MRC HIVAN Forum 25 October 2011


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There are numerous changes taking place in South Africa, in the economy, politics and health. All these are interdependent and embedded in a social milieu which brings a number of pressures on health services and systems. The major event in the medium to long term is the impact of the National Health Insurance. Other contextual factors of importance include the range of social determinants of health and disease, with the provision of water, sanitation, electricity and housing being the key services. South Africa will also be influenced in the future by the major diseases it harbours at present. This seminar provided some insight into how these factors will impact on the South African Health Services.

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  • Remove of any country Add gdp Add diseases – make arrow different colours Box – 1 maternatl and child health and 1% of global burden nCN - <1 % HIV – 17% Arrow – text in brackets
  • MRC HIVAN Forum 25 October 2011

    1. 1. Hoosen Coovadia Emeritus Professor of Paediatrics and Child Health, Emeritus Victor Daitz Professor of HIV Research, University of Kwazulu-Natal. Director, Maternal Adolescent and Child Health, University of the Witwatersrand. A Vision of Healthcare in South Africa: 2025-2030 Presentation to the Medical Research Council of South Africa. Durban 25 th October,2011
    2. 2. The Highest Priorities
    3. 3. Eliminating Poverty and Reducing Inequality are Key Strategic Objectives Reducing inequality Eliminating poverty Too few South Africans are employed Poor educational outcomes High disease burden
    4. 4. South Africa: A Cocktail of Four Colliding Epidemics <ul><li>HIV/AIDS and TB </li></ul><ul><li>17% of HIV burden </li></ul><ul><ul><li>23 times > global average </li></ul></ul><ul><li>5% of TB burden </li></ul><ul><ul><li>7 times > global average </li></ul></ul><ul><li>Non-communicable diseases </li></ul><ul><li>< 1% of global burden </li></ul><ul><ul><li>2-3 times > average developing countries </li></ul></ul><ul><li>Violence and injury </li></ul><ul><li>1.3% global burden of injuries </li></ul><ul><ul><li>2 times global average for injuries </li></ul></ul><ul><ul><li>5 times global average for homicide </li></ul></ul><ul><li>Maternal, newborn & child health </li></ul><ul><li>1% of global burden </li></ul><ul><ul><li>2-3 times > average for comparable countries </li></ul></ul>
    5. 5. Government has Broadened Access to Public and Private Services for Many Citizens Source: Statistics SA: General household survey 1996 and 2007
    6. 6. Child Health and Development in South Africa, 2010 - 2011 Source: South Africa Child Gauge 2010/2011. Children ’s Institute. University of Cape Town. <ul><li>No access to clean water: > a third of all children. In 2009; slightly worse than 2008. </li></ul><ul><li>No access to toilets : >a third [6.8m];> 7m in 2008 </li></ul><ul><li>Hunger: 3 million [15.7%] of 18.6 million children in country; 3.3m of 18.8m in 2008. </li></ul><ul><li>Poverty: 61% of children in households with a per capita income <R552/month. </li></ul><ul><li>> 2m [10.9%] children live in back-yards/shacks in informal settlements ; 2.3m in 2008. </li></ul><ul><li>Living in households with no adults employed : 6.6m in 2009;6.5m in 2008. </li></ul>
    7. 7. WHY DO AFRICAN MOTHERS DIE? WHY DO MOTHERS DIE IN SOUTH AFRICA? Source: Saving Mothers Report. DoH. Source: Khan KS et al. Lancet 2006.
    8. 8. <5 MR South Africa Source: South African Child Gauge 2005:57 and Ahmad OB et al. Bull WHO 2000; 78:1175-1191
    9. 9. The Income Gap Between Races is Widening and the Gini Coefficient is Between 0.58 to 0.83 Mean monthly per capita income (2007 Rand) Source: IES data; SA development indicators; 2008; S van den Berg CDE.
    10. 10. IMR per 1000 live births Wealth quintile Poverty and Inequity: Under Five Mortality Rate by Quintile, SA
    11. 11. Source: Miriam Altman. HSRC, 2011 Hunger in the Metros Highest share of hungry households and most extreme levels of hunger occur in urban metros. 36% of all seriously hungry households are found in CT, Ekhurhuleni, Johannesburg and OR Tambo. (GHS 2007)
    12. 12. Strategic Outputs for the Government Programme by NSDA Outputs (By 2014) Maternal Mortality Child Mortality TB Cure Rates New HIV Infections ARV Access Life Expectancy Innovative and enhanced activities, not “business as usual”
    13. 13. <ul><li>Anti-Retrovirals [ART]: Services points from490 to 2 205 health centres; ART-certified Nurses from 250 to 2 000;ARV prices slashed by 53%. </li></ul><ul><li>HIV Testing: from 2 million to 12 million PERSONS. </li></ul><ul><li>Persons on ARVs: from 923 000 in 2010 to 1.4 million [by June 2011]. </li></ul><ul><li>Human Resources: increase in intakes of students, new infra-structure at existing tertiary hospitals, new medical school in Limpopo, R16.1 billion for next 3 years mainly for new training posts. </li></ul>“ Achievements Over Last Year” Chris Bateman. “Motsoaledi declares war on disease-causing products”. SAMJ 2011; 101: 503-504
    14. 14. Source: Ameena Goga. South African AIDS Conference 2011. Durban; HMC. Personal Communication.
    15. 15. Climate Change Impacts on Health
    16. 16. <ul><li>Budget Speech 2011. “War on Industries: “ </li></ul><ul><li>Tobacco </li></ul><ul><li>Alcohol </li></ul><ul><li>Fast-Food </li></ul><ul><li>Existing Health System: </li></ul><ul><li>Lopsidedly Curative </li></ul><ul><li>Hospi-centric </li></ul><ul><li>Destructively costly </li></ul><ul><li>Unsustainable. </li></ul>“ Motsoaledi Declares War on Disease-Causing Products” Chris Bateman. SAMJ 2011; 101: 503-504
    17. 17. We Need a Development Path That Promotes Growth AND Social Equity 1994 Today 2030 Economic growth Social equity
    18. 18. <ul><li>Nation: Characteristics </li></ul><ul><li>Common history </li></ul><ul><li>Common culture </li></ul><ul><li>Similar ethnic origins </li></ul><ul><li>United by language </li></ul><ul><li>Religion </li></ul><ul><li>Location </li></ul><ul><li>Social and economic equities </li></ul><ul><li>An “Imagined” SA </li></ul><ul><li>Single geographic space </li></ul><ul><li>Social and economic equities </li></ul><ul><li>Common citizenship based on “Multiple Identities” but “ Uniting Values”. </li></ul><ul><li>Build on Diversity </li></ul><ul><li>Address concerns of various layers of SA- ”inclusive” </li></ul><ul><li>Constructed on our “Interconnected Differences” </li></ul>Foundations for National Cohesion and a “South African Identity”
    19. 19. “ A large part of the financial and human resources for health is located in the private health sector serves a minority of the population. Medical schemes are the major purchasers of services in the private sector which covers 16.2% of the population . The public sector is under-resourced relative to the size of the population that it serves and the burden of disease it bears.The public sector has disproportionately less human resources than the private sector yet it has to manage significantly higher patient n umbers ” . The Constitution has outlawed any form of racial discrimination and guarantees the principles of socio-economic rights, including the rights to health .
    20. 20. The 2008 World Health Report of WHO: Three Trends That Undermine the Improvement of Health Outcomes Globally Hospital Centrism (Mainly Curative) Fragmentation Services Programmes Uncontrolled Commercialism
    21. 21. **Commission on Old Age Pension and National Insurance (1928) **Committee Of Enquiry into National Health Insurance (1935) **National Health Service Commission (1942 -1944) **Health Care Finance Committee 1994 **Committee of Inquiry on National Health Insurance (1995) **The Social Health Insurance Working Grou&quot;p (1997) **Comittee of Inquiry into a Comprehensive Social Security for South Africa (2002) **Ministerial Task Team on Social Health Insurance (2002) **Advisory Committee on National Health Insurance (2009) **National Health Insurance Historical Development of National Health Insurance
    22. 22. Objectives of the NHI NHI Improved access and quality health services. Pool risks. Procure services on behalf of the entire population and efficiently mobilize and control key financial resources. Strengthen the Public Sector.
    23. 23. Source: Ataguba & McIntyre (2009) Imbalances Between Need and Benefits In The SA Health System
    24. 24. Inequities
    25. 25. Inequity in Funding
    26. 26. Differences in Public and Private Health Sectors in SA (2007)
    27. 27. Sources: South African Health Review, HST; SA Nursing Council Disparities in Public and Private Sector SA Health Workforce (2008)
    28. 28. Trends in Private Hospital & Medical Aid Costs Over Past Ten Years % Change over 10 years Rand (% Change over 10 years)
    29. 29. Medical Scheme Contributions as a % of Income according to wealth <ul><li>INCOME . % CONTRIBUTION </li></ul><ul><li>Lowest >14% </li></ul><ul><li>Middle +/-12% </li></ul><ul><li>Higher > 9% </li></ul><ul><li>Richest 5.5% </li></ul>
    30. 30. Intended Relationships in the NHI
    31. 31. Four Key Interventions
    32. 32. The Breadth, Depth and Height of Universal Coverage Source: McIntyre, 2010
    33. 33. Payment <ul><li>Funds from a combination of sources : </li></ul><ul><li>* Fiscus </li></ul><ul><li>Employers </li></ul><ul><li>Individuals </li></ul>
    34. 34. How Will South Africa Grow? 2020
    35. 35. Source: South Africa Budget, 2011
    36. 36. Cost of Packages of Care <ul><li>The model indicates that resource requirements under this model increases from R125 billion in 2012 to R214 billion in 2020 and R255 billion in 2025 if implemented gradually over a 14-year period. </li></ul><ul><li>The budget is R110 billion in 2012/13 . Medical scheme contributions are estimated to total about R92 billion in 2010 . Over R227 billion spent on health services in 2010, equivalent to 8.5% GDP </li></ul>
    37. 37. National Health Insurance will require an increase in spending on health from public resources (general tax revenue and a mandatory National Health contribution) that is faster than projected GDP increases. However, the ultimate spending on a universal health system relative to GDP (of 6.2%) is less than current spending by government and via medical schemes (of 8.5%). Cost of Packages continued
    38. 38. South Africa – Long-term Budgets 2014 until 2030 – 5% Annual Growth
    39. 39. Re-Engineered Community-Oriented PHC-Based DHS Model Source: Baron and Sasha – Re-engineering for PHC in South Africa (2010)
    40. 40. Source: Baron and Sasha – Re-engineering for PHC in South Africa (2010) Clinic and Community Primary Health Care Outreach
    41. 41. <ul><li>Governance without Government </li></ul>The Changing Ontology of Politics
    42. 42. <ul><li>A regulation can claim political legitimation only if it could be based on a rational discourse of those potentially affected by it. </li></ul><ul><li>The decision-making process of a democratic government has to reflect the needs, fears, values and aims of the citizens which manifest in a communicatively constructed public sphere. </li></ul><ul><li>The linguistic construction of the public sphere is done by more or less spontaneously emerging civil society associations that map, filter, amplify, bundle and transmit problems, needs and values. </li></ul>We owe Jürgen Habermas the idea of rational deliberation Democracy and its (new) enemies: Guido Palazzo HEC University of Lausanne Jürgen Habermas – The Convincing Power of the Better Argument