Budgetary allocations are difficult to assess as national allocations filter down to provincial

and local levels. The medium term expenditure estimate for Maternal, Child and Women's Health remained static from 2001-2004 (Estimates of National Expenditure, 2001, 310).

Some shortage of resources is also suggested by the fact that only about 50% of designated TOP facilities are currently functioning (Adar and Stevens).

This scores a T are there appear to be insufficient resources for all services and facilities.

HUMAN RESOURCES 1

The Guidelines for Maternal Care 2000 (National Department of Health) cover the management of conditions that commonly arise in maternal deaths. These have been developed and distributed to provinces (Annual Report, 2002). Training has been conducted on the guidelines and on data collection.

There is a capacity problem with trained staff in the health sector generally (reflected for example in the fact that only 50% of designated facilities are functioning). Of the 885 obstetricians and gynaecologists registered in South Africa, the vast majority is in private practice and there is an uneven provincial spread in the public sector. The provision of trained midwives is also a problem. Measures have been developed to address this. For example, nursing training now requires all professional nurses to do six months midwifery, thus enabling them to be classified as midwifes. Advanced midwifery courses are available.

In general, the staffing and building of capacity at provincial and district levels is an ongoing process. Provincial and urban/rural differences have resulted in uneven development within and across provinces. Moreover, the integration of services remains an issue.

The Confidential Enquiry looks at avoidable factors, missed opportunities and substandard care that played a role in maternal deaths. In over half the deaths reported from 1999-2001 'there were health care worker related avoidable factors in the management of the event that leads to the women's death. This was most significant at the primary level where in just under three quarters of cases there were avoidable factors in cases managed at some point in their care'. (Executive Summary of Confidential Report, 5). In addition, a number of studies have shown women patients to be verbally and physically abused by health workers (Penn-Kekana and Blaauw, 33).

This scores a ' I' given staffing, capacity and attitude problems.

RESEARCH 2

The government has established a National Committee on Confidential Enquiries into Maternal Deaths. Ongoing research has been conducted into the magnitude of the problem of maternal deaths, the pattern of disease causing such deaths, the avoidable factors, missed opportunities and substandard care related to these deaths. Recommendations have been made into ways of decreasing maternal deaths.

See various reports of the National Committee on Confidential Enquiries into Maternal Deaths.

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This research has identified a range of causes of maternal death relating to the patient, the community, the health system and the practice of individual health workers.

This ongoing programme of research scores a '2\

INVOLVEMENT OF CIVIL SOCIETY 2

Civil society has been involved in the NCCEMD and in research projects for the Department of Health. There is a strong working relationship between Academia and research NGOs and government in this area.

Within civil society, women's organisations have focussed on the issue of abortion. NGOs involved in advocacy have found government to be receptive. In addition, NGOs have been involved in strengthening services.

Extensive involvement of civil society scores '2'.

INFORMATION DISSEMINATION I

The Report of the NCCEMD suggested that termination of pregnancy services and family planning services should be widely advertised to the public.

Government has been involved in several initiatives including National Pregnancy week in February. Guidelines have been developed and distributed on the five big killers of pregnant

women.

However, as with many other areas, information dissemination could still improve in terms of reach (language, location, age etc). This scores a * 1'.

MONITORING AND EVALUATION 1

Monitoring

The government (through the National Committee on Confidential Enquiries into Maternal Deaths) has put in place and sought to improve the reporting mechanisms for maternal deaths.

A key objective for 2001/2 was to strengthen the programme to monitor maternal deaths (Department of Health, Annual Report, 2002). A standard maternity case record has been distributed and training workshops on the use of this have been held in five provinces.

However, the system is not fully in place.

Evaluation

The Department of Health has commissioned research by the Reproductive Health Research Unit (Wits University) into the impact of the new Termination of Pregnancy law on unsafe abortions.

Ongoing evaluation also occurs through the reports of the NCCEMD. The Department of Health also commissioned a study on evaluating the quality of care in maternal health services to act as a baseline for evaluating implementation of the NCCEMD reports. Government is also collaborating on a research project to evaluate the impact of staff

leaving the reproductive health services (Interview, Penn-Kekana).

As a monitoring and evaluation system is not fully in place, this scores a ' 1\

CONTRACEPTION

INTRODUCTION

Family planning policy and services have historically been connected to racist policy goals.

The apartheid government pursued demographic goals in its family planning policy with a racist population control policy underpinning the provision of contraception to black South Africans (national Contraceptive Guidelines, 6). Even after an 'ideological shift' which saw (at least in theory) the improvement of women's health through adequate birth spacing as the objective of contraception from the 1980s, there was 'no real improvement in the quality of care as the delivery of family planning was firmly institutionalised within a demographic framework' (at 6).

Despite this history of 'population control', South Africans hold positive views about the need for family planing and there is a high percentage of contraceptive use in South Africa in relation to the rest of sub-Saharan Africa. The 1998 South African Demographic and Health Survey found that three-quarters of women of reproductive age had used a contraceptive, while nearly two-thirds (62%) currently used some form of contraceptive. The injectable contraceptive was the most common method. There were considerable age, race and socio-economic differences in access to and type of contraception used (SA Demographic and health Survey summarised in National Contraception Guidelines, 9-11).

One of the core objectives of the new democratic government in its bid to transform the health system was to recognise that 'contraceptive, maternal, child adolescent and women's health are integral components of sexual and reproductive health-care' (National Contraceptive Guidelines, I).

International standards

The ICPD requires states to provide universal access to a full range of safe and reliable family planning methods as part of comprehensive sexual and reproductive health care (BPA 106 (e,I), ICPD, 7.2, 7.4, 7.6, 7.14(a), 7.16; Cedaw 12.1). Family planning programmes should be linked to broader reproductive programmes (ICPD 7.6, 7.16, 8.8). Policies and programmes should be developed for unmet needs for quality family planning information and services.

However, governments should not impose incentive schemes or demographic goals on family planning services in forms of quotas or targets for the recruitment of clients. Coercion has no part in family planning services (ICPD principle 8, 6.4, 6.25, 7.12, 7.16, 7.22).

Plans for services should include:

> Plans to improve the quality of care through:

> Ensuring accurate information and access to the widest possible range of safe and effective family planning methods;

> Ensuring a sufficient and continuous supply of high-quality contraceptives and follow-up care;

> Providing information on STIs and HIV and AIDS and make condoms available;

> Including facilities for the diagnosis and treatment of common STIs and other reproductive tract infections;

> Provide post-abortion counselling, education and family planning information to help avoid repeat abortions;

> Providing counselling on breastfeeding and longer intervals between births; and

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> Providing referral for additional reproductive health services (BPA 97, 106(h,k,u,r), 108 (m), ICPD 7.6, 7.23 (a,b,c,f,h), 7.30, 7.32, 7.33, 7.41, 8.17, 8.18, 8.25, 8.31, 8.35).

International targets require universal access to a full range of safe and reliable family planning methods which are not against the taw, as part of comprehensive sexual and reproductive health care in all cases by 2015 (BPA 106 (e,I), ICPD, 7.2, 7.4, 7.6, 7.14(a), 7.16; Cedaw 12). and the removal of all major remaining barriers to family planning use by the year 2005, including unnecessary legal, medical, clinical and regulatory barriers to information and methods (ICPD 7.19, 7.20).

NGOs should be involved in monitoring public and private family planning (ICPD 7.18) and Family planning services should be evaluated utilising user perspectives and qualitative and quantitative measure, including client surveys (ICPD 7.23(g)).

REPORTING X

NOT APPLICABLE

RATIFICATION X

NOT APPLICABLE

POLICY 2

The Constitution recognises that the right to security of the person includes the right to making decisions concerning reproduction. Women also have the right of access to reproductive health-care (sections 12 and 27). This frames government policy on contraception.

The Health Sector Strategic Framework 1999-2004 included reducing teenage pregnancy and improving women's health as core health priorities.

In 2002, the government launched its National Contraceptive Policy Guidelines after a two year consultation process. This policy moves away from a 'population control' approach to increase women's access to quality health services and to emphasise choice. The Guidelines set out three policy objectives:

> to remove barriers that restrict access to contraceptive services;

> to increase public knowledge of client's rights, contraceptive methods and services; and

> to provide high quality contraceptive services.

The policy also recognises that contraception services should be integrated these within reproductive health-care services within in the overall primary health care system.

This comprehensive policy scores a '2'.

LAW I

The National Contraceptive Guidelines call for the review and revision of all legislation to allow the full implementation of the Guidelines (at 14-15). It also identifies some of the law

that require amendment. Several laws have been amended such as the Sterilisation Act, some legislation (such as the Childcare Act) still needs to be addressed. The Childcare Act requires revision 'pertaining to the age at which minors can receive medical treatment in order to meet their health and social needs, without assistance from their parents/guardian. The Guidelines suggest review of the situation of children under 14.

The incomplete law reform process scores a ' 1*.

DEVELOPMENT OF A PLAN 1

The provision of contraception should be part of a broader package of health-care and this is envisaged in the National Contraceptive Guidelines. However, in practice, there remains a challenge to develop the infrastructure of contraceptive services as part of expanded services (Adar and Stevens).

The National Contraceptive Guidelines identify the strategies needed to meet the policy objectives of removing barriers, increasing knowledge and providing high quality services (at 20-23). It provides a general plan at national level that still has to be developed further for implementation in the provinces. More detailed plans have been finalised at national level and in some provinces, but not all (Schneider, email).

The uneven development of plans at provincial level scores a ' 1'.

TARGETS 1

Targets are in the process of being finalised (Schneider, email). This scores a 'P.

INSTITUTIONAL MECHANISMS 1

The Maternal, Child and Women's Health and Nutrition cluster at national level is responsible for policymaking and the production of training and education materials. The provincial Maternal, Child and Women's Health directorates manage contraceptive services in the provinces. National policy guides these directorates, which oversee delivery that takes place through the district health system. 'Contraceptive service delivery points range from those at community level, mobile units, clinics and community health centres to district hospitals, referral/tertiary hospitals and academic centres' (National Contraceptive Guidelines, 12).

While there is clarity as to the mechanisms for delivery, and contraceptive services are widely available in the public health service, they still need to be made available in all health institutions and a regular supply ensured (Adar and Stevens). In particular, there are problems with access to sterilisation services, IUD provision, adolescent services (National Contraceptive Guidelines, 12). Thus in practice, there remains a challenge to develop the infrastructure of contraceptive services as part of expanded services (Adar and Stevens). This is tied into the overall process of transformation of public health sector.

The ongoing development of the infrastructure of contraceptive services scores a 'P.

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BUDGET 2

There is a general budget for Maternal, Child and Women's Health, but it is difficult to obtain a breakdown of expenditure. The high usage of contraception within South Africa suggests that there is an adequate budget for this. However, the development of further plans will require further budgeting. In the meanwhile, this scores a '2'.

HUMAN RESOURCES 1

Some guidelines have been developed (The Guidelines for Maternal Care in South Africa, 2000, address the need to counsel women on their future contraceptive needs) and some training has been carried out in respect of contraception.

However, the National Contraceptive Guidelines noted staff shortages, high turnover and an inadequate work performance by many contraceptive service providers, and the need for comprehensive reproductive health-care training, guidelines and regular up-dating (National Contraceptive Guidelines, 12-13). Other commentators have noted the fact that there are 'insufficient resources' across the country, and

[i]t is evident that health workers are feeling challenged and stretched and as a result may be resistant to having to provide more services. Improved management and training could assist in motivating health workers (Adar and Stevens, 2002).

In addition, 'the relationship between clients and service providers needs urgent attention to enable clients to feel that they are choosing the contraceptive that suits them best, as opposed to the health provider' (Adar and Stevens, 2002; National Contraceptive Guidelines, 13).

Patient choice needs to be prioritised and sensitivity in dealing with your people.

The NCG Guidelines demonstrate that the government is aware of these problems of human resource capacity and that they are being addressed over time. This scores a ' 1'.

INVOLVEMENT OF CIVIL SOCIETY 2

The two-year process of developing contraceptive guidelines was consultative, involving stake-holders in the government and in civil society. In addition, research units and academic institutions have been involved in policy and implementation research.

The Guidelines envisage the partnerships with other government sectors, the private sector and NGOS in improving the quality of care (at 22).

At this stage in the process, there has been a history of positive involvement of civil society, at least in so far as research and policy expertise is concerned. While there is little evidence of involvement with NGOs, this has not been an issue on which NGOs have organised. Where there has been additional involvement with youth groups etc, it has been tied in to AIDS work (eg. Government funded loveLife programme).

Positive involvement of civil society scores a '2'.

RESEARCH 2