South Africa’s public health system is a countrywide network of care facilities ranging from mobile and rural clinics to huge academic hospitals in the urban centres.
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Health care in South Africa varies from the most basic primary health care, offered free by the state, to highly specialised, hi-tech health services available in the both the public and private sector.
However, the public sector is stretched and under-resourced in places. While the state contributes about 40% of all expenditure on health, the public health sector is under pressure to deliver services to about 80% of the population.
The private sector, on the other hand, is run largely on commercial lines and caters to middle- and high-income earners who tend to be members of medical schemes. It also attracts most of the country’s health professionals.
This two-tiered system is not only inequitable and inaccessible to a large portion of South Africans, but institutions in the public sector have suffered poor management, underfunding and deteriorating infrastructure. While access has improved, the quality of health care has fallen.
The situation is compounded by public health challenges, including the burden of diseases such as HIV and tuberculosis (TB), and a shortage of key medical personnel.
However, the South African government is responding with a far-reaching reform plan to revitalise and restructure the South African health care system, including:
- Fast-tracking the implementation of a National Health Insurance scheme, which will eventually cover all South Africans.
- Strengthening the fight against HIV and TB, non-communicable diseases, as well as injury and violence.
- Improving human-resource management at state hospitals and strengthening co- ordination between the public and private health sector.
- Deploying “health teams” to communities and schools.
- Regulating costs to make health care affordable to all.
- Increasing life expectancy from 56.5 years in 2009 to 58.5 years in 2014.
The bulk of health-sector funding comes from the South Africa’s National Treasury. The health budget for 2012/13 was R121-billion, which was aimed at improving hospitals and strengthening public health ahead of the National Health Insurance scheme.
In 2011, total spend on health was R248.6-billion – or around 8.3% of GDP, way above the 5% recommended by the World Health Organisation (WHO). Despite this high expenditure, health outcomes remain poor when compared to similar middle-income countries. This can largely be attributed to the inequities between the public and private sector.
According to the National Treasury’s Fiscal Review for 2011, the GDP spend on health was split as follows:
- R120.8-billion (48.5%) in the private sector, which covers 16.2% of the population or 8.2-million people, many of whom have medical cover.
- R122.4-billion (49.2%) in the public sector, which is made up of 84% of the population, or 42-million people, who generally rely on the public health care sector.
- The remaining R5.3-billion (2.3%) is donor and NGO spend.
National, provincial and local
Before South Africa’s first democratic elections, hospitals were assigned to particular racial groups and most were concentrated in white areas. With 14 different health departments, the system was characterised by fragmentation and duplication. But in 1994 the dismantling began, and transformation is now under fully under way.
However, high levels of poverty and unemployment mean health care remains largely the burden of the state. The Department of Health holds overall responsibility for health care, with a specific responsibility for the public sector.
Provincial health departments provide and manage comprehensive health services, via a district-based, public health-care model. Local hospital management has delegated authority over operational issues, such as the budget and human resources, to facilitate quicker responses to local needs.
Public health consumes around 11% of the government’s total budget, which is allocated and mostly spent by the nine provinces. How these resources are allocated, and the standard of health care delivered, varies from province to province.
A Health Charter has been devised with the aim of creating a platform for engagement between sectors to address issues of access, equity and quality of health services as well as issues of broad-based black economic empowerment and employment equity.
South Africa has more than 110 registered medical schemes, with around 3,4-million principal members (and 7,8-million beneficiaries).
Hundreds of NGOs make an essential contribution to HIV, Aids and TB, mental health, cancer, disability and the development of public health systems. The part played by NGOs – from a national level, through provincial and local, to their role in individual communities – is vitally important to the functioning of the overall system.
National Health Insurance
The Department of Health is focused on implementing an improved health system, which involves an emphasis focus on public health, as well as improving the functionality and management of the system through stringent budget and expenditure monitoring.
Known as the “10-point plan”, the strategic programme is improving hospital infrastructure and human resources management, as well as procurement of the necessary equipment and skills.
Under this plan, health facilities – such as nursing colleges and tertiary hospitals – are being upgraded and rebuilt to lay the way for the implementation of the National Health Insurance (NHI) scheme.
The NHI is intended to bring about reform that will improve service provision and health care delivery. It will promote equity and efficiency to ensure that all South Africans have access to affordable, quality health care services regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.
The NHI will be phased in over 14 years, beginning in 2012. In 2012/13, the government earmarked R1-billion to its pilot projects.
Apart from infrastructure and management overhauls, another factor for ensuring the success of the NHI will be the strict regulation of the sector to make it more affordable to all South Africans.
There are 4 200 public health facilities in South Africa. People per clinic is 13 718, exceeding WHO guidelines of 10 000 per clinic. However, figures from March 2009 show that people averaged 2.5 visits a year to public health facilities and the usable bed occupancy rates were between 65% and 77% at hospitals.
Since 1994, more than 1 600 clinics have been built or upgraded. Free health care for children under six and for pregnant or breastfeeding mothers was introduced in the mid-1990s.
The National Health Laboratory Service is the largest pathology service in South Africa. It has 265 laboratories, serving 80% of South Africans. The labs provide diagnostic services as well as health-related research.
In March 2012, 165 371 qualified health practitioners in both public and private sectors were registered with the Health Professions Council of South Africa, the health practitioner watchdog body. This includes 38 236 doctors and 5 560 dentists.
- The doctor-to-population ratio is estimated to be 0.77 per 1 000. But because the vast majority of GPs – 73% – work in the private sector, there is just one practising doctor for every 4 219 people.
In response, the Department of Health has introduced clinical health associates, midlevel health-care providers, to work in underserved rural areas.
About 1 200 medical students graduate annually. In some communities, medical students provide health services at clinics under supervision. Newly graduating doctors and pharmacists complete a year of compulsory community service in understaffed hospitals and clinics.
In an attempt to boost the number of doctors in the country, South Africa signed a co- operation agreement with Cuba in 1995. South Africa has since recruited hundreds of Cuban doctors to practice here, while South Africa is able to send medical students to Cuba to study.
South Africa believes the Cuban opportunity will help train the doctors it so desperately needs for the implementation of the National Health Insurance Scheme.
Other agreements exist with Tunisia and Iran, as well as between Johannesburg Hospital and Maputo Central Hospital.
The government has also made it easier for other foreign doctors to register here.
The Allied Health Professions Council of South Africa had 3 773 registered “complementary health” practitioners in 2012.
Statutory bodies for the health-service professions include:
The National Health Act, 61 of 2003, provides a framework for a single health system for South Africa. The Act provides for a number of basic health care rights, including the right to emergency treatment and the right to participate in decisions regarding one’s health.
The implementation of the Act was initiated in 2006, and some provinces are engaged in aligning their provincial legislation with the national Act.
Other legislation relating to health care, some recently passed, include laws which aim to:
- Ensure all health establishments comply with minimum standards through an independent entity (National Health Amendment Bill, 2010)
- Make drugs more affordable and provide for transparency in the pricing of medicines (Medicines and Related Substances Amendment Act, 59 of 2002)
- Regulate the medical schemes industry to prevent it from discriminating against “high risk” individuals like the aged and sick (Medical Schemes Act, 1998)
- Legalise abortion and allow for safe access to it in both public and private health facilities (Choice on Termination of Pregnancy Act, 92 of 1996)
- Limit smoking in public places, create public awareness of the health risks of tobacco by requiring certain information on packaging, and prohibt the sale of tobacco produces to anyone younger than 18 (Tobacco Products Control Amendment Act, 23 of 2007)
- Provide for the introduction of mandatory community service for nurses (Nursing Act, 2005)
- Introduce a process to develop and redesign mental health services so as to grant basic rights to people with mental illnesses (Mental Health Care Act, 2002)
- Allow non-pharmacists to own pharmacies, with the aim of improving access to medicines (Pharmacy Amendment Act, 2000). This came into effect during May 2003.
Other important developments in health care policy and legislation include:
HIV and tuberculosis
Aids and other poverty-related diseases such as tuberculosis and cholera place a tremendous strain on South Africa’s health care system. According to Statistics South Africa, in 2011:
- The overall HIV prevalence rate was 10,6%. About one-fifth of South African women in their reproductive ages were HIV positive.
- There were 5,38-million people living with HIV. This was up from 4,21-million in 2001.
- 16,6% of the adult population (aged 15-49) years was HIV positive.
- There were about 2,01-million orphans due to HIV.
- New HIV infections for 2011 among adults was estimated at 316 900.
- An estimated 1,06-million adults and 105 123 children were receiving antiretroviral treatment in 2010. This was up from 101 416 and close to 12 000 children in 2005.
In May 2012, the government said it had cut the mother-to-child transmission rate from 3.5% in 2010 to less than 2%. It also said the rate of new infections had dropped from 1.4% to 0.8% in the 18 to 24 age groups.
HIV and TB are dangerous bed fellows: the co-infection rates exceed 70%, with TB being the most common opportunistic infection in HIV-positive patients.
Because of late detection, poor treatment management, drug-resistant forms of TB (known as DR-TB or multidrug-resistant TB; and XDR TB or extensively drug-resistant TB) have increased significantly, with about 5 500 cases diagnosed during 2009.
Integrating the double scourge of HIV/Aids and TB for the first time, the government has launched the National Strategic Plan for HIV/AIDS and TB for 2012 – 2016. It is shored up by a provincial implementation programme.
The plan seeks to address the social structural drivers of HIV/Aids, STD and TB care, prevention and support; to prevent new infections; to sustain health and wellness; and to protect human rights and access to justice of sufferers.
The HIV Counselling and Testing (HCT) campaign was launched in April 2010 – by mid- 2012, almost 20-million people had been tested and knew their status. Millions were also screened for TB.
Increasing the number of anti-retroviral sites as well as nurses certified to initiate ARV treatment has seen 1.7-million people placed on ARV treatment, from 1.1-million in 2009. South Africa has the largest ARV therapy programme in the world, and an improved procurement process has seen a 50% decrease in the prices of ARV drugs.
South Africa is a signatory to several international commitments such as the UN’s Millennium Development Goals (MDGs), which seeks to address the health needs of women and children. However, in South Africa the health of mothers and children remains poor.
According to statistics from WHO, South Africa has a maternal mortality ratio of 310 deaths per 100 000 lives births. The infant (under-1) mortality rate in 2010 was 41 deaths per 1 000 live births, while the under-5 mortality rate was 57 per 1 000 live births.
Under the national prevention of mother-to-child (PMTCT) programme, every pregnant woman is offered HIV testing and counselling. If a woman tests positive for HIV, she is put on to a regime of anti-retroviral therapy to avoid transmitting the virus to her baby, and is offered a continuum of treatment, care and support for herself and her infant.
But it is really access and utilisation of antenatal care services that most influence pregnancy outcome, child survival and maternal health. The renewed focus on primary health and the improving and expanding the health system infrastructure should go some way to addressing the high mortality rates – and get South Africa closer to the MDG target of reducing infant mortality to 20 by 2015.
The Department of Health has a strategic plan in place which identifies “priority interventions” that will have the greatest influence on reducing mortality rates, as well as enhancing gender equity and reproductive health.
The campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), an African Union initiative, was launched in May 2012 and aims to reduce maternal and infant mortality rates.
Immunisation is a significant barrier against disease and death, and the rates of children receiving their primary vaccines have steadily been increasing under immunisation programmes. These aim to protect children against vaccine-preventable diseases, such as measles, TB, cholera and pertussis.
Measures to improve child health also include the expansion and strengthening of school health services and the establishment of district clinical specialist teams.
Other prevention services, such as regular deworming and growth monitoring, help protect children’s health.
The Health of our Children report in 2010, which surveyed 8 966 children, found that HIV prevalence among infants (age 0 to 2 years) was 2.1%, lower than the 3.3% average in the age 0 to 4 years, suggesting a positive impact of the national Prevention of Mother-to-Child Transmission programme, begun in 2006.
Malaria is not endemic in South Africa, and does not pose a major health risk. According to the WHO’s World Malaria Report 2010, only 4% of the population is at high risk of malaria and 6% at low risk, while 90% live in malaria-free areas. Almost all cases are caused by Plasmodium falciparum. Transmission occurs seasonally, with peak rates of infection occurring in April and declining by June.
An estimated 80% of South Africans consult with traditional healers alongside general medical practitioners.
The Medical Research Council (MRC) founded a traditional medicines research unit in 1997 to introduce modern research methodologies around the use of traditional medicines. It also aims to develop a series of patents for promising new entities derived from medicinal plants.
Brand South Africa reporter
Last reviewed: 2 July 2012
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