Finance

This report highlights the achievements of the Greater Tzaneen Sub-District (former Halegratz District) in improving health care delivery without a fully-fledged Sub-District Management Team. The aim of the report is not to play down the importance of DMTs, but rather to emphasise that motivated and commitment task teams can bring significant improvement in delivery of the health care services. The Greater Tzaneen Sub-Districts success depended on Quality of Care Task Teams, which were guided by an Interim Sub-District Manage-ment Team (Sub-DMT) that did not have the authority described above.

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.

This Equity Gauge represents a partnership between legislators and the Health Systems Trust. It is designed to support national and provincial legislators in their policy monitoring role and specifically in monitoring the move towards equity in health and health care. Although there has been considerable progress towards equity since the first democratic elections in 1994, the picture painted in the Gauge is still bleak. Whilst the homelands no longer exist in any formal sense, their legacy remains, impacting harshly upon the lives of those who live in these areas. Whether equity in health and health care is measured by health status, by province, by race, or according to the urban/rural divide, it is almost exclusively, poor African people, whose lives are most impoverished by inequity in South Africa. The Gauge will be regularly revised. This will allow it to be updated and findings from new research to be incorporated. It will also enable progress and changes to be traced over time.

The objectives of the HER should be to determine total expenditure on health care and quantify its distribution by type of service, geographic area, and input category, and its sources of finance. It should provide information on all public and private sector sources of finance and providers of services, but not on other health-related activities, such as water supply and sanitation.

Like health, good nutrition is the outcome of many and multiple factors. Nutrition is affected by the policies and activities of numerous sectors, including agriculture, finance, health, education, water and environmental affairs and welfare. That is why problems of poor nutrition in South African communities need to be addressed in a comprehensive and integrated manner, and a previous editorial has argued for leadership from the Health Ministry in developing a common national strategy for good nutrition in South Africa.

In order for the health workers (managers, clinicians and support staff) in a district to work efficiently and effectively, they should have as much control over what they do as possible. One of the key areas where districts should have their say is in the management of resources in the district. This means, in effect, that districts should have the accountability and responsibility for financial decision making, and therefore control over staffing.