In 2017, the Bhekisisa Centre for Health Journalism published an article titled “#SizaMap: Where to get a safe, legal abortion in South Africa”. In addition to exposing the dire state of abortion services in South Africa, Bhekisisa also provided a search tool that would assist anyone seeking an abortion with locating the health establishment closest to them where they could access safe abortion services.
Two years later, to our knowledge, this is the only national database of facilities that offers abortion services.
On 13 September 2019, member of parliament Ms A Weber of the DA asked the minister of health three questions relating to access to abortion services. One of the questions was for the names of all the approved clinics and/or institutions where abortions are legally allowed to take place.
In his written response, the minister provided a list containing 357 facilities (clinics, community health centres and hospitals). At first glance, this seemed like a significant number. However, with just a little bit of investigation, we found that all was not as it seemed.
According to the minister, 32 public health establishments in the Eastern Cape are designated to offer abortion services. SECTION27 contacted 28 of the listed facilities to confirm whether they offered abortion services and if so, up to which stage of the pregnancy. 25% of the contacted facilities responded that they did not do so and, one facility responded that it was still awaiting training from the Department of Health.
We also discovered that the list included private health facilities.
While private facilities may go some way towards improving access to abortion services, these services are accessible only to those who can pay the fees. Further, and perhaps unsurprisingly, the private health facilities are concentrated in urban areas.
The inequitable distribution of designated facilities is one of the factors which has a direct impact on the extent of women’s access to pregnancy termination services. Access for specific groups, particularly women from rural areas continues to be a problem. It becomes even more problematic in relation to second-trimester abortions.
For these reasons, the inclusion of private health facilities as facilities that offer safe abortion services, is cold comfort for those who cannot afford to pay and for those in rural areas.
Designation, therefore, does not mean that services are actually accessible or available.
What does the law require?
In terms of the Choice on Termination of Pregnancy Act, the MEC for health in a province is obliged to designate clinics, community health centres and hospitals as the places where one can get an abortion in the respective province. Unless designated, abortion services cannot be offered at a facility.
However, there exists another discrepancy in that some designated facilities do not always provide these services. In 2000, (nearly 20 years ago) a review of the implementation of the Choice on Termination of Pregnancy Act (CTOPA) by the Community Law Centre reported that there was a disturbing discrepancy between designated and operational facilities. The review attributed these discrepancies to factors including a lack of trained staff, non/poor allocation of financial resources to acquire equipment and conscientious objection.
The big question is how many of these issues have been resolved?
The State has a constitutional duty to respect, protect, promote and fulfil everyone’s right to access to health care services. Further, section 195(1)(g) of the Constitution, which sets out the basic values and principles governing public administration, states that transparency must be fostered by providing the public with timely, accessible and accurate information.
Giving inaccurate and incomplete information about where health care services can be obtained does not create an environment in which every individual can gain access to health services through their own efforts. Instead, it exacerbates the challenges. It results in already vulnerable women seeking time-sensitive health care services, being sent from pillar to post and in some cases then resorting to unsafe, unregistered and illegal backstreet abortions.
Purpose of parliamentary questions
Questions are an important means used by members of parliament to ensure that government is accountable to Parliament for its policies and actions and, through Parliament, to the people. While these questions often imply criticism of government policies and actions, they are an important means of getting information.
What then is required of a health minister who has been asked to respond to pertinent issues affecting women’s rights and their health?
In this case, the minister was asked to provide a list of facilities that have been approved to offer abortion services. He duly responded. But was his response satisfactory?
In my mind, there exists a duty that goes beyond simply answering a question. There is a duty to provide accurate information that can be of use to the people; a duty to do more than the bare minimum, to be comprehensive; and a responsibility to bear in mind that millions of people rely on the information that you give to make decisions that impact their lives.
This is not just a moral duty, it is a constitutional obligation. Section 12 of the National Health Act states that the national department and other office-bearers have a duty to ensure that appropriate, adequate and comprehensive information is disseminated.
At the very least, there should have been some efforts from the minister to confirm whether the facilities on this list actually provided the services in question.
In fact, this information should be readily available to the minister. In terms of section 3(4) of the CTOPA, every year, the MEC of health must submit the statistics of any approved facilities to the minister. Surely an analysis of these statistics should reveal that there are designated facilities that are not offering abortion services?
This information is essential for determining what the interventions for improving access to abortion services need to be. Is there a need for designating additional facilities, or would it be sufficient to only ensure that the facilities that have already been designated are adequately capacitated to offer the services? Unfortunately, if the minister’s attitude is only to answer the questions that have been asked, and not engage properly, we are unlikely to see any improvement.
In the past few months, some provincial departments have taken to social media platforms to inform people of where to obtain safe abortions. It’s commendable, but it is not enough.
Firstly, not everyone is on social media. Secondly, at every other lamppost in every city, you will find a poster from an illegal abortion provider promising safe, quick and painless abortion. One of the ways to counter this is to provide accurate and comprehensive information.
The fact that one cannot simply access abortion services at any health establishment makes the duty to disseminate accurate, comprehensive and useable information all the more important. As the steward of the country’s health system, and as someone whom we hope is fully aware of the challenges relating to accessing abortion services, the minister should not have been, and must not be comfortable to do the bare minimum as he did in his written response.
That said, it is also incumbent on members of Parliament, our representatives, to ask the right questions, to interrogate the responses and to not be satisfied with “lists” that are devoid of detail. MC
Tendai Mafuma is a legal researcher on the health rights team at SECTION27. She holds Msc Biochemistry and LLB degrees from Rhodes University. She clerked for Justice Mbuyiseli Madlanga at the Constitutional Court of South Africa. Her areas of work include mental health, access to medicines, and sexual and reproductive health rights.