The world is becoming increasingly urban, with over half of the world’s total population now residing in cities. While urban areas offer many economic and livelihood opportunities, they are increasingly characterised by growing inequality. In South Africa, both former homelands and peri-urban areas have been severely neglected in terms of health care and services, resulting in very poor-quality care and extreme discrepancies between rural and urban health statistics. Yet, there is recognition of the need to address peri-urban sexual and reproductive health (SRH) in South Africa.
South African adolescents experience very high levels of pregnancy, due to uneven gender relations, limited comprehensive sexuality education, and poor access to sexual and reproductive health and rights (SRHR) services, including quality contraception options. Poverty and place of residence strongly affect outcomes of adolescent sexual health in South Africa. While it is recognised that women and girls living in low-income residential areas are negatively affected in relation to many aspects of health, including SRHR, very little information is available on health within peri-urban cities and on the interconnections between poverty, place and health. Given this, we set out to understand how ICTs in general, and mHealth in particular, might provide new ways of addressing adolescent sexuality, reproductive health and place in South Africa.
Mobile phones are ubiquitous in South Africa, including in rural, peri-urban and slum contexts. However, investment in infrastructure tends to be in middle class areas where those inhabiting the spaces pay for use, and South Africa is renowned for its high data costs. By contrast, peri-urban and township areas suffer from inadequate access to services, including poor network coverage, weak satellite signals, insufficient bandwidth and limited voice capacity due to congestion and demand. As high unemployment causes a lack of security, women do not carry mobile phones for fear of being attacked and robbed. In some instances women share mobile phones. Rural areas are plagued by uneven conditions of access: female-headed households have poor access to mobile phones, poor satellite reception, no broadband, high data costs, lack of infrastructure as well as health, education and transport inequalities. In general, women and adolescent girls also have less time to access ICTs due to the gendered division of labour and additional domestic burdens. It is also difficult, and often unsafe, to access internet cafes and other public places where ICTs might be freely available. Inequality in ICT access thus maps the pattern of apartheid inequality.
There are also constraints in terms of electricity, language, cost and design - as one responded said, ‘Space is not an issue, rather it is cost’. Patterns of inequality cannot be addressed simply through access. Special policy measures are needed to support infrastructural and other developments in rural areas, inner-city slums and peri-urban areas, but if left to market forces, these areas will remain under-resourced. Yet, as no such policy prescriptions exist, most technical interventions make no attempt to deal with this. For example, although the National Department of Health (NDOH) is aware of the challenges of rural and peri-urban health for women and adolescent girls, MomConnect – its new national Maternal and Child Health programme – does not address high-risk HIV-pregnancies in peri-urban areas, or offer ways of ensuring transport and places for safe delivery in rural areas. It was, as one member of the task force informed us, ‘too complicated to add any nuance at this stage’. Thus MomConnect deals with questions of space only in terms of connectivity. Implementers working with the NDOH argue that ‘technically on paper, there is no area [in South Africa] without connectivity’. While recognising that connectivity may sometimes mean climbing a hill to receive a signal – and putting aside the mental image of pregnant women climbing hills to read their pregnancy-related SMS messages – ‘MomConnect will deal with it by hoping that there is a facility to receive a signal and that women may have to try different sim cards and perhaps change their service providers’.
As technology improves and programmes expand, the challenges of addressing place-related health issues change. Increasingly, content is being dispersed to mobile phones throughout Africa, so it is not always possible to link subscribers to particular countries or places. As many SRHR topics – abortion, diverse sexual orientations and gender identity, sex work, adolescent sexuality, condoms – are highly politicised and possibly banned, implementers focus on neutral, uncontentious topics and health-related facts. As one implementer, running an Africa-wide, sexual health social networking forum for young people, commented: ‘What I did as a better-than-nothing solution is I hired an international sexual health advisor to produce information as neutrally as possible’. Yet, implementers still come up against place-related challenges: ‘I wrote a manual about being tested for sexual diseases, but found that the tests were not offered… Place is the biggest missing puzzle piece in our service’.
The problem is political – rural, peri-urban, and inner-city areas are underserviced because of past historical injustice, because the poor live in these areas, because there are no policy prescriptions forcing cell phone operators to provide technology and services to these areas, and because the poor have no purchasing power. Poor women’s and adolescents’ health as experienced in these areas is not eye-catching – gender-based violence, abortion, adolescent rape – and their rights to challenge these experiences are difficult, politically-sensitive topics which do not buy votes. Nor are they easily addressed through the sale of m-health products. The challenge of adolescents’ and women’s SRHRs in rural, peri-urban, and inner-city areas is political. Yet, for many, the solution proposed is often technical.