Women in South Africa are living a wide diversity of lives. Some women’s lives are determined by economic and social dictates and necessities; others are leveraging economic and social opportunities that are opening up in a democratic environment. Many women choose to be mothers; others do not. Many women choose mixed sex partnerships; others find their place in same sex relationships. Many are exposed and vulnerable to disease and violence; others are more protected in their personal and social environments. An equitable health system should be in a position to provide services to all, taking not only their economic means into account, but also the wide variety of sexual reproductive health needs that exist in our country.

Given this diversity of women’s lived experiences, the edition of Agenda – The politics of women’s health in South Africa explores and deliberates on women’s access to health rights and services in order to deepen and widen scholarly and activist conversations on women’s health issues. The journal was launched at an event co-hosted by Agenda and the Human Sciences Research Council (HSRC) on 22 August 2012. The event took the form of a video conference between participants in the HSRC offices in Pretoria, Durban and Cape Town. A wide range of stakeholders attended the event – from local, provincial and national government; members of the Commission of Gender Equality; members from the African Union; civil society organisations; academics; journal guest editors and authors and media representatives. As Janine Hicks, Chair of the Agenda Feminist Media Board, explained in her welcoming address, the journal launch and subsequent Dialogue celebrated 25 years of African feminist publishing during Women’s Month by spotlighting women’s health issues. It provided a platform not only for those who contributed to the journal to present the outcomes of their research, but also provided a forum for a conversation with the Deputy Minister of Health, Dr Gwen Ramokgopa, around central concerns about women’s health issues that are not adequately addressed by present policy and practice.


Prof Vasu Reddy (HSRC, and member of the Agenda Editorial Advisory Board) lauded the role that Agenda has played in providing a platform for feminist research and writing over the last 25 years. Started through the tireless collective effort of a group of volunteer activists who were determined that woman’s voices be heard in the pre-democratic struggle for freedom in South Africa, Agenda brought out a quarterly self proclaimed feminist journal that took issue with male domination and patriarchy in the build up to a democratic dispensation. Building on lessons learnt by other liberated African states, the collective aimed to prevent the sidelining of women’s interests from the struggle agenda in the transition to a democratic government. In 2012, Agenda Feminist Media can look back proudly on 25 years of African feminist publishing.  It has engaged with the many gender and race power dynamics taking place in post-apartheid society, and has offered critical analyses of the new gender machinery.  In the late 1990s, the journal did not ignore the impact that the HIV and AIDs pandemic was having on women, and offered a forum for women to engage around experiences of stigma and discrimination. Continuing violence against women, founded on the damaging social constructions of gender, has been a constant theme, with calls for men’s activism around finding new ways for being men without violence. Since 2002, the journal has reached a wider audience in Africa, with six issues focussed on African feminism. After conducting an extensive evaluation of its work in 2009/2010, Agenda has streamlined its organisational strategy to focus on the production of the accredited journal in partnership with Taylor and Francis publishers, and to improving its distribution scope and engagement with broader publics through the new social media platforms, and the production of pod casts to raise awareness of gender equality issues. Agenda continues to work towards its goal to synergise academic research and writing with informed activism and advocacy.

Rationale for the issue on the state of women’s health and policy recommendations The guest editors for the issue, Mandisa Mbali and Sethembiso Mthembu, stated that many women do not experience public sector health services as providing the necessary support to routinely implement their sexual and reproductive decisions in a safe manner. The overall objectives for the edition The politics of women’s health in South Africa were: 1. To draw together research and writing on the dominant women’s health concerns and issues. 2. To highlight under-examined women’s health policy issues (for example, cervical cancer, coerced sterilisation, especially of HIV positive women and maternal mortality). The edition sought: 1. To shed light on the nature of the state since 1994. Although South Africa has a gender progressive Constitution and gender machinery, mainstreaming gender has lead to a bland technical approach to the understanding of women’s health issues. 2. To acknowledge a decline in focussed political will to improve women’s position generally and health particularly, making it central to develop strong informed advocacy efforts to ensure that the planned National Health Insurance (NHI) policy is gender progressive. 3. To highlight the need to continue advocacy that is informed in its core by women’s lived experiences. In reviewing the articles in the journal, the editors established the following common threads running through all the contributions: 1. Although important laws have been passed pertaining to women’s rights and health rights, health related issues persist. This indicates a need to focus on how these laws are being implemented. 2. There is still a need for law reform in a number of areas in order to promote women’s rights and health rights, for example, the decriminalisation of sex work; provisions for health providers to screen for possible domestic violence during clinic visits. 3. Activism and advocacy must move beyond single issues into comprehensive advocacy platforms for sexual and reproductive health and rights (SRHR). 4. Civil society and government should collaborate to find solutions. 5. The development of the NHI is a critical moment in health policy and could be an important turning point to improving women’s health and welfare. Women’s health issues must be integrated into the design phase of the policy and not included as an afterthought. 6. A comprehensive women’s health policy is more than maternal and child health services. The relevance of this edition of Agenda  is reflected in the fact that feminists are not wringing their hands about the state of women’s health, but are engaging with the issues, are investigating solutions, and are sharing the outcomes and recommendations with other stakeholders, including government.  The editors summarised the central concerns as follows: 1. There is a gap between women’s constitutional rights and their experiences of health service delivery. 2. Women’s health has received limited political attention in post-apartheid South Africa. The rejection of feminism/s and acceptance of gender approaches to the post-apartheid development project may be the centre of the marginalisation of women’s health. 3. The acceptance of ‘women as mothers’ as the dominant ideological construction of women can explain the current position of women’s health in South Africa.  4. The absence of a comprehensive women’s health policy and practice has lead to crises in women’s health with regards to HIV and AIDs and concomitant rises in maternal mortality; inadequate programmes to address the growing rise in cervical cancer; inadequate attention to screening for sexual violence in the health service; coercive sterilisation practices; and the lack of a comprehensive well-resourced contraception policy which takes reproductive justice matters of the past into account, and is sensitive to the current challenges in relation to HIV vulnerability and infection.

Given that the NHI presents a great opportunity for the Ministry of Health and those tasked with ensuring that South Africa lives up to its women’s rights commitment, the following recommendations were made:

1. We call upon the Minister of Health to enact a comprehensive policy that will address women’s health in its totality. We call for this policy to guard against ‘the women as mothers’ approach’ as this has proved to not work for the majority of women. 2. We call upon the Minister to prioritise cervical cancer, in particular in the context of HIV.  3. We call upon the Minister to prioritise reducing maternal mortality. 4. We call upon the Minister to champion the transformation of the health system in line with our Constitution. 5. We call for prioritisation of a human rights culture, redress and justice in health care violations, in particular as these affect women. 6. Lastly and not least, we call upon the Minister of Health to audit all women’s health services, prioritising the ones listed above. The purpose of such an audit will be to understand the nature of the crises and to have an idea of the resources needed for transformation and delivery. We call on the Minister to utilise such an audit to ring fence NHI resources for women’s health. Experience has taught us that good resourcing and accountability can be achieved if there is a policy in place. The time for a comprehensive policy on women’s health is now.

As women’s rights lobbyists, researchers, and policy analysis activists, the guest editors concluded with the offer of cooperating and working with the Minister and the national gender machinery in the realisation of these endeavours.

The state of women’s health: Department of Health perspective Address by the Hon Deputy Minister of Health Dr Gwen Ramokgopa Dr Olive Shisana, President and CEO of the HSRC, introduced the Deputy Minister to the forum participants. The deputy minister is a well qualified health professional. She qualified as a medical doctor in 1989, and followed this with further post graduate qualifications in both Public Health and Health Economics and Finance. Dr Ramokgopa headed the IDT national health programme, and has served in the Gauteng legislature, becoming the MEC for Health in 2006. She served as the mayor of Tshwane before being appointed Deputy Minister of Health in 2010. Dr Ramokgopa has a history as an activist in the struggles against apartheid both within the student and women’s movement, and has served in a variety of advisory capacities for organisations and institutions in the health sector. In her introduction, Dr Ramokgopa paid tribute to Agenda for developing and maintaining a platform for the expression of views around gender inequality – in relation to the struggle in the past, for formulating ideas about the new democracy, and for continued critical feminist and gender analysis in the post-apartheid South Africa. She said that research and inquiry is central to the formulation of policy and in understanding challenges. Adopting a scientific and evidence based approach to understanding problems in our world, and in devising appropriate solutions and interventions, increases the success rate of political solutions. Agenda’s publication of feminist research and scholarly analysis and its focus on gender equity in policy formulation play an important role. Turning her attention to the general outcomes and recommendations raised by the edition’s guest editors, the Deputy Minister concurred that the Department needed to continuously develop policy and monitor its implementation in order to realise the human rights guaranteed by the Constitution. The Department of Health, in cooperation with other stakeholders from civil society has, since the event of democracy, been actively involved in extending health services – 40% of the clinics now operative in the country were established since 1998, for example. There is still, however, much to be done, especially in realising the Millennium Development Goal on child and maternal mortality. Successes to date have, however, been recorded – for example the prevention of malaria and reduction in the rate of HIV mother- to-child transmission. Central to the improvement of policy and the delivery of health services, is the Department’s commitment to the social compact and thus to building an activist society where there is a fully participatory democracy with human rights issues at the forefront. Women’ participation in developing policy and in registering the gaps is welcomed. Working together – civil society and government – will assist to capacitate the Department to deliver better health services.1 Indeed, during a recent summit held in the Eastern Cape by the Progressive Women’s Movement, the Minister of Health committed to work together with women on organised platforms to ensure that women’s health issues will be taken into account in the development of the NHI policy. The gender mainstreaming approach taken by the government has borne fruit when viewed from the increase in women’s participation in governance and decision-making structures, but when considered from the point of view of improved quality of life for women – both in terms of access to services and in terms of empowerment in daily life – South Africa is not performing well on these indices. The government should be centrally concerned about improving women’s health and well being. Given their role as nurturers, the health of a nation will be secured if the health of women is secured. Dr Ramokgopa reiterated the importance of working together to promote women’s health and well being, and to ensure that new policy – like the NHI – is designed to ensure that women’s health rights remain on the agenda. As regards the specific women’s health issues raised by writers in The politics of women’s health, the Deputy Minister made the following points:

1. The Department of Health inherited an extensive burden of disease and a highly dysfunctional health system. 2. Given social inequalities, universal health coverage via the NHI is centrally important. 3. Treatment, care and prevention in the context of the explosive HIV epidemic have been a huge challenge. However, successes have been measured: • Working together with community structures, around 20 million people have been tested for their status over the last 18-24 months; • 1,7 million people are on treatment; • There has been a huge reduction of mother-to-child transmission (MTCT) – from 8% in 2008 to 2.7% this year. Here the national department has learnt from the Department of Health in KwaZulu-Natal where the decentralisation of health services and the extended use of community health workers has impacted positively in MTCT reduction; • South Africa has excellent specialised HIV researchers. 4. The Department of Health has now adopted a dual protection approach – focussing on family planning as well as contraception and termination of pregnancy – moving towards more comprehensive interventions, especially as regards young women. 5. The high maternal mortality rate is unacceptable. Although the containment of HIV will reduce this rate eventually, the Department has this year released a cluster of policies to reduce the mortality rate. These encompass the increase in access to family planning and contraception; the investment in the training of nurses in contraception measures; training more midwives; the deployment of dedicated obstetric ambulances; the establishment of maternity waiting homes in rural areas; the development of district specialist teams which will include a qualified obstetrician in all districts in South Africa (to be launched in September); and increasing the number of medical practitioners (students sent to Cuba to study). 6. The Department is especially concerned about reported cases where human rights have been violated in the implementation of its policies, for example, coerced sterilisation. Dr Ramokgopa called on women to report such cases to the Ministry so that disciplinary procedures can be undertaken when health providers act unethically. 7. Lastly, the Deputy Minister welcomed the feminist analysis of the NHI in Agenda, and noted that suggestions would be taken into consideration as the NHI is rolled out in 10 pilot studies. She drew attention to two important measures that the Department was taking to synchronise with the NHI: • In order to improve the platform of service delivery, a Bill is presently before Parliament to establish an office of standards of compliance for public sector health delivery. • In order to reduce the disease burden1 and to promote a healthy life style, the Department will soon be announcing legislation that will promote physical activity, the reduction of salt in food products, and limit advertising for alcohol. In conclusion, Dr Ramokgopa thanked activists for their continued advocacy work around women’s rights, called on them to continue to make their voices heard, and ensured them that the Ministry would be there to listen to any concerns.

Open discussion: Conversations with the Deputy Minister of Health Janine Hicks thanked Dr Ramokgopa for her input and requested that she convey thanks to the Minister of Health for honouring the event through his deputy. The forum was opened to for discussion.  Dr Shisana informed the forum that the HSRC was to conduct research on the NHI and gender issues. They planned to cooperate with the Department of Health and share outcomes. The Deputy Minister welcomed this research and cooperation. The New Women’s Movement raised the question of a possible summit on the NHI and gender, and ensuring the participation of grassroots women in policy development and monitoring the implementation. In her response the Deputy Minister made it quite clear that the approach to health delivery practiced by the Department required grassroots participation and implementation to be effective. Three streams of interventions were important in this regard:

• The schools’ health programmes; • The district health specialist team programme; • And the municipal ward based health workers programme (the target is to have at least 10 trained health workers in every ward in the country); Through these interventions, the Department has numerous opportunities to work with grassroots organisations and respond to their concerns. The NGO Breast Sense made a passionate plea for the Department to acknowledge breast cancer as it is developing into one of main cause of mortality among women from cancer – young and old alike – and to make its treatment a national priority. At the moment women with breast cancer had few places to go as the provision of oncology services in the public health sector is hopelessly inadequate. These concerns were supported by other forum participants. Dr Ramokgopa accepted that breast cancer constitutes a women’s health issue that requires special attention. Concerns were also raised at the Health Summit, and she suggested that a follow up summit focussing specifically on breast (and cervical) cancer should be organised in the near future. She was not aware of the correspondence that Breast Sense has had with her Department over the last five years, and committed to investigate this. In response to a question regarding when the NHI roll out will start, Dr Ramokgopa pointed out that pilots in selected areas have already begun. The Department has also launched an audit of the 4 000 public health clinics operating in South Africa in order to form a picture of what was needed in each to provide adequate health services to their communities. She requested forum participants and their organisations to assist in the monitoring of clinic performance as well.

Women’s health issues: a trilogy of cases A selection of writers whose research was featured in The politics of women’s health in South Africa were invited to talk briefly to their to the research, addressing the question of women’s rights abuses in coerced and forced sterilisation, the rationale for the call for the decriminalisation of sex work, and the consultation process leading to the founding of the newly formed Sexual Rights and Heath Initiative-South Africa (SHARISA). Cases of forced and coerced sterilisation have been reported in South Africa, despite laws and policies governing this procedure that stress that it should be a woman’s informed choice to take this route. Coercion occurs when financial or other incentives, misinformation or intimidation tactics are used to exact agreement. Forced sterilisation occurs when it is conducted without the woman’s knowledge, or when she is not given the opportunity to provide consent. Zaynab Essack reported on the outcomes of the qualitative research that she and her colleague Ann Strode have conducted around the impact of forced/coerced sterilisation of 22 HIV positive women. She illustrated how this experience had affected these women’s lives by quoting the women directly from the interviews conducted with them. All these women recounted the devastating consequences of forced/coerced sterilisation, • On their physical and mental health • On their relationships with family and their community • On their identity as women, and feelings of self worth • And the financial challenges, if they had attempted to reverse the sterilisation. HIV-positive women who are coerced into undergoing a sterilisation procedure or who are sterilised without their consent enter a cycle of discrimination. They are discriminated against due to their HIV-positive status as there is a perception that HIV-positive women should not engage in sexual relationships or have children. As women who are not able to bear children, they are further discriminated against and stigmatised. Marlise Richter provided a brief insight into the nature of the sex industry in South Africa and the health vulnerability reported by sex workers. Researchers have found that sex workers experience a high level of violence, with over 30% reporting that they are forced into sex against their will, members of the police force being amongst the perpetrators. This incidence of rape coupled with limited access to regular health care due to prejudicial practice on the part of health workers, results in an estimated 45-69% prevalence of HIV amongst sex workers. Criminalisation of sex work results in high mobility, making it difficult to monitor the health status of individual workers, and increasing the potential spread of HIV and AIDs. Both the Department of Health and the South African Aids Council (SANAC) have failed to implement programmes for sex workers. Although the decriminalisation of sex work was included in the draft National Strategic Plan for HIV, TB and STI 2012-2016, it was dropped during the last negotiations between government and civil society. This process is recorded in the article in the issue of Agenda. Richter outlined the New Zealand model for decriminalising sex work as an example of good human rights practice. Here sex workers can organise themselves into trade unions, receive unemployment benefits, and are covered by occupational health laws. The outcome of this decriminalisation process has been that sex workers can work in a more protected environment. The fear that decriminalisation would lead to an increase in sex work proved to be unfounded. Kathathso Makoetle and Barbara Klugman spoke on the establishment of SHARISA in 2011 .The decision to start SHARISA was one of the outcomes of consultations conducted with 53 organisations since 2010 on why civil society mobilisation around sexual and reproductive health and rights (SRHR) has declined in the last decade.   Although conducive SRHR policies had been developed in the immediate post-apartheid period, they are not being consolidated. A detailed framework for SRHR based on substantial consultation was developed in 2010/2011.3 This was initiated by the Department of Health but, as yet, there has been no action on it. Despite victories and the gains made around SRHR, these are threatened by:

1. The limited capacity to deliver on good policies (it was, however exciting to hear of a cluster of steps currently being taken by the Department of Health to improve delivery and the quality of health services). 2. The cultural and social environment that remains patriarchal and thus hazardous for both women and other groups stigmatised on the basis of their sexual identities. The proposed Traditional Court Bill presents a threat to rural women’s access to their rights to equality, not excluding SRHR. 3. There is a major gap in the public and political discourse, with no coordinated voice engaging both the public and government on SRHR issues. 4. There is a reluctance to play a critical role around SRHR issues. Advocacy is weak partly because people do not want to “embarrass their leaders”, and partly because civil society organisations tend to be single issue based, compete for resources, are not as strong in organisational ability as they were in the 1990s, and many do not operate within a coherent human rights framework. Consequently there is little collaboration with each other. During the process of the consultation, it became clear that there was a need for a coordinating body, yet none of the organisations felt that they could take on this responsibility, thus SHARISA, a registered not for profit organisation, was established.  SHARISA aims to increase the number of public opinion leaders, decision makers and service providers who promote sexual and reproductive health and rights as enshrined in the South African Constitution. This it will do by: • Enabling the cooperation between civil society organisations; • Building the capacity of trainers from various stakeholders around SRHR; • Building the capacity of the younger generation in SRHR. The present environment poses enormous challenges in realising SRHR, yet the formation of SHARISA is a step in the right direction for developing as cooperative effort to face them.

Open discussion: Ideas for future activism Participants from Pretoria, Durban and Cape Town proposed the following lines of action: • An alternative possibility to a follow up summit (these tend to be talk shops with few outcomes that are actually actioned) could be for the Commission for Gender Equality (CGE) to hold a series of hearings around women’s health issues. These hearings could potentially lead to more positive policies and action as the Commission could play an oversight role to hold government accountable for implementation. • Given that this Dialogue calls for a comprehensive approach to SRHR and the implementation of comprehensive services, it becomes centrally important to actively involve men in the processes, especially in the context of the Department of Health’s dual protection approach of family planning and contraception choices and provision. • Breast and cervical cancer are important women’s health issues to be tackled through policy and service delivery. There seems to be a disconnect between the cancer register and the Department of Health that needs to be addressed.4 • Continued capacity building of health practitioners is imperative. • There needs to be a concerted effort to package health information in such a way that it is understandable to the ordinary woman and man

Summary of the outcomes and recommendations from the Dialogue on the state of women’s health Janine Hicks synergised the various contributions made during the Dialogue into the following outcomes and recommendations: 1. The National Health Insurance policy could be seen as a turning point for women’s health. It presents an opportunity to engender health policy and to address particular problems and issues impacting on women’s health and concerns around discrimination. 2. In order to ensure that this opportunity is leveraged fully; • there is a practical recommendation that an audit be conducted on health services as a starting point to define the issues and identify the service gaps;5 • Furthermore, follow up meetings with the Department of Health and other stakeholders should be planned, whether these take the form of a summit or hearings organised by bodies like the CGE. Hicks, as a Commissioner who serves on this body, will actively promote this idea amongst her colleagues. 3. Given that a detailed framework for SRHR has already been developed, there is a call for this to be examined, and policy around SRHR be consolidated. Copies of the relevant documents were given to the Deputy Minister for her perusal. 4. Issues and concerns were raised about the responsiveness of the Department of Health, and access to appropriately packaged information on health rights and policy issues in order to reach and inform ordinary citizens. 5. There was a request and strong urge to focus attention on breast and cervical cancer as growing concerns around women’s health, with a call for a follow up summit dedicated to this issue. 6. There is a need to bring the debate around the decriminalisation of sex work back into the public area, and to intensify advocacy for legislative change that is long overdue in South Africa. 7. Particular concern was raised around incidences of forced and coerced sterilisation, specifically of HIV-positive women. The Deputy Minister extended a call for such incidences to be reported to the Department of Health directly to ensure that they are investigated.

Concluding remarks from the Deputy Minister of Health Dr Ramokgopa welcomed the acknowledgement paid during the Dialogue on progress that the Department has made in improving health services, and committed to continue researching health issues and delivery models to come up with innovative ways to meet the challenges. She pointed out that the success of the NHI depends on all South Africans acknowledging that the country has an extremely high burden of disease, and that equity of access to services is central to decreasing this burden. She supported the call for the involvement of men in SRHR processes. The increase in the rate of suicide amongst young black unemployed men also makes them a group for concern. She supported the initiative for the Commission for Gender Equality to host a series of hearings. Should a summit be held in addition, she agreed that this would only be worthwhile if it has impact. This means putting a monitoring system in place to follow up that recommendations and targets are fulfilled. As it is important for all advocacy avenues to be leveraged, she noted that the National Health Forum offers a possibility for civic participation, as does the district health system model. She said she will take up the recommendations on sex work. This issue tends to be difficult – sex work exists and we cannot pretend that it does not. In conclusion, Dr Ramokgopa lauded advocacy initiatives around women’s health issues. In order to sustain democracy, she said, we cannot become complacent – an active civil society is necessary.

Compiled by Jean Westmore-Susse

Footnotes 1. Since 2010, the Department of Health has embarked on what it has termed the “Reengineering of the Primary Health Care Approach” to health care delivery. This approach is driven by the following principles: equity; quality; efficiency; integrated and comprehensive care; community involvement and inter-sectoral collaboration. The approach is central to the delivery of public health services envisaged by the NHI. 2. The Department of Health argues that South Africa is faced with a quadruple burden of disease: • HIV and Aids and TB • Non-communicable diseases • Injuries and violence • High child and maternal mortality rate 3. The framework included the following documents: Sexual and Reproductive Health and Rights: Reviewing the Evidence. July 2011 Sexual and Reproductive Health and Rights: Fulfilling our Commitments 2011-2021 and Beyond. July 2011 Sexual and Reproductive Health and Rights: Policy and Service Gaps. July 2011 4. “No one knows what the cancer prevalence and incidence are in South Africa, because the country’s cancer registry has not been updated since 1999”. Dr Carl Albrecht, head of Research at the Cancer Association of South Africa in an interview for the Mail & Guardian, August 24 to 30 2012 5. Work has already been done on this with regard to SRHR in the documents mentioned under footnote 3.



For more information contact:

Lou Haysom: Managing Editor, Agenda (031) 304 7001/2 or

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