A review of South Africa’s health system shows the patient is improving, but warns of possible relapse, writes Ferial Haffajee
The policies of Minister of Health Dr Nkosazana Zuma are more readily associated with the screaming headline than the sober assessment.
>From the importation of Cuban doctors to the radical changes she is planning to medical aids, and her more recent attempts to ban tobacco advertising, she has become adept at the art of upsetting apple-carts.
It is Zuma’s more basic goal to provide equal health care for all by the year 2020 that the Health Systems Trust has turned its attention to. This week the trust launched its annual South African Health Review, a 218-page document. The document is the culmination of research by a wide assortment of academics and researchers who have attempted to assess just how far-reaching Zuma’s changes have been.
Their prognosis: things are getting better, but they could get worse. Some of the good news is that more than six in 10 South Africans live within 5km of a health care facility and that three out of four children aged between 12 and 23 months are fully immunised.
Things could get worse because the government’s growth, employment and redistribution strategy is beginning to make itself felt. It has strict budget deficit targets and consequently government departments must spend less to bring income in line with expenditure.
This is the bitter pill to be swallowed in pursuit of more attractive growth rates, but its side effect is that real spending could be cut.
The review says: ”As the population is increasing more rapidly than the budget, it is anticipated that real per capita government expenditure will decline from R3 960 in 1995/1996 to R3 720 in 2000/2001.”
One of the impacts of such a real cut in spending is that provincial health spending may fall – whereas the review notes that great achievements have been notched up by the provinces in bringing their spending on health in line with the national average. A survey of 294 clinics and 84 regional and district hospitals has revealed that some of the poorest provinces have seen the greatest improvements in health care.
Complex measurements of this improvement include an assessment of everything from basic infrastructure like electricity and equipment to the availability of condoms and the ability of nurses to treat simple problems.
While urban hospitals were electrified and had sufficient potable water, in the rural areas fewer than four in five hospitals had electricity and 69% had potable water. Nine out of 10 hospitals had electrocardiogram machines and four in five surveyed had X-ray equipment, but one in five district hospitals surveyed did not have oxygen available to all surgical wards.
Five of the country’s nine provinces were able to report improvements in their emergency response time, although the survey found that more than half of all clinics have to wait more than an hour for emergency transport to arrive.
In the areas of health, as in many others, South Africa is still two nations: an urban and a rural. Rural health care still lags behind the service offered by urban clinics and hospitals and the Cinderella provinces of the Eastern Cape and Northern Province are dogged by ill-health.
”It is clear,” says the review, ”that enormous inequalities in health need to be addressed. Ambitious plans have been formulated, however, it is a major challenge to implement these plans particularly in the face of a rapidly growing Aids epidemic.”
An example: while Zuma has fashioned health policy to place emphasis on primary health care, only 35% of the clinic’s surveyed had a full-time primary health care nurse. Low numbers of health workers knew the answers to simple tests for treating common ailments like diarrhoea and sexually transmitted diseases.
More than a quarter of the hospitals surveyed did not stock condoms, while less than three-quarters stocked a standard tuberculosis drug. These figures are indicators of the health system’s ability to deal with these epidemics.
The review says that this year much of the Department of Health’s time will be spent formulating a new national health Act, which will establish a legislative framework for a national health system. Zuma is destined again for the headlines as she moves to refashion a moribund system.
Other challenges pinpointed include the need for an efficient database and information system – few hospitals use computers – and better daily use of medical data. It also recommends that doctors, pharmacists, nurses and other health providers must be available to areas of greatest need to meet the challenge of health care for all by 2020.
It recommends ”government-to-government medical exchange programmes [like the Cuban doctor programme], community service programmes, [and] transfer of personnel to local governments specifically targeted at underserved provinces and geographic areas”.