Cui bono?: a capabilities approach to understanding HIV prevention and treatment for pregnant women and children in South Africa
Date
2010-06-29T06:52:34Z
Authors
Sprague, Courtenay
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Abstract
The global health revolution of the last 50 years has generated significant health gains
in terms of increased life expectancy and reduced maternal mortality. South Africa,
an upper middle income country, has performed poorly along the same development
indicators. Development gains for women and children won over two decades
are now being reversed, largely due to HIV/AIDS. This is in spite of the evidence
that lifesaving antiretroviral medication can prolong life and enhance quality of
life. Using a joint capabilities and health equity lens, this thesis seeks to understand
a critical development problem in South Africa – premature mortality in pregnant
women and children attributed to HIV – an infectious disease that is both preventable
and treatable.
The research identifies key barriers faced by pregnant and postnatal women with
HIV who seek (freely available) access to PMTCT (prevention of mother to child HIV
transmission) and ART (antiretroviral therapy) programmes in the public health sector.
The study considers whether disparities in, and missed opportunities for, preventing
and treating HIV in these population groups comprise avoidable, systematic and
unfair health inequities. The implications for the capabilities of women and children
with HIV in this country are also explored.
Qualitative research methods are employed to investigate the research concern.
Semi-structured interviews with 83 women comprise the mainstay of the field
research. Interviews with 37 caregivers of children with HIV, together with patient
files and interviews with key informants, supplement the data collection. Research
was undertaken in two sites in two provinces: Eastern Cape and Gauteng. Each site
constitutes a bounded case study. A rural-urban perspective is put forward – with
attention to equity considerations in access to maternal-child HIV services.
The study evinces a host of avoidable factors in the operational delivery of ART/PMTCT,
along a range of intervention points in the continuum of care: including the antenatal,
labour, postnatal and pediatric wards. While some of these factors are influenced
by individual behaviour, the vast majority are directly linked to the health system
– illuminating the ways in which the health system serves as a social determinant of
health (SDH), and often restricting, constraining, and ironically, preventing people
from obtaining the interventions and information they need to improve their health. iii
By connecting the empirical findings related to ART/PMTCT within the health system
to the capabilities and health equity literatures, an understanding of disparities in
access to, and delivery of, such services – and their importance in shaping health,
development and health outcomes of these population groups – becomes clearer. As a
consequence, strengthening the public health system is a necessary first step to ensuring
at least some of the minimum conditions that allow people to be healthy. As an entry
point, there is great scope for systems’ interventions that would address the shortfall
in health for black South Africans and deprivations in their health capability.
At the same time, the research reveals that – owing to the contribution of social
determinants of health (e.g., factors that impact on health such as living and working
conditions, but lie outside the realm of healthcare) to health status: good health is not
achieved solely by access to and provision of good healthcare. This reality underscores
the importance of health as a central capability; and good health as a normative social
goal. In the capability view, the moral concern for state and society is the reduced
capability of individuals due to health inequities that are socially-constructed, and in
turn, changeable. Recommendations to address modifiable factors related to effective
ART/PMTCT provision in these facilities are put forward, with a set of suggestions
for future research in maternal, child and women’s health in South Africa.
Description
PhD, Faculty of Law, Commerce and Management, University of the Witwatersrand, 2009.
Keywords
HIV/AIDS, women, children, prevention