the whip."

Miss Rawson caught her hand and held it tight. "Courage, darling! You
know Denzil does not think he can really do much. Of course, it depends a
great deal upon the exact terms of your father's will. But even if he is
legally your guardian, I don't think he can actually force you to live with
him. If he is not, Denzil says we can snap our fingers. But, for all that, I
dare not tackle him alone. We must be off, and at once. And nobody must
know, not even the servants, that we are going beyond London. I have about
fifteen pounds in the house here, and I will write to my bankers, with a
check, instructing them to cable out more money to me to Paris, or
Brussels, or wherever it is we start from—I'll look out the route."

"Where are we going?"

"To St. Petersburg, I think—don't you?"

 Rona gasped. She repeated the words mechanically. "To St. Petersburg!
Oh, Aunt Bee!"

"It seems to me the safest course. The man looked to me as if he were

prepared to be very disagreeable. If we simply go to Paris, he might follow
us. But I should judge that the state of his exchequer would render Russia
quite out of the question——"

"Oh, how wonderful you are! But we shall want a passport for Russia,
shall we not?"

"I could get that anywhere where there is an English Embassy. Let me
see, we had better take Gorham, I think."

Gorham was Miss Rawson's maid, a middle-aged, superior woman,

attached to her mistress, and fond of Rona. "We will not tell anyone our
destination until we are safely off," went on Miss Rawson; "Gorham must
be told that we shall be away for a month, at least, but the servants here
must be left under the impression that we return without fail on Tuesday
evening. I will even order the dinner for that night before I go, and tell cook
that I expect a gentleman to dine with us. Then if he does hear that we are
away, and makes inquiries, his suspicions will be lulled."

Upon consulting the time-table, they found that all Was easy. By driving
to Weybridge they could catch a 5.56 train, reaching Waterloo at 6.49, in
plenty of time to dine comfortably and catch the 9 p.m. boat train, by which
means they would arrive in Paris at five o'clock next morning.

Miss Rawson had a cousin—one Mrs. Townsend, known in the family

as Cousin Sophy—who lived in Kensington and was in feeble health. Aunt
Bee unblushingly told her household that she had news that this good lady
was suddenly taken worse, and that she must go at once. As she did not like
to leave Miss Rona at home alone, she should take her; and as they must put
up at an hotel, she should also take Gorham. As they should probably stay
only a night, or perhaps two, she wished nothing said in the village of their
absence; and, as the Squire was known to dislike Sunday traveling, she
wished Jones to drive the luggage cart out by the back way and go along the
lane, and not by the high road, that the village might not be scandalized.
 "I don't think," said the newly fledged conspirator, "that he will suspect
us of bolting, after my asking him to dinner like that. Was it not a good
thought of mine to say we were engaged to-day and Monday? Conspiracy
comes terribly easy when once one tries it! Cheer up, darling, we shall get
off with no trouble at all. And on Tuesday afternoon I will dispatch a
telegram to him, saying that I am sorry to have been suddenly called away.
Mercifully, I have a balance of several hundred pounds in the bank just
now, which I have been saving up to buy furniture with when Denzil and
you turn me out! We shall do admirably."

Rona flung her arms about her neck. "I think it is too much," she said, in
a choked voice. "Let me go—let me disappear! Why should you lavish
money, time, health, on me? Who am I? Nobody knows. And I have done
nothing but harm. I have made them both unhappy. Give me ten pounds and
let me go away and hide, and earn my own living—ah, let me!"

Her mouth was stopped with a kiss, and an injunction not to be a little
fool. "I enjoy it," said Aunt Bee, with an air of evident sincerity. "I never
got a chance to do a desperate thing like this before. Who would think of
staid old Miss Rawson, the mainstay of the Girls' Friendly Society and the
Clothing Club, telling tarradiddles to her servants, and rushing off across
Europe, in defense of a helpless beauty with villains in pursuit! I feel as if I
were in a book by Stanley Weyman!"

In fact, her capacity and energy carried all before them, and triumphed
even over Gorham's consternation when, upon arriving in London, she
found that, so far from having reached their goal, they were but at the
starting-point of their journey.

The obtaining of their passport and waiting for their money delayed
them in Paris for four-and-twenty hours. But they felt fairly safe, and made
up their minds not to worry. They arrived at St. Petersburg absolutely
without adventure, and found themselves in a spacious, well-appointed
hotel, where English was spoken, and in a capital which did not seem to
differ much from other foreign capitals, except in the totally unknown
character of the language, and a curious Oriental feeling which seemed to
hover in the air rather than to express itself in any form of which me could
take note.
 Miss Rawson was much inclined to plume herself upon her successful
disappearance. They had written to Denzil to inform him of the step they
had taken, and why. On reaching St. Petersburg, they telegraphed to him
their arrival and address. If all had gone well with his journey, he should
have been almost a week at Savlinsky by now, and might have important
news for them.

A telegram arrived the following morning. "No news Felix. Please await
letter—Denzil."

That was all. They could not tell, from its necessary brevity, whether he
was displeased at their daring dash or no. But there was nothing for it but to
stay on in their hotel for a week or two, until the arrival of the letter alluded
to.

And in truth there was plenty to see, plenty to interest them. It

disappointed Rona that the ice and snow which she had associated with the
idea of Russia were absent—that the weather was fine, and, if anything, too
hot to be comfortable. But this enabled them to go about and to enjoy the
sights of the place.

And then their first misfortune suddenly befell them. Miss Rawson, in
stepping out of a droshky, wrenched the knee which had been troubling her
that summer, displacing the bone in its socket, and tearing and bruising the
ligaments, so as to produce acute inflammation.

It was the kind of accident which happens one hardly knows how or
why. One may get out of a cab every morning for five-and-twenty years,
and the following day injure oneself seriously in so doing. The doctor called
in—an English doctor was at once forthcoming—thought very gravely of it.
It was a far worse matter than a simple fracture, he said. Absolute rest was
the only thing possible. He used every effort to reduce the inflammation.
But the pain was so great and so continuous that the patient could not obtain
any sleep; and the day after the accident she was so ill that Rona was very
anxious about her.

That same day came a letter from Denzil. He said he was very glad to
hear that they had come out, though he could hardly have advised so
extreme a course had he known it to be in contemplation. As they were
there, he hoped they were fairly comfortable, and would not mind staying
on until he had some idea as to what was best to be done. He said that the
place where he was was far from civilization, and though the Russian,
Vronsky, did all he could for his comfort, he found himself very unwell, as
a result, he supposed, of his long journey, or the difference in climate, or
way of living, or anxiety. There was no news of Felix. He related the
circumstances of his disappearance, and of the pursuit of Cravatz. He said
that Vronsky was far from hopeless, for the Governor suggested that Felix
was perhaps keeping out of harm's way until he heard that the Nihilist was
laid by the heels. He himself could not but think that had Felix intended to
go into hiding, he would have informed Vronsky, and not left him to fret
and distress himself. Vronsky's devotion to his brother was touching. He
meant to leave him everything of which he died possessed. He was in a
large way of business. He had confided to Denzil that he believed Nadia
Stepanovna, the Governor's daughter, was interested in Felix——

("Dear me, what a good way out of our difficulty that would be!" sighed
Aunt Bee.)

They had every hope of hearing of the arrest of Cravatz in a few days.
The police had been put on his track by a wandering Kirgiz. ("What on
earth is a Kirgiz?" said Aunt Bee.) When his arrest was a known fact, they
might hope to ascertain where Felix was, unless he had been the victim of
foul play. But an exhaustive search all along the route between Nicolashof
and the mines had resulted in no discovery; and his attached servant, Max,
was missing also. He concluded by remarking how fortunate it was that,
owing to the proximity of the Governor's summer residence, they had a line
of telegraph in so remote a spot. He recounted his own journey there, and
added that he would write more, but that he felt increasingly unwell, and
was afraid he should have to go and lie down.

It was a disquieting letter. They did not like to think of Denzil being ill,
so far from them, or from a doctor, or from any friends. He could not speak
a word of Russian; and though Vronsky had improved in his English under
the tuition of Felix, he had had of late little use for that tongue, and it had
grown rusty.
 Aunt Bee almost forgot her pain in discussing the hard case in which
Denzil must find himself. They talked of little else all day.

Next morning, when poor Miss Rawson awoke from the only nap she
had been able to snatch during a night of agony, it was to hear that another
telegram had arrived.

"Vanston very ill, wishes you to come.—Vronsky."

Miss Rawson buried her face in the pillow and sobbed. What was to be
done? It was an impossibility for her to think of traveling. Yet the idea of
Denzil alone and ill in that awful place was torment to her. Rona made up
her mind.

If she could not offer to the man who loved her the devotion which he
craved, she could at least offer service. She remembered his extreme
kindness when she, the frightened, penniless little fugitive, had lain ill at the
Cottage Hospital.

The least she could do would be to hasten to him, ill as he was, and
lonely among aliens.

"I shall go, Aunt Bee," she said, quietly. "It is of no use your trying to
stop me. I can manage quite well. I have Denzil's letter here, giving a full
account of his journey. I have only got to get into the right train at Moscow,
get out of it at Gretz, and hire a carriage to take me on. You have Gorham
here to stay with you, and I shall be all right, I have plenty of common
sense."

"Rona, it is impossible—impossible, and you know it! A girl of your

age and appearance to go a drive of five hundred miles, alone, with these
savages—what would Denzil say?"

"Denzil will not know until it is over," was the quiet answer. "Now,
dear, it is of no use to fuss. What have the two Vanstons done for me? What
have I ever done in return? Here is a thing I can do. Why, women do such
things every day. I know a girl who went back to her husband from England
to Japan, right along this trans-Siberian line, by herself. You must not
hinder me, for I am going, dearest."

It was in vain to argue with her. Her mind was quite made up. She went
out to Cook's Office, took her ticket, made her passport arrangements, and
came back triumphant to pack her trunks. The doctor, when called into
consultation, thought the plan a little daring, but by no means beyond the
bounds of possibility. He had, as it chanced, a patient, a lady who lived
farther along the line, and who was, by a fortunate coincidence, going that
way, so that she could travel with Rona as far as Gretz. "As for the drive,"
he said, "it is a main road almost all the way; there are posting-stations and
good horses. I think the drivers are an honest set of men; and I do not see
why she should not be safe."

In short, the girl's determination carried the day. "Do not let us think of
Mrs. Grundy," said she; "let us only think that Denzil is ill, and wants me.
He has every right to have me, if I can get to him by any means in my
power."
 CHAPTER XXIV

VERONICA "ON HER OWN"

And so I look upon your face again.
What have the years done for me since we met?
Which has prevailed, the joy of life or pain?
Do you recall our parting, or forget?

Show me your face. No! Turn it from my sight!

It is a mask. I would lay bare your heart.
You will not show me that? I have no right
To read it? ... Then I know my doom. We part.
Words for a Song.

In after days, when Veronica looked back upon that journey, it seemed
to her as if it had lasted for months.

As its slow hours crept by, she grew to have a feeling that she had been
traveling ever since she could remember, and must go on traveling till she
died. The train moved on, and on, and on, like a thing which, once started,
can never stop again. After the first twelve hours she had a bad attack of
train sickness, an ailment from which she had never before suffered; and
she lay sleepless during the night hours, with aching head and parched
mouth, tossing about on her berth, and with her mind unable to detach
itself, even for a moment, from a thought so dreadful that never, till faced
by this dreary solitude, had she dared to put it into words.

She knew, she had known, ever since their interview in the rock garden,
that she no more loved Denzil than she loved his absent brother. She did not
love him, and she vehemently desired not to marry him. Yet, somehow or
other, she had caused him to believe that she returned his affection. She
was, practically, engaged to him. She had deceived both brothers, and it
seemed to her that, search as deeply as might be into her own heart, she had
not done so wittingly.
 The case simply was that her heart had never been aroused. Her hour
had not come. She did not know love. Each of these two young men had
wanted of her something which she had not to bestow. To each she had
offered in return something else. There was, however, one notable
distinction between the two affairs. Felix had excited her best feelings. She
had felt for him pity, sympathy, the instinctive womanly desire to comfort
and sympathize with the lonely, the unfortunate. Denzil, on the other hand,
had stood in her imagination for home, peace, safety, well-being. It had
been her selfishness which had responded to his call. He could give her an
assured position, and life in the surroundings which she loved. Felix was
the asker, Denzil the bestower. To marry Felix demanded sacrifice; to marry
Denzil was to accept benefits at his hands.

But, if she considered which of the two had the more claim upon her
allegiance, she found herself bewildered, divided. Felix had saved her life,
but Denzil had preserved it. As she envisaged the situation, she felt that the
die was cast. Her letter to Felix had bound her to Denzil. She wondered,
over and over to herself, whether Felix had received that letter, and what he
had felt upon reading it. Here, in her isolated loneliness, far from Aunt Bee,
far from Denzil, she began to have an inkling as to what letters would mean
to the exile, and to realize what Felix might have experienced, upon seeing
her writing, snatching open the envelope, and reading the complete
extinction of her own feeling for himself....

Was his present disappearance—could it be—the result of her cruelty?

Had it made him reckless?

Such thoughts poisoned the weary hours of the endless night. And
through them all beat upon her brain the knowledge that Denzil was ill, so
ill that he had wired for them to come to him. He would not have taken so
extreme a course, had his sickness not been serious—had he not been in
danger.

What should she do, if after the bitter strain of her long journey, she
found him dead when she arrived at Savlinsky?

She pictured herself alone, in the mining village, with no woman near,
with nobody but Vronsky, the Russian! Was it, after all, mad of her to
undertake such a journey?

She was thankful to rise from her sleepless couch, and shake off the
wild dreams which visited her with every moment of unconsciousness. The
varying country, the dim Ural Mountains, into the heart of which they
ascended, the increasingly strange garb of the people, left hardly any
impression upon her usually active mind. But during the day she rallied
from her misgivings of the previous night, and girded at herself for a
coward.

There was nothing to take off her mind from its treadmill of
apprehensions. The lady who was her fellow-traveler spoke English, but
was very dull, and most likely herself thought the girl unresponsive. It had
proved impossible to get English books for the journey, and she was
without refuge from the harassing thoughts which yelped about her like
snapping wolves.

As the train bore her along the endless road, as day faded into night and
morning dawned again along the illimitable plain, and sun shone and wind
blew and clouds drifted, and meal-times came and passed like telegraph
posts, the thought of her treachery—her double treachery—was ever in her
mind, aching, desolating.

Her fellow-traveler's encouraging assurance that they would be at Gretz

in an hour or two was an untold relief. At Gretz she hoped for tidings of
Denzil. She had telegraphed, before leaving St. Petersburg, that she was
starting, and asked to have news wired to Gretz. Her telegram, in its brevity,
said nothing of the fact that she was coming alone.

Of itself, the idea of escape from the noise and motion of the train was
something to be eagerly anticipated. To walk upon firm ground, to stand
still, to sit upon a chair—these were boons indeed.

But when the train had departed, bearing with it the one creature with
whom she was on speaking terms, and she stood upon the platform at the
station and looked around at the dull, dirty town and the wild-looking
people, she had a moment of sheer panic. How isolated she was! How the
days had rolled by, without her being able to hear, either from the beloved
aunt she had left, or the lover to whom she journeyed!

She shivered as she stood, for a heavy rainstorm had but just passed
over the town, and everything seemed dank and dripping.

She drew out her paper, upon which the doctor had written down for
her, "Drive me to the Moscow Hotel." "I want to stop at the post-office." "I
want a carriage and horses to go to Savlinsky," and various such necessary
formulæ.

It was only half-past ten o'clock in the morning, so she was determined,
if a carriage could be secured, to stay only for lunch at the hotel, and start
upon her journey at once. The friendly St. Petersburg doctor had seen that
she had a store of tinned food with her, but it was with a sharp pang that she
realized that however much she wished to supplement her stores she could
not do so, as she could not say one word of Russian.

She found herself the center of a gesticulating crowd of men, all

proffering unintelligible service, saying to her things which she could not
understand. She could not pronounce the words the doctor had written
down for her, though she had tried to learn. She had to show the written
paper to the barbarian crowd that surrounded her. Its purport was,
apparently, understood, for, with many gesticulations, and noises which she
hoped and believed were of a friendly nature, she found herself conducted
to a curious-looking vehicle in waiting outside; and, earnestly repeating
"Hotel, Post Office, Posting-house," she got in, and was driven through
such a slop of mud as she had never before encountered. Pausing presently,
she found they were at what looked like a stable doorway. Her driver made
signs for her to alight, and she concluded that he was explaining that he had
brought her first to the posting-house to give her order, as it was on the way.
She dismounted trembling, almost slipping in the filth, and, peeping
through the half-open gate, saw a dirty courtyard within, where one or two
ostlers were at work; and, facing her, across an incredible swamp of stable
refuse, the door of a house, which was presumably the place where she
must give her order. Gathering her skirts about her, she entered the
disgusting place, and stood wavering, glancing round in desperation, and
despising herself for her want of resource.
 She saw that she had been imprudent in trusting herself, with no
knowledge of the language, in such regions. But she was in for this journey
now, and meant to win through to Denzil if she died in the attempt. She
must not be deterred by the smells nor the mire of the stable yard: and she
advanced with determination.

Just as she did so, two men came out from the door-way which she was
approaching, and stood upon the stone step in the full light of day. One was
presumably the Russian stable-keeper, a wild kind of person, but apparently
amiable. He was in eager converse with a tall man, very well dressed, who
held a cigar between his fingers.

The clouds were breaking, and a watery sun at this moment lit up the
squalid scene. It shone upon this unexpected figure, and it shone also upon
the far more surprising appearance of the English girl, in her dainty apparel,
picking her way through the muck.

The stranger's keen, alert gray eyes grew fixed, and for a moment he
stood, rigid and still as a stone, while his bronzed, finely-cut face turned
pale.

Rona stopped short. There was no recognition at first upon her face. But
something in the change which passed over his struck a wild conviction into
her mind.

It was the missing man—Felix Vanston.

* * * * * *
*

How changed! That was her first thought. The image in her memory of
a gaunt, pale, bearded youth, thin and stooping, faded and died away. This
was a Man, in the fullest sense of all that word can mean. It was fortunate
that his own recognition of her had been instantaneous. Even now she was
not sure, until he came towards her, through the rotting straw.

His color had not changed, while hers was now fading visibly from the
cheeks to which it had rushed in tumult. He was wholly self-possessed and
dignified, though his surprise must have been greater than hers. As he came
nearer she had a conviction, deep and certain. He had received and read her
letter. She could have declared that the lines of his mouth expressed a light,
scornful contempt.

Without a word said, she knew and felt herself condemned.

But, whatever the young man's feelings at the meeting, hers must be
predominantly those of relief. In spite of the violent shock which his
appearance gave her, she was conscious of almost frantic joy, at sight, in
that weird place, not merely of a compatriot, but of a friend.

"David!" she uttered at length, using in her confusion the name by

which she had always known him. "Then you are alive—you are safe, after
all."

He was quite close to her now. She felt dizzy, and as though she could
hardly bear such nearness. She thought, suddenly and irrelevantly, of the
way in which they had clung together, she and he, in the little arbor at
Normansgrave—clung each to each, and felt that to part was terrible.

... He was speaking. She must listen, must bear herself rationally. He
was holding her hand, lightly—for an instant—then he had dropped it, and
she heard his voice. That, too, was changed, with the subtle transmutation
which had passed over him.

"I am sorry," he said, "that my disappearance has apparently caused far

more anxiety and trouble than I could have anticipated." He hesitated, rather
as if he expected her to explain her miraculous appearance in Siberia. But
she could not have uttered a word. After a pause he went on—"Surely it
cannot be—on my account?—I mean, I am at a loss to explain your being
here."

She made a mighty effort then, and brought out a few gasping words.

"Denzil—he is at Savlinsky. He is very ill. I am on my way—to him."

 He looked oddly enlightened. The lines of contempt, or indifference,
deepened about his almost too expressive mouth. "May I ask if my brother
has any idea of the—er—remarkable course you are pursuing?"

She assented eagerly. "He is expecting me. I—I must go on directly."

For a moment she wrestled with her feelings, then commanded herself.
"You don't know what it is to see you—to see the face of a friend," she
faltered. "I feel so lost, so bewildered. You will help me, will you not? I
want a tarantasse."

"No," he replied, "what you must have is a povosska—a thing with a

hood. I was just ordering one for myself. I, too, am going to Savlinsky—"
he paused, eying her doubtfully. She forestalled him.

"Then, for pity's sake, let me travel with you! I—I will try not to be
troublesome. I hope you don't mind, but it would be such a relief—I feel
much less courageous than I expected. I can't understand a single word, and
it makes me feel helpless."

Felix bowed. "At what time would you wish to start?" he asked.

"As soon as I have had some lunch. I am very hungry. Eating upon the
train made me feel ill."

"Let me put you into your carriage, and, if you will wait a minute for
me, I will give the order and escort you to the inn."

He piloted her through the dirt, seated her in her carriage with a few
words to the driver, whose manner at once became more respectful, and,
having returned to the stable-keeper, soon rejoined her, and in a few
minutes they were seated, side by side, clattering through black, gluey mud,
among swarms and swarms of excited people, who thronged the streets in
dense crowds.

"What quantities of people," she said wonderingly, glad to have

something upon which she could remark naturally. "I never knew that such
a place could be so thickly populated."
 "Oh," he answered, with a certain frigid reluctance, "it is not always like
this. To-day is exceptional. These are sightseers."

"Indeed!" she replied, anxious only to avert silence, "what was the sight
they have come to see?"

There was a perceptible pause before he replied: "An execution."

She grew crimson, and flashed a look at him. He was staring in the
opposite direction. "Was it—was it Cravatz?" she asked, under her breath.

"It was." The words seemed to issue from a steel trap.

"Then you are free?" she breathed.

"And unattached," he responded, dryly.

She was silenced, and they drove on some little distance, until a thought
flashed into her mind.

"Oh," she said, "I was forgetting! Please ask him to drive to the post-
office. I must see if there is a message from Mr. Vronsky about Denzil."

Felix called an order to the driver, and then turned to her. "Do you really
tell me that my brother demanded of you that you should take this
formidable journey to him alone?"

"Oh, no, no! Please don't imagine that! He thought Miss Rawson would
come too. We were both at St. Petersburg, but Aunt Bee had an accident,
and hurt herself so seriously that she could not move. So I determined to
come alone. Mr. Vronsky's telegram was alarming."

"I congratulate you upon your devotion," remarked Felix, as the carriage
stopped at a wooden house. "My brother is a lucky man."

"He is a very good man," said the girl, nettled by the sneer. "Please ask
for the name of Rawson," she added, pettishly.

He soon came out, with a message. "Condition much improved."

Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebookfinal.com