Illness-related impoverishment in rural south Africa: why does social protection work for some households but not others?

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.