BackgroundThere is an increasing burden of chronic illness in low and middle income countries, driven by TB/HIV, as well as non-communicable diseases. Few health systems are organized to meet the needs of chronically ill patients, and patients' perspectives on the difficulties of accessing care need to be better understood, particularly in poor resourced settings, to achieve this end. This paper describes the experience of poor households attempting to access chronic care in a rural area of South Africa.MethodsA household survey (n = 1446 individuals) was combined with qualitative longitudinal research that followed 30 case study households over 10 months. Illness narratives and diaries provided descriptive textual data of household interactions with the health system.ResultsIn the survey 74% of reported health problems were 'chronic', 48% of which had no treatment action taken in the previous month. Amongst the case study households, of the 34 cases of chronic illness, only 21 (62%) cases had an allopathic diagnosis and only 12 (35%) were receiving regular treatment. Livelihoods exhausted from previous illness and death, low income, and limited social networks, prevented consultation with monthly expenditure for repeated consultations as high as 60% of income. Interrupted drug supplies, insufficient clinical services at the clinic level necessitating referral, and a lack of ambulances further hampered access to care. Poor provider-patient interaction led to inadequate understanding of illness, inappropriate treatment action, 'healer shopping', and at times a break down in cooperation, with the patient 'giving up' on the public health system. However, productive patient-provider interactions not only facilitated appropriate treatment action but enabled patients to justify their need for financial assistance to family and neighbours, and so access care. In addition, patients and their families with understanding of a disease became a community resource drawn on to assist others.ConclusionIn strengthening the public sector it is important not only to improve drug supply chains, ambulance services, referral systems and clinical capacity at public clinics, and to address the financial constraints faced by the socially disadvantaged, but also to think through how providers can engage with patients in a way that strengthens the therapeutic alliance.

Objective  To explore why South African women still abort outside designated services where there is substantial legal service provision. Design  Descriptive study. Setting  Three hospitals in Gauteng Province in South Africa. Sample  Forty‐six women attending hospital with incomplete abortion who had abortions induced outside of designated facilities. Methods  An interviewer‐administered questionnaire with open and closed questions was completed. Induction status was determined from answers to a set of closed questions. Open‐ended questions explored the circumstances of induction. Main focus of interviews  Methods of induction used, barriers to legal service use. Results  Nearly two‐thirds of women (n= 38) had self‐induced or had consulted a traditional healer. A minority of these women (n= 11) indicated that they did this because they experienced barriers to legal service use. For others it was presented as a ‘natural’ response to a health problem (unwanted pregnancy). Several women (n= 10) were given misoprostol by a doctor, nurse, or pharmacist. Fifty‐four percent of the women had not used legal services because they did not know about the law, while 15% knew of their legal rights, but did not know of a legal facility. Others did know where to access legal services but feared rude staff (17%) or breaches of confidentiality (6.5%). Others (6.5%) had been unable to get a legal abortion early enough in pregnancy to comply with the law. Conclusions  Lack of information on abortion rights under the Act and perceived poor quality of designated facilities were the most important barriers to access and should be addressed by policymakers and health service management. The willingness of women to self‐medicate and visit traditional healers in these circumstances may influence the overall ability of the new legislation to reduce abortion morbidity.

Summaryobjective To measure the direct cost burdens (health care expenditure as a percent of total household expenditure) for households in rural South Africa, and examine the expenditure and use patterns driving those burdens, in a setting with free public primary health care and hospital exemptions for the poor.methods Data on illness events, treatment patterns and health expenditure in the previous month were assessed from a cross-sectional survey of 280 households conducted in the Agincourt Health and Demographic Surveillance site, South Africa.

Illness is a major risk to people's livelihoods in resource-poor settings, particularly where there are rising levels of chronic illness. Measures that improve access to treatment are increasingly seen as a vital form of social protection for vulnerable households, and central to the achievement of the Millennium Development Goals. International attention is also focussed on cash transfers as a strand of social protection, and on the potential complementarities between free health care and cash transfers in assisting vulnerable people to cope with illness-related shocks. South Africa provides an interesting setting to examine how households are accessing social protection measures because the government has removed some user fees, implemented hospital-level exemptions and extended cash transfers including the non-contributory pension and child support grant. This paper presents findings from household research in rural South Africa. Qualitative and quantitative methods were used to assess the links between illness-related costs and impoverishment over time, the protection effects of free health services, cash transfers and social networks, and the factors influencing access to these three forms of social protection. Different degrees of success in drawing on these resources affected capacity to cope with illnesses and made a considerable difference to whether households sustained their livelihoods, struggled or declined. Cash transfers combined well with free health care to build resilience among some households. However, households without access to at least two strands of the social protection net were impoverished by the direct and indirect costs of long-term illnesses. The implications for policies on improving the uptake and coverage of social protection measures are discussed. Copyright © 2009 John Wiley & Sons, Ltd.

The value of the social sciences is increasingly recognised in health services and clinical research, contributing to an increasing number of multi-disciplinary, multi-method studies. Such studies offer numerous advantages, but also pose particular challenges, including different approaches to or foci in research ethics across disciplines. Drawing on two similar studies conducted in coastal Kenya and in rural South Africa, we share the ethical challenges we faced in relation to several key principles, the responses we adopted, and the new dilemmas that resulted from our actions. Given that multi-disciplinary, multi-method studies are often reviewed by committees with greater familiarity with biomedical than social science research, we conclude by drawing on our experiences, and the wider literature and guidelines around conducting social science research, to make suggestions of additional considerations for social science elements of multi-disciplinary research. We also emphasise that in practice it is the social relationships that are established between researchers and field-teams, and between field-teams and community members, that are critical to fulfilling the moral (as opposed to the legal) aspects of ethics guidelines. These essential elements of ethical practice, and of producing quality data, are not easily tested and checked by ethics committees. Rather they are linked to the insight and integrity of the principle investigators and their research teams. Copyright © 2009 John Wiley & Sons, Ltd.