A decade of health: some reflections
Chalking up the Department of Health’s score for the decade is difficult, as
many achievements have been undermined by the HIV/AIDS epidemic.
In addition, government’s major health policy direction since 1994 – the
move away from a hospital-based system to primary health care (PHC) – has
brought with it both achievements and further challenges.
A key achievement of the PHC policy is that far more people now have easier
access to basic health care, thanks to the upgrading and building of 701
clinics in the past decade.
Accessibility has also been improved by removing financial barriers. In
1994, the government extended free basic healthcare to pregnant women and
children under the age of six. Two years later, free primary care was
extended to all those who needed it. In 2003, a range of free services was
extended to those with disabilities.
Better access to health care has meant that the immunisation rate of
children has improved. As a result, tetanus in babies and polio has been
eliminated, and there were only eight recorded cases of measles in 2001.
But the shift to PHC has not eased the burden on hospitals. Instead,
admissions have increased by about 100 000 a year since 1994, mainly as a
result of AIDS and trauma. Those requiring care are usually much sicker than
in the past, so need more care and stay longer.
Despite the rapid expansion of primary health services and the increasing
burden of AIDS, health expenditure in real terms has declined, according to
Department of Health research (all in 2002 prices).
In 1997/8, real expenditure was R32.9-billion but in 1999/2000, this dropped
to R30.9-billion. Expenditure is expected to rise to R36.8-billion in
2005/6, but in real terms this amounts to little more than an annual
increase of 1.4%.
In 1997/8 government allocated R989 per person whereas, by 2005/6, it will
be spending R948.
The introduction of free health services absolved even those who can afford
to pay from doing so. Some form of cost recovery is vital, possibly through
social health insurance, although there is a real danger that such a
compulsory insurance could put further economic pressure on the working
poor.
While the structures and systems in which to deliver health care to all
citizens have been improved, the glaring glitch in the move to PHC has been
the department’s failure to manage its human resources properly.
Health workers have borne the brunt of the combination of an increase in
primary services and a decrease in expenditure. Their working conditions
have deteriorated steadily as they have had to deal with more patients yet
they have received little financial compensation.
Staff shortages have lead to the deterioration of services, particularly in
densely populated urban areas. Under pressure from patients and blamed for
poor services, many health workers have sought work in the private sector
and overseas.
Many posts are standing vacant and, in 2002 there were 4% fewer professional
nurses in the public service than in 2000.
Ironically, it is easy for overseas countries to poach our doctors and
nurses but red tape makes it very difficult for a foreign health
professionals to work in South Africa.
In late January 2004, government finally listened to health worker
organisations and introduced “scarce skill” and “rural” allowances ranging
from 10-37% of their annual salaries. While this is a positive step, it is
too early to assess its impact.
Government has also introduced a year of compulsory community service for
newly qualified doctors, dentists, pharmacists and other health
professionals to address staff shortages.
Other problems associated with PHC include erratic drug supplies and
breakdowns in the referral of patients who need more specialised care from
clinics to district, regional and tertiary hospitals. Such problems have
been exacerbated by the destabilisation of district health structures caused
when municipal boundaries were redrawn.
Aside from improved immunisation, children’s health in the last decade has
been boosted by the schools feeding scheme and the compulsory fortification
of basic foods including mealie meal and brown bread.
Women now have access to abortion services before their 12th week of
pregnancy. However, there has not been a decline in maternal deaths although
experts attribute this largely to HIV-related illnesses rather than poor
health services
Government’s interventions in private health, motivated by the need the
private sector to take responsibility for more citizens, have been brave but
the results have been disappointing. In 1999, it became illegal for medical
schemes to reject any paying customer or dependent. This year, medical
schemes were compelled to offer a range of chronic care as part of their
basic packages.
However, the membership of private schemes has remained stagnant at around
16% of the population – largely as a result of above-inflation increases in
contributions. Government’s recent efforts to contain the costs of medicines
may finally succeed in making private care more affordable.
Aside from attending to the health systems and human resource problems,
government needs to pay urgent attention to the management of communicable
diseases. The number of tuberculosis cases almost doubled between 1996 and
2002, largely as a result of HIV/AIDS. Yet the cure rate for 2001 was an
unacceptable 54% (the target was 85%).
The roll-out of anti-retroviral drugs provides an opportunity to revitalise
a range of health services, such as drug supplies and laboratory support.
But there is a serious threat of multi-drug resistant HIV if the rollout is
not done properly. So far, very little community mobilisation has taken
place, yet the education of patients and communities is key to the success
of the programme.
Ensuring that health services are equitable, both between provinces and
within provinces – particularly between rural and urban areas – remains a
challenge that is complicated by fiscal federalism.
Government has also committed itself in the 2003 Health Act to the gradual
devolution of more health responsibilities to local government, starting
with environmental health services in July 2004. However, this policy
direction needs careful consideration given the many weaknesses at local
level.
Author
-
Kerry Cullinan is the Managing Editor at Health-e News Service. Follow her on Twitter @kerrycullinan11
View all posts
Republish this article
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Unless otherwise noted, you can republish our articles for free under a Creative Commons license. Here’s what you need to know:
-
You have to credit Health-e News. In the byline, we prefer “Author Name, Publication.” At the top of the text of your story, include a line that reads: “This story was originally published by Health-e News.” You must link the word “Health-e News” to the original URL of the story.
-
You must include all of the links from our story, including our newsletter sign up link.
-
If you use canonical metadata, please use the Health-e News URL. For more information about canonical metadata, click here.
-
You can’t edit our material, except to reflect relative changes in time, location and editorial style. (For example, “yesterday” can be changed to “last week”)
-
You have no rights to sell, license, syndicate, or otherwise represent yourself as the authorized owner of our material to any third parties. This means that you cannot actively publish or submit our work for syndication to third party platforms or apps like Apple News or Google News. Health-e News understands that publishers cannot fully control when certain third parties automatically summarise or crawl content from publishers’ own sites.
-
You can’t republish our material wholesale, or automatically; you need to select stories to be republished individually.
-
If you share republished stories on social media, we’d appreciate being tagged in your posts. You can find us on Twitter @HealthENews, Instagram @healthenews, and Facebook Health-e News Service.
You can grab HTML code for our stories easily. Click on the Creative Commons logo on our stories. You’ll find it with the other share buttons.
If you have any other questions, contact info@health-e.org.za.
A decade of health: some reflections
by Kerry Cullinan, Health-e News
August 24, 2004