1. Health in South Africa since 1994:
achievements and challenges.
Will current policy initiatives resolve the
crisis?
SaSa
A WHO Collaborating Centre for Research and Training in Human Resources for Health
David Sanders
Emeritus Professor
School of Public Health
University of the Western Cape
Member of Global Steering Council
Peoples Health Movement
Member of Steering Committee PHM South Africa
2. South Africa’s comparative performance in health
Disease pattern and premature mortality – levels and
causes
Health policy and the health sector: advances and
continuing challenges
NHI and ‘Re-engineering PHC’: rationale and
challenges to implementation
Proposed priority initiatives to address health
challenges, including the role of social movements
3. Democracy: so much promise …
• Legislation
– Constitution
– UNCRC
– Children's act
• Policies & programmes
– basic services
– in social grants &c
– clinic building
– Tobacco control
– Food fortification
– PSNP
• Global
– Adoption of MDGs
5. National Health Indicators
• Life expectancy 49.41 (60)
• Infant mortality 33.4
– EC 45 vs WC 18
• Under five mortality 47.7
- KZN 61 vs WC 25
• Maternal mortality 300
• No. living with HIV 5.58 million
South African Health Review 2011
6. Quadruple burden of disease
pre-transitional diseases and poverty related
conditions eg childhood undernutrition and infections,
maternal mortality
emerging chronic diseases eg obesity, heart disease,
diabetes, mental ill-health
injuries - including interpersonal violence
HIV/AIDS and TB epidemics (TB cases increased
from 109,000 in 1996 to 341,165 in 2006. 55% cases
also have HIV)
MRC Burden of Disease Unit, 2004
7. Millennium development goal 4
Goal 4: Reduce child mortality
Reduce by two-thirds, between 1990 and 2015, the
under-five mortality rate
Photo:LReynolds
11. Causes of under-five deaths in South Africa
• Neonatal causes;
pneumonia,
diarrhoea and other
child illness; and
HIV/AIDS each
account for 30% of
U5 deaths
• According to Child PIP
60% of children were
underweight and a
third were severely
malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12, 2008, 1294-1304
15. Trends in diarrhoea deaths
numbersofchilddeaths
Numbers increasing, but fewer die
Source: Tony Westwood
16. Diarrhoea in the city
Numbers increasing, but fewer dehydrated
Source: Tony Westwood
17. Good paediatrics & health system
performance is not enough
Selective PHC:
Access to good health care
Dealing with the causes?
✓
✗
These (& the causes of the causes)
lie outside the domain of the DoH …
and the dominant 'narrow' paediatric
vision of child health
18.
19. Table XX: Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20%
of households
Children in
richest 20%
of households
Income poverty
*
100% 0%
Child hunger
*
28% 3%
Inadequate water
*
54% 9%
Inadequate sanitation
*
47% 9%
Overcrowding
*
28% 5%
Educational throughput
†
46% 17%
Clinic far from home
*
46% 25%
Source: Statistics South Africa (2011) General Household Survey 2010. Analysis by Katharine Hall, Children’s Institute, UCT.
* See Part 3: Children Count – The numbers for more information on these indicators.
†Proportion of children aged 16 – 17 who have completed compulsory schooling (grade 9).
21. Figure 2. Diabetes prevalence based on 1985 WHO criteria presented by age categories for men
and women in 1990 and 2008/09.
Peer N, Steyn K, Lombard C, Lambert EV, et al. (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans.
PLoS ONE 7(9): e43336. doi:10.1371/journal.pone.0043336
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043336
25. Consumption of sweet beverages and confectionery
Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola
products per person per year, an increase from
around 130 in 1992 and 175 in 1997.
In 2010, up to half of young people were reported to
consume fast foods, cakes and biscuits, cold drinks,
and sweets at least four days a week.
Carbonated drinks are now the third most commonly
consumed food/drink item among very young urban
South African children (aged 12–24 months)—less
than maize meal and brewed tea, but more than
milk . Hawkes C. (2002), Coca-Cola Company (2010)
Theron et al (2007), Reddy et al. (2010)
27. • There is a shortage of healthy
low-fat food and little fresh fruit
and vegetables in the
townships.
• ‘Low-fat milk is not available in
our shops’, stated one of the
CHWs after she had tried to
cut down on the fat in her diet.
• ‘I am scared of exercising
because I will lose weight and
people may think that I have
HIV/AIDS.’
Chopra M, Puoane T. Diabetes Voice 2003; 48: 24–6.
Societal Factors in Obesity
32. Rapid growth of supermarkets in
South Africa
• Supermarkets now share at
least 50-60% of food sales50-60% of food sales in
South Africa, with the
majority of this growth
occurring after 1994
• In a recent study, nearly
two-thirdstwo-thirds of households in a
rural area in South Africa
were now buying their food
at supermarkets
Number of households in two rural areas in
Transkei, Eastern Cape going to supermarkets
Xume Luzie Total
Percent of
total
78.4% 50.0% 64.8%
Source: D'Haese, Marijke, and Guido Van Huylenbroeck. "The rise of
supermarkets and changing expenditure patterns of poor rural households
case study in the Transkei area, South Africa." Food Policy 30 (2005): 97-113.
34. Total imports of soft drinks and processed snack
foods into South Africa and other SADC countries
Source: FAOSTAT detailed trade data
35. Regional trade and investment policies in SADC since 1990
• early 1990s: ongoing liberalization associated with multilateral trade
negotiations
• 1996: SADC trade agreement signed
• 1997-2003: South Africa strengthens investment policy and signs 22
Bilateral Investment Agreements
• 1999: South Africa signs bilateral agreement with European Union (EU)
• 2000: SADC trade protocol comes into effect; Government of South
Africa strengthens support for regional export and investment
• 2002: new Southern Africa Customs Union Agreement completed
• 2007: Interim Economic Partnership Agreement concluded between EU
and Botswana, Lesotho, Namibia, Swaziland and Mozambique
• 2008: SADC Free Trade Area completed (except for Angola,
Democratic Republic of the Congo, Seychelles)
36. “… trade policy that
actively encourages the
unfettered production,
trade, and consumption of
foods high in fats and
sugars to the detriment of
fruit and vegetable
production is contradictory
to health policy …” (p 10)
37. From a Nestlé press release:
Vevey, February 21, 2008
“Popularly positioned products (PPPs). Products
aimed at lower income consumers in the developing
world, will continue to grow strongly in 2008 and
beyond. Nestlé PPPs, which mostly consist of dairy
products, Nescafé and Maggi culinary products,
grew by over 25% to reach around CHF 6 billion in
sales in 2007. The overall market for such products in
Asia, Africa and Latin America is estimated at over CHF
80 billion.”
38. Olivier de Schutter
UN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence, The Guardian, 9 March 2012
39. SA: Income share by decile
Leibbrandt, Finn & Woolard (2012).
http://dx.doi.org/10.1080/0376835X.2012.645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
% share
of income
41. “…the underlying philosophy for restructuring the
health system is the primary health care
approach, with emphasis on appropriate,
comprehensive, promotive, preventive, rehabilitative
and curative care provided by appropriate PHC
facilities, with priority for PHC service in rural areas
and poor urban areas…based on full community
participation…”
National Health Plan 1994
Policy endorsement of PHC
42. Comment
The concept of PHC had strong sociopolitical
implications. It explicitly outlined a strategy
which would respond more equitably,
appropriately and effectively to basic health care
needs and ALSO address the underlying social,
economic and political causes (determinants) of
poor health.
43. SELECTED KEY POLICY ADVANCES
AND IMPLEMENTATION SUCCESSES
• Unification of separate health services
• Establishment of districts
• Anti-smoking legislation
• Free health care for mothers and children
• Choice on Termination of Pregnancy Bill
• Notification of and enquiry into maternal deaths
• Clinic building programme (1800 built)
• Essential drugs list
• Primary School Nutrition Programme
• HIV/AIDS programmes expanded (PMTCT & ART)
44. ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC
POLICIES AND BIOMEDICAL DOMINATION
• Failure to address inequities between public
and private sectors
• Voluntary severance packages and downsizing
of health workforce
• Ringfenced funding of tertiary and academic
care but not primary
• Grossly inadequate funding (until recently) of
priority programmes e.g. HIV/TB
• Failure to implement intersectoral approaches
• Slow transformation of training programmes
• Increasing dominance of managerialism
• Abandonment for 10 years of community health
worker programmes
45.
46. Size of private insurance
WHO National Health Accounts database
47. Health workforce
Drs per 10 000 population
Source: WHO country profile [http://apps.who.int/nutrition/landscape/report.aspx?iso=rwa]
51. Currently, both the coverage and quality of these priority
interventions are inadequate, especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings. Only 35% of young children (12 – 59
months) received vitamin A supplements, 38% of
pregnant women received antenatal care in the first 20
weeks of pregnancy, and only 26% of babies were
exclusively breastfed for the first six months.
Department of Health (2012) Strategic Plan for Maternal, Newborn, Child and
Women’s Health (MNCWH) and Nutrition in South Africa 2012 – 2016. Pretoria: DoH.
Shisana O et al (2010) South African National HIV Prevalence, Incidence, Behaviour
and Communication Survey, 2008: The Health of Our Children. Cape Town: HSRC
Press.
52. Immunisation
DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source: WHO country profile [http://apps.who.int/nutrition/landscape/report.aspx?iso=rwa]
53. What are the key challenges to improving
access to quality health care?
54. Key actions to strengthen the health system
Dedicated, adequate and skilled health workforce
Sustainable and equitable access to health
services
Competence and accountability from managers
and leaders
Lancet 374, 2009: 760
55. • National Health Insurance (NHI)
• Re-Engineering Primary Health
Care
56.
57. Health care financing and rationale for NHI
Mechanism for addressing:
• Existing health system challenges
Ensuring whole population is:
• Able to get care when needed - 16.6% experience difficulty in
accessing health care (Shisana et al 2007)
• Financially protected from the costs of care (currently 13% of
health care spending is out-of-pocket)
58. National Health Insurance Proposal
Recognition of the crisis
Principles:
– Universal coverage
– Social solidarity
– Equity
– Access
– Efficiency
– Primary health care
59. Increase funding of health services through:
•Increased allocations from general tax revenue
•Mandatory health care contributions by employees
and employers
•Removal of tax subsidies to medical aids
•Pool these funds
60. Purchase from accredited providers (public and private):
Medical schemes will remain:
Likely that membership will decline
Fewer schemes
61. Additional aspects of NHI
• NHI fund administered separate from DOH
• Office of Standards Compliance
• Accreditation of facilities
• 11 Pilot districts – PHC model (current)
63. The three key recommendations are essentially:
1.Strengthen the district health system (DHS).
2.Place much greater emphasis on population based
health and outcomes, which includes a new strategy for
community-based services through a PHC outreach
team based on community health workers (CHWs) and
mobilising communities.
3.Pay greater attention to those factors outside of the
health sector that impact on health, the social
determinants of health (“upstream factors”)
63
64. Three streams for Re-engineering PHC
(a) a ward based PHC outreach team
for each electoral ward;
(b) strengthening school health
services; and
(c) district based clinical specialist
teams with an initial focus on
improving maternal and child
health.
64
66. PHC outreach team
– Professional nurse,
– staff nurse and
– community health care workers
The PHC outreach team will provide
comprehensive PHC health care services to a
defined number of families. Each PHC
outreach team will operate out of a PHC clinic
which is based within the community that it
serves. A PHC clinic may accommodate more than
one PHC outreach team with a recommended
maximum of three PHC teams per clinic
66
68. Global examples of CHW ratios
Brazil:
•248,000 CHWs
•Population of 121 million
•1 CHW for a population of approx 500 people
Thailand:
•750 000 village health volunteers
•Population of 70 million
•1 VHV to 93 people / 5 per 15 households
Rwanda:
•60 000 CHWs
•11 million population
•1/5th
population of South Africa with the same number of
CHWs
69. Evidence for impact of community health workers
delivering curative interventions
Diarrhoea
Pneumonia
70. Implementation of CCM in Africa
pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
71. Evidence for impact and cost-effectiveness
of community health workers
• Recent systematic review including studies
from Sub Saharan Africa on impact of CHWs
delivering curative interventions for children
• CHWs in national programmes achieved large
mortality reductions of 63% and 36%
respectively, with curative interventions.
Christopher et al. Human Resources for Health, 2011
72. • Selection
• Training
• Health system factors – esp support & supervision
• Community factors
• Political, macroeconomic and international factors
• Financial and non-financial incentives
Factors influencing success of CHW
programmes
Lehmann and Sanders, WHO, 2007,
http://www.who.int/hrh/documents/community_health_workers.pdf
Haines, Sanders et al, Lancet, 2007, Vol. 369, pages 2121-2131
74. Nearly 60% of the existing Human Resources are
either nurses or paramedical workers while
doctors contributed to less than 7%
Rwanda now has 60,000 CHWs
76. Trend in Early Childhood Mortality
Deaths per 1,000
live births
28 ?
MDG
50 ?
MDG
77. U-5 MR: Rwanda & SA
U-5 deaths / 1000 live births
Source: WHO country profile [http://apps.who.int/nutrition/landscape/report.aspx?iso=rwa]
Rwanda
SA
MDG goals
78. Current CHW training and scope of practice
in South Africa
• Focusses on assessment and referral
• No curative functions
• Advising families where CHWs could be
delivering the interventions themselves:
“Inform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and
other necessary micronutrient supplements.”
Monitoring of pilot NHI site in NW province shows
that most frequent reasons for referral to health
facility are to collect Vit A and anthelminthics
79. Summary
• The current CHW programme will not
result in desired reductions in child
mortality without extending their scope
to include some curative functions and
improving the ratio of CHWs to
househods
80. NHI Pilot Districts
12 months progress report
Presentation to the Portfolio Committee on Health
Committee Room 514, Marks Building
24 July 2013
81. Background
• August 2011: NHI Green Paper – action plan
• April 2012: NHI pilot districts to prepare for:
– Purchasing of services;
– Engaging the private sector;
– Introducing a district health authority;
• April 2013: Rapid appraisal to:
– Assess progress in preparing for NHI
– Provide a framework for monitoring
82. NHI domains appraised
1. NHI management
2. Hospitals
3. Quality
4. Primary Health Care
re-engineering
5. Infrastructure &
Equipment
6. Human Resources
7. Health information
8. District Management
Teams
9. Conditional Grant
10.Referral
11.Contracting Private
83. Key
Nearly or completely achieved (where numerical data available >75%)
Partially achieved (where numerical data available 25 - 74%)
Minimally, or not achieved (where numerical data available <25%)
No data available
Tabular summary per District
86. NHI COULD be a mechanism to redistribute health care
resources BUT some key challenges need to be
addressed
Definition of an acceptable ‘package’ of services
Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of
NHI fund
Regulation of private sector – to ensure that
inequities are not aggravated
87. Some key challenges need to be addressed
Reconsider ratio of CHWs to households. Several
countries have two tiers of CBWs – full-time CHWs and
part-time CBWs in a ratio of 1:10. This could generate
>400 000 jobs
Definition of an acceptable ‘package’ of services
including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING
ACCOUNTABILITY
88. Rapidly increase investment in training: re-open
nursing colleges, increase output and appropriate
training by medical schools and other HEIs
Brazil has more than 2.5 million workers formally employed in the
health sector, which represents about 1.3% of the country’s
population. South Africa has only 150,509 health professionals in a
population of 51 million (constituting 0.3% of the population) in
2010.
Rapidly increase output of MLWs
Reorientate health professionals to be able to
address local social determinants
Reorientate specialists in District Specialist Teams
89. Reduce power of conservative professional bodies;
enlarge ‘scope of practice’ of non-doctors
Improve incentives and support in rural areas
Upgrade infrastructure in rural/peri-urban areas
REBUILD AND STRENGTHEN CIVIL SOCIETY
90. PEOPLE´S HEALTH
MOVEMENT
The Peoples Health Movement (PHM) is a
large global civil society network of health
activists supportive of the WHO policy of
Health for All and organised to combat the
economic and political causes of deepening
inequalities in health worldwide and revitalise
the implementation of WHO’s strategy of
Primary Health Care.
www.phmovement.org
91. Current Situation
• Awaiting next government draft
• Planning a coalition of progressive organisations
• Campaigning around key elements:
– Free at the point of service
– Single payer system
– Stop private sector subsidies
– No public funds for private profit
92. EXAMPLE: Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION
O.R.T.
NUTRITION
SUPPORT
EDUCATION
FOR PERSONAL
& FOOD
HYGIENE
MEASLES
VACCINATION
BREAST
FEEDING
WATER
SANITATION
HOUSEHOLD
FOOD
SECURITY
Editor's Notes
Biological – TB bacteria
Behavioural – Smoking
Societal – cultural norms – smoking is a sign of success
Structural interventions – Types of houses which increase vulnerability, Tobacco legislation
What about diarrhoea mortality? Here 2 things stand out: (1) a falling death rate from diarrhoea with time in most subdistricts (apart from bumps in 2013 in Khayelitsha, Northern and Southern subdistricts), and (2) enormous inequalities between subdistricts.
Is this due to population sizes? U5MR shows us answer.
Key points: Welcome reduction in the number of cases with dehydration; suggests effective primary care interventions: ORS in particular. Improved access and quality of early interventions.
But total number children with diarrhoea increased from around 4,500 in 2010 to almost 6000 in 2013.
Two possible reasons: (1) incidence of diarrhoea in young children is increasing, or (2) the total number of small children in the metro is increasing: probably both.
This takes us back to the story of the river: The health system is working better — we rescue more children from the diarrhoea river. But then we send them back to the upstream area where they fell into it. Selective PHC vs Comprehensive PHC as visualised in the 1978 Declaration of Alma Ata & Community Orientated PHC developed by the Karks at Pholela in rural KZN in the early 1940s. It focuses on effective, targeted interventions aimed at reducing mortality through prevention and early recognition and treatment of disease. GOBI-FFF the classic example, has saved countless children&apos;s lives.
But it can’t address underlying causes of ill health. These, and the &apos;causes of the causes&apos; cannot be tackled by DoH alone. Requires concerted intersectoral action by other government sectors and meaningful, transformative and empowering community participation. The latter confronts power relationships and is therefore political.
By &apos;narrow&apos; paediatrics I mean the still dominant hegemonic narrow biomedical view of paediatrics as the prevention, diagnosis and treatment of disease through mainly technical and increasingly specialist and subspecialist approaches.
