Managing Social transitions forHealth: The Experience from SouthAfricaCharles Hongoro8thGlobal Symposium on Health Promotion12thJune 2013Social science that makes a difference
Social science that makes a differenceOutline• Global social transitions with healthimpacts• Resulting Demographic &epidemiological transitions• Transformation of the South Africanhealth system towards UHC
Social science that makes a differenceSocial Change ?• Mr Mohammed Iqdal Chaudhry defines is asthe reorganisation of society in terms of timeand space• Horton and Hunt defined is as change inoverall societal structure and relationships ofa society. Social change is the alternation ormodification that takes place in a socialstructure or function of a society. It is thechange in both material and non-materialculture• Social change effects on health?
Social science that makes a differenceGlobal social transitions with healthimpacts• Industrialisation/development/growth oftechnology -• Globalisation/global Capitalism -• Global recession -• Urbanisation -• Migration -• War/conflict -• Environment/global warming -
Social science that makes a differenceResulting Demographic and epidemiological transitions• North:– Declining populations– Aging populations:• Increase in NCDs• Impact on economy & less resources for health– Increasing refugee/immigrant populations(migration)• Poor health outcomes among refugee/immigrantpopulations (often living in poverty, credentials from homecountry not approved, food insecurity, stress, etc.)– Decline in funding for health (global recession)• Decline in funding for health research, slows pace oftechnology development, etc.
Social science that makes a differenceResulting Demographic & epidemiological transitions• South:– Increasing life expectancies (addressing burden ofcommunicable disease, increase in health technologies)• Increase in NCDs• Double burden of communicable & NCDs (e.g. more people livingwith HIV/AIDS)– Increasing populations in urban areas (urbanisation)• Poor health outcomes in urban slums– Decline in funding for public health (global recession)• Shrinking global resources for health– Poverty and poor conditions for workers (global capitalism)• Poverty, poor health outcomes
Social science that makes a differenceThe Experience of South Africa• 1994, political freedom but massive social and economicinequalities• Growth in public investments in health, education, housingwater and other economic sectors such as mining, etc.• Significant economic growth but limited employmenteffects and equitable benefits• The budget for health is 8.6% of GDP by 2011/12 (almostsplit 50:50 public versus private)• BUT–health outcomes not commensurate with spend• Mixed health system itself a major determinant of healthoutcomes• Health Promotion, disease prevention/control key toaddressing the high disease burden - multi-sectoralinteraction a must -HiAP
Social science that makes a differenceFinancing mechanisms in countries with universal healthsystems compared with South Africa and the USA (2009)Source: McIntyre (2012) using data from WHO National Health Accounts dataset0%10%20%30%40%50%60%70%80%90%100%AustraliaAustriaBelgiumCanadaDenmarkFinlandFranceGermanyIrelandItalyJapanNetherlandsNewZealandNorwayPortugalSpainSwedenSwitzerlandUnitedKingdomCostaRicaCubaThailandSouthAfricaUSAPercentoftotalhealthcareexpenditureMandatory pre-payment Voluntary pre-payment Out-of-pocket
Social science that makes a differenceGovernment Ministries and Inter-sectoral SolutionsHealth in All PoliciesAgriculture,Forestry& FisheriesEducationDefense &MilitaryVeteransHealthEnvironmentalAffairsTrade &IndustryTransport Sport &RecreationHealth PromotionFinance
Social science that makes a differenceTransformation of the South African Health System• The high burden of disease and health careneeds require changes (inter alia) to the healthsystem to ensure:• Improvements in health status• Integration of public & private sectors (2 tiersystem)• Cost containment and improving efficiency inresource use across sectors• Improving sustainability of financing healthservices
Social science that makes a differenceTransformation of the South African Health System• In 2011, Green Paper on NHI– health systemreforms published for public comment• Public comments received and documentrevised into a white paper (Technical TaskTeam)• Draft White paper being finalised by NDoH• Two key elements:• Improving service delivery & quality of healthservices especially in the public sector• Improving health system financing in terms offairness and financial risk protection• NB: 11 pilot districts started in 2012
Social science that makes a differenceOverarching Principles• Constitutional Right to access health care –– Section 27 of the 1996 Constitutional Bill of Rights states that“everyone has the right to access health care services, includingreproductive health care, and that the State must takereasonable legislative and other measures, within its availableresources, to achieve the progressive realisation of these rights.”• Social Solidarity-– All regardless of their socio-economic status will benefit fromNational Health Insurance, which is based on income cross-subsidies between the affluent and the impoverished, and riskcross-subsidies between the healthy and the sick. Such cross-subsidisation will also ensure that the cost burden of ill health isequitably distributed across the life-cycle.
Social science that makes a differenceGoals of UHC• To ensure that the entire population isentitled to benefit from needed, qualityhealth care;• To extend over time the range of services towhich the population is entitled; and• To reduce the extent to which the populationhas to make direct, out-of-pocket paymentsfor health services.
Social science that makes a differencePopulation coverage & Service Benefits• Who is covered? All South Africansand legal permanent residents.• What is covered? Comprehensive listof services with emphasis on healthpromotion, disease prevention andcontrol activities• Who will provide services? Bothpublic and private providers
Social science that makes a differenceServices Delivery Platforms• Emphasis on PHC to ensure access, andaffordability and sustainability of the systemthrough disease prevention and healthpromotion activities at that level.• Three PHC teams established:– 1) Ward based PHC teams– 2) Integrated School Health programme– 3) District Clinical Specialist Support Teams
Social science that makes a differenceWard Based PHC teams• To be deployed in each municipal ward, supported by anurse and linked to a PHC facility such as a clinic.• Each PHC agent will be allocated households to visit on aregular basis.• Purpose is to provide health promotion education, identifythose in need of preventive (e.g. immunisations), curativeor rehabilitative services, and refer those in need ofservices to the relevant PHC facility.• Also facilitate community involvement and participation inidentifying health problems and behaviours that placeindividuals at risk of disease or injury and implementappropriate interventions to address these problems at acommunity level.
Social science that makes a differenceIntegrated School Health Programme• ISHP to improve the physical and mental healthand general well-being of school age children.• It provides a range of promotive, preventive andcurative services and will include a focus onchild abuse, oral health services, visionscreening services, eradication of parasites,nutritional services, substance abuse, sexual andreproductive health rights including familyplanning services, and HIV and AIDS relatedprogrammes.• Initial phase- quintile 1 and quintile 2 schools (i.e.the poorest 40%) will be prioritised.
Social science that makes a differenceDistrict Clinical Specialist Support Teams• Each team includes seven specialists namely:obstetrician and gynaecologist; paediatrician;anaesthetist; family physician; advanced midwive;advanced paediatric nurse; and PHC professional nurse.• The teams will undertake the following four functions:– Develop guidelines and protocols to provide qualitycare for maternal, neonatal and child health services;– Identify training gaps and conduct training to fill thesegaps;– Solicit clinical from specialists in the private sectorwhenever necessary; and– Conduct mortality assessments and regularly reportoutcomes within specified periods.
Social science that makes a differenceInstitutional Arrangement for NHI• Largely tax funded plus other taxes (Treasury)• National Health Insurance Fund (NHIF)– singlefund and single payer• To actively purchase services from both publicand private providers• District Health Authorities – to be establishedto coordinate and manage district healthservices• Mixed payment mechanisms
Social science that makes a differenceKey Messages• Managing health effects of social transition only possiblethrough multi-sectoral action• Health in All Policies – applauded but sectoral interestsremain – require a new leadership – SA New DevelopmentPlan – provides a real opportunity for HiAP• Societies are constantly in transition and therefore needfor adaptive policies and systems approach to planning &implementation• Lessons can be drawn from the experience ofmainstreaming HIV/AIDS in all sectors• Achieving sustainable UHC only possible in the context ofsustained disease prevention and health promotionactivities• The Health Sector must also put its house in order byimproving health systems capacity and resilience!
Social science that makes a difference• I THANK YOU