Dr Hillary Southall
Reaction to the Health Plan put forward by Dr Jonathan=20 Broomberg and Dr Olive Shisana to restructure the=20 National Health System for universal primary health=20 care has been cautious and somewhat non-committal.=20 Editorials such as those in last week’s Mail Guardian, for instance, have not done justice to this=20 ambitious, bold and imaginative plan. It is not just=20 about dropping the fees at public sector primary care=20 facilities and creating an essential drug list. It is=20 rather about a major overhaul and restructuring of=20 health care services in this country. The implications=20 are huge.
When the British introduced their National Health=20 Service in 1948, free access to all levels of care,=20 including clinics and general practitioners, hospitals=20 and tertiary services, drugs, and diagnostic tests, was=20 guaranteed. The focus was on equity.
The theory was that if sick and poor people could=20 afford health care, diseases would gradually be=20 eliminated, the population would become healthier and=20 healthier, the NHS would become cheaper and cheaper and=20 could eventually be phased out when the need for it=20 eventually disappeared. How wrong they were! For a=20 start, health care costs have continued to rise as the=20 focus of treatment has changed from widespread=20 infectious diseases, which were relatively cheap to=20 combat, to social and degenerative diseases which are=20 expensive to address.
More important than cost, there is another lesson to be=20 learnt from the British National Health Service. By and=20 large, it is healthy to be rich! Time and again it has=20 been shown that the better-off people are, the=20 healthier they tend to be, and, surprisingly, the=20 healthier they are the more they tend to use the health=20 services. In the nearly fifty years of its existence,=20 not only has the gap in health status between the=20 richest and poorest patients in the British NHS=20 widened, but also the gap in utilisation between rich=20 and poor, the difference in the frequency with which=20 patients consult their doctors, has also widened.
The lesson for South Africa is clear. Making equity in=20 itself and by itself the objective of a National Health=20 System, and even ensuring free access to services and=20 the removal of financial barriers for the poorest of=20 the poor does not ensure increased access by those most=20 in need.
And this is why the Broomberg/Shisana Plan is so=20 clever. It does not simply focus on slogans of “free”=20 and “equal”. It is radical and masterful in its=20 proposals, and it is supported by rigorous evidence,=20 thoughtfulness, and attention to detail.
Among other things, the plan proposes the training of a=20 cadre of primary health care nurses with clinical=20 skills; it proposes improving pay and conditions of=20 public sector doctors and other health care=20 professionals; it emphasises the role of management and=20 the need for reliable information; and it calls for=20 everyone to register with their District Health=20 Authority. Whatever, ‘yes, but’ problems one may have,=20 the report seems to have anticipated them.
The most significant recommendations, at least to me as=20 a health economist, are those relating to the=20 establishment of the market in health through District=20 Health Authorities acting as “public purchasers” from=20 private and public providers. This will provide a means=20 for controlling the private sector, preventing the=20 total imminent collapse of many private medical aids,=20 and drawing the private and public sectors together=20 into one National Health System.
Judging from the editorials, I wonder if the=20 significance of this has been fully recognised. It may=20 come as a surprise to many that this proposal, coming=20 as it does from the ANC, is a variant of the highly=20 controversial Thatcherite restructuring in the United=20 Kingdom. The variant is that it covers only a basic=20 package of primary health care.
One of the rationales behind the British reform lay in=20 the failure of the resource allocation formula and=20 other measures to achieve a more geographically equal=20 provision of services. Just as South Africa’s health=20 infrastructure is concentrated in Gauteng, Cape Town=20 and Durban, so too has the British infrastructure=20 proved difficult to move away from the concentration in=20 the London teaching hospitals. The theory is that while=20 it may take time to move hospitals, money is more fluid=20 and can be given to under-served areas which can then=20 buy services further afield.
The Broomberg plan is so good because it is so clever.=20 It is also extremely ambitious, and one should=20 recognise that as one of its values. Nothing short of a=20 radical plan could save the South African health care=20
Dr Zuma and Dr Shisana face considerable challenges in=20 the months and years ahead in the implementation of=20 this plan. And if I have concerns, this is where one of=20 them lies. For instance, simply on the question of=20 registration, I live in a province where the primary=20 school children feeding programme revealed twice the=20 number of children — in the flesh as it were — as=20 previously planned for on paper. With all the plans for=20 an elaborate National Health Information System I would=20 be happy just to know how many and who lives where. Is=20 it really realistic to anticipate a universal register=20 by 1997? The training, the administration, the=20 paperwork, the management, the change in culture to=20 free enterprise and the market, each one alone is=20
My other main concern lies in the adequacy of the=20 measures planned to correct the geographical inequities=20 of the past. The report talks about incentives and=20 forced service, but there is enough experience from=20 elsewhere in the world that such measures are not=20 effective. There is evidence that candidates must be=20 drawn from the area they are intended to return to, and=20 also that they must be trained in appropriate settings=20 near their homes.=20
It is not entirely clear whether Dr Shisana’s objective=20 is equity or the raising of health status and whose. In=20 any case the reforms can at least give hope to a=20 thoroughly demoralised public health sector and a=20 rapidly collapsing private one. At best these reforms=20 might herald the way for changes in other sectors. They=20 could be the beginning of actions showing more vision=20 and imagination than the ANC has shown to date. They=20 are certainly dramatic, they are certainly brave, and=20 they certainly deserve more credit than the media are=20 giving them.