Thesis (MPhil)--Stellenbosch University, 2000. / Some digitised pages may appear illegible due to the condition of the original hard copy. / ENGLISH ABSTRACT: Medicine in our country is under severe stress, brought about by internal and external forces that need a response from the medical profession. The profession's attempts and response will fall short unless the profession itself is aligned with the new social ethos and the responses are based on the profession's inherent values. Problem Statement: Medical doctors have always been highly valued in society because of the duty they have when illness and disease set in. As individuals, doctors have fulfilled other important roles in the communities where they work. These include giving advice to young people on career choices, counseling on various matters and provision of material help where there is need. This profession has for a long time been shrouded in mystery, being a trade learnt by a few. All these factors contributed to their social standing increasing phenomenally. There is a view that this has also led to public perceptions that doctors are the rich untouchable elite who have no interest or are unconcerned about problems faced by society. The medical profession faces a challenge that is more significant because of the value placed on it by society. The numerous submissions by the victims of human rights abuses to the Truth and Reconciliation Commission have cast a shadow of doubt on the medical profession for its complicity in these acts. The present government has declared transformation of health care as one of its top priorities. The response of the medical profession to this initiative has so far not led to any significant changes of public perception that the profession is unwilling to participate in the transformation of our society. The challenge and subject of discussion in this thesis therefore is: "What is the ideal role of the medical profession in a transforming South African society?" The medical profession, being the nerve centre of health care, has a big responsibility in social transformation. Doctors stand accused as a collective for failing to protect the human rights of patients and not living up to the standards of ethics required of them when patients' rights were violated. The Truth and Reconciliation Commission record of the hearings into the role of the professional organisations in health is used in this thesis to illustrate how serious society views the medical profession's role in the human rights abuses of the past. Based on the T. R. C's report and the assumption that society traditionally places high value on the medical profession, I conducted a survey among South African doctors to test their attitudes towards a range of policy and transformational issues. The unit of analysis was the medical doctors who are in active practice in South Africa in whatever mode of practice. The survey sought to explore the awareness of the respondents about a range of transformation policy changes and invite their comments on the role that they envisage for the medical profession in the process of transformation of society. There is unfortunately scarcity or a lack of applicable South African literature on this topic thus limiting local material for referencing. The search of international literature only yielded the subject of the study of professional values and not necessarily the role of a medical profession in a transforming society. The medical profession has to re-visit its foundations, analyse its history and map out its future in the context of the South African realities. It must find a way of aligning itself with the new ethos and diverse cultures South Africa possesses. Medicine has its own traditional goals and values derived and adapted from society's diverse cultural value systems. With its national and international networks, the inherent knowledge and skills that it possesses, guided by an ethical code, the Hippocratic Oath that serves as a public promise, it influences policy on the country's health care system - a mechanism that government uses to provide a basic human need. The medical profession therefore has to be responsive to the needs of society as much as society needs to support the profession. This thesis explores the role that the profession should play in a transforming South African society. The argument is that this can only be done through the profession examining its values and aligning itself with broader societal value systems, the moral and social norms. It is further argued that visible realistic commitment by the profession to public health will lead to an improvement in its public image. It is the actions or non-actions of the majority that the public notices. The majority of respondents to the survey have indicated that they approve of the transformation policies in health but that they may differ in the way they were introduced. / AFRIKAANSE OPSOMMING: Die geneeskunde in ons land is onder geweldige druk as gevolg van interne en eksterne faktore en dit is nodig dat die mediese beroep reageer. Dit sal die beroep egter nie help om te reageer indien sy lede hulle nie met die nuwe maatskaplike etos vereenselwig nie en die reaksie op die inherente waardes van die mediese beroep geskoei word nie. Probleemstelling Mediese dokters is nog altyd baie hoog geag deur die gemeenskap as gevolg van die verpligting wat hulle het om na mense om te sien wanneer hulle siek word. In hulle individuele hoedanigheid het dokters ook ander belangrike bydraes tot hulle gemeenskappe gelewer. Dit sluit in: advies aan jong mense oor loopbaankeuses, berading en die verskaffing van finansiele hulp waar nodig. Die beroep as sulks was egter vir baie lank ietwat van 'n misterie omdat dit 'n vakrigting is waarin baie min mense hulle kon bekwaam. Al hierdie faktore het die maatskaplike aansien/waarde van dokters geweldig verhoog. Daar is ook diegene wat van mening is dat hierdie faktore aanleiding gegee het tot die openbare mening dat dokters 'n ryk en onaantasbare elite is en glad nie in die probleme van die gemeenskap belangstel nie. Die etlike voorleggings deur die slagoffers van menseregtevergrype aan die Waarheids- en Versoeningskommissie het ook vrae rondom die beroep se betrokkenheid by sodanige gevalle laat ontstaan. Die huidige regering het die transformasie van gesondheidsorg as een van sy grootste prioriteite verklaar. Die reaksie van die beroep hierop het tot dusver nie tot enige noemenswaardige veranderinge in die openbare mening dat dokters nie bereid is om aan die transformasie van ons gemeenskap deel te neem gelei nie. Wat is die ideale rol van die mediese beroep in die transformasie van die Suid- Afrikaanse gemeenskap? As die senusentrum van gesondheidsorg het die mediese beroep 'n groot verantwoordelikheid in maatskaplike transformasie. Dokters word kollektief beskuldig dat hulle nagelaat het om die menseregte van pasiente te beskerm en nie voldoen het aan die nodige etiese standaarde wat van hulle verwag word in die tyd toe pasienteregte geskend is nie. Die rekord van die verhore van die Waarheids- en Versoeningskommissie oor die rol van professionele gesondheidsorganisasies is vir die doeleindes van hierdie tesis gebruik om te illustreer hoe ernstig die gemeenskap voeloor die mediese beroep se rol in die menseregte vergrype van die verlede. Gegrond op die WVK-verslag en die aanname dat die gemeenskap die mediese beroep hoog ag, het ek 'n meningsopname onder 300 Suid-Afrikaanse dokters gedoen om hulle houding jeens 'n aantal beleids- en transformasiekwessies te toets. Die eenheid van analise was mediese dokters wat in die aktiewe praktyk staan, ongeag hulle praktykgebied. Die opname het gepoog om te bepaal wat die vlak van bewustheid by die respondente oor 'n aantal beleidsveranderinge gerig op transformasie is, en hulle uit te nooi om kommentaar te lewer op die rol wat hulle meen die mediese beroep behoort in die proses te speel. Ongelukkig is daar nie toepaslike Suid-Afrikaanse literatuur oor die onderwerp beskikbaar me. 'n Internasionale literatuursoektog het net studies rondom waardes opgelewer, en nie oor die rol van 'n mediese beroep in die transformasie van 'n gemeenskap nie. Die mediese beroep moet die grondslag van sy wese in oenskou neem, die geskiedenis analiseer en sy toekoms in die konteks van die Suid-Afrikaanse realiteite uitstippel. Die beroep moet 'n manier vind om homself met die nuwe etos en uiteenlopende kulture van Suid-Afrika te vereenselwig. Die geneeskunde het sy eie tradisionele doelwitte en waardes gekry en aangepas vanuit die uiteenlopende kulturele waardestelsels van die gemeenskap. Deur middel van sy nasionale en internasionale netwerke, inherente kennis en vaardighede, die leiding van 'n etiese kode, die Eed van Hippokrates wat as 'n belofte aan die publiek dien, beinvloed die mediese beroep die land se gesondheidsorgstelsel - 'n meganisme van die regering om in 'n basiese menslike behoefte te voorsien. Die mediese beroep moet daarom ingestel wees op die behoeftes van die gemeenskap in dieselfde mate as wat die gemeenskap die beroep behoort te ondersteun. Hierdie tesis ondersoek die rol wat die mediese beroep behoort te vervul in 'n Suid-Afrikaanse gemeenskap waar transformasie besig is om plaas te vind. Daar word geargumenteer dat dit net gedoen kan word indien die beroep sy waardes ondersoek en hom met die breer maatskaplike waardestelsels vereenselwig. Daar word verder geargumenteer dat 'n sigbare realistiese verbintenis van die mediese beroep tot openbare gesondheid tot die verbetering van sy openbare beeld sal lei. Dit is die optrede of nie-optrede van die meerderheid wat die publiek raaksien. Die meerderheid respondente in die meningsopname het aangedui dat hulle die transformasiebeleid vir gesondheid ondersteun, maar dat hulle verskil van die wyse waarop dit in werking gestel is.

Thesis (DMed)--Stellenbosch University, 2008. / The comparative study presented in this dissertation specifically aimed to assess fracture risk in black (Xhosa) and white South African women by evaluating known determinants of bone strength as well as the propensity to falls. We thus compared the prevalence of clinical (historic) risk factors for osteoporosis, measured and compared vertebral and femoral bone mineral density (BMD) employing dual energy X-ray absorptiometry (DEXA), ultrasound variables using the Sahara sonometer, serum parathyroid hormone (PTH) and 25-OH Vitamin D, mineral homeostasis and modern biochemical markers of bone turnover, bone geometry and the propensity to falls. Finally, we determined the prevalence of vertebral fractures in these black and white South African females. 1. Significant ethnic differences were noted in the presence and frequency of historical clinical and lifestyle risk factors for osteoporosis. Blacks were heavier and shorter, they consumed less calcium, were more inactive, preferred depot-medroxyprogesterone acetate as contraceptive agent and were of higher parity. Whites smoked more, preferred oral oestrogen containing contraceptive tablets and were more likely to have a positive family history of osteoporosis. Hormone therapy was used almost exclusively by postmenopausal whites. Inter-ethnic differences in weight, physical activity and high parity was most marked in the older subjects. 2. We found that peak spinal BMD was lower, but peak femoral BMD similar or higher (depending on the specific proximal femoral site measured) in black South-African females compared with whites. The lower peak spinal BMD was mainly attributed to lower BMD’s in the subgroup of black females with normal to low body weight, indicating that obesity either protected black females against a low spinal BMD or enhanced optimal attainment of bone mineral. An apparent slower rate of decline in both spinal- and femoral BMD with ageing was noted in the black females compared with whites in this cross-sectional study – an observation which will require confirmation in longitudinal, follow-up studies. This resulted in similar spinal BMD values in postmenopausal blacks and whites, but significantly higher femoral BMD measurements in blacks. The volumetric calculation of bone mineral apparent density (BMAD) at the lumbar spine and femoral neck yielded similar results to that of BMD. Spinal BMAD was similar in blacks and whites and femoral neck BMAD was consistently higher in all the menopausal subgroups studied. Weight significantly correlated with peak- and postmenopausal BMD at all sites in the black and white female cohorts. Greater and better maintained body weight may be partially responsible for slower rates of bone loss observed in black postmenopausal females. Most of the observed ethnic difference in BMD was, in fact, explained by differences in body weight between the two cohorts and not by ethnicity per se. 3. A low body weight and advanced age was identified as by far the most informative individual clinical risk factors for osteopenia in our black and white females, whereas physical inactivity was also identified as an important individual risk factor in blacks only. Risk assessment tools, developed and validated in Asian and European populations, demonstrated poor sensitivity for identification of South African women at increased risk of osteopenia. The osteoporosis risk assessment instrument (ORAI) showed the best results, with sensitivities to identify osteopenic whites at most skeletal sites approaching 80% (78% - 81%). The risk assessment tool scores appear to be inappropriate for our larger sized study cohort, especially our black subjects, thus resulting in incorrect risk stratification and poor test sensitivity. General discriminant analysis identified certain risk factor subsets for combined prediction of osteopenia in blacks and whites. These risk factor subsets were more sensitive to identify osteopenia in blacks at all skeletal sites, compared with the risk assessment tools described in the literature. 4. Higher ultrasonographically measured broadband ultrasound attenuation (BUA) and speed of sound (SOS) values were documented in our elderly blacks compared with whites, even after correction for differences in DEXA determined BMD at the spine and proximal femoral sites. BUA and SOS showed no decline with ageing in blacks, in contrast to an apparent significant deterioration in both parameters in ageing whites. If these quantitative ultrasound (QUS) parameters do measure qualitative properties of bone in our black population, independent of BMD as has been suggested in previous work in Caucasian populations, the higher values documented in elderly blacks imply better preservation of bone quality in ageing blacks compared with whites. The correlation between QUS calcaneal BMD and DEXA measured BMD at the hip and spine was modest at best. QUS calcaneal BMD was therefore unable to predict DEXA measured BMD at clinically important fracture sites in our study population. 5. Bone turnover, as assessed biochemically, was similar in the total pre- and postmenopausal black and white cohorts, but bone turnover rates appeared to differ with ageing between the two racial groups. A lower bone turnover rate was noted in blacks at the time of the menopausal transition and is consistent with the finding of a lower percentage bone loss at femoral sites at this time in blacks compared with whites. Bone turnover only increased in ageing postmenopausal blacks, and this could be ascribed, at least in part, to the observed negative calcium balance and the more pronounced secondary hyperparathyroidism noted in blacks. Deleterious effects of secondary hyperparathyroidism on bone mineral density at the proximal femoral sites were demonstrated in our postmenopausal blacks and contest the idea of an absolute skeletal resistance to the action of PTH in blacks. The increase in bone turnover and the presence of secondary hyperparathyroidism due to a negative calcium balance may thus potentially aggravate bone loss in ageing blacks, especially at proximal femoral sites. 6. Shorter, adult black women have a significantly shorter hip axis length (HAL) than whites. This geometric feature has been documented to protect against hip fracture. The approximately one standard deviation (SD) difference in HAL between our blacks and whites may therefore significantly contribute to the lower hip fracture rate previously reported in South African black females compared with whites. Average vertebral size was, however, smaller in black females and fail to explain the apparent lower vertebral fracture risk previously reported in this population. Racial differences in vertebral dimensions (height, width) and/or other qualitative bone properties as suggested by our QUS data may, however, account for different vertebral fracture rates in white and black women – that is, if such a difference in fact exists. 7. The number of women with a history of falls was similar in our black and white cohorts, and in both ethnic groups the risk of falling increased with age. There is a suggestion that the nature of falls in our black and white postmenopausal females may differ, but this will have to be confirmed in a larger study. Fallers in our postmenopausal study population were more likely to have osteoporosis than non-fallers. Postmenopausal blacks in our study demonstrated poorer outcomes regarding neuromuscular function, Vitamin D status and visual contrast testing and were shown to be more inactive with ageing compared with whites. An increased fall tendency amongst the black females could not however be documented in this small study. Quadriceps weakness and slower reaction time indicated an increased fall risk amongst whites, but were unable to distinguish black female fallers from non-fallers. 8. Vertebral fractures occurred in a similar percentage of postmenopausal blacks (11.5%) and whites (8.1%) in our study. Proximal femoral BMD best identified black and white vertebral fracture cases in this study. Quite a number of other risk factors i.e. physical inactivity, alcohol-intake, poorer physical performance test results and a longer HAL were more frequent in the white fracture cases and could therefore serve as markers of increased fracture risk, although not necessarily implicated in the pathophysiology of OP or falls. However, in blacks, only femoral BMD served as risk factor. Similar risk factors for blacks and whites cannot therefore be assumed and is deserving of further study. White fracture cases did not fall more despite lower 25-OH-Vitamin D, poorer physical performance and lower activity levels than non-fracture cases. Calcaneal ultrasonography and biochemical parameters of bone turnover were similar in fracture and non-fracture cases in both ethnic groups. Our study data on vertebral fractures in this cohort of urbanized blacks thus cautions against the belief that blacks are not at risk of sustaining vertebral compression fractures and emphasize the need for further studies to better define fracture prevalence in the different ethnic populations of South Africa. 9. In our study, hormone therapy in postmenopausal white women improved bone strength parameters and reduced fall risk. In hormone treated whites compared with non-hormone users, a higher BMD at the spine and proximal femur as determined by DEXA were documented and all QUS measurements were also significantly higher. The biochemically determined bone turnover rate, as reflected by serum osteocalcin levels, was lower in hormone users. Fall frequency was lower in the older hormone treated women (≥ 60yrs) and greater quadriceps strength and reduced lateral sway was noted. Only one patient amongst the hormone users (2%) had radiological evidence of vertebral fractures compared with four patients (6%) amongst the never-users. As hormone therapy was used almost exclusively by whites in this study population, the impact of hormone therapy on postmenopausal black study subjects could not be assessed.

As the economic hub of South Africa, Johannesburg attracts cross-border migrants in search of improved livelihoods; over half the population of some of its inner-city suburbs are made up of cross border migrants. Globally as well as locally, foreigners have been blamed for the spread of diseases such as HIV. As a result, they have suffered challenges in accessing public healthcare, particularly antiretroviral treatment (ART) for HIV. Studies have shown that despite these challenges - foreigners experienced better ART outcomes than nationals. There is a need to explore the ways in which cross border migrants use to access and to stay on treatment, given the wide-range of challenges that they face during their stay in Johannesburg. Semi-structured interviews with five nurses and ten cross-border migrants currently receiving ART, along with non-participant observations, were used to collect data from two public clinics in inner-city Johannesburg. Analysis suggests that the family network in the country of origin remains critical, as cross border migrants are not disclosing their status in the city in which they live, but do so to their families in their countries of origin. Data shows that when it comes to accessing and staying on treatment, cross-border migrants go to the clinic every month as do nationals; ask for more treatment from nurses when going home temporarily; eat healthily; but hide when taking medication, and negotiate confidentiality and trust within their families in countries of origin. Some are found to access treatment in their countries of origin while staying in Johannesburg. Despite the lack of social networks in the inner city, this data suggests that cross-border migrants are successful in accessing and continuing with ART. There is need for future research to look at social networks for internal migrants, so as to compare results.

Introduction South Africa has a two tiered health care system: a private sector catering for seven of the 47 million people and public sector providing care to the majority. The private sector consists of for-profit providers that are funded either through medical schemes, health insurance policies or out of pocket expenditure. To attain the goal of the health care system of improving health, it is essential that healthcare financing is understood. The provision of quality, accurate and comprehensive financial data is necessary for the efficient mobilization and allocation of financial resources. Health Expenditure Reviews and National Health Accounts provide such invaluable information. Aim To provide a trend analysis of health financing and expenditure data for the private health care sector in South Africa from 01 January 2003 to 31 December 2006. Methods This study is employs an observational, descriptive cross-sectional design. The methodology used in the study is adapted from the World Health Organization’s guide to producing National Health Accounts. Data was obtained from the Council for Medical Schemes annual reports and from Statistics South Africa Income and Expenditure Survey. The annual average medical inflation for each of the years was removed from the nominal value so that a real trend analysis could be observed. Results For the four year period, the overall cost-drivers of consolidated schemes were private hospitals (31.0-35.0%), medical specialists (20.0-21.0%), medicines dispensed out of hospital (17.0-22.0%) and non-healthcare expenditure like administration and broker fees (14.0-15.0%). From the households’ consumable expenditure on health, 37.0% was spent on medical services, 35.0% on pharmaceutical products and 11.0% on hospital services. Discussion The majority of expenditure in the private sector is through medical schemes. The precise amount spent by households is unknown due to the lack of data but it is a large amount for the South African household. Proper National Health Account Matrices could not be constructed since access to data was limited, not routinely available and not disaggregated at the required level. Recommendations Better quality information on out-of-pocket household expenditure and expenditure in the traditional sector is needed. To improve access to the private sector, the proposed policy and legislative changes need to be implemented. / Thesis (MMed.)-University of KwaZulu-Natal, Durban, 2010.

There is increasing concern that newly qualified registered nurses (RNs) find it difficult to make a smooth transition from completing their four-year nursing training to taking up their posts as first time RNs. In a constantly changing healthcare system, these newly qualified RNs are expected to work independently and be competent in applying the decision making and problem-solving skills gained during their training. While certain aspects of clinical incompetence may be ascribed to individual factors, the importance of the clinical learning environment and its influence on the development of clinical competence cannot be ignored. Nurses need support and guidance to effect a successful transition from being novice to competent nurse and the environment is regarded as important in developing technical competencies. The research study followed a positivistic, quantitative paradigm, where the hypothesized relationship between clinical learning environmental factors and clinical competence of newly qualified RNs were explored. Data was collected from the experienced RNs in the hospitals by means of a structured pre-existing questionnaire, namely the Competency Inventory for Registered Nurses (CIRN). Descriptive statistics and inferential statistics were used to analyse data. The analysed data was used to describe the findings. Recommendations were made based on the findings. Results suggested that the development of clinical competence is dependent on both the individual and context. Positive relations were reported between clinical learning environmental factors and clinical competencies.

This study was motivated by the commitment of the researcher to contribute towards the agenda for the development of women, in particular women affected and infected with HIV/Aids, through a better understanding and improved knowledge of the national and international legal and policy framework aimed at empowering women in South Africa. This study builds on countless efforts which have been implemented internationally to transform the world and create a peaceful and liveable world for women who have been historically oppressed, unrecognised and, in the case of women affected and infected with HIV, stigmatised. An increasing trend towards recognising the need to advance women and acknowledge their status in the community on the part of the international community was observed and then explored in the literature review which was conducted for the purposes of the study. The development of women is dependent on an enabling environment which is free from all forms of discrimination. Poverty, gender-based violence, cultural perceptions, as well as traditional and religious practices, all contribute to the challenges facing women. In addition, HIV/Aids is a continuous threat and impacts greatly on the lives of both women and their families. The aim of the study was to explore the contribution that the Commission of Gender Equality (CGE) makes towards a better quality of life for women and also to contribute to the development of a strategy to optimise the integration of HIV/Aids issues into the mandate of the CGE. The requisite data was collected through an extensive literature study of the research field, a document analysis and personal interviews with Commissioners of the CGE. The data were complemented and supported by the inputs of focus groups in which community members provided inputs about their experiences of the role played by the CGE at a community level. ii Data revealed limitations in the effective functioning and the measurable impact of the CGE. These were subsequently addressed in the design of a suggested strategic plan. The limitations included aspects relating to CGE organisational structure; the knowledge and skills of personnel, the lack of role clarification; the lack of a coordinated strategy; as well as a deficient working plan which, in its current format, shows a lack of continuity as a result of high staff turnover, a weak continuity strategy when commissioners’ term of office ends, limitations in terms of financial resources, and the absence of monitoring and control systems. / Health Studies / D. Litt. et Phil. (Health Studies)

The maternal mortality ratio (MMR) and neonatal mortality rate (NMR) have been persistently high in South Africa, with black, poor, rural women and neonates mostly affected. The MMR and the NMR are indicative of the health of the population and reflect deeper issues such as inequitable distribution of the country’s resources, social exclusion, deprivation, and lack of access to quality public services. The purpose of the study was to develop a model to meet the overall health needs of the socially excluded, the deprived and the vulnerable women by listing those factors that influence maternal and child health outcomes. From the point of view that individual reproduction and health decision-making takes place in a milieu comprising multiple socio-economic and cultural factors, this study attempts to add to the body of knowledge on maternal and child health in order to influence policies and interventions. Data was collected through a multi-staged, qualitative research design. The results show how structural factors result in high risk for poor maternal and child health outcomes, suggesting that the high rates of poor health outcomes are evidence of deprivation of women’s needs due to poverty leading to an inability to cope with pregnancy and childbirth. The results are used to develop a model that proposes pathways for policy action to confront both the structural and intermediary determinants of maternal and child ill health and mortality. These pathways operate through integrative and inter-sectorial mechanisms intended at empowering women and enhancing female reproductive health care activities. / Sociology / D.Litt. et Phil. (Sociology)

Data quality is one of many challenges experienced in electronic healthcare (e-health) services in South Africa. The collection of data with substandard data quality leads to inappropriate information for health and management purposes. Evidence of challenges with regard to data quality in e-health systems led to the purpose of this study, namely to prioritise data quality challenges experienced by data users of e-health systems in South Africa. The study followed a sequential QUAL-quan mixed method research design to realise the research purpose. After carrying out a literature review on the background of e-health and the current status of research on data quality challenges, a qualitative study was conducted to verify and extend the identified possible e-health data quality challenges. A quantitative study to prioritise data quality challenges experienced by data users of e-health systems followed. Data users of e-health systems in South Africa served as the unit of analysis in the study. The data collection process included interviews with four data quality experts to verify and extend the possible e-health data quality challenges identified from literature. This was followed by a survey targeting 100 data users of e-health systems in South Africa for which 82 responses were received. A prioritised list of e-health data quality challenges has been compiled from the research results. This list can assist data users of e-health systems in South Africa to improve the quality of data in those systems. The most important e-health data quality challenge is a lack of training for e-health systems data users. The prioritised list of e-health data quality challenges allowed for evidence-based recommendations which can assist health institutions in South Africa to ensure future data quality in e-health systems. / Computing / M. Sc. (Computing)

The world population is ageing, and this is also relevant to South Africa. At the same time the potential support ratio (the number of persons aged 15 to 64 years per one older person aged 65 years or older) is falling, and the dependency burden on potential workers increases. To alleviate the financial burden on the aged, and their families, it has become necessary to develop a financial plan to cover the cost of frail care. The overall purpose of this research is to determine whether any financial plans exist which are relevant. If nothing existed, a plan had to be developed. The research methodology for this study comprised the following steps: Firstly, the demographics of the world and South Africa were researched. The concept of frail (long-term) care in the United States of America and New Zealand was investigated to determine what is available. The subsidisation concept of the South African Government towards caring for the elderly was also investigated. Secondly, a questionnaire was sent to the residents of five retirement complexes in George to determine their interest in such a plan. The records of the frail care unit that these residents utilise were analysed to determine the number of residents needing frail care. A comparative study of the cost of frail care in the Southern Cape was undertaken. Thirdly, two options to partly subsidise the cost of frail care were examined, where the first option covers the running cost, and the second option, subsidising one third of the frail care cost, builds up a sustainable fund after the first five year period. The funds of the second option can then be utilised in the subsequent years to increase the subsidisation portion of frail care cost. The final step of this study entailed the formulation of recommendations to implement the frail care nursing levy as soon as possible, with special attention given to the following: a) It must be compulsory for new residents to join the fund. b) A yearly capital amount of R100 000 or more is needed to sustain the fund. c) A contract must be drafted to set out all the rules and regulations to the residents. d) An attitude change amongst some residents is required. Individuals must realise that the success of this plan depends upon themselves and with the necessary support could make a significant contribution towards their own peace of mind if and when frail care is needed.

This study aims to characterize and understand the search for health in a rural Transkeian community. It begins with the observation that the people of Jotelo have to negotiate considerable hardships in their daily lives. These hardships include the impact of malnutrition, undernourishment and a wide range of diseases like tuberculosis, typhoid and gastro-enteritis. To survive ill-health, people develop numerous practical strategies. Most significantly, they attempt to maximise availalble resources, like cash, their relations with others and local medical facilities. Hence the study attempts to characterize how and why patients select various kinds of therapy in their search for health. By focusing on patients' recourses to treatment, the study reveals that the search for health is as much a personal experience as it is a social and economic one. This idea is developed in an analysis of the links betw'een work, illness and social reproduction. The point which emerges from this discussion captures the central theme of the study: the search for health is a profoundly personal, social and economic experience. This notion is strengthened by an examination of the historical and contemporary nature of local health and health care. It is observed that health and health care is intimately linked to the local and wider political economy. This not only serves to contextualise the discussion on patients' actual experiences, but points to the fact that these experiences are part of wider processes. By depicting the search for health in this way, the study hopes to have illustrated what people do in times of illness and why. Yet it also claims to have gone beyond such a depiction. By abstracting from its findings, it aims to conclude that the search for health is not merely caused by various local and wider processes, to which it has referred. In other words, it hopes to avoid a deterministic view of patients' experiences in times of distress. Instead, it is argued that the search for health is ultimately an integral part of the local and wider economic and political environment