Institute for Economic Research on Innovation (IERI): Erika Kraemer-Mbula Lindile Ndabeni, Rasigan Maharajh, Khanya-aicdd: Kamal Singh, Zandile Sibiya.

Institute for Economic Research on Innovation (IERI): Erika Kraemer-Mbula Lindile Ndabeni, Rasigan Maharajh,

Khanya-aicdd: Kamal Singh, Zandile Sibiya

Nelson Mandela Metropolitan University: Enver Motala

Rural health systems in South Africa: local

innovation and potential for social inclusion

Outline

1. Purpose of the study

2. Conceptual background

3. Methodology

4. Characterisation of rural systems and healthcare in rural South Africa

5. Empirical findings: mapping rural health systems, learning processes, interactions and innovations

6. Conclusions

1- Purpose of the study

Collect evidence on the link between innovation and inclusive development: understand innovation as a potential driver of social inclusion.

Understand the local system from which innovations in the provision of healthcare services may emerge.

Pushing the boundaries of the innovation systems framework – broadening the range of actors (formal and informal actors), and strongly based on the users’ perspective (demand)

2- Conceptual background

Health care inequalities almost inescapably lead to situations of social exclusion (Sen, 2002; Anand, 2004)

Healthcare offers great opportunities for innovation (e.g. Chataway et al, 2010, Casiolatto and Lastres, 2007)

Local Innovation and Productive Systems (LIPS) – Redesist Network (Casiolatto, Lastres and Maciel, 2003; Lastres and Casiolatto, 2005; Soares, Maharajh, Scerri, 2013).

Innovation and social inclusion

Social exclusion Different to poverty Inability for individuals and groups to participate in the

economic, social and cultural life of society in which they live.

Social inclusion Giving marginalised groups equal access to the rights,

opportunities and resources enjoyed by others in society This includes access and participation in public resources

dedicated to innovation and R&D (e.g. health services or knowledge produced in universities as public goods)

3. Methodology Two municipalities: Mbizana and Ingquza Hill (Eastern Cape Province) Broad consideration of rural health systems: inclusive of formal and

informal First hand data collection at five levels (interviews and

visual documentation) 1. Service providers – formal and informal (hospital, clinics,

private healthcare practitioners, traditional healers, etc) 2. Users – patients and other members of the community (e.g.

primary schools) 3. Organisations with functions of education, training and

research such as technical schools, universities, technological centers and social organisations.

4. Organisations with representation functions such as associations and unions

5. Public organisations with promotion and policy functions

Definition of the research object: innovation in health systems in rural areas

Characterization of the local system (LIPS): identifying the local productive and innovative system (LIPS) which is connected to innovation in the selected sector Who are the relevant actors of the system? Role in knowledge generation? How do they connect with each other?

4- Characterisation of rural systems in South Africa

Strong presence of traditional customs High levels of unemployment Low household income Predominantly based on self-employment and small

informal businesses Inadequate infrastructure (physical and digital):

deteriorating medical infrastructure High levels of illiteracy Disperse population around a small town centre High incidence of HIV/AIDS

Mbizana and Ingquza Hill Population

Mbizana: 270,000 Ingquza Hill: 280,000

Low levels of formal education Mbizana: 80% population stops at

primary/secondary school Ingquza Hill: only 2.4% people have

completed secondary education (matric) Growing unemployment

Mbizana: from 68% in 1997 to 74% in 2007

Ingquza Hill: 78% unemployed (2007) Prevalence of informal sector

Mbizana: increase of 5% between 1997 and 2003 (around 2,000 informal traders)

Ingquza Hill: n/a

Mortality rate under 5 Mbizana: n/a Ingquza Hill: 88 deaths per 1000 births

Prevalence of HIV/AIDS Mbizana: est. 25%-35% Ingquza Hill: est. 20%-30%

Low income Mbizana: 76% no income Ingquza Hill: 71% below the poverty

line (between R6,000 and 40,000 per annum)

Poor sanitation and infrastructure Mbizana: 1% flush toilets, 6% pit

toilets, 36% no sanitation (households) Ingquza Hill: 26% pit latrine, 40% no

sanitation (households)

Rural context

Economic system is highly informal

Characterisation of healthcare needs in rural South Africa

High incidence of HIV-AIDS, related TB and STDs Other prevalent illnesses:

Illnesses related to mal/poor nutrition Illnesses related to poor sanitation infrastructure Diabetes High blood pressure Asthma Epilepsy Diarrhoea

Usual need for: Prenatal care and birth assistance Accidents – e.g snake bites

5. Empirical findings- Mapping the key actors of rural healthcare systems

Local formal health organisations - comprise rural hospitals, clinics, networks of community health workers, and NGOs.

The local semi-formal organisations include those that are have some degree of formalisation – for instance registered traditional healers, traditional chiefs – which provides them with registered membership and recognition by formal organisations (such as government departments), but nevertheless lack a legal status.

The local informal health system is comprised by a range of actors, from individual self treatment to a network of traditional healers.

Health care considerations All members of the community are users The concept of health is highly contextual: defined by

cultural beliefs and social values (physical health, psychological health & health education, spiritual health)

The choice of healthcare service providers is not only guided by access but also by trust and cultural factors About 60%- 80% of the South African population currently use

the traditional medical sector as their first contact for advice and/or treatment of health concerns.

Formal healthcare would be the first contact point for diseases in which the user was familiar with the treatment provided by the clinic/hospital.

Formal health systems Mbizana

2 hospitals 18 clinics – 14 out of 31 wards (each ward comprises with several

villages) have no formal health facilities. Existing clinics often with no access to water and electricity.

Community Health workers – DoH or linked to clinics NGOs focused on HIV/AIDS CBOs – paralegal, etc

Ingquza Hill 2 hospitals 41 clinics – 13 out of 32 wards have no health facilities. Existing clinics

often have no electricity and water Community Health workers – DoH or linked to clinics NGOs focused on HIV/AIDS CBOs

Rural hospitals

Rural Clinics

HIV/AIDS NGOs

NGOs

Informal health systems

Associations of traditional healers (2-3 per locality)

Independent/un-registered traditional healers (hundreds)HerbalistsTraditional birth attendantsTraditional surgeonsDivine healersFaith healers

Informal community arrangements

Traditional medicine “ [includes] diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness” (WHO)

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Traditional healers

Linkages, knowledge sharing and learning processes

Example A: Knowledge sharing between traditional birth attendants and nurses

Example B: Knowledge sharing between traditional healers, NGOs and CHWs and DoH for HIV/AIDS information and prevention.

Example C: Knowledge sharing between traditional healers and homeopathic community and the university

Example D: Sharing knowledge amongst traditional healers – Forums of Traditional Healers

Innovations in rural health systems

Innovation in governance of integrated health systems Problem observed: poor communication between healthcare providers

manifests in long waiting times to receive treatment. Addressing the challenges of the referral system through an ICT-based

system that integrates referrals from traditional healers, CHW, clinics and hospital to improve speed and quality of health services to patients.

E.g. Benguela Institutional innovation in skills development

Problem observed: lack of doctors and nurses in rural health facilities Addressing the shortage of skills by tailoring the training of health

professionals to the needs of rural hospitals E.g. Umthombo Youth Development and Foundation

Innovation in skills development

Shortage of skills puts severe pressures on rural health systems in South Africa Rural hospitals & clinics find it difficult to recruit and retain health

care professionals Perceived lack of career by health professionals Disconnection of health professionals with community and culture in

rural areas Innovation: tailoring the training of health professionals to the

needs of rural communities and rural hospitals NGO/Community/Rural Hospital/University/ platform Selection of students at early stage in rural communities Funding for training linked to internships and commitment for

future employment in rural hospital Healthcare professionals becoming agents for change and role

models in their communities

6. Conclusions Territorial context and culture matter Need for an integrated system of healthcare delivery:

Informal systems of provision of health services strongly linked to culture and traditions. Work on the basis of what is there.

Need for a broader approach to supporting innovation beyond formal organisations, including innovations in the sphere of institutions and social sectors.

Need to find effective ways to transform the needs and interests of the poorest and marginalised actors into effective demand, and to connect this demand to the supply side of innovative activity.

Divergence between advances in theory and what is happening on the ground Theory: increasingly supports heterodox,

interdisciplinarity, systemic theories, knowledge and technological convergence [Genomics and Biotechnology; Geo-engineering]

Practice: Alternative ways of thinking have been pushed to the margins; Orthodox teaching predominates in university curriculum; Disconnection between the multiple sources of knowledge production and intermediary orgs.

Holistic view of knowledge generation and skills formation – inclusive and sustainable solutions must build on a deep understanding of local dynamics New kind of scientist, researcher & engineer, fully aware of what is going

on in society and who has the skills to deal with societal aspects of knowledge and technologies

Generation of interdisciplinary and trans-disciplinary thinkers Implications for university curricula, structure of universities, Fundamental

change of epistemology, education, pedagogy and organizational change transformation of higher education: integrating a systemic view of

sustainability in education and society : interface between scientific and other types of knowledge

Establishment of trans-disciplinary platforms: connect experts, future researchers and policy-makers on real topics – know who are the drivers, listen to intermediaries! And engage them in research agenda development.

Thank you

Obrigado/ Спасибо/ शु�क्रि�या�/ 谢谢 / ngiyabonga

[email protected] www.ieri.org.za Faculty of Economics & Finance,

Tshwane University of Technology,

159 Nana Sita Street,Pretoria CBD, 0002,Gauteng Province,Republic of South Africa.