Dr Olive Shisana, special adviser to the minister of health, discusses the reasons behind the parlous state of health services — and the way forward
THE health status of the majority of South Africans remains poor, and the distribution of death and disability reflects the inequities of the past. In 1992, the number of children who died in their first year of life was nearly eight times higher among blacks than in the white community. The same picture emerges if we look at the diseases that can be prevented by childhood immunisation or at adult diseases such as tuberculosis, where we find that 400 new cases are reported among coloureds and 200 cases among blacks every year.
When we look at the reasons behind this bleak picture, we come face to face with an equally badly distributed network of health care services. Just over five percent of South Africa’s doctors work in rural areas, which are home to more than 40 percent of the population. In contrast, more than 65 percent of doctors are clustered in metropolitan areas.
When we look at the distribution of health centres, dispensaries and community hospitals, the same inequitable pattern appears. For example, there are more than seven beds per thousand people in metropolitan areas but only four beds for the same number of people elsewhere.
The reasons why this is so are clear. The new Ministry of Health has inherited a system of allocating resources in which the money available does not follow the people who need care. Instead, it is tied to the existing facilities and the services they offer.
It has been estimated that more than 65 percent of the public-sector health care budget is allocated to hospital care and that 30 percent goes to academic hospitals alone. In contrast, only about six percent of the public-sector budget is attributable to local authorities, reflecting the lack of emphasis given to preventive and promotive health care.
Although we are spending an increasing proportion of our gross national product on health (6,2 percent in 1990/91), at least 50 percent of this is spent in the private sector, to which only 20 percent of our people have access. When we look at the number of rands spent per capita, we find that there is about a fourfold difference between the white and the black population, and between the least and most well-off provinces.
It is not just that we are dealing with an inequitable system; the resources we have available are used inefficiently. This is true not only in the public sector; in parts of the private sector too money is used wastefully. Overall, poor control and distribution of medicines cost the government between half a billion and one billion rand a year.
Inequity and inefficiency on this scale is unacceptable. We need to explore as a matter of urgency what can be done. But our room to manoeuvre is limited, especially when we recognise that funding from traditional sources (primarily tax revenues), for both recurrent and capital spending, is limited now and has been declining in real terms for several years.
Private insurance organised through medical aid schemes — the main alternative to state financing — is in a somewhat parlous state. The state contributes R1,8- billion spent in this way, but only 19 percent of the population, at the most, benefits from coverage. Even for those who are covered, benefits vary significantly and groups such as the elderly remain vulnerable to rising costs and limited coverage. Concentrating on reimbursable services, the medical aid schemes also represent poor value for money in terms of the overall population’s health needs.
We therefore need to look at alternatives — alternatives for making better use of existing resources and alternative ways of raising additional money, particularly for primary care, the priority of the reconstruction and development programme.
To this end, the minister of health has appointed a committee of inquiry, which has been asked to investigate the feasibility of mobilising additional resources through a national health insurance system or a publicly supported system, and to assess the financial, human and material resources needed to provide access to primary care of acceptable quality to the whole population.
The committee will do two things. First, it will identify a range of options for mobilising more money for primary care. Secondly, in making recommendations as to the way forward, it will examine the implications of those options, so that we will be in a position to know how any change in health financing will help to address the problems we have identified.
The committee has already been given a clear policy framework to guide its work. All South Africans should have access to quality primary care regardless of race, gender, income and place of residence. The public health care system must be affordable and sustainable. It will be consistent with the objectives of the RDP, it will promote efficiency and be able to control
In addition to these broad objectives, we are concerned that the members of the committee will closely examine the implications of their recommendations in the light of how a change in the way we raise money for health will affect the way our national health system functions in the future.
The members of the committee have a major, but vitally important, task ahead of them. In addition to their own deliberations, they will seek oral and written evidence from all stakeholders before formulating their proposals. They have been asked to submit their report by the end of April 1995.
The members of the committee have a major, but vitally important, task ahead of them. In addition to their own deliberations, they will seek oral and written evidence from all stakeholders before formulating their proposals. They have been asked to submit their report by the end of April 1995.
The Committee has already been given a clear policy framework to guide their work. All South Africans should have access to quality primary care regardless of race, gender, income and place of residence. The PHC system must be affordable and sustainable. It will be consistent with the objectives of the RDP, it will promote efficiency and be able to control costs.
In addition to these broad objectives, we are concerned that the members of the Committee of Enquiry will closely examine the implications of their recommendations in the light of how a change in the way we raise money for health will affect the way our national health system functions in the future.
They will examine how any system of payments or incentives is likely to affect the quality and mix of services provided at primary level. We have to move away from a system where the attention of medical staff focuses on prescriptions and referrals to hospitals, and towards one where prevention and promotion take their proper place.
They will examine whether the financing system is designed so that it will ensure that primary care facilities can act as effective “gatekeepers” for secondary and tertiary care. This is because we are anxious to reverse the present situation in which large hospitals are treating people whose needs can be more effectively met at health centres and clinics at far lower cost.
We recognise the inter-dependence of the public and private sectors in health care. The Committee will examine whether new forms of financing are such that it will be possible to ensure a more productive relationship between public facilities and private GPs. We are anxious not only to bring more medical doctors into the primary care network, through contracts or other mechanisms – but also to ensure that the provision of care in the public sector is strengthened by such an initiative.
Any system of payment ot health care providers, through capitation or other contractual means will need to be examined to ensure that it leads to improved performance – in both the quality and range of services
The Committee will examine the nature and content of a basic package of curative and preventive services to which everyone should have access. In so doing they will confront the difficult issue of striking a balance between the need for focusing on those services that produce the most health gain and the need to be responsive to what people actually want.
Nurses are the backbone of South Africa’s health system. Any change in financing will need to be examined to ensure that it promotes the development of non-medical personnel – both as providers and managers.
Lastly, any reform in the way our health system is financed must be congruent with our overall aim of establishing a health system which is responsive to users, accountable to the community, and which enables us to achieve better stewardship of all the resources – both human and financial – that we have at our