EQUITY GAUGE PROFILES: CAPE TOWN, SOUTH AFRICA

Research & Monitoring Advocacy & Public Participation Community Involvement Key People & Partners

Introduction to Cape Town:
In the City of Cape Town, like the rest of South Africa, there are vast disparities between the wealthiest communities living in comfortable first world conditions, and the poorest, who live in conditions similar to the worst found in developing countries. Since health or ill-health is mainly determined by broad socio-economic and environmental factors such as income, housing, water and sanitation, rather than the availability of health services, it is not surprising that there are gross health inequities across Cape Town, resulting from the history of apartheid.

Because the Apartheid system conflated its racial and economic policies, the communities of Cape Town remain almost as clearly separated in "racial" terms as they were a decade ago. Poorer communities live on the peripheries of the Metropole and the state and city continue to struggle to meet the housing, infrastructure and services backlog. In the 1990s, newly established freedom of movement also enabled large numbers of rurally based South Africans to migrate to the city, from even greater conditions of poverty and deprivation. At the same time, the legacy of poverty, and poor education and training for black communities of South Africa, makes it difficult for large parts of these communities to find employment or to afford housing, services or transport to and from low paying jobs. The Metropole therefore includes areas of sprawling low cost housing, interspersed with shack settlements.

Inequity in health resources
South Africa's political history has resulted in racially separate and grossly inequitable provision of health services. Those who least require the services, have access to more varied and a greater proportion of health and health related services than those who require them most. Not only has this resulted in gross inequity of health service provision, but it has also resulted in fragmentary and uncoordinated provision of services. The Cape Town Gauge has developed a practical strategy for equitable allocation of resources, between the health districts in the Cape Town Metropole, based on their present and predicted future health needs and on efficient planning to meet these needs. Future work will include a practical strategy for equitable allocation of resources between levels of care in the Cape Town Metropole, that is, primary, secondary and tertiary care.

Key People: (all from the School of Public Health, University of Western Cape)

• David Sanders
• Ruth Stern: Co-ordinator
• Gavin Reagon
• Hazel Bradley
• Vera Scott
• Nomvuyo Dayile
• Uta Lehmann
• Nikki Schaay
• Mickey Chopra

Key Partners:

• School of Public Health, University of Western Cape
• City of Cape Town
• The Provincial Government of the Western Cape
• Western Cape Department of Water Affairs and Forestry
• Specific Non Governmental Groups and Community Based Organisations, according to the different programmes

Websites of Interest:
For more information about the Cape Town Equity Gauge, visit the School of Public Health Website, at www.soph.uwc.ac.za

Research and monitoring work includes measuring inequities in health needs using secondary data both on health need and on health services resource allocation. These measures illustrated a significant mismatch, with those with the greatest need, receiving the least resources. Working with health managers, the Gauge has developed a 'resource allocation framework and tool' to remedy this situation.

· The secondary data has also been used to set the context for the development of tracer conditions programmes.. These programmes, which aim to provide deeper insight into the impact of the inequities on poor communities, are prioritizing conditions identified by the authorities when the Equity Gauge was initiated. The tracer conditions are:

• Diarrhoea/worm infestation: a multi-faceted programme that includes deworming and curriculum development in schools, and a community sanitation programme, led by a community based Water and Sanitation Forum.
• HIV/AIDS/TB: an audit of service provision across the city; a study into the impact of HIV/AIDS on nurses; and a collaborative initiative with the South African Gauge looking at provision in three different contexts.
• Research on the causes of premature mortality in Cape Town, which shows that in all but one health district, homicide is the main cause of death in men between 15 and 45.
• An action research programme into the impact of poverty on hypertension and diabetes in one of the poorest districts, working with community health workers to develop an implementation plan.

The Advocacy work spans the above programmes, and adopts a range of approaches. The main advocacy approach is through a partnership approach, so that those with responsibility for service delivery are integrally involved in the programmes that are developed. Other approaches include presentations to the local and provincial government, presentations to community forums and organisations, presentations at a range of events, including conferences and seminars, meetings of the health related organizations, such as the People's Health Movement, and coverage in the local press. Reports have been written on all aspects of work and these are presented to relevant audiences, that is, managers, politicians and community organizations. Communities have been mobilized to raise issues on particular issues, such as the work on worm infestation and diarrhea. Finally, all of this experience is being integrated into courses run by the School of Public Health.

Example of community involvement:
The tracer conditions provide an excellent opportunity to work in close collaboration with communities. For example, the tracer condition, diarrhea is being tackled through a community-led forum and action research programme. Identification of high levels of worm infestation in schools led to an integrated schools programme which includes de-worming of the children, inclusion of health and sanitation as part of the school curriculum, and improved provision of sanitation in the schools. The second aspect has been a pilot of dry sanitation toilets as an option for informal settlements. Dry sanitation toilets had not previously been tested in Cape Town, and so the pilot is being used to influence the Strategy for the Upgrading of Informal Settlements. A report on this action research has been completed, and is available on the SOPH website. A community based Water and Sanitation Forum has been developed as part of this process, and it is now taking a lead in determining the programme. The capacity building of the Water and Sanitation Forum is a key responsibility of the Cape Town Equity Gauge.