tag:theconversation.com,2011:/africa/topics/nhi-21856/articlesNHI – The Conversation2023-06-29T10:39:41Ztag:theconversation.com,2011:article/2086042023-06-29T10:39:41Z2023-06-29T10:39:41ZSouth Africa’s National Health Insurance bill has noble aims but leaves too much uncertain: it needs more work<figure><img src="https://images.theconversation.com/files/534572/original/file-20230628-17-36iu2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa’s National Health Insurance (NHI) bill has <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01294-1/fulltext">passed</a> the first hurdle towards becoming law, getting the country closer to its vision of achieving universal access to healthcare.</p>
<p>Section 27 of the country’s <a href="https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf#page=15">constitution</a> states that everyone has the right to access to healthcare. The <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">NHI bill</a>, which has been passed by the national assembly, is the manifestation of this provision.</p>
<p>Universal access to healthcare and the NHI are related. But they are not the same thing. </p>
<p>Universal access to healthcare is <a href="https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)">an ideal</a> which supposes that everyone should have the same access to healthcare. The NHI bill is a tool to achieve universal health coverage. It aims to ensure that all South Africans have access to quality healthcare services. The bill also aims to provide for the establishment of a fund which will be used to pay for almost all medical treatments from accredited providers. </p>
<p>But this bill has been contentious from inception. There have been multiple court challenges, with <a href="https://businesstech.co.za/news/government/696225/nhi-heading-to-court-with-many-more-legal-challenges-to-come/">more to come</a>, and numerous different voices have been raised <a href="https://www.gov.za/speeches/health-welcomes-pretoria-high-court-judgement-national-health-insurance-10-nov-2022-0000">against it</a>.</p>
<p>The aim of the NHI is a good and noble one. But the bill is bad law because it fails to provide reasonable certainty. Several court rulings have flagged this. The bill will have massive consequences, so it should be <a href="https://www.news24.com/news24/southafrica/news/sama-rejects-nhi-bill-in-its-current-form-20230530">rejected</a> and not enacted in its current form.</p>
<h2>The vision</h2>
<p>South Africa has a two-tier healthcare system. Those who have the financial resources, or medical insurance, use private healthcare practitioners and facilities. Those who do not have these resources use public practitioners and the facilities provided and paid for by the state.</p>
<p>The current healthcare system has not sufficiently catered for good quality healthcare for all. This system has precluded the poor or those without medical aid from using a large number of health professionals, services and facilities. The NHI will establish <a href="https://moneytoday.co.za/national-health-insurance-pros-cons/">a single pool</a> of healthcare funding for private and public providers. It will pay both these providers on exactly the same basis and expect the same standard of care from them. </p>
<p>For South Africans without medical aid (health insurance) or in lower income groups, the NHI will offer more equitable access to healthcare services. It will allow them to consult private practitioners and to attend private facilities. The NHI also purports to improve the resourcing of public hospitals and healthcare services as the burden of care will be more evenly distributed.</p>
<p>For South Africans who do have medical aid, the NHI may be a shock to the system. Those who are accustomed to private care may have to settle for lower standards while still paying a similar or higher fee. South Africans within a certain income bracket will have to make mandatory monthly payments towards healthcare in addition to carrying a higher tax burden.</p>
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<a href="https://theconversation.com/south-african-taxpayers-will-bear-the-brunt-of-national-health-insurance-122409">South African taxpayers will bear the brunt of National Health Insurance</a>
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<p>Medical aid schemes will not be able to offer any services that are offered by the NHI. Private medical insurance will only be able to provide for “complementary or top-up cover” that doesn’t overlap with services covered by the NHI. </p>
<p>These issues are clear, but the NHI bill contains lots of grey areas. </p>
<h2>Grey areas</h2>
<p>The rule of law requires that everyone, citizens and corporates and governments, adhere to the law. They can only do so if the law is clear and unambiguous. Laws must provide reasonable certainty. </p>
<p><a href="http://www.saflii.org/za/cases/ZACC/2005/3.html">South African courts</a> have explained it like this: </p>
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<p>The law must indicate with reasonable certainty to those who are bound by it what is required of them so that they may regulate their conduct accordingly. </p>
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<p>The current version of the bill is uncertain in the following key areas: </p>
<ul>
<li><p>the migration of hospitals to semi-autonomous entities </p></li>
<li><p>the structure of the contracting unit for primary healthcare needs</p></li>
<li><p>establishment of the fund </p></li>
<li><p>the Health Patient Registration System </p></li>
<li><p>accreditation issues</p></li>
<li><p>purchasing of services </p></li>
<li><p>the amendment of other pieces of legislation to make room for the NHI and payment concerns.</p></li>
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<p>A significant concern relates to the uncertainty regarding what will be covered by NHI and what will not. As the bill expressly aims to cover the costs of certain healthcare services, it is reasonable to expect that these services be clearly set out. How can we follow the law when we do not know what it is? Without this certainty, the bill is vague and so it cannot be seen as good law.</p>
<p>The bill is also vague on how the NHI fund will be financed. Recent estimates have put its cost at more than <a href="https://www.iol.co.za/news/south-africa/kwazulu-natal/nhi-bill-do-we-need-it-who-will-pay-for-it-how-will-it-affect-my-medical-aid-all-your-questions-answered-6574c217-8f19-4dd3-9f6b-7a5230ac02de">R500 billion a year</a> (about US$27.6 billion). And what will happen to medical aid schemes? <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf#pag=19">Section 33</a> of the bill, which provides for the role of medical aid schemes, is open to the interpretation that these schemes will disappear. </p>
<p>Real doubt exists as to whether an NHI system will ever be workable in South Africa. The bill has been described as an <a href="https://www.dailymaverick.co.za/article/2023-06-25-national-health-insurance-is-a-big-fat-empty-promise-experts/">empty promise</a>. Again, this is bad.</p>
<h2>Ideal and practice</h2>
<p>Universal access to healthcare and the ideal of a national system of health insurance are important concepts which relate directly to core human rights, and as such are noble and necessary.</p>
<p>However, it’s often the case that an ideal falls short in practice. The NHI bill is no exception. Many concerns and critiques have been raised against the bill and its implementation. Satisfactory solutions have not yet been offered. </p>
<p>The NHI cannot be avoided. But to benefit all and live up to its potential, it should be fully thought through, planned in detail and not rushed.</p><img src="https://counter.theconversation.com/content/208604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Larisse Prinsen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The NHI bill aims to ensure that all South Africans have access to quality healthcare services.Larisse Prinsen, Senior lecturer in law, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1402042020-07-07T14:16:24Z2020-07-07T14:16:24ZSouth Africans must be healthier for universal healthcare to succeed<figure><img src="https://images.theconversation.com/files/344819/original/file-20200630-103649-19tkk9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People exercising in Ellis Park in Johannesburg, South Africa. </span> <span class="attribution"><span class="source">Dino Lloyd/Gallo Images via Getty Images</span></span></figcaption></figure><p>Achieving a healthy population isn’t easy for any country – rich or poor. One of the approaches that’s gained traction over the past two decades is preventative care through <a href="https://www.ncbi.nlm.nih.gov/books/NBK235764/">health promotion</a>. Simply put, health promotion means keeping people healthy. This is seen as particularly useful in developing countries, where levels of preventable noncommunicable diseases are high, the resources to treat disease are scarce and the cost of treating sick people is often higher than programmes to keep people healthy.</p>
<p>The health promotion approach has two areas of focus. One is preventing disease through activities like health education messaging, screening and testing for conditions. The other is addressing the upstream drivers and causes of poor health. These include social and economic factors such as poverty and unemployment. They also include smoking, excessive drinking, low levels of exercise, poor diet, sub-standard living conditions, gender-based violence and mental illness. </p>
<p>The health promotion approach aims to change people’s behaviour and choices. But it is not enough just to tell an individual how to be healthy: people need support and social structures to promote, sustain and maintain healthy choices. </p>
<p>A number of countries have successfully adopted this approach using health promotion foundations. <a href="https://en.thaihealth.or.th/">Thai Health</a> is one example. Similar <a href="http://www.samj.org.za/index.php/samj/article/view/6281/4910">foundations</a> have been established in Switzerland, Austria, the Philippines and Malaysia. </p>
<p>In a <a href="http://www.samj.org.za/index.php/samj/article/view/12864/9145">recently published paper</a>, we argue that South Africa also needs a health promotion and development foundation if its proposed universal healthcare programme, the National Health Insurance (NHI), is to succeed. </p>
<p>Through the <a href="http://www.health.gov.za/index.php/nhi">NHI</a> South Africa (and legal long-term residents) are to be provided with essential healthcare, whether they can <a href="https://theconversation.com/coronavirus-pandemic-holds-lessons-for-south-africas-universal-health-care-plans-137443">contribute</a> to the NHI fund or not.</p>
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<a href="https://theconversation.com/south-african-taxpayers-will-bear-the-brunt-of-national-health-insurance-122409">South African taxpayers will bear the brunt of National Health Insurance</a>
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<p>But South Africa faces high levels of disease, in particular <a href="http://www.samj.org.za/index.php/samj/article/view/12864">noncommunicable diseases</a> such as diabetes, hypertension, cancer and obesity. Many noncommunicable diseases can be prevented. The NHI is likely to battle to cope with treating large numbers of sick people, but much of this treatment could be avoided by promoting health and reducing disease. </p>
<p>In our <a href="http://www.samj.org.za/index.php/samj/article/view/12864">paper</a> we set out how this radical change of approach could be achieved and why health promotion could be an effective use of the limited funds.</p>
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<a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">Why South Africa's plans for universal healthcare are pie in the sky</a>
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<h2>Getting healthier</h2>
<p>Noncommunicable diseases, many of which are avoidable, are having a significant impact on the health of South Africans and the South African healthcare system.</p>
<p>The increase in noncommunicable disease risk factors will likely lead to rising healthcare costs. </p>
<p>For example, in 2018, the public health sector spent an <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2019.1636611">estimated</a> R2.7 billion ($198 million) on patients diagnosed with diabetes. The estimates increased to R21.8 billion when undiagnosed diabetes patients were considered. The total costs associated with diabetes are likely to increase to R35.1 billion ($2.5 billion) in 2030.</p>
<p>Another common condition, <a href="https://pubmed.ncbi.nlm.nih.gov/17952226/">hypertension</a>, is an important risk factor for cardiovascular diseases and chronic kidney disease. It is often found in combination with diabetes. In <a href="https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf">South Africa</a> 46% of women and 44% of men over 15 had hypertension in 2016. This is almost double the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31919-5/fulltext">world average</a> and has nearly doubled since 1998. </p>
<p>The <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf">2016 South African Demographic and Health Survey</a> indicates high levels of obesity, which has health and cost implications. Forty-one percent of women are obese, a condition associated with an 11% increase in healthcare <a href="http://www.samj.org.za/index.php/samj/article/view/7260">costs</a>. </p>
<h2>What needs to be done</h2>
<p>Health behaviour in South Africa needs to shift from the norm of waiting to get sick and then accessing healthcare to preventing disease and keeping healthy.</p>
<p>To encourage this, we <a href="http://www.samj.org.za/index.php/samj/article/view/12864">propose</a> the establishment of a multi-sectoral National Health Commission or an independent Health Promotion Foundation linked directly to the NHI Fund. It should include several relevant government departments, civil society, academics and researchers. </p>
<p>Health promotion programmes need to be based on more than health knowledge. For example, individuals can’t practise good hand hygiene when water is not available, or eat healthy foods when these are not affordable. South Africa’s specific <a href="https://theconversation.com/pandemic-underscores-gross-inequalities-in-south-africa-and-the-need-to-fix-them-135070">realities and needs</a>, including poverty and its related behavioural impacts and health consequences, must be taken into account. This is why different government departments and stakeholders would need to work together.</p>
<p>We don’t know exactly how much of the noncommunicable disease burden could be eased by modifying risk factors. But the World Health Organisation
has <a href="https://www.paho.org/hq/dmdocuments/2011/paho-policy-brief-1-En-web1.pdf">estimated</a> that in the Americas 80% of all heart disease, stroke and type 2 diabetes mellitus and over 40% of cancer is preventable through multisectoral action. </p>
<p>Some of the changes that could make a difference to health are quite indirect.
For example, it is often not safe to exercise on the streets, so communities need to have more active and visible policing and accessible open spaces free from traffic and other competing activities to make increased exercise a realistic option. Healthy food needs to be subsidised and more easily available, and places that sell alcohol and tobacco need to be located at prescribed distances from schools. </p>
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Read more:
<a href="https://theconversation.com/south-africa-moves-one-step-closer-to-a-sugar-tax-and-a-healthier-lifestyle-88045">South Africa moves one step closer to a sugar tax -- and a healthier lifestyle</a>
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<p>Just how much funding is needed to promote health? Health promotion experts are calling for <a href="http://www.samj.org.za/index.php/samj/article/view/12864">2%</a> of the NHI Fund to be dedicated specifically to promoting health and preventing illness. This is certainly a reason to improve health promotion funding in South Africa. We cannot afford to wait any longer.</p>
<p>The WHO’s global <a href="https://www.who.int/ncds/prevention/launch-global-business-plan-for-ncds/en/">business case</a> for noncommunicable diseases shows that if low- and low-to-middle-income countries put in place the most cost-effective interventions, by 2030 they will see a return of US$7 per person for every dollar invested. This is certainly a reason to improve health promotion funding in South Africa. We cannot afford to wait any longer.</p><img src="https://counter.theconversation.com/content/140204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melvyn Freeman has contracts of work from the World Health Organization and Higher Health. He is a member of the Department of Health think tank on mental health.</span></em></p><p class="fine-print"><em><span>Charles Parry and Jane Simmonds do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa faces high levels of noncommunicable diseases such as diabetes and hypertension. The NHI is likely to battle to cope with treating large numbers of sick people.Jane Simmonds, Associate Staff, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research CouncilCharles Parry, Director, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research CouncilMelvyn Freeman, Extraordinary Professor, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1374432020-05-17T08:50:35Z2020-05-17T08:50:35ZCoronavirus pandemic holds lessons for South Africa’s universal health care plans<figure><img src="https://images.theconversation.com/files/331354/original/file-20200429-51485-vvyfa1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A healthcare worker collecting a swab for a COVID-19 test from a community member. </span> <span class="attribution"><span class="source">AFP via Getty Images</span></span></figcaption></figure><p>The National Health Insurance (NHI) has become an idealistic concept known as “imaginary”. It’s become the idea onto which all South Africa’s aspirations for healthcare have been projected. The dream of a system that is fairer, less divided and more efficient. It’s even been called “<a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">pie in the sky</a>”. </p>
<p>It’s clear that some version of the NHI is going to happen regardless of anyone’s opinion. And its success or failure will be determined by the extent to which all South Africans contribute to it. </p>
<p>The <a href="http://www.health.gov.za/index.php/nhi">NHI</a> is a financing system that will make sure that all South Africans have access to essential healthcare, regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.</p>
<p>Other middle-income countries such as <a href="https://www.who.int/bulletin/volumes/86/4/08-030408/en/">Brazil</a> and <a href="https://www.who.int/bulletin/volumes/97/6/18-223693/en/">Thailand</a> have shown that it can be done.</p>
<p>This dream of a single national health system could be realised if South Africa is able to articulate a common vision for all its citizens. </p>
<p>But in a complex system such as the health sector, the ideal of universal health coverage as intended by the <a href="https://www.parliament.gov.za/project-event-details/54">NHI</a> is unlikely to be attained overnight with the passing of legislation. </p>
<p>The envisaged system can only be implemented through incremental and deliberate bottom-up design. It must incorporate the outcomes of experimentation and reflection with stakeholders at all levels of the system, over time. </p>
<p>The COVID-19 pandemic is shedding light on how best to go about building the NHI – and what to avoid.</p>
<p>On the positive end, it has highlighted the country’s interconnectedness and mutual dependence across sectors. The health minister has shown great leadership and <a href="https://mg.co.za/article/2020-04-13-covid-19-in-south-africa-trends-and-next-steps/">collaborated closely</a> with the scientific community.</p>
<p>On the negative side, the acute crisis has prompted government to work top-down through a centralised command structure. This is not how effective systems based on <a href="https://www.who.int/docs/default-source/primary-health/vision.pdf">primary healthcare</a> are built. In the absence of a design approach with clear cycles of learning and feedback of evidence from the ground up, the risk is that the whole NHI system will fail to be implemented. There are many examples of the “implementation gap” between well-intentioned policy and actual practice in South Africa.</p>
<p>So how do people think about healthcare? The most prevalent idea is that of fixing a machine, as if the body just needs a little help when it breaks down occasionally. The metaphor of war</p>
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<p>may be helpful in responding to the acute crisis of the COVID-19 pandemic. But in the longer term it is not a constructive approach to building an equitable health system for all. The challenge needs to be thought of in different ways.</p>
<h2>A more appropriate metaphor</h2>
<p>A health system is more than a complicated organisation, it is an extremely complex one. The human body itself is an appropriate image of a complex, adaptive system. It’s a biological marvel in which each part simultaneously affects every other part. A further level of complexity arises when these changing systems are challenged by trauma or illness, and have to adapt to new environments or stressors. </p>
<p>It is remarkable how the body inexorably tends towards preserving or re-developing a functional norm after a catastrophic disturbance such as a stroke or major trauma.</p>
<p>COVID-19 is just such a trauma – an assault to all of our systems, out of the blue. Like the process of adapting to the challenges of a chronic disability, the South African health system must moreover cope with the inherent deficits in society resulting from the legacy of colonialism and apartheid, which created the enormous <a href="https://theconversation.com/pandemic-underscores-gross-inequalities-in-south-africa-and-the-need-to-fix-them-135070">inequities</a> that have been laid bare by the pandemic. </p>
<p>The fundamental divide between the for-profit value system of the private health sector on the one hand, and the human rights-based approach of the public sector on the other, needs to be <a href="https://www.dailymaverick.co.za/article/2020-04-06-outbreak-provides-valuable-insights-needed-to-implement-national-health-insurance/">bridged rather than deepened</a>, building on the intersectoral innovations that the pandemic has elicited. </p>
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Read more:
<a href="https://theconversation.com/covid-19-shows-that-where-there-is-political-will-there-is-a-way-to-work-across-sectors-134999">COVID-19 shows that where there is political will there is a way to work across sectors</a>
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<p>South Africa could learn a lot from the process of physical rehabilitation, and how a person can adapt to complex disruptions, with the pragmatic help of a team of skilled health professionals, through relationships and hope. Whatever the nature and extent of the precipitating historical event, the unrelenting task is to restore order out of chaos, and to work in solidarity with the patient to optimise their function over time. ‘Resilience’ is defined as the positive adaptation to significant adversity, that builds capacity for future challenges, in contrast to negative adaptations that ultimately make things worse.</p>
<p>The country’s health system will need such ongoing rehab post-COVID-19 to overcome divisions and build a national health system from the bottom up. The ideal of universal health coverage as intended by the NHI will require a deliberate process of experimentation, reflection and incremental adaptation over a number of years. Fundamental principles of primary healthcare, such as equity, health promotion and community participation, will be critical.</p>
<p>This COVID-19 pandemic highlights the fact that South Africa already has the technical expertise and capacity, in governance, in health economics, in health systems, in information systems, as well as in community participation in health. </p>
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Read more:
<a href="https://theconversation.com/investing-in-research-is-south-africas-best-insurance-policy-against-crises-135706">Investing in research is South Africa's best insurance policy against crises</a>
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<p>Inspiring initiatives in purpose-driven social entrepreneurship are motivated not by private profit but by public benefit. And there are population-based capitation <a href="https://gh.bmj.com/content/4/Suppl_8/e001551">models for primary care</a> in other middle-income countries that are already working well. </p>
<p>COVID-19 has brought many of these initiatives to the fore, to bridge the divide between those who have and those who don’t. Solidarity and commitment to the common good are the pivotal values that are needed at this time and into the future. </p>
<p>There is hard and persistent work that needs to be planned for, like a kind of ongoing rehabilitation process, to realise the dream of one health system for all South Africans.</p><img src="https://counter.theconversation.com/content/137443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steve Reid receives funding from South African Medical Research Council. He is a non-executive board member of two NPCs: Jembi Health Systems and Tekano Health Equity South Africa.</span></em></p>There is hard and persistent work that needs to be planned for, like a kind of ongoing rehabilitation process, to realise the dream of one health system for all South Africans.Steve Reid, Medical academic and Chair of Primary Health Care, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1320422020-03-03T13:52:35Z2020-03-03T13:52:35ZGhana needs a better policy to guide care for cancer patients<figure><img src="https://images.theconversation.com/files/316273/original/file-20200219-10985-fq5y9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse in a hospital checks an IV</span> <span class="attribution"><span class="source">Wikimedia Commons</span></span></figcaption></figure><p>The <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf">World Health Assembly</a> urged countries in 2014 to include palliative care into their health systems. Its resolution called for equitable services, available to everyone who needs them. <a href="https://www.who.int/cancer/palliative/definition/en/">Palliative care</a> encompasses the support system for patients and their families when they face life-threatening illnesses. It aims to improve quality of life, relieve pain, and help people cope with death. </p>
<p>Palliative care is essential because it gives patients a choice in deciding how their pain and symptoms will be managed. Second, it ensures that patients enjoy the highest quality of life that is practically possible in the circumstances. Because of the increasing care required as a patient’s condition advances to the terminal stage, palliative care is a team approach. It includes nurses, doctors, social workers, volunteers, faith leaders and other health care professionals in supporting the care and well-being of patients and their families. </p>
<p>People are living <a href="https://journals.sagepub.com/doi/full/10.1007/s12290-008-0047-5">longer</a> than before because of advances in medical technology that makes the sick survive longer. The downside is that a longer life span increases the chance of a person experiencing illnesses such as cancer and heart disease, and this, in turn, increases the need for palliative care.</p>
<p>So palliative care is essential, especially when the illness is incurable or treatment is ineffective. And it is of great concern in contexts where healthcare resources for diagnosis and treatment are limited. </p>
<p>Cancers are among the leading <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">causes</a> of illness and death globally. Almost two-thirds of these deaths occur in developing countries, where palliative care is limited or nonexistent.</p>
<h2>Cancer and care in Ghana</h2>
<p>Ideally, <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-136">palliative care</a> should be accessible at all levels of health care and should place patients and families at its centre. The multi-disciplinary team approach ensures efficiency and is the best way to provide optimal palliative care.</p>
<p>In <a href="https://www.researchgate.net/publication/267814449_A_Structured_Approach_to_End-of-Life_Decision_Making_Improves_Quality_of_Care_for_Patients_With_Terminal_Illness_in_a_Teaching_Hospital_in_Ghana">Ghana</a>, patients with cancers and their families who seek services at oncology departments and palliative care units have to pay for treatment. In some cases, such services are inadequate or not within their means. Patients with national health insurance cards afflicted with most cancers and conditions like chronic kidney disease have to pay because the ailments are on the health insurance exclusion <a href="http://www.nhis.gov.gh/benefits.aspx">list</a>. </p>
<p>Currently, patients have to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426378/">pay</a> for any care relating to cancer (other than breast or cervical cancer): diagnostics, chemotherapy and radiotherapy. </p>
<p>The <a href="https://www.graphic.com.gh/news/health/cost-of-cancer-treatment-worries-patients-dr-aryeetey.html">cost</a> of managing cancer, especially advanced cases, is usually beyond the financial means of patients and their families. Expecting them to pay for it does not conform to the equity principle advocated by the World Health Assembly. The scarcity of palliative care services and the financial barriers to using them amount to an ethical problem. It is unethical to deny cancer patients the same level of treatment given to, say, malaria patients.</p>
<p>Ghana does not have a clear <a href="https://www.businessghana.com/site/news/general/201259/Government-to-introduce-palliative-care-policy">national policy</a> on palliative care. It is reported that it took the <a href="https://www.modernghana.com/news/499268/breast-cancer-screening-to-go-under-nhis.html">advocacy</a> of a few women with breast cancer and the support of some health staff to lobby and petition Ghana’s parliament to get the treatment of cervical cancer under the national health insurance scheme. </p>
<p>The lack of access to palliative care in Ghana leads to considerable suffering for patients and their families. A recent <a href="https://www.nottingham.ac.uk/research/groups/ncare/news/congratulations-yakubu-salifu.aspx">qualitative study</a> conducted by my colleagues and I among men with advanced prostate cancer and their family caregivers in Ghana highlighted two main issues. These were challenges and burden of care as well as the support and coping strategies adopted. </p>
<p>Participants expressed the overburdening nature of the care responsibility. They spoke of feeling “alone in the middle of a deep sea”, disruption of their lives, and unhappiness. The only support available to them is their social network, their extended family and their faith.</p>
<p>It is also an issue for health professionals as they are expected to show the “<a href="https://journals.sagepub.com/doi/abs/10.1177/175045891702701001">6Cs</a>” – care, compassion, courage, communication, commitment, and competence. Healthcare professionals are unable to provide competent and collaborative palliative care without a policy and a budget provision. </p>
<p>Ghana needs a holistic palliative care policy and a clear, sustainable financial commitment to ensure its implementation. The Medical and Dental Council, as well as the Nursing and Midwifery Council of Ghana should ensure that the training of nurses and doctors in palliative care is prioritised. Government and relevant agencies must take the lead in ensuring that there is a practical palliative care policy that is tailored to the Ghanaian health system and the needs of patients.</p><img src="https://counter.theconversation.com/content/132042/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yakubu Salifu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ghana’s lack of a palliative care policy is posing a significant challenge to effective healthcare for cancer patients.Yakubu Salifu, Lecturer, Palliative Care, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1286342019-12-11T12:57:51Z2019-12-11T12:57:51ZHow South Africa can build a child-centred health care system<figure><img src="https://images.theconversation.com/files/306094/original/file-20191210-95130-812jgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Child health care remains uneven in South Africa and varies between provinces and districts.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>It is more than 20 years since the South African constitution first guaranteed children’s “right to basic health care services”. This is part of a broader commitment to ensure children’s rights to optimal survival, health and development. The question is how close South Africa is to realising these rights in practice. </p>
<p>We address this issue in a <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2019/CG2019%20-%20%281%29%20Prioritising%20child%20and%20adolescent%20health.pdf">chapter</a> of the <a href="http://www.ci.uct.ac.za/sites/default/files/image_tool/images/367/Child_Gauge/South_African_Child_Gauge_2019/ChildGauge_2019_final_print%20%28sm%29.pdf">South African Child Gauge 2019</a> report. </p>
<p>Unlike adults’ right to health, children’s right to basic health care services is not subject to progressive realisation. Children should therefore be prioritised within the health care system. Yet the state has still not defined an essential package of health care services for children. This makes it difficult to determine what they are entitled to and what the state should be held accountable for. </p>
<p>Without a defined package, there’s a danger that the drive for efficiencies and cost saving may result in a limited basket of care that doesn’t address the complex needs of children. This is particularly true for those with chronic (long term) health conditions. </p>
<p>This essential package of care needs to be supported by a set of norms and standards. These need to specify the infrastructure, equipment, medicines and staff needed to meet the unique needs of children and adolescents. A clear package will also make explicit how health care establishments need to be equipped. These would include neonatal and paediatric wards as well as emergency medical services and primary health care services, where children currently have to compete for attention with sick and injured adults. </p>
<p>In other facets of the health system, too, budgets, building of infrastructure and medicine supplies need to consider children’s unique needs. </p>
<p>A child rights approach to health requires health professionals to treat children and their caregivers with respect and communicate effectively. Health care providers also need to build children’s and adolescents’ capacity to take responsibility for their own health and include them in decision making. </p>
<p>These fundamental shifts in the balance of power between adult and child, doctor and patient have been found to relieve pain and suffering. They also improve diagnosis, compliance with treatment, patient satisfaction and health outcomes. </p>
<h2>Training health workers</h2>
<p>The United Nations Committee on the Rights of Child has called for children’s rights to be integrated in the curriculum and performance criteria of all professionals working with children. These include health and allied professionals, teachers and social workers. The aim is to ensure that they are better attuned to children’s needs and rights. </p>
<p>For example, the <a href="http://www.lincare.co.za/?m=2019">LinCARE</a> programme, where a team of health workers provides mother and child health care in Limpopo province, aims to reduce neonatal mortality. It does this by improving the quality of care during pregnancy and labour. The programme is aimed at ensuring that all women have a positive pregnancy and birth experience. It includes antenatal classes and ensures that women have practical and emotional support from a birth companion and kind, respectful and technically competent clinical staff.</p>
<p>As part of current preparation for a <a href="http://www.health.gov.za/index.php/nhi">national health insurance</a> system, which is aimed at extending universal health care to all South Africans, bolstering the primary health care system offers three opportunities to strengthen the child health workforce and improve the quality of care: </p>
<ul>
<li><p>Community health workers play a central role in bringing health care services close to home, particularly for children living in poor or remote households. It’s therefore encouraging to see the national department of health’s commitment to employing them and paying them the minimum wage. This should improve supervision and support and ensure greater continuity of care between community-based services and health care facilities. </p></li>
<li><p>School health teams are another essential ingredient of the child system, helping to screen older children and address barriers to learning. Yet coverage reaches only one third of pupils in their first year of schooling and 20% of grade 8 learners. Its effectiveness is compromised by the shortage of health and other social service professionals, such as social workers, oral hygienists and dentists, psychologists, physiotherapists, speech and language therapists and occupational therapists.</p></li>
<li><p>Finally, district clinical specialist teams provide essential leadership for child and adolescent health at district level. For example, neonatal mortality has dropped by 30% in districts where there are paediatricians and paediatric nurses, yet less than half of specialist teams have a full paediatric team.</p></li>
</ul>
<h2>What needs to be done</h2>
<p>The progress for child health has been uneven in South Africa with significant variation between provinces and districts. For example, immunisation varied from 90% in Mpumalanga to 69% in the Eastern Cape – signalling persistent inequities in access and coverage of care.</p>
<p>Given these challenges, greater investment is needed to strengthen systems and build a workforce for child and adolescent health. National health insurance provides an important opportunity to ensure universal health coverage and financial risk protection for the poor, as well as to improve the quality of care. </p>
<p>This requires leadership for child health at every level of the health care system – from individual encounters with children and their families, to ensuring that child health is adequately represented on key decision-making structures that will decide how resources are allocated.</p>
<p>Very importantly, it requires that the health sector works with and alongside other sectors. Interventions such as sufficient good quality food, good quality education, safe water and sanitation, good housing, safe roads and safe communities can significantly promote the health and well-being of children.</p>
<p><em>The South African Child Gauge 2019 report is published by the Children’s Institute at the University of Cape Town. The theme of the 2019 issue – “Child and adolescent health: leave no one behind” – is a call to prioritise child and adolescent health and put children at the heart of the health care system.</em> </p>
<p><em>Lori Lake, a co-editor of the Child Gauge report, also contributed to this article.</em></p><img src="https://counter.theconversation.com/content/128634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maylene Shung-King does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Children’s right to health is paramount: here’s what needs to be done to build a child-centred health care system.Maylene Shung-King, Professor, Health Policy, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253802019-10-31T14:45:11Z2019-10-31T14:45:11ZHow a lack of competition in South Africa’s private health sector hurts consumers<figure><img src="https://images.theconversation.com/files/297309/original/file-20191016-98678-1gqympv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Netcare is one of three hospital groups found to dominated the facilities market.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>An extensive inquiry <a href="http://www.compcom.co.za/healthcare-inquiry/">into South Africa’s health market</a> was recently concluded – the first ever process in the country that involved gathering evidence and then studying the private healthcare market from the perspective of competition and competition law. </p>
<p>The investigation ran over five years and included over 43 million individual patient records, 11 million admissions, specifically commissioned <a href="http://www.compcom.co.za/healthcare-inquiry/">studies</a>, written submissions, public hearings and seminars. The investigation focused on hospitals, doctors, and funders. Funders include the medical schemes who purchase healthcare on behalf of members, and the administrators and managed care organisations that medical schemes contract with.</p>
<p>South Africa’s Competition Commission set up the inquiry in response to prices in the private healthcare sector which, it said, only a minority of South Africans could afford. The country has a two-tiered health system. About <a href="http://www.statssa.gov.za/publications/P0318/P03182018.pdf#page=37">71%</a> of the population uses public sector, while the private sector serves around <a href="http://www.statssa.gov.za/publications/P0318/P03182018.pdf#page=37">27%</a>. </p>
<p>Ideally competition should translate into lower costs and prices, better quality, and generally more value for money for consumers. In its final report, which was <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/HMI-Executive-Summary.pdf">released recently</a>, the inquiry found that competition wasn’t working as it should in private healthcare. The sector was characterised by high and rising costs, significant overuse, and no discernible improvements in health outcome. </p>
<h2>Lack of competition</h2>
<p>There were a number of factors that – alone or in combination – led to a lack of competition in the sector. </p>
<p>One factor is that three hospital groups dominated the facilities market: Netcare, Mediclinic and Life. They accounted for more than 80% of the hospital beds and 90% of all the admissions. These three hospital groups, both individually and collectively, were able to secure steady and significant profits year-on-year. A few firms owning the majority of the market is an indication that competition may not be working effectively. </p>
<p>Hospitals don’t attract patients, they compete for doctors who admit patients. Most doctors had contracts with the big three. Successful entry by new hospital owners is very difficult as they cannot attract doctors as easily. </p>
<p>Hospital groups are also able to build additional hospitals where they aren’t needed, resulting in an oversupply of beds and ultimately overuse of services. </p>
<p>In South Africa more people are admitted to ICU compared to eight other countries with comparable <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/Health-Market-Inquiry-Report.pdf">published data</a>. The inquiry panel estimated that the country could save more than R2.7 billion – or 2% of its current private health care spend – if it halved the number of people admitted to ICUs and improved the care for patients in wards. Only the critically ill should be admitted to ICU. But the inquiry found that some of the patients who were in ICU could have been treated in wards.</p>
<p>There are no measures of quality of care in the public domain. This means that members of medical schemes and funders (who purchase healthcare on behalf of medical scheme members) weren’t able to judge if the care provided by doctors and specialists was effective.</p>
<p>The entire premise of effective competition is that purchasing healthcare services should be based on value – a combination of price and quality. This isn’t possible in South Africa. </p>
<p>There’s no way to assess if the care provided was improving health outcome. This is particularly problematic as the inquiry found significant over-servicing by doctors which cannot be explained by their patients’ level of illness. Doctors use a fee-for-service billing model. This means they bill patients for each service they perform during a consultation. In this system, the more you do the more you earn. This is called a perverse incentive and without knowing the impact of health outcomes neither doctors nor patients know if the extra tests or interventions are worth the cost. They also don’t know if it is improving health outcomes.</p>
<p>The inquiry also found doctors and specialists worked as individuals -– not as a team. There is growing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403641/">evidence</a> and acceptance internationally that team-based care is better and more cost effective. </p>
<p>Medical schemes compete for younger and healthier individuals. To do this, schemes have created numerous benefit packages. But these packages aren’t comparable. Medical schemes have done this in response to the absence of a mechanism for equalising risk between medical schemes. Medical scheme members do not know what they are paying for. Neither are they able to judge the quality of care. </p>
<h2>Recommendations</h2>
<p>The recommendations are aimed at creating greater competition, transparency, and accountability on how medical scheme member’s money is spent. They also aim to increase competition on the supply side (hospitals, doctors, and specialists) and on the demand side where funders represent the consumer. </p>
<p>Recommendations include a supply side regulator, whose job will be to:</p>
<ul>
<li><p>assist provinces in issuing licenses for hospitals;</p></li>
<li><p>assist with a process and a platform for price setting for doctors;</p></li>
<li><p>conduct or contract out research looking at cost-effective healthcare interventions, including technology; and</p></li>
<li><p>facilitate access to reliable information on quality of health and health outcomes measurement.</p></li>
</ul>
<p>To increase competition on the funder’s side, and to improve transparency for the consumer, the recommendations include that all medical schemes offer one comparable insurance package. In addition, government should introduce a mechanism to equalise risk between medical schemes so that they compete on the merits – not on risk or age selection.</p>
<h2>What next</h2>
<p>The recommendations have implications for the South African governments plan to introduce a National Health Insurance in a bid to level out the playing field between the public and private health care sectors. The plan is that the National Health Insurance will operate as a funding mechanism to move South Africa closer to universal health coverage. </p>
<p>Implementing the recommendations set out in the inquiry report is an essential step towards creating an environment where the purchaser – the National Health Insurance fund – will purchase from a private healthcare market that is competitive with lower costs and prices, and more value for money for consumers.</p>
<p>The National Health Insurance bill talks about strategic purchasing or value based purchasing which refers to using the capacity in the private sector to relieve the public sector. This aligns with the health market inquiry recommendations.</p>
<p>But it needs an independent supply side regulator to enable competitive price setting and coding mechanisms. Codes form the basis on which prices are determined – which is necessary for the National Health Insurance fund to reimburse providers. Value based purchasing also requires implementation of performance and outcomes reporting and monitoring. </p>
<p><em>Dr Lungiswa Nkonki was a panel member of the Health Market Inquiry.</em></p><img src="https://counter.theconversation.com/content/125380/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lungiswa Nkonki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The entire premise of effective competition is that purchasing of health services should be based on value - a combination of price and quality.Lungiswa Nkonki, Senior Lecturer, Department of Global Health, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1248142019-10-09T14:43:55Z2019-10-09T14:43:55ZWe did the sums on South Africa’s mental health spend. They’re not pretty<figure><img src="https://images.theconversation.com/files/295982/original/file-20191008-128644-1gtdayo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa has taken steps towards strengthening mental health care in the last 20 years. These include reforming the <a href="https://www.gov.za/sites/default/files/gcis_document/201409/a17-02.pdf">Mental Health Care Act 2002</a> and developing a <a href="https://health-e.org.za/wp-content/uploads/2014/10/National-Mental-Health-Policy-Framework-and-Strategic-Plan-2013-2020.pdf">National Mental Health Policy Framework and Strategic Plan 2013–2020</a>. </p>
<p>The strategic plan aims to integrate mental health into general health services to reduce the burden of untreated mental health conditions. It also aims to transform the system to provide quality mental health services that are accessible, equitable and comprehensive, particularly for community-based mental health care.</p>
<p>But significant information gaps have limited the country’s ability to initiate a sustained response to mental health care. For example, the most up to date population based prevalence estimates of the burden of mental disorders date as far back as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191537/">2003/4</a>. </p>
<p>The failure to implement the public policy on mental health was brought to light by the <a href="https://theconversation.com/patient-deaths-show-south-africas-care-for-the-mentally-ill-is-in-disarray-72472">Life Esidimeni tragedy in 2017</a>. Nearly 150 patients died after being moved from the Life Esidimeni Hospital to unlicensed facilities. </p>
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Read more:
<a href="https://theconversation.com/patient-deaths-show-south-africas-care-for-the-mentally-ill-is-in-disarray-72472">Patient deaths show South Africa's care for the mentally ill is in disarray</a>
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<p>New challenges are now arising with the planned introduction of the National Health Insurance (NHI) scheme, which is intended to move South Africa closer to universal health coverage. But <a href="https://ijmhs.biomedcentral.com/articles/10.1186/s13033-019-0260-4">early evidence</a> from NHI pilot districts show an inconsistency with the strategic plan and limited integration of mental health. If the relevant priorities aren’t explicitly reflected in the policies and activities supporting the NHI, mental health is likely to remain on the back burner. </p>
<p>The system must be clear about the care that mental health patients are entitled to and how providers will be identified and paid. Mental health care has to be recognised as an integral part of the health care system. </p>
<p>South Africa needs a good grasp of the problem and the resources required to address it. </p>
<h2>The gaps</h2>
<p>Until recently the country knew very little about a range of important factors related to mental health care. These included: the current state of investment in mental health; whether these investments were being used optimally; where the inequities in resourcing and access lay; and what priorities and plans should be in place to address these inequities. </p>
<p>In response to some of the biggest information gaps, we worked with national and provincial health departments and the South African Medical Research Council. We evaluated the health system costs of mental health services and programmes in South Africa for the 2016/17 financial year. We also documented and evaluated the available resources and constraints to inform a rational approach to planning effectively to improve mental health service delivery.</p>
<p><a href="https://academic.oup.com/heapol/advance-article/doi/10.1093/heapol/czz085/5572608">Our findings</a> offer – for the first time – a nationally representative reflection of the state of mental health spending. They draw attention to inefficiencies and constraints in existing mental health investments in the country. </p>
<h2>The current situation</h2>
<p>South Africa spends 5% of the total health budget on mental health services. This is in line with the lower end of <a href="https://www.who.int/mental_health/evidence/dollars_dalys_and_decisions.pdf">international benchmarks</a> of the recommended amount that countries should spend on mental health. </p>
<p>Yet, alarmingly, our study crudely estimated a treatment gap of 92%. This means that fewer than 1 in 10 people living with a mental health condition in South Africa receive the care they need. We also found huge disparities between provinces in the allocation of mental health resources. Provincial spending on mental health ranged widely across all levels of the health system. For example, in Mpumalanga, spending on mental health per uninsured South African was R58.50 while in the Western Cape it was R307.40. </p>
<p>Inpatient care took up 86% of the mental health care budget. Spending at specialised psychiatric hospitals made up 45% of the total. Services at the primary level of care made up only 7.9% of overall mental health spending. </p>
<p>This reflects a reactive mental health care system that is focused on treating the most severe conditions, rather than preventing or providing early interventions.</p>
<p>Mental health care users were admitted for longer periods than other patients – twice as long as other patients at district hospitals. At regional and tertiary hospitals, their admissions lasted around 6 to 8 times longer. At central hospitals, they spent almost 5 times longer. Mental health patients spent an average of 157 days in psychiatric hospitals per admission. Nearly 1 in 4 mental health patients were readmitted within three months of being discharged from any hospital. Readmissions alone consumed 18% of South Africa’s total mental health spend. </p>
<p>This indicates a highly inefficient system that fails to help patients transition to care in their communities. There is potential for cost savings in providing continuity of care and supporting people to live well in their communities after discharge from hospital.</p>
<p>Other findings included: </p>
<ul>
<li><p>Only three provinces had child psychiatrists in the public sector. </p></li>
<li><p>There was an extreme shortage of psychiatrists and auxiliary workers critical for rehabilitation and supportive services.</p></li>
<li><p>There wasn’t alignment between the national database of NGOs licensed by the department of health and those reported through primary data collection. </p></li>
<li><p>A number of drugs critical for the management of chronically disabling conditions such as bipolar disorder and depression, were not routinely available. </p></li>
<li><p>Most district hospitals weren’t compliant with the Mental Health Care Act, though they are expected to provide 72-hour assessments and subsequent referrals for further care, treatment and rehabilitation.</p></li>
</ul>
<h2>Way forward</h2>
<p>For the first time, South Africa has a <a href="https://zivahub.uct.ac.za/articles/An_Evaluation_of_the_Health_System_Costs_of_Mental_Health_Services_and_Programmes_in_South_Africa/9929141">nationally representative reflection</a> of the state of mental health spending and an appreciation of the inefficiencies and constraints emanating from existing mental health investments. This is one of the highest sample sizes of any costing study conducted for mental health in low- and middle-income countries.</p>
<p>Our study points to some obvious improvements that could be made. These include stronger service delivery at community and primary health care levels. And better referral pathways could reduce unnecessary readmissions. This would also shorten hospital stays. </p>
<p>The next phase must focus on accelerating the country’s progress towards meeting the goals set out in the strategic plan and taking forward the recommendations of the <a href="https://www.sahrc.org.za/index.php/sahrc-media/news-2/item/1811-media-statement-sahrc-to-release-the-report-on-the-national-investigative-hearing-into-the-status-of-mental-healthcare-in-south-africa">South African Human Rights Commission Report</a>. With these study findings in hand, the government now has a baseline from which to begin a rational planning process. </p>
<p>The government has asked us to help develop a mental health investment case for the country, which comes at a crucial time for the country’s mental health response, in light of the recent passing of the <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">NHI Bill</a>. This work will involve intensive and ongoing dialogue with a range of players involved in the provision of mental health services and research across the country.</p><img src="https://counter.theconversation.com/content/124814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sumaiyah Docrat is a staff member of the University of Cape Town and her PhD is supported by the South African Medical Research Council through its Division of Research Capacity Development under the SAMRC National Health Scholars Programme from funding received from the South African National Treasury. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the University of Cape Town, the South African Medical Research Council or the PhD funders.</span></em></p><p class="fine-print"><em><span>Crick Lund is a staff member of the University of Cape Town and King's College London. He has received research funding from the UK Department for International Development, the Wellcome Trust, the UK National Institute for Health Research, the South African National Research Foundation, the US National Institute of Mental Health, the UK Economic and Social Research Council and Wellspring Philanthropic Fund. </span></em></p>Less than 1 in 10 people living with a mental health condition in South Africa receive the care that they need.Sumaiyah Docrat, Health Economist in the Alan J. Flisher Centre for Public Mental Health, University of Cape TownCrick Lund, Professor in the Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1228062019-09-11T13:41:52Z2019-09-11T13:41:52ZRebuilding health systems from the bottom up: a South African case study<figure><img src="https://images.theconversation.com/files/291505/original/file-20190909-109962-1hazous.jpg?ixlib=rb-1.1.0&rect=15%2C26%2C2533%2C1594&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community care worker providing treatment to a TB patient at her home. </span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:DOT_administering_treatment.jpg">Wikkicommons/Stherere23</a></span></figcaption></figure><p>The recent publication of the <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">National Health Insurance Bill</a> in South Africa has provoked <a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">vigorous debate</a>. Many question whether the proposed reforms contained in the Bill offer meaningful solutions to the <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-signing-presidential-health-compact-25-jul-2019-0000">well-documented</a> <a href="https://www.hqsscommission.org/">crisis</a> in South Africa’s health system. </p>
<p>This crisis is two-fold. On the one hand is the lack of access and poor quality in the public health system which serves around <a href="https://www.dailymaverick.co.za/article/2019-08-20-is-the-national-health-insurance-bill-open-to-a-constitutional-challenge/">85%</a> of the population. On the other hand is an expensive and inefficient private health sector for the remaining minority. There are massive inequities in the distribution of resources between the two sectors. </p>
<p>There is widespread recognition that health system legislation alone will not address the deep seated problems in both sectors. Top-down reforms like those proposed in the NHI Bill need to be complemented by a bottom-up process of strengthening health systems. This must be focused on the most decentralised level of the health system, the district health system. South Africa’s public health system is organised into 52 health districts. </p>
<p>My colleagues and I at the University of the Western Cape believe that this sort of strengthening is not only possible – it’s already happening in pockets. We have <a href="https://doi.org/10.1093/heapol/czz060">engaged</a> with district, provincial and national government players to document the potential of such bottom-up initiatives. </p>
<p>Our recently published <a href="https://doi.org/10.1093/heapol/czz060">research</a> showed how coordinated action by local, provincial and national government players, working with existing resources, can create a fairly rapid turn-around in the performance of health districts. The case study we focused on could provide valuable lessons as South Africa prepares to introduce the NHI. </p>
<h2>Gert Sibande District</h2>
<p>Gert Sibande is a health district in the largely rural province of Mpumalanga. In 2014, this district had the highest death rate from severe acute malnutrition in the country: <a href="https://doi.org/10.1093/heapol/czz060">28%</a> of children younger than five who were admitted to hospital with the condition died during their stay. </p>
<p>But there was a dramatic decline in deaths in Gert Sibande over the three years that followed. The number of children who died from severe acute malnutrition dropped to one-third of the previous levels <a href="https://doi.org/10.1093/heapol/czz060">9%</a>. This decline in deaths was associated with a <a href="https://doi.org/10.1093/heapol/czz060">59%</a> drop in admissions. </p>
<p>In other words, children with severe acute malnutrition weren’t only receiving more effective treatment, cases were being prevented from occurring in the first place. </p>
<p>Severe malnutrition has been a major contributor to child deaths in South Africa, along with causes such as pneumonia and <a href="http://www.samj.org.za/index.php/samj/article/view/12238">diarrhoea</a>. Despite South Africa’s wealth, child malnutrition remains unacceptably <a href="https://foodsecurity.ac.za/wp-content/uploads/2018/04/Final_Devereux-Waidler-2017-Social-grants-and-food-security-in-SA-25-Jan-17.pdf">high</a>. Addressing this is a national priority. </p>
<p>Our research team conducted in-depth interviews with healthcare providers and their managers, to identify how the rapid improvements in acute malnutrition outcomes in Gert Sibande District were made possible. </p>
<p>Interviewees reported widespread shifts in mindsets and practices over the three years. These included improved quality of hospital care for children with severe acute malnutrition and more rigorous identification of children at risk of malnutrition in primary health care facilities. Better referral systems and household follow-up of children by community health workers were also key. </p>
<p>We were particularly interested in understanding how these shifts were triggered in a public health system that is frequently regarded as being trapped in a culture of poor <a href="https://www.hqsscommission.org/">performance</a> and low accountability. </p>
<h2>Key health system interventions</h2>
<p>Changes were initially prompted by consensus in Gert Sibande District that there was a problem to be addressed. This was followed by a series of health system strengthening interventions. These included:</p>
<ul>
<li><p>the appointment of a recently retired, senior public sector manager from another province to visit the district once a month; </p></li>
<li><p>a system of reporting deaths to senior district clinicians and programme managers within 24-hours; </p></li>
<li><p>regular processes of problem analysis and response in district and sub-district structures involving managers, clinicians and information officers;</p></li>
<li><p>empowering dietitians, who were previously marginal actors, to play a central role in steering the response; </p></li>
<li><p>a system of reciprocal accountability where expectations of performance were matched by the provision of support and resources; </p></li>
<li><p>improved supply chains through the provincial office; and,</p></li>
<li><p>building capacity for connected systems thinking. </p></li>
</ul>
<p>Apart from the appointment of the part-time facilitator, no external donor resources were sourced or deployed to the district.</p>
<p>We characterised these interventions as producing three kinds of system-level change. One was “ways of thinking” (knowledge and the use of evidence). The second was “ways of governing” (leadership, participation and coordination). The third was “ways of resourcing” (inputs and capacity). </p>
<h2>Way forward</h2>
<p>The experience of Gert Sibande District is not unusual. There are several “pockets of effectiveness” in South Africa’s public health <a href="https://www.spotlightnsp.co.za/2018/09/21/building-public-health-system-capacity-for-nhi-learning-from-disease-specific-successes-for-system-development/">system</a>. This points to the latent capabilities available in this system. </p>
<p>We believe that unlocking this latent capability needs the kind of deliberate actions seen in Gert Sibande. The system-level changes and health outcomes achieved through such actions will, in turn, only be sustainable in the long run if they are enabled by higher levels of the system. </p>
<p>This entails, firstly, a recognition that change at the frontline won’t be engineered by a stroke of the legislative pen. Meaningful change requires systematic approaches to strengthening, working directly at base of the health system. Gert Sibande’s experience suggests that this does not necessarily have to cost more. </p>
<p>Secondly, national leaders are the best placed to steer a wider consensus on the need to separate political from administrative decision-making in the health system, especially at provincial level. Meritocratic appointment of district and provincial managers, accompanied by more decentralised decision-making on appointments of staff and use of funds, would be an important first step. </p>
<p>A third supportive action would be to invest heavily in developing distributed leadership and management capacity, oriented to public value, as part of a reinvigorated focus on human resources for health.</p>
<p>These approaches could lay the groundwork for a successful NHI that genuinely addresses systemic problems from the bottom up rather than imposing solutions from the top down. </p>
<p><em>Maria van der Merwe and Beauty Marutla from the Mpumalanga department of health, and Joey Cupido and Shuaib Kauchali from the National department of health contributed to this article.</em></p><img src="https://counter.theconversation.com/content/122806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Schneider is a professor in the School of Public Health, at the University of the Western Cape. She holds a South African Research Chair in Health Systems Governance and receives funding from the South African Medical Research Council and the South African National Research Foundation. </span></em></p>Top-down reforms like those proposed in the NHI Bill need to be complemented by a bottom-up process of health system strengthening.Helen Schneider, Professor, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219922019-08-19T08:11:39Z2019-08-19T08:11:39ZWhy South Africa’s plans for universal healthcare are pie in the sky<figure><img src="https://images.theconversation.com/files/288366/original/file-20190816-192219-jswkjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa has a skewed healthcare system with an under-funded public sector and an expensive private sector.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Performance in South Africa’s two tier health system – the public and the private – has been worsening for some time. Politicians have attempted to attribute the decline in the public sector to a myriad of ills, none of their making. These include migrants; insufficient funds; insufficient staff; medical schemes; lawyers suing them for medical negligence; the existence of two tiers and even the middle class. </p>
<p>However, the real reasons place the blame firmly at their door. They are also largely responsible for the problems in the private sector. </p>
<p>In the face of these manifest failures, and to address the weaknesses in South Africa’s universal health coverage framework, the government has proposed an overtly political way forward – the <a href="http://www.health.gov.za/index.php/nhi">National Health Insurance Fund</a> (NHI). </p>
<p>Through this proposal the framers seek to collapse both the public and private systems into a single organisation. The proposers have done little more than outline enabling legislation for a new state-owned enterprise. It remains a mystery as to what this proposal has to do with the system-wide crises in the public sector, or the market failures in the private sector. </p>
<h2>Public health care failures</h2>
<p>Institutionalised patronage within provincial and national government has destroyed the capabilities of public health organisations – both national and provincial.</p>
<p>The country’s Health Ombudsman has also stated that the <a href="https://www.dailymaverick.co.za/article/2018-06-06-healthcare-rsa-is-still-afloat-maintains-minister-aaron-motsoaledi-while-it-sinks-around-him/">public health system is in a state of crisis</a>. And the Auditor General last year bluntly pointed out the country’s health services are in crisis.</p>
<p>This view is widely shared by civil society groups working in the health sector. </p>
<p>Evidence of the crisis can be seen in the mounting contingent liabilities for medico legal claims due to admitted medical negligence. These are now adding up to <a href="https://www.medicalbrief.co.za/archives/provincial-health-services-risk-r80-4bn-medical-negligence-claims/">more than a third</a> of the national health budget and growing.</p>
<p>A close look at the cases points to major failures in the system. For example, the bulk of claims are related to cerebral palsy cases. This is because sub-standard maternity services are being provided to mothers in the public health services. This has led to avoidable brain damage to children at birth.</p>
<p>These failures are matched by maternal mortality ratios at public facilities. The numbers are staggering, and place South Africa as an outlier for a country of its level of development. In 2017 the maternal mortality ratio in South Africa’s public sector was 135 deaths for every <a href="https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/">100,000 live births</a> in comparison to a benchmark for <a href="https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/">peer countries of around 42</a>. </p>
<p>The cerebral palsy cases as well as the maternal deaths are indicative of institutionalised mismanagement resulting from system-wide governance failures. </p>
<p>The picture isn’t universally bad. Public health services have been maintained in the Western Cape where irregular expenditure is much lower than in the country’s other eight provinces. The Western Cape’s lower maternal mortality ratio and almost non-existent medico legal cases are also testament to a much more efficiently run system which includes stronger governance regimes.</p>
<h2>Private sector failures</h2>
<p>South Africa has very high private health care costs, putting it out of reach for most people in the country.</p>
<p>The high costs have been a major point of contention for decades. In a bid to address the issue the country’s Competition Commission launched a health market inquiry five years ago. Its report, released earlier this year, highlighted a number of major market failures. These included a lack of transparency in the way health policies are sold, as well as a lack of competition between private health care providers.</p>
<p>The <a href="http://www.compcom.co.za/wp-content/uploads/2018/07/Health-Market-Inquiry-1.pdf">health market inquiry</a> has made a series of recommendations to fix the problems.</p>
<p>The former Minister of Health <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/Speech-by-Dr-A-Motsoaledi-Minister-of-Health-to-the-Competition-Law-Conference-06-07-September-2012.pdf">sought to blame</a> the failures of the public health sector on the high costs of the private sector. But no evidence has been marshalled to demonstrate how this could rationally occur. </p>
<p>As the inquiry pointed out, market failures have resulted in higher costs for medical schemes members. And it blames the government for these market failures, pointing out that they can only be addressed by coherent and well governed government regulation. </p>
<p>The question is whether the government will listen to the health market inquiry. </p>
<h2>Universal healthcare</h2>
<p>The planned NHI in South Africa has no equivalent in any setting in the world. It’s deeply flawed on a number of fronts.</p>
<p>Firstly, in other countries systems of universal health coverage seek to cover people and groups who have inadequate healthcare coverage. But the public scheme South Africa is proposing goes much further than this. It’s designed to include people who already have cover through their own private contributions.</p>
<p>Secondly, it’s unaffordable. The proposal envisages raising tax revenue upward of 3% of Gross Domestic Product to cover medical scheme members through a public scheme. This would be equivalent to a 31% increase in personal income tax or a 63% increase in corporate taxes. </p>
<p>Thirdly, the legislation and supporting policy framework is short of any meaningful content. There have been no institutional or financial feasibility studies done. This is despite the fact that the NHI has been on the policy agenda for the past 10 years. </p>
<p>Fourthly, the department of health has shown that it’s incapable of coping with the current health system. It would therefore clearly not be able to take on something as complex as what’s envisaged.</p>
<p>Fifthly, the only analysis on the proposed NHI is from a failed set of <a href="https://www.businesslive.co.za/bd/national/2019-07-28-nhi-pilot-projects-reveal-deep-problems/">pilot projects</a>. The government’s own <a href="https://www.businesslive.co.za/bd/national/2019-07-28-nhi-pilot-projects-reveal-deep-problems/">evaluations</a> of these pilots provide no evidence for the proposed framework. </p>
<p>And lastly, a particularly fatal aspect of the proposed NHI is that it fails to address a model that’s allowed patronage to flourish and that has served South Africa so poorly. At the heart of the problem is the fact that the proposed new Fund would give the Minister of Health full discretion over all senior appointments. He would also be able to ensure political control over procurement of R450 billion in services and the accreditation of all public and private health establishments </p>
<p>The only conclusion that can be drawn from this state of affairs is that the NHI proposals are yet another symptom of the health crisis. Only a failing health department could generate a proposal like this and take it seriously – let alone expect everyone else to join them in their fantasy.</p>
<h2>So, what should happen?</h2>
<p>The reforms required to put South Africa’s health system on a better footing have been glaringly obvious for some time. </p>
<p>The public health system can only be turned around by a combination of governance reforms and decentralisation. This requires the implementation of supervisory structures, such as boards for hospitals, district authorities and statutory councils that are insulated from political appointments and interference. Politicians should be entirely separated from the operational aspects of health service delivery. </p>
<p>For its part, the private sector requires the implementation of the health market inquiry recommendations. Some of these include setting up a pricing regulator to manage annual price negotiations for hospitals and doctors and the establishment of an information regulator to bring quality of care information on private and public health services to the surface. </p>
<p>What South Africans don’t need is another five years of pretence that this team can create a brand new health system out of the ashes of the two existing systems. Unfortunately all we can be certain of are the ashes.</p><img src="https://counter.theconversation.com/content/121992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex van den Heever is affiliated with: the Helen Suzman Foundation as an unremunerated Fellow; and was a lead economist on the Health Market Inquiry until the end of 2017.</span></em></p>South Africa’s planned NHI has no equivalent in any setting in the world. It’s deeply flawed on a number of fronts.Alex van den Heever, Chair of Social Security Systems Administration and Management Studies, Adjunct Professor in the School of Governance, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1209252019-07-29T12:43:20Z2019-07-29T12:43:20ZMigrants must be part of South Africa’s universal health plan. Here’s why<figure><img src="https://images.theconversation.com/files/285841/original/file-20190726-43114-1290yoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">International migrants often struggle to access healthcare. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Seven years ago the United Nations (UN) endorsed <a href="https://www.uhc2030.org/un-hlm-2019/a-history-of-universal-health-coverage-in-the-un/">universal health coverage</a> as key to sustainable development and global security. </p>
<p>The South African government has taken up the challenge. President Cyril Ramaphosa has <a href="https://www.businessinsider.co.za/cyril-ramaphosa-state-of-the-nation-adddress-sona-national-assembly-job-eskom-violent-crime-2019-6">underscored</a> the government’s commitment to introducing South Africa’s verion of universal health coverage. He said that the revision of a new law to implement National Health Insurance (NHI) was at an “advanced” stage. The aim is to ensure that all in the country have access quality healthcare, without prejudice or financial detriment. </p>
<p>The country still has a long way to go. A <a href="https://www.businesslive.co.za/bd/national/2019-07-28-nhi-pilot-projects-reveal-deep-problems/">recent report</a> on the 11 districts where the NHI was piloted found that the projects were plagued with problems. Medicine stock levels in clinics and hospitals couldn’t be monitored because there was no internet connectivity and vacant posts couldn’t be filled because posts had been frozen. Teams of medical specialists were expensive, overworked and failed to achieve targets of improving infant health. </p>
<p>According to the <a href="https://www.who.int/whr/2010/10_summary_en.pdf?ua=1">World Health Organisation</a> (WHO) three features must be present for universal health coverage to be achieved. </p>
<p>The first is that the services provided must be extensive and include health promotion, prevention, treatment, rehabilitation as well as palliative care. The second is coverage, which includes some form of financial risk protection. </p>
<p>The third feature is universality. This means that everyone within the borders of a <a href="https://www.who.int/whr/2010/en/">country</a> must be included. The WHO has emphasised that this means international migrants – irrespective of legal or migration status – <a href="https://www.who.int/migrants/about/mh-qhc/en/">must be included</a> too. And that they must be afforded access to a minimum of <a href="https://gh.bmj.com/content/bmjgh/3/5/e001031.full.pdf">essential and affordable healthcare services</a>.</p>
<p>A glaring weakness in South Africa’s proposed NHI is care for migrants. Rather than addressing its aims of ensuring equitable access to quality healthcare for all, the NHI – in its current form – legitimises the persistent exclusion of international migrants from South Africa’s public health system.</p>
<h2>Migrants in South Africa</h2>
<p>South Africa is home to approximately <a href="https://www.sahrc.org.za/index.php/sahrc-media/opinion-pieces/item/1422-ensuring-health-and-access-to-health-care-for-migrants-a-right-and-good-public-health-practice">2 million international migrants</a>, around <a href="http://www.statssa.gov.za/census/census_2011/census_products/Census_2011_Census_in_brief.pdf">4% of the total population in 2011</a>. Most are from elsewhere in the Southern African Development Community region and have moved to South Africa in search of more work opportunities. </p>
<p>But migrants living in South Africa struggle to access public services – <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/">including healthcare</a>. This is the case even though they are <a href="https://www.sahrc.org.za/index.php/sahrc-media/opinion-pieces/item/1422-ensuring-health-and-access-to-health-care-for-migrants-a-right-and-good-public-health-practice">legally entitled to</a> these services. <a href="https://www.dailymaverick.co.za/article/2018-03-29-medical-xenophobia-public-hospitals-deny-migrants-health-care-services-sahrc/">Reports</a> of people being turned away from government health facilities due to immigration status, nationality or language spoken are widespread.</p>
<p>Migrant women in particular have experienced multiple challenges when attempting to access antenatal care, including at the time of <a href="https://www.dailymaverick.co.za/article/2015-09-06-health-e-news-mothers-and-children-are-collateral-damage-in-immigration-clampdown/">delivery</a>. Some facilities have even refused to allow women to take their newborns home if they couldn’t pay for <a href="https://www.health-e.org.za/2015/07/15/hospitals-hold-babies-for-randsom-say-mothers">services</a>. </p>
<p><a href="http://www.samj.org.za/index.php/samj/article/view/8569/6230">Looking after the health of migrants</a> is good for economic and social development. Excluding international migrants from the public health care system can result in a population wide risk. Denying a part of the population access to preventative and curative health services, undermines efforts to control infectious diseases – including HIV and tuberculosis. This has particularly worrisome implications for <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.25137">current HIV treatment as prevention interventions</a>.</p>
<p>The country’s existing law on migrant access to healthcare services is quite clear. It’s <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/what-does-the-law-say-about-migrants-and-refugees-accessing-healthcare-in-south-africa/">unlawful</a> under the country’s Constitution to deny anyone, including migrants, access to healthcare services. </p>
<p>The question, then, is will the NHI build on these provisions and make the situation better for international migrants? Or will the NHI be in contravention of South Africa’s constitutional commitment to the rights and protection of all who live in it? </p>
<h2>The gaps</h2>
<p>How can the South African government make sure that international migrants don’t get left behind in efforts towards universal health coverage? </p>
<p>The answer is two-fold. First, South Africa needs to adopt a <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/9_Towards%20a%20migration%20aware%20health%20system%20in%20South%20Africa_a%20strategic%20opportunity%20to%20address%20health%20inequity.pdf">“migration-aware” approach to the health system</a> and ensure that this is included in the NHI bill. </p>
<p>Second, the country needs to learn from <a href="https://gh.bmj.com/content/bmjgh/3/5/e001031.full.pdf">Thailand</a>. As another low- and middle-income country, Thailand’s successful approach to universal health coverage that includes cover for undocumented migrants, provides important lessons. In Thailand, health insurance for documented and undocumented migrants has been introduced, and the provision of <a href="https://www.who.int/bulletin/volumes/95/2/16-179606/en/">migrant-friendly services</a> has been strengthened.</p>
<p>To achieve universal health coverage, there needs to be concerted effort across all of society. Political will and effective policies are paramount but it’s equally important to provide correct information and society wide education. </p>
<p>This will be difficult to implement in South Africa given the hostility international migrants face from community members and healthcare providers. Migrants are regularly <a href="https://africacheck.org/2019/01/29/analysis-are-south-africas-public-hospitals-overburdened-by-foreign-patients/">blamed for a range of ills</a> in the country, including unemployment, disease and poverty.</p>
<p>South Africa’s newly appointed Minister of Health, Zweli Mkhize, recently promised a <a href="https://www.dailymaverick.co.za/article/2019-07-15-could-a-national-health-insurance-fund-be-just-months-away/">social compact on health</a>. But it remains to be seen if this will reflect the importance of engaging with international migration as the government grapples with finalising its’ plans for universal health coverage.</p><img src="https://counter.theconversation.com/content/120925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jo Vearey receives funding from the Wellcome Trust.</span></em></p><p class="fine-print"><em><span>Sasha Frade does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Excluding international migrants from the public health care system can result in a population wide risk.Sasha Frade, Sasha Frade is a PhD student, as well as an Associate Lecturer, in the Demography and Population Studies, University of the WitwatersrandJo Vearey, Associate Professor, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1121622019-02-20T14:44:24Z2019-02-20T14:44:24ZSouth Africa’s finance minister delivers a budget designed to steady the ship<figure><img src="https://images.theconversation.com/files/259943/original/file-20190220-148513-52lhi2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South African Finance MInister Tito Mboweni delivering the 2019 budget speech in parliament. </span> <span class="attribution"><span class="source">GCIS</span></span></figcaption></figure><p>South Africa is supposed to be a secular state, but one can perhaps forgive Tito Mboweni, the Minister of Finance, for quoting numerous biblical verses in his <a href="https://www.gov.za/speeches/v-20-feb-2019-0000">2019 Budget Speech</a>. After all, South Africa’s fiscal situation is enough to make many people hope for divine intervention.</p>
<p>The 2019 budget numbers show that the past year has been no exception to some “new normals” that have been established in South Africa. These include slow economic growth, state-owned enterprises requiring unplanned financial support, failing plans aimed at stabilising national debt levels, and tax revenues significantly lower than forecast. </p>
<p>All were present in this year’s budget.</p>
<p>Economic growth forecasts have been revised down from a paltry 1.7% to 1.5%. Revenue collection was R42.8bn lower than expected in the 2018 Budget. And Mboweni is promising to stabilise gross national debt slightly above 60% of gross domestic product in 2023. This follows many failed promises in previous budgets to stabilise gross national debt below 50% of GDP.</p>
<p>The reasons for these failures are largely to be found outside of the Treasury and Ministry of Finance. Tax revenue shortfalls are partly due to low economic growth and problems in <a href="https://theconversation.com/why-removal-of-south-africas-tax-boss-is-key-to-ramaphosas-chances-of-success-106455">tax administration</a>. In addition, the South African Revenue Service has been clearing a backlog in refunds that had accumulated under the previous commissioner. On top of this, the financial and operational crisis at the <a href="https://businesstech.co.za/news/energy/299720/eskom-to-end-power-cuts-after-week-of-disruption/">troubled power utility Eskom</a> has necessitated some drastic measures. </p>
<p>The budget has to aim for fiscal decisions that serve the public interest and maintain the stability of public finances. So did the proposals tabled constitute a good response to the situation? And what are the implications?</p>
<p>Mboweni continues to walk a precarious tightrope. The budget is likely to be well-received by the private sector because it wasn’t asked to make any meaningful sacrifices while some sectors can look forward to new opportunities. Individual citizens and the state itself will bear the brunt of the most difficult decisions. </p>
<p>The only real defence for this asymmetry is a belief that wooing business and potential investors will lead to the economic growth and job creation needed to emerge from the current crisis. But there is no guarantee of that, and the likely negative effects on citizens have arguably been given too little attention.</p>
<h2>Major proposals</h2>
<p>Eskom is the main factor driving the most significant proposals in the 2019 Budget. Mboweni confirmed President Cyril Ramaphosa’s <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-2019-state-nation-address-7-feb-2019-0000">announcement</a> that government intends to split Eskom into three parts (generation, transmission and distribution). What’s new is that the budget suggests transmission will be the first to be formed and private sector investors invited in. </p>
<p>From a public finance point of view, the critical announcement is that Treasury will be providing Eskom with financial support of R23bn a year over the next few years (and possibly longer).</p>
<p>There are no major changes to tax policy. But the government will try to get more revenue (about R10bn in 2019/20) from individual taxpayers by not adjusting tax brackets upwards for inflation. It will also increase taxes on alcohol and cigarettes. Tax on fuel will also go up and will now include a carbon tax.</p>
<p>The 2020 Budget will announce measures to raise an additional R10bn in tax revenue.</p>
<p>To try and limit the effect of Eskom support on overall government spending (and debt), the budget proposes to cut other areas of public expenditure by R50bn. The proposal is that this will be done through reducing the number of public servants and cutting funding to programmes that have under-spent or under-performed.</p>
<p>Finally, the budget proposes to raise the amount set aside for unexpected spending to R13bn for 2019/20 to account for possible financial support to other state-owned enterprises. </p>
<p>In line with an earlier policy, the Treasury has said that it ultimately intends to sell public assets to offset such support. These, however, aren’t listed.</p>
<h2>Implications and concerns</h2>
<p>In his speech, Mboweni said that:</p>
<blockquote>
<p>Pouring money directly into Eskom in its current form is like pouring water into a sieve. </p>
</blockquote>
<p>Past evidence certainly seems to support this claim. So why another R23bn per year for a failing enterprise? </p>
<p>The main reason is that the utility supplies the country with power. In addition, a lot of Eskom’s debt is being guaranteed by the Treasury. This means that the utility’s financial and operational problems are now the nation’s problems. Besides the dramatic evidence provide by <a href="https://mybroadband.co.za/news/energy/295616-eskom-deepens-south-africa-power-cuts-as-moodys-flags-risk.html">power cuts</a> in recent weeks, individuals citizens have also been affected by dramatically <a href="https://www.thesouthafrican.com/eskom-electricity-price-hike-approved-2019/">increasing electricity tariffs</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=542&fit=crop&dpr=1 754w, https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=542&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/259944/original/file-20190220-148545-1y0l63u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=542&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Finance Minister Tito Mboweni, left, shares a light moment with President Cyril Ramaphosa, before delivering the Budget speech.</span>
<span class="attribution"><span class="source">GCIS</span></span>
</figcaption>
</figure>
<p>Past efforts to resolve Eskom’s problems have clearly failed. It remains to be seen how Ramaphosa and Mboweni’s promise that it will be different this time will turn out. And while the general case for restructuring the electricity sector is strong, it is debatable whether doing that now will improve or exacerbate Eskom’s crisis.</p>
<p>Support for Eskom will be funded by cuts in spending elsewhere. A major component is a reduction of R27bn in salary payments. Treasury has been encouraging reductions in the number of public servants for some time: the budget shows that the number of employees declined by 16,000 at national level and almost 50,000 at provincial level between 2015 and 2018. </p>
<p>The Treasury’s plan for further cuts involves offering early retirement packages. The hope is that about 30,000 (out of 125,000) public servants aged between 55 and 59 will accept the offer. A serious concern is that the move might lead to the most competent public servants leaving. And that recent cuts have harmed state capacity and service delivery.</p>
<p>These are the kinds of issues that will need to be watched closely if Treasury’s proposed cuts are accepted by Parliament.</p>
<h2>Odds and ends</h2>
<p>As always, the Budget contained some proposals that are progressive but constitute an almost trivial level of expenditure. There is R157million in 2019/20 for free sanitary pads for learners in poorer schools. And in an attempt to respond to concerns about the increase in VAT to 15%, there will be VAT zero-rating on white bread, cake flour and sanitary pads. </p>
<p>In addition, the salaries of members of parliament and provincial legislatures, along with some state executives, will be frozen. </p>
<p>Meanwhile, other major policy issues from previous years have already faded into the background. Free higher education will be continued, with spending rising from R27bn to R40bn in 2021/22. But this major policy change has already been relegated to a paragraph of information with little detail on how funding decisions are being made at the level of individual students.</p>
<p>Mboweni’s strategy was clearly to downplay the negative effects of expenditure cuts on the one hand, and on the other to pin the country’s hopes on improvements in economic growth, revenue collection and the finances of state-owned enterprises. If none of these happen, no amount of biblical verses will shore-up the nation’s finances and economy.</p><img src="https://counter.theconversation.com/content/112162/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Seán Mfundza Muller receives funding from a European Union-funded project, "Putting People back in Parliament", led by the Dullah Omar Institute (University of the Western Cape), in collaboration with the Parliamentary Monitoring Group, Public Service Accountability Monitor (Rhodes) and Heinrich Boell Foundation (South Africa). He is affiliated with the Public and Environmental Economics Research Centre (University of Johannesburg), regularly making inputs to Parliament oversight of the national budget, advising civil society groups on public finance matters and consulting for private sector organisations on an ad hoc basis. He resigned from the South African Parliamentary Budget Office in 2016. The views expressed are his own.</span></em></p>South Africa’s finance minister delivered a budget that tried to balance serving the public interest, while maintaining the stability of public finances.Seán Mfundza Muller, Senior Lecturer in Economics and Research Associate at the Public and Environmental Economics Research Centre (PEERC), University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1109292019-02-04T13:41:19Z2019-02-04T13:41:19ZWhy delays to fixing health care are bad news for South Africans<figure><img src="https://images.theconversation.com/files/256828/original/file-20190201-75085-1u55v1t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over 80% of South Africans rely on state facilities like Chris Hani Baragwanath, the third largest hospital in the world.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The release of a final report about the state of competition in South Africa’s private health sector has been <a href="https://www.businesslive.co.za/bd/national/2019-01-24-competition-commission-cuts-back-probes-due-to-lack-of-funds/">delayed again</a>. It was compiled by an <a href="http://www.compcom.co.za/panel-members/">inquiry panel</a> made up of medical, legal and economic experts. The panel heard submissions from a range of stakeholders including members of the public, civil society organisations as well as private hospital groups. </p>
<p>The inquiry was <a href="https://theconversation.com/explainer-how-competitive-is-south-africas-private-health-care-sector-99799">set up</a> under the auspices of the country’s competition authority in 2013. It’s <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/Amended-Terms-of-Reference-for-Market-Inquiry-Private-Healthcare-Sector.pdf">remit</a> was to investigate characteristics of the private health sector that may prevent, distort or restrict competition. Its <a href="http://www.compcom.co.za/provisional-findings-and-recommendations-report/">preliminary report</a>, released in July 2018, concluded, among other things that the sector was highly concentrated in the hands of a few major players. The final leg of work was to get inputs from various players on the initial findings before concluding the inquiry. The inquiry has cost tax payers <a href="https://www.businesslive.co.za/bd/national/2019-01-02-market-inquiry-into-private-health-care-cost-r197m-says-ebrahim-patel/">R197 million</a> so far. </p>
<p>Another delay of the report – which should have been released in March 2019 –is therefore bad news. The sooner South African authorities deal with the issues of anti-competitive behaviour in the private sector, the more likely access to quality health care will improve. </p>
<p>South Africa has a two-tiered health care system. The public sector is under-resourced and stretched while the private sector is highly sophisticated and expensive. Even though only <a href="http://www.compcom.co.za/wp-content/uploads/2016/08/WHOOECD_HMIsubmission2_30Aug16-FINAL.pdf">16%</a> of the country’s population uses private health care, it nevertheless gets a large portion of the government’s health expenditure in subsidies. </p>
<p>At the same time, private health costs continue to balloon and fewer people can afford it.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-how-competitive-is-south-africas-private-health-care-sector-99799">Explainer: how competitive is South Africa's private health care sector</a>
</strong>
</em>
</p>
<hr>
<p>The inquiry’s preliminary recommendations offered a clear agenda for how the private sector can become an integral part of the current national health system. There must be no more delays: if South Africa is to reach its lofty goal of universal health coverage, the report must be released and those recommendations adopted.</p>
<h2>Key findings and recommendations</h2>
<p>The inquiry examined three aspects of the private sector.</p>
<ul>
<li><p>Medical schemes through which people pay for private health services and the administrators who run them. </p></li>
<li><p>Private facilities, such as hospitals and clinics. </p></li>
<li><p>Medical doctors and specialists in the private sector. </p></li>
</ul>
<p>The key preliminary <a href="http://www.compcom.co.za/provisional-findings-and-recommendations-report/">findings and recommendations</a> were:</p>
<ul>
<li><p>Medical schemes provide multiple plan options for cover without providing adequate information to understand what they cover, how the plans compare and what value the patients receive. As a result, consumers aren’t able to compare what schemes offer or choose plan options on the basis of value for money.</p></li>
<li><p>There is a lack of transparency on the pricing of health care goods and services, standardised reporting of health outcomes and implementation of evidence-based guidelines and treatment protocols. </p></li>
<li><p>Medical practitioners and specialists are concentrated in the private sector. As a consequence, there is time to over-service and inefficient use of expertise and time. </p></li>
</ul>
<p>In light of these and other findings, the inquiry made a number of recommendations to remedy the situation.</p>
<p>These included putting measures in place to enable the Council for Medical Schemes, which regulates medical aids, to exercise more effective oversight.</p>
<p>In addition, to ensure that people who belong to medical aids get more comprehensive cover, the inquiry proposed that all medical schemes also offer a standalone standardised obligatory basic benefit option. The basic option would include a standard basket of goods and services and be comparable among schemes. This option would include cover for the prescribed minimum benefits, make provision for the treatment of these prescribed minimum benefits outside of hospital settings and add primary and preventive care. </p>
<p>And the inquiry recommended tighter regulation of the sector through the establishment of a dedicated health care regulatory authority. This would govern the number and distribution of doctors and hospitals to meet current and future needs. And it would ensure the development of clinical protocols as well as shape the structure of payment systems. </p>
<p>The inquiry also recommended that a centralised national licensing framework be introduced. This would accredit all health facilities including clinics, hospitals and GPs’ rooms. Another recommendation was to establish a price-setting mechanism. </p>
<h2>Important</h2>
<p>The recommendations are innovative and would go a long way toward making health care in the country more equitable. But South Africans will have to keep waiting to see if they actually bear fruit. </p>
<p>The latest development is that, due to a lack of funds, all the inquiry’s work has been suspended until the end of the financial year in March after which a new date for the release of the final report will be published in the Government Gazette.</p>
<p>It’s important that the inquiry is allowed to complete its task sooner rather than later. This is because its findings could have a bearing on a piece of legislation currently making its way through parliament – the <a href="https://pmg.org.za/call-for-comment/691/">Medical Schemes Amendment Bill</a>. The bill proposes changes to medical scheme governance and benefit options. Reports suggested that the department of health <a href="https://www.businesslive.co.za/bd/national/health/2018-12-13-medical-schemes-amendment-bill-waiting-for-outcome-of-health-inquiry/">wanted to wait for the outcome</a> of the inquiry before finalising the bill.</p>
<p>The inquiry could also affect the <a href="http://www.health.gov.za/index.php/gf-tb-program/398-national-health-insurance-bill-2018">National Health Insurance Bill</a> which is meant to herald in universal health care. But the bill is mired in controversy. The most recent version was recently rejected by the country’s cabinet which instructed the national department of health department to review what’s been proposed. </p>
<p>Until the final report is released, South Africans must contend with a fragmented, poorly regulated and expensive health care delivery system.</p><img src="https://counter.theconversation.com/content/110929/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wezile Chitha currently heads an oncology service funded through a tender from the KwaZulu Natal Department of Health. He is an ANC member, member of South African Committee of Medical Deans.</span></em></p>South Africa’s Competition Commission has delayed the release of the final report of an inquiry into the private healthcare again.Wezile Chitha, Assistant Dean: Strategic Affairs, Faculty of Health Sciences, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/994042018-07-05T15:38:51Z2018-07-05T15:38:51ZNew healthcare plan promises to overhaul South Africa’s massively skewed system<figure><img src="https://images.theconversation.com/files/226237/original/file-20180705-122253-srcx81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The proposed National Health Insurance aims to provide health care for all South Africans.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/rafiqs/14869270980/in/photostream/">Flickr/Rafiq Sarlie</a></span></figcaption></figure><p>Since 1994 South Africa has invested substantial resources in health care services. As a result, it’s has made significant health gains. For example, nearly 4 million people get HIV treatment and mother-to-child transmission has nearly been eliminated. </p>
<p>Service delivery has also been significantly expanded to more than 4000 health facilities. And there’s been a large increase in the number of health care professionals. </p>
<p>But health care needs aren’t static. For example, non-communicable diseases like diabetes and hypertension are now <a href="http://www.who.int/nmh/publications/ncd_report_full_en.pdf">responsible for more deaths</a> than HIV and TB combined. And in some instances successes have created challenges. For example, the expansion of HIV treatment has meant that there’s now a large cohort of chronic patients requiring ongoing care. In addition, the reality of a largely youthful population requires interventions so that health gains aren’t lost. </p>
<p>Health services in South Africa are delivered by a large public health system as well as very sophisticated (and profitable) private health providers. Funding in the public sector has declined progressively for the past six years. The result is that public health services are under increasing strain and unable to deliver adequate care to poor people, particularly those living in rural areas.</p>
<p>The private sector has also been under pressure. This has led to price hikes, making many medical aid schemes unaffordable. Membership numbers aren’t growing, partly due to the country’s very high unemployment levels – medical aid membership is linked to formal employment. The result has been even more pressure on the public sector.</p>
<p>Reform is clearly needed. All that’s in dispute is what it should look like. </p>
<p>The release of the <a href="https://www.gov.za/sites/default/files/41725_gon635s.pdf">National Health Insurance bill</a> is the government’s answer to the problem. The central plank of the plan is a National Health Insurance Fund that will buy health care services from health professionals and deliver through both public and private facilities. </p>
<p>The bill has been met with a raft of criticism, included funding concerns and the fact that it won’t fix the collapsing public system. But I believe that more fundamental questions need to be asked: does it address the goal of delivering universal access to health care for all South Africans? And can it do it in a way that doesn’t incur catastrophic expenditure?</p>
<p>The answer to these two questions I believe is yes.</p>
<h2>Breaking with the past</h2>
<p>Despite the bill’s flaws, it has two great merits. </p>
<p>The first is that it addresses the country’s current approach to health care where the quality and type of services people receive is informed more by their socio-economic status rather than their need for care. Instead, it adopts a population-based approach. This means that budgets would be allocated based on how many people live in an area and what their disease profiles and health care needs were. </p>
<p>If properly implemented, this approach would result in lower health costs over time because diseases like diabetes and hypertension could be detected earlier and health conditions would be managed more efficiently. </p>
<p>It’s second major merit is that it looks at health services through three vantage points: </p>
<ul>
<li><p>what services are needed, </p></li>
<li><p>who needs them, and</p></li>
<li><p>who will deliver them. </p></li>
</ul>
<p>This means that it separates who procures the health services from those who will deliver them. </p>
<h2>A change of focus</h2>
<p>The bill also promises to transform the way money is spent on health care because it’s premised on separating the procurement and the provision of health care services. This has two benefits. </p>
<p>Firstly, it will mean that health budgets are allocated more efficiently based on health needs rather than purely on use. Secondly it can potentially unlock significant savings through strategic procurement.</p>
<p>The country spends just under a half a trillion rand on public and private health care combined. But the funds aren’t allocated and spent efficiently.</p>
<p>For example, nearly half of the money that goes to primary care services is being spent on managing chronic HIV patients. While spending to maintain access to HIV care is important, funds need to allocated to dealing non-communicable diseases which are becoming an increasingly significant public health threat. </p>
<p>The private sector services has its own set of problems. Chief among them is that it’s approach is curative – that is treating people in hospitals – rather than preventative. </p>
<p>The bill envisages that primary health care facilities will become the main point of entry for all patients. </p>
<h2>Greater equity</h2>
<p>There’s another benefit to the proposed scheme: a more equitable spread of services. </p>
<p>There are currently over 4000 public health facilities that service over 80% of the population’s primary health care needs. In the private sector there are close to 5000 general practitioners who service the health care needs of only 16% of the population. And most are concentrated in urban areas.</p>
<p>People in rural areas are therefore largely dependent on an ailing under resourced public sector. </p>
<p>At the centre of the proposed universal health care system is the promise that everyone will have access to health care where they need it without incurring vast expenses. </p>
<p>By consolidating the health market, the bill opens the door to more equitably allocate resources. </p>
<p>If it’s successfully implemented, this approach offers a real opportunity to address the country’s grossly unequal access to health services.</p>
<h2>A marathon, not a sprint</h2>
<p>The national health insurance should be seen as an opportunity to bring about much needed health care reform in South Africa. But South Africans need to wake up to the fact that implementing this highly complex new system will be more like running a marathon rather than a sprint.</p>
<p>The final implementation of the national health insurance is still a long way off – another two phases are planned. And the release of the bill is also only the first legislative step. Over the next four years 12 additional pieces of legislation are expected to be introduced. </p>
<p>South Africans should be prepared to be patient.</p><img src="https://counter.theconversation.com/content/99404/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Russell Rensburg does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa’s health care needs to be reformed so that everyone has access regardless of affordability or location.Russell Rensburg, Programme Manager Health Systems and Policy, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/990282018-06-28T14:04:52Z2018-06-28T14:04:52ZSouth Africa’s universal health care plan falls short of fixing an ailing system<figure><img src="https://images.theconversation.com/files/225142/original/file-20180627-112604-12nm7oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A patient collects her medication at a clinic in Khayelitsha, South Africa.</span> <span class="attribution"><span class="source">MSF/Sydelle WIllow Smith</span></span></figcaption></figure><p>South Africa’s Health Minister Aaron Motsoaledi has finally gazetted the bill detailing an ambitious plan to roll out universal health care in the country through a <a href="https://www.gov.za/sites/default/files/41725_gon635s.pdf">National Health Insurance</a>. </p>
<p>The bill responds to a global campaign spearheaded by the <a href="http://www.who.int/universal_health_coverage/en/">World Health Organisation</a> and linked to the <a href="http://indicators.report/targets/3-8/">UN’s sustainable development goals</a> to make sure that no-one is left behind in accessing quality health care. </p>
<p>There’s no dispute that South Africa’s health care system needs major reforms. There are considerable inequities in health care between <a href="https://theconversation.com/a-human-step-to-equal-health-care-in-south-africas-rural-hospitals-41648">urban and rural areas</a>; between public and private <a href="https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=3752&context=honors_theses">health sectors</a> and between primary health care and hospital care. And the country has a complex disease burden with heavy caseloads of <a href="https://theconversation.com/scientists-are-combining-forces-to-tackle-the-deadly-duo-of-tb-and-hiv-62378">HIV, TB</a> and <a href="https://theconversation.com/south-africas-sugar-tax-a-bold-move-and-the-right-thing-to-do-72010">non-communicable diseases</a>. </p>
<p>South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on health care. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector. </p>
<p>The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private health care costs and poor quality of care. </p>
<p>But in its current form the proposed legislation won’t be a silver bullet. There are still too many inconsistencies and unanswered questions for it to be the final roadmap to universal health care in the country. </p>
<p>For example, the bill focuses on curative services, missing an opportunity to take a public health approach that focuses on disease prevention, health promotion and health protection. In addition, it doesn’t address the relationship between the public and private health sectors which is seen as a major impediment to fundamental change. </p>
<h2>How it will work</h2>
<p>The bill is informed by a vision of ensuring equitable access to quality health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The proposed insurance fund envisages the consolidation of public and private revenue into one funding pool. </p>
<p>The idea is to enable a more equitable system through, for example, cross-subsidisation and ensuring that essential services are made available. </p>
<p>All people will have to register as users of the fund at an accredited health care establishment or facility (whether public or private). And the fund will decide on the health benefits that the facilities will have to provide. This will depend on what resources the facility has. People will be able to pay for complementary health service benefits not covered by the fund. </p>
<p>To be paid, health care providers, such as general practitioners and hospitals, will have to register with the fund. They will have to claim for each patient that they treat and will have to keep a record of diagnosis, treatment and length of stay.</p>
<h2>Governance</h2>
<p>The structure that’s been proposed for the fund is raising concerns on two fronts: it appears unnecessarily cumbersome and there’s a lack of clarity on lines of command.</p>
<p>The bill makes provision for the fund to establish an independent board that will report to South Africa’s Parliament. But it makes no mention of how the board will engage with the health minister (political custodian) and public servants in the health department. Nor does it explain how the performance of the fund will be evaluated. </p>
<p>The bill also introduces two additional management layers: district health management offices and contracting units for primary health care. These units will provide primary health care services in specific areas. It includes a district hospital, clinics and community health centres as well as ward-based outreach teams and private primary care service providers. They will be contracted by the fund. </p>
<p>National, provincial, and municipal health departments will still exist. </p>
<p>But the bill fails to explain the relationship between the district health management offices and the contracting units and how they will engage with the national, provincial and municipal health departments. </p>
<p>Given that there are ten health departments operating in South Africa – a national department and one in each of the country’s nine provinces – these additional offices and units could result in a more cumbersome bureaucracy. This could lead to more inefficiency and greater opportunity for corruption. </p>
<p>The new structure will also change the responsibilities of provincial health departments. Some of the proposals don’t make sense such as the idea that municipalities should take control of managing communicable diseases. Ideally this should be a national function, given the serious threat that is posed by some infectious diseases. </p>
<h2>Many questions</h2>
<p>Other parts of the bill are also unclear. These range from financing to how complaints will be managed.</p>
<p><strong>Health financing and management:</strong> The bill doesn’t explain what the tax implications of the national health insurance will be for citizens. It also doesn’t set out the mechanisms that will be put in place to strengthen financial planning and monitoring systems, particularly in the public health sector. These are very important given current <a href="https://www.news24.com/Archives/City-Press/R12bn-unaccounted-for-in-Gauteng-health-department-20150429">chronic overspending</a>, inadequate financial management and corruption and lack of accountability in many <a href="https://www.thesouthafrican.com/public-health-fail-report-reveals-that-sas-health-facilities-are-in-crisis/">provincial health departments</a>.</p>
<p><strong>Service provision:</strong> The bill says everyone is entitled to a comprehensive package of services at all levels of health care. But it doesn’t spell out what these packages will include. Given budgetary constraints, it’s obvious that there will inevitably have to be trade-offs and difficult choices. </p>
<p><strong>The health workforce:</strong> South Africa doesn’t have a comprehensive health workforce strategy with detailed norms and standards. This remains the Achilles heel of health sector reform in the country. The lack of detail remains a serious omission in the bill. </p>
<p><strong>Complaints mechanisms:</strong> The bill introduces a new separate complaints directorate – the investigating unit. But it’s unclear whether this will be the first level of complaints or whether it’s a duplication of the complaints directorate in the existing Office of Health Standards Compliance. There also isn’t clarity about where the Health Ombud fits in. </p>
<p>Ensuring that South Africa has a quality affordable health care system is critical. And the bill presents an important opportunity to think systematically about what needs to be done to fix the current health system. But there is still a long way to go.</p><img src="https://counter.theconversation.com/content/99028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel receives funding from the National Research Foundation. </span></em></p>The bill to provide universal health care in South Africa is not the silver bullet for the challenges in the health sector.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/522312015-12-12T15:05:39Z2015-12-12T15:05:39ZSouth Africa needs to spend more on healthcare to achieve universal cover<figure><img src="https://images.theconversation.com/files/105544/original/image-20151212-30705-111yrpd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse weighs a baby at a clinic in Johannesburg. South Africa has released its policy document to implement its universal health coverage plan.</span> <span class="attribution"><span class="source">Reuters/Antony Kaminju</span></span></figcaption></figure><p>For the second time the world is celebrating Universal Health Coverage Day. It comes as the South African government releases its universal health coverage policy to ensure equitable, accessible and affordable healthcare: the National Health Insurance White <a href="http://www.health.gov.za/index.php/2015-12-11-14-46-54?download=1114:national-health-insurance-white-paper-10-dec-2015">Paper</a>.</p>
<p>Although the goal of universal health coverage has been a feature of the country for the past two and a half decades, implementation has not been effective. </p>
<p>On taking office, President Nelson Mandela launched his flagship project: free health services for pregnant women and children aged <a href="http://www.ci.org.za/depts/ci/pubs/pdf/general/gauge2006/gauge2006_healing.pdf">under 6</a>. This was followed by free primary healthcare <a href="http://www.ci.org.za/depts/ci/pubs/pdf/general/gauge2006/gauge2006_healing.pdf">services</a>. Mandela recognised access to healthcare as an essential human right. But he also realised it was an important contribution to the nation-building project, along with other elements of the African National Congress’ Reconstruction and Development Programme.</p>
<p>Yet, in 2015, the picture is far from perfect. About 8 million South Africans have expensive private healthcare while 42 million people rely on an under-resourced <a href="https://theconversation.com/south-africa-cant-lose-its-nerve-on-universal-health-care-40423">public sector</a>. Inadequate access to healthcare perpetuates inequalities.</p>
<p>In addition, South Africa has a “missing middle”. These are people who are insufficiently poor to be exempted from paying user fees for public hospital services but often too poor to afford them. Many eligible for “free” healthcare face insurmountable indirect costs, especially for <a href="http://dx.doi.org/10.1016/j.socscimed.2012.11.035">transport</a> At the same time, for many who belong to medical schemes, monthly contributions and associated out-of-pocket payments consume an unsustainable proportion of their <a href="http://dx.doi.org/10.1057/gpp.2012.35">incomes</a>.</p>
<p>How can this be, given the early aspirations of the first democratic government?</p>
<h2>A lost decade</h2>
<p>The first decade of the post-apartheid era saw a surprising <a href="http://resyst.lshtm.ac.uk/sites/resyst.lshtm.ac.uk/files/docs/reseources/Working%20paper%206.pdf">decline</a> in per capita government expenditure on health, after taking inflation into account. This happened despite increasing per capita Gross Domestic Product. The share of the government budget allocated to health also declined and stagnated at around 11.7% for much of this decade. It has never returned to its 1996 high of <a href="http://resyst.lshtm.ac.uk/sites/resyst.lshtm.ac.uk/files/docs/reseources/Working%20paper%206.pdf">14.1%</a>.</p>
<p>This was linked to the implementation of a macroeconomic policy called the Growth, Employment and Redistribution <a href="http://www.treasury.gov.za/publications/other/gear/all.pdf">strategy</a> (GEAR) which was launched in 1996. The strategy reined in public expenditure and resulted in a squeeze on spending for health and education. </p>
<p>At the same time the Department of Health was struggling to remedy severe backlogs in healthcare infrastructure and human resource production inherited from the apartheid era. The HIV/AIDS epidemic was also escalating into the biggest in the world.</p>
<h2>Solving the problem</h2>
<p>If South Africa is to achieve equitable access to the full range of health services - not only primary healthcare services but also to hospitals - the fiscal policy limit on government revenue as a percentage of GDP needs to be lifted.</p>
<p>The limit of 25%, applied since GEAR was introduced, is well below the average in other middle-income countries. Latin America sits at over 32% <strong>link</strong> while Central and <a href="https://www.imf.org/external/pubs/ft/fm/2014/01/pdf/fm1401.pdf">Eastern Europe</a> sits at 37%. The average for countries in the Organisation for Economic Cooperation and Development (OECD) in 2013 was <a href="https://stats.oecd.org/Index.%20aspx?DataSetCode=REV">34%</a>. Increasing this limit is critical, given massive income inequality in South Africa.</p>
<p>It will be important to focus on progressive revenue sources, including taxing the wealthiest more effectively, as well as multinational corporations. This would be in line with the global agreement reached for funding the sustainable development goals.</p>
<p>But new government revenue will not easily flow to the health sector. National and provincial health leaders have generally battled to make the case for health in national and provincial decision-making bodies. This has been a function, at some points, of weak health leaders combined with insufficient technical and analytical capacity to support bids, especially in costing <a href="http://resyst.lshtm.ac.uk/sites/resyst">programmes</a>.</p>
<p>Successive ministers of finance have also at times resisted requests for increased funding from the Department of Health, especially when they distrusted the public health sector’s ability to <a href="http://resyst.lshtm.ac.uk/sites/resyst">deliver</a>.</p>
<p>These are some of the political and administrative challenges that characterise the struggle policy-makers and health advocates face on a daily basis to protect spending on healthcare. These challenges will intensify with the struggle to implement National Health Insurance.</p>
<p>To preserve the impetus towards universal health coverage, the Minister of Health and others need to engage with debates within Cabinet and Treasury on appropriate macroeconomic and fiscal policy choices. The Department of Health will strengthen these arguments, and win the trust of colleagues from Cabinet and Treasury, if it is able to demonstrate achievements in service delivery and combat corruption.</p>
<p><em>*This article is based on an article that appeared in the South African Medical <a href="http://www.samj.org.za/index.php/samj/article/view/10339">Journal</a> in December 2015.</em></p><img src="https://counter.theconversation.com/content/52231/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Doherty is a member of two NHI Workstreams. This work is based on research supported by the RESYST (Resilient and Responsive Health Systems) research
consortium funded by UKaid from the Department of International Development.
DM is supported by the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation (NRF) of South Africa.
Any opinion, finding and conclusion or recommendation expressed in this article is that
of the authors, and the NRF and UKaid do not accept any liability in this regard.</span></em></p><p class="fine-print"><em><span>Di McIntyre receives funding from the Department of Science and Technology and National Research Foundation. She has served on various policy committees related to developing proposals for the NHI and has been appointed to serve on various NHI Workstreams related to planning for the implementation of the NHI.</span></em></p>South Africa’s plan for universal health coverage has taken another crucial step with the introduction of a new policy document aimed at delivering more equitable healthcare.Jane Doherty, Senior researcher in health policy and systems and part-time lecturer , University of the WitwatersrandDi McIntyre, Professor in the Health Economics Unit, School of Public Health and Family Medicine , University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/489492015-10-22T03:36:48Z2015-10-22T03:36:48ZUniversal health care is a tall order given southern Africa’s poor finances<figure><img src="https://images.theconversation.com/files/99165/original/image-20151021-15434-10xneeu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health care in Zambia is free but fraught with difficulties. </span> <span class="attribution"><span class="source">EPA/Kim Ludbrook</span></span></figcaption></figure><p>Creating universal health care – one of the targets under the newly ratified <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">Sustainable Development Goals</a> – will have different challenges for each country depending on their economic strength, relationships with donors, and their government’s investment into the health sector.</p>
<p>In southern Africa, the task will be even greater. To attain these healthcare goals, the region has more work to do than any other – especially considering its <a href="http://www.sadc.int/themes/poverty-eradication-policy-dialogue/">high poverty</a> levels and HIV and tuberculosis disease <a href="http://www.sadc.int/issues/hiv-aids/">burden</a>. The region is also still reliant on <a href="http://www.sadc.int/news-events/news/reduce-dependence-donor-funding-sadc-urged/">donors</a> despite efforts for governments to shoulder responsibility for health care.</p>
<p>Universal coverage, as defined in the goal, is access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines. It also includes protection from financial risk in terms of health care. The goal is that by 2030, all regions will have universal health care.</p>
<p>In southern Africa, South Africa and Zambia have taken the first steps towards universal health care. But both programmes are struggling to live up to expectations.</p>
<h2>A look at South Africa</h2>
<p>When South African Health Minister Aaron Motsoaledi introduced the <a href="http://www.bowman.co.za/FileBrowser/ContentDocuments/NHI.pdf">national health insurance (NHI) plan</a>, his idea was that it would bridge the healthcare <a href="http://www.gov.za/speeches/minister-aaron-motsoaledi-health-dept-budget-vote-201516-5-may-2015-0000">divide</a> between the wealthy and the impoverished. This is an inequality that stems from a legacy of poor health care for black and poorer people dating to apartheid. </p>
<p>The divided healthcare system in South Africa means that those who access public services often face severe delays, <a href="http://www.hst.org.za/publications/stock-outs-south-africa-national-crisis">stockouts</a> and inconsistencies in treatment. Public healthcare providers are often under-equipped and poorly staffed. The private sector, on the other hand, is supported by private health care insurance. Those who can afford it receive treatment by specialists, increased access to medicine and seldom experience delays in receiving services.</p>
<p>The NHI plan is intended to be implemented over 14 years. The first five years will see health facilities upgraded and health workers employed and trained.</p>
<p>If implemented correctly, the national health insurance scheme will:</p>
<ul>
<li><p>provide healthcare funding for all citizens based on a contributory system with wealthier people contributing more;</p></li>
<li><p>improve negotiations with providers such as hospitals, clinics and healthcare professionals to supply services and rational payment levels with quality assurance;</p></li>
<li><p>create one public fund with adequate reserves and funds for high-cost care; and</p></li>
<li><p>promote efficient and effective service delivery in both public and private sectors.</p></li>
</ul>
<p>But the plan has been described as <a href="http://mg.co.za/article/2013-05-03-00-let-private-skills-come-to-nhis-aid">unfeasible</a>. South Africa’s current healthcare system cannot support all-out-access to health care. There are several reasons why.</p>
<p>First, the health insurance proposal is a costly exercise. The government has yet to publish the funding model for the NHI, but one <a href="http://econex.co.za/publication/nhi-note-7/">estimate</a> published in 2010 pegged the cost of the insurance at US$16billion (R216 billion) per year. The estimate included existing government expenditure on health, which for 2015-16 is budgeted at <a href="http://www.treasury.gov.za/documents/national%20budget/2015/review/chapter%205.pdf">R157.3 billion</a>. </p>
<p>Some academics have estimated that increase by the proposed plan would need a 17% <a href="http://www.health-e.org.za/wp-content/uploads/2013/05/b443983d20a5b269befacd5f580f2d14.pdf">tax increase</a>, which is not feasible for the South African taxpayer.</p>
<p>Second, distribution of healthcare funds, a lack of trained healthcare professionals and increasing healthcare costs all detract from ministerial capacity to regulate public health care. The proposed plan is meant to address these concerns, but with the financial burden the plan will impose, it is currently unlikely that it will resolve these concerns.</p>
<p>However, the NHI plan could change how providers are paid, allowing everyone to access health care based on what patients need, not what they can afford. </p>
<h2>Health care for all in Zambia</h2>
<p>Universal access to health care in Zambia looks slightly different. Under the current administration, access to health services and medicine is free. In 2006, healthcare fees were dropped for patients in rural areas – the first step to provide free care for all Zambian citizens.</p>
<p>But the system has not been running smoothly. It has been plagued by medicine stockouts, a lack of trained healthcare professionals, uneven access to healthcare services in rural areas and a limited capacity from the ministry to maintain services.</p>
<p>Zambia’s health budget has <a href="http://www.reportlinker.com/p01083759-summary/Zambia-Pharmaceuticals-and-Healthcare-Report-Q1.html">increased</a> from USD1.42 billion (8.746 billion Kwacha) in 2014 to USD1.57 billion (9.983 billion Kwacha) in 2015. Despite this substantive allocation to <a href="http://info.worldbank.org/etools/docs/library/48612/zambia.pdf">health care</a>, there are still <a href="https://equinetafrica.org/bibl/docs/DIS29ngulube.pdf">budgetary</a> issues and irregular distribution of funds. </p>
<p>It was widely thought that user fees were the greatest reason for a lack of use of healthcare facilities. Dropping the fees resulted in a <a href="https://equinetafrica.org/bibl/docs/Dis57FINchitah.pdf">40% increase</a> in the use of healthcare services. But it failed to consider additional costs citizens would incur as they needed transport and access to clinics. This was unsustainable for them. </p>
<p>As a result of the increased costs related to transport, the poor in Zambia still struggle to access health care and medicines despite the premise of universal access to health care and medicines. </p>
<p>The challenges have also meant that the government has had extra costs in implementing the system. These are mainly transport costs because medicine stockouts require multiple trips back and forth and untrained staff mean trained staff need to travel to different hospitals in different regions.</p>
<p>Zambia cannot abandon its policy of free health care. Despite these challenges, however, the perception of universal access to health care in Zambia is still quite positive. The government is seen to be making increased efforts to address these challenges, including training staff, addressing supply chain management issues and managing funds allocated for health care.</p>
<h2>The regional health dilemma</h2>
<p>The challenges in Zambia and South Africa are faced in many unequal societies. In the developed world, universal health care is entirely different. Many Western systems rely on heavy taxation of their citizens to provide adequate universal access to health care. This cannot be a reality in southern Africa. Considering the high levels of poverty, most people cannot be taxed.</p>
<p>Universal health care would be positive for countries in the region, who all need access to health care and medicines. But the financial implications create barriers for this ideal. Many governments lack resources to provide health care for the impoverished. </p>
<p>That’s not to say it could never be achieved or that the ideal should not be worked towards. Increased collaboration with regional organisations, including the <a href="http://www.sadc.int/">Southern African Development Community</a> could assist in creating regional solutions for universal access to health care for the region. This would allow for stronger partnerships and increased funding to mitigate these challenges, and develop solutions to challenges faced by the Global South.</p><img src="https://counter.theconversation.com/content/48949/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erica Penfold receives funding from the Economic Science and Research Council. She is affiliated with The South African Institute of International Affairs. </span></em></p>Healthcare that everyone can access is an important step in bridging the inequality in a country. In reality though, its hard to implement properly.Erica Penfold, Research Fellow, South African Institute of International AffairsLicensed as Creative Commons – attribution, no derivatives.