Question

describe key health challenges, and briefly discuss possible reasons for the prevalence of these conditions, and then, critically evaluate the actual and proposed mechanisms of action within the South African National Health System post 1994, in order to achieve the vision of “ Optimal Health for All”

Answer 1

Greetings of the day!

Answer:

Key Health Challenges:

Challenges Notwithstanding the major successes achieved during the twenty-years , of democracy ,after 1994, the health sector continues to be besieged with major challenges. These include the following:

(a) Poor quality of care, illustrated by persistent complaints and evidence from patients, civil society and the media about services provided at health facilities.

(b) Persistent health inequities

(c) Spiralling costs of care in the private health sector

(d) Limited progress with the implementation of the District Health System

(e) Operational management weaknesses

(f) Declining levels of community participation

(g) High Maternal Mortality Ratio

(h) Rising burden of Non-Communicable Diseases

(i) Violence and injuries

(j) Unaddressed social determinants of health

(k) Instability of the Health Leadership

Possible reasons for the prevalence of these conditions:

These challenges have several root causes:

• First, South Africa has a dual and fragmented health system, which has given rise to major health inequalities. The private sector serves only 17,9% of the population (9,285 million people), and the public sector serves 82,2% (51,943 million people). The private sector has the majority of medical specialists; medical doctors; pharmacists and dentists, but remains accessible to only a segment of the population that can afford medical aid.
• Second, although health care delivery is a concurrent function between the national and provincial spheres of government, while local government is responsible for municipal health services, co-ordination of policy implementation between the three spheres has not been optimal.
• Third, The inability of the health sector to implement a wellfunctioning District Health System (DHS) as a vehicle for the delivery of Primary Health Care (PHC) is a case in point. Whereas the country has been demarcated into 52 health districts, and district managers appointed, there has been limited delegation of powers by provinces to district and facility health management..
• Fourth, community participation in health issues has also diminished over the years. Fifth, Gross financial mismanagement also exists, and has, for instance, led to the Department of Health in Limpopo Province being placed under national administration, and several senior government officials being subjected to disciplinary processes for financial misconduct.

Efforts to combat such unethical behaviour in the public health sector must be escalated. In most parts of the country the health sector has weak operational management capacity at subnational levels. This is evidenced by poor financial management reflected in the reports of the Auditor-General of South Africa; inefficient patient information systems; inefficient drug supply and management systems, which impact on patient care and patient waiting times.

Management capacity has also been compromised by inappropriate appointments made over the years in critical positions, including those of Chief Executive Officers of Hospitals. Furthermore, although health outcomes in South Africa have improved enormously, particularly during the fourth term of democracy, they are not yet commensurate with the country’s expenditure on health, which amounts to 8,5% of the Gross Domestic Product (GDP). These outcomes also do not yet compare favourably with those of other middle income countries, including the BRICS countries. The country’s progress towards the health related MDGs is regarded as significant, but insufficient.

The actual and proposed mechanisms of action within the South African National Health System post 1994, in order to achieve the vision of “ Optimal Health for All”:

The National Health Insurance (NHI) Proposal and Its Plan to Address the Problems of the South African Health System It is these combined problems of inadequate public health services, inefficient and escalating costs of private care, and extreme and widening health inequalities, that the current NHI proposals seek to address.

Initially announced as a key priority by the ANC in its 2009 Election Manifesto, and subsequently confirmed by President Jacob Zuma in his 2010 State of the Nation Address, the NHI proposals were eventually released in the form of a Green Paper for Public Consultation in August 2011 (RSA 2010).

The launch of the final White Paper, initially scheduled for late 2012, has been delayed and is at the time of writing, still outstanding. The broad objective of the NHI is to put into place the necessary funding and service delivery mechanisms to enable the creation of an efficient, equitable and sustainable health care system in South Africa.

In order to address the imbalances in access, utilization of services and health care outcomes among the different socioeconomic groups, the NHI proposals intend a fundamental transformation of the system. The new NHI system will be underpinned by an NHI Fund which will provide finance for health care and will enter into contracts with public and private hospital specialists and public and private GP practices to deliver health services free of charge to every South African citizen and legal resident.

The NHI will be based on the following principles and objectives:

• universality;

• social solidarity;

• equity;

• efficiency;

• quality and effectiveness;

• integrated single system;

• care free at the point of use;

• comprehensive range of health care services.

Of these, universality and social solidarity are possibly the most pivotal, since they assert that all citizens regardless of their socioeconomic (or any other) status will be able to access the same essential health care services on the basis of need regardless of their financial means. It redefines health care as a public good rather than a market commodity and entitlement as a social right. South Africa would thus join the majority of OECD NHS and Social Insurance health systems which encompass five key income cross-subsidies between population groups: from rich to poor; healthy to sick; young to old; individuals to families and men to women.

Funding the NHI

The new system will be funded through (mainly) general tax sources, a new mandatory employment insurance contribution for higher earners, and the removal of tax subsidies for private insurance. Both employers and employees will contribute to the new NHI Fund. The proposed funding structure is highly progressive and must be understood in the context that it is estimated that approximately only 5.2 million South Africans are employed in the formal sector and currently pay income tax (that is 19.14 per cent of the working population) and estimated unemployment rates are between 25 and 40 per cent. According to the 2011 Green Paper it is anticipated that the NHI will require R145 billion additional funding over the next 14 years.

The proposed NHI funding model predicts that fiscal resource requirements will increase from R125 billion in 2012 to R214 billion in 2020 and R255 billion in 2025 over a 14-year period (in real value terms as estimated in 2010). These figures must be compared to current spending on health (2010/11 figures) which was R101 billion, increasing to R110 billion in 2012/13 (2010 prices). Spending in the private sector through medical scheme contributions totaled R90 billion in 2009 (2010 prices). A total of over R227 billion was thus spent on health services in South Africa in 2010, equivalent to approximately 8.5 per cent of GDP (RSA 2011). According to a KPMG report (KPMG 2012) which reviewed the NHI financing model, per capita expenditure on healthcare will increase by 14 per cent in real terms under the NHI arrangements.