The publication of this Health Review forms an important milestone in health systems reform in South Africa and serves three important functions. First, it presents available information about health and health care in a systematic and comprehensive manner. In doing so, it provides an instrument whereby the implementation of new health policies can be evaluated periodically. Second, it critiques policy developments in the health sector in an attempt to document progress and identify resolved and unresolved policy questions. Third, it helps formulate a research agenda to address and clarify unclear policy issues.
The South African Health Review 1996 documents the degree to which structural reform and policy formulation within the health sector has translated into real improvements in service delivery and the quality of peoples lives. In sum, the Review reveals a mixed scorecard. Progress has been excellent in some areas, whereas others show little movement. This, the Review argues, is the nature of health reform.
Perhaps the overriding success of the Ministry of Health has been the process of restructuring towards primary health care, reflected both in the organisation of health care and expenditure patterns. Equally impressive has been the introduction of an essential drugs list within the public sector, which is likely to improve the availability of medicines over a relatively short period of time. At local level, the Department of Health can take credit for generating tremendous enthusiasm for change amongst service managers and health workers.
But in the critical areas of financing and health legislation, progress has been slow. Discussions about some form of social health insurance have borne little fruit. A new Health Act is in its seventh draft, but has not been available for public comment. In addition, controversy over Cuban doctors and vocational training for new graduates has often obscured the need for a comprehensive plan for addressing the maldistribution of health personnel in South African - from province to province, between public and private sector, and between hospital and primary care facilities. All of the above need to be addressed as a matter of urgency in the next year.
The South African Health Review 1996 tackles Sarafina 2 head-on, and considers its effect on HIV/AIDS prevention, the ability of the Department to make progress over the past year, and the relationship between the executive and legislative arms of health governance. But it places the biggest controversy faced by the Health Department during 1996 in the context of the full programme of health care reform initiated by the Ministry. Areas of energy and activity which serve as the vanguard of health reform have been identified, as have bottlenecks which impede progress.
Paying for health care: a comprehensive primary health care approach - alternative to national health insurance
The South African Health review is a recognised barometer of the progress of reform in the health service. This years health review is frank in its assessment of successes and failures, but expands its scope of information by including a survey of the realities in clinics in every province in the country.
While previous reviews have focused on the development of new policies as part of the restructuring in the health sector, this Review concentrates on trying to assess the extent to which new policies have been translated into real improvements in the quality of life of South Africans. The Review found that while major steps forward have been made in the arena of policy, much remains to be done in order to implement these policies.
The clinic survey highlights the fact that despite the commitment to providing primary health care for everyone there is continuing disparity between service provision in rural and urban areas, with rural people, and poorer provinces still losing out. For example, the survey showed that only 41% of rural clinics have an ambulance at their door step within an hour of an emergency call compared with 74% in urban clinics. The move towards more equitable provision has become even more uncertain now that funding for health is at the discretion of provincial cabinets, (from the beginning of the 1997/98 financial year each province received a block grant from the national Treasury).
In contrast with 1996 which saw only one new piece of legislation, in 1997 a number of pieces of legislation with the potential to reform the health services were introduced to parliament, nonetheless problems remain with implementation. The possibility for women to exercise their constitutional right to reproductive choices improved dramatically when termination of pregnancy legislation came into effect in February 1997, but service provision has proved to be patchy at best with a number of provinces doing much less than their proportional share of terminations. The clinic survey reveals that only just over 60% of rural clinics and about 85% of urban clinics offer family planning services on a daily basis.
With South Africa facing one of the worst TB epidemics in the world, there has been commitment at national and provincial level to implementing a new control programme. However many barriers still exist, and despite remarkable improvements in some provinces, the clinic survey demonstrates that only 10% of rural and 25% of urban clinics receive results within the time recommended by the Tuberculosis Control Programme.
In the hospital sector detailed baseline studies have resulted in clear plans for what needs to be done to achieve physical improvements and work towards reducing inequalities as well as make changes in a range of other fields. The challenging task of implementing these plans remains.
In the field of human resources there have been efforts to re-shape an urban centred, hospital based and doctor dominated service. However there has been uneven progress and a comprehensive strategy which will attract personnel to work in currently under resourced predominantly rural areas has still to be developed.
The Review found it was difficult to measure what has really changed for a poor person in need of health care. One thread running through the Review is that more reliable up-to-date information is needed in order to assess, evaluate, plan, prioritise and improve. This information is required in every part of the health system.
The 1998 Review concentrates on equity and attempts to highlight progress that has been made as well as identify blocks to providing equitable public sector services throughout South Africa. Research commissioned specifically for the Review sheds light on the health status of South Africas population and key areas of the health system including finance and expenditure, human resources, information systems, pharmacy, and service delivery in clinics and district hospitals. This is provides a comprehensive, authoritative and independent review of South Africas health system.
In 1998 the greatest inequity remains the difference between those who predominantly use private sector health care and those who do not. Just under one fifth of South Africas population belong to a medical aid scheme, yet this group has access to 85% of pharmacists and 60% of medical specialists working in South Africa.
In the field of public sector spending comparisons of provincial health budgets indicate that great steps forward were made in the years 1995/6 and 1996/7 with most budgets coming closer to the national average. However since that time progress has stagnated, with the gap between expenditure per person in the North West, Mpumalanga and Northern provinces and the national average remaining a cause for concern. Comparisons of spending within provinces indicate that disparities are greater even than those between provinces. In Potchefstroom and Grahamstown Districts for example, for every R4 spent on health services in the public sector, R1 was spent in the Odi and Mount Frere Districts.
With regard to the distribution of health sector personnel, disparities tend to occur between the more urbanised and historically better funded provinces and those which are predominantly rural. For example there are forty nurses per 10,000 population in the Western Cape whereas in the Northern Cape and Mpumalanga there are only 20 and Gauteng has 2000 people to every pharmacist while the comparable figure in the Northern Province is 16000.
A survey of 294 clinics and 84 regional and district hospitals provides information about service delivery and indicates the variations that exist between provinces and between rural and urban facilities. While 100% of clinics in the Northern Cape have all TB drugs available this is true for only 20% of clinics in the Northern Province and HIV testing is available in less than half of clinics in the Eastern Cape, North West, KwaZulu-Natal, and Northern Provinces. The investigation of maternal deaths was used as one of the indicators to measure the quality of care in hospitals and it was found that less than half of hospitals have meetings where infant and maternal deaths are investigated and discussed.
Results of this survey are compared with a survey of clinics undertaken in 1997 and the findings indicate improvements in some areas. Seventy one percent of all clinics have a functioning telephone in 1998 as compared with 63% in 1997 and 83% of clinics provide family planning services on a daily basis in 1998 as compared with 72% in 1997.
The South African Health Review is accompanied by Technical Reports that provide more detail in the areas of financing, the private sector, pharmacy and service delivery in hospitals and clinics.