Establishing priorities for advocacy in South African Health.

To develop an appropriate health policy agenda the National Progressive Primary Health Care Network (NPPHC) and the South African Health and Social Services Organization (SAHSSO) conducted situational analyses in 4 areas: an informal peri-urban area within the Durban functional region in Natal a rural area in the Mhala-Mapulaneng district in the North Eastern Transvaal the informal settlement of Botshabelo in the Orange Free State and a dense township dwelling in Soweto. The analyses were based on interviews with health workers and community leaders a national survey and a questionnaire for health service administrators. All 4 areas were characterized by poverty unemployment low educational levels lack of a clean water supply or refuse removal system housing shortages or overcrowding and political violence. Preventable diseases such as water-borne diarrhea and malnutrition cause substantial morbidity yet health services tend to be inaccessible distributed inequitably of poor quality and with unclear administrative structures. Community members interviewed indicated that clinic fees were too high especially given the low quality of care and there was a general mistrust of the competency of doctors and nurses. There was a lack of consensus on the meaning of community participation; some viewed it as a vehicle for empowerment while others felt the strategy would be exploited as a means to deny government assistance. Overall respondents were supportive of a greater role for community health workers and more involvement on the part of nongovernmental organizations. A priority at present is attention to the many socioeconomic factors that are compromising the health of black South Africans and overshadowing the rationalization of health services.