Reflections on a decade of health
An assessment of the Department of Health’s delivery over the past decade earns it a mixed report. This article was first published in the South African Health Review in July 2004.
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
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
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