Health Systems Trust Equity Gauge Project

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Health Systems Trust Equity Gauge Project

• A Partnership between the Health Systems Trust
  and South African Parliamentarians
• Presented by Antoinette Ntuli

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Objectives

• To actively monitor equity in health and health
  care
• Support legislators in utilising equity oriented
  information and analysing health policy
  especially with regard to budgeting and resource
  allocation
• Instil the notion of monitoring equity as a key
  strategy for the promotion of equity among the
  media and the general population of South Africa
• Strengthen the accessibility and quality of
  health data
• Pilot mechanisms whereby disadvantaged
  communities can utilise information to better
  advocate for improvements in equity and the
  meeting of their health needs
• Stimulate responsiveness of legislators, local
  councillors and service providers to needs
  identified by their communities.

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Key Equity Promoting Achievements Since 1994

• Equity enshrined in SA constitution
• Equity underpins policy development
• Unitary Public Health System
• Progress with the establishment of a District
  Health System
• Free Primary Health Care and free care for
  children and pregnant mothers
• Upgrading of existing and building of many new
  clinics
• Introduction of community service for newly
  qualified health personnel

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Promulgation of Legislation

• Health Specific Legislation impacting on
• Medical Schemes
• Medicines and related substances
• Mental health
• Tobacco products
• Professional Councils
• Laboratories

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Value for Money? Some International Comparisons
Country South Africa Botswana Thailand Venezuela
GDP per capita in 8908 6872 6132 5495
Under 5 mortality per 1000 69 59 30 23
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Public/Private Divide

• Private sector expenditure in 2000 was R3898 per
  person, almost five times Public sector
  expenditure of R779 per person
• Less than 1 in 5 people have medical aid coverage
  
• Almost 70 of whites having medical aid coverage
  while less than 10 of Africans have medical aid

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Health Status in South Africa

• Infant mortality rate 47 for Africans and 11
  for whites
• Under 5 mortality rate 64 for Africans and
  15 for whites
• Provincial as well as racial inequities
  stunting twice as prevalent in Mpumalanga where
  it is 30 as in the Western Cape where it is
  under 15

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Public Sector Expenditure

• Per capita expenditure is below R650 in four
  provinces while it is more than R1200 in the
  Western Cape.
• Sometimes inequity within provinces is even
  greater, with some districts spending as much as
  four times more than others per person on health
  care

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Trends in Government Financing of Health Care

• 1992/3 to 1997/8
• Growth in Government Financing
• Move towards greater provincial equity
• Shift of resources to primary health care
• 1998/9
• Reversal of redistribution between provinces
• Limited growth in PHC expenditure

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Health Sector Financing
Doherty et al. 2002.Health financing and
expenditure in the post-apartheid era. 2002 SAHR
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Household Spending on Health Care

• A survey of households affected by AIDS found
  that they spent on average a third of their
  income on healthcare with some rural families
  spending half of their income on health care.
• 54 of income of rural households was spent on
  health care compared to 26 for urban households
• From A Survey of Households impacted by
  HIV/AIDS in South Africa What are the
  Priority Responses?

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Inequity in Provincial Health Spending
250
200
150
100
50
1996/97
-
Rands
1997/98
(50)
1998/99
(100)
(150)
(200)
(250)
(300)
Free State
Gauteng
Eastern Cape
Mpumalanga
Western Cape
Northern Cape
KwaZulu-Natal
Northern Province
Doherty et al. 2002.Health financing and
expenditure in the post-apartheid era. 2002 SAHR
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Personnel

• In Eastern Cape and Northern Province 12
  medical practitioners per 100 000 people as
  compared with 32 in the Western Cape
• Between 60 and 70 of spending is on salaries

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Health Care Personnel in the Private and Public
Sectors 1999
Source National Health Accounts, The private
sector report 2001
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HIV/AIDS

• Difficult to monitor impact of HIV on equity.
  However it is expected that those areas already
  most disadvantaged are likely to be more
  disadvantaged by HIV. This is born out by a
  recent study among families affected by AIDS
• There is also evidence that AIDS is making this
  poverty worse. It is difficult to imagine a
  response to this epidemic that does not in some
  way try to alleviate poverty and address the lack
  of basic services like sanitation
• From A Survey of Households impacted by HIV/AIDS
  in South Africa What are the Priority
  Responses?

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Household Sewerage Disposal
From A Survey of Households impacted by HIV/AIDS
in South Africa What are the Priority
Responses?
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Impact of HIV/AIDS

• Estimates as to HIV related bed occupancy in
  hospitals are as high as 60
• Life expectancy to drop by as much as 20 years by
  2010
• Social impact may be devastating as a result of
  the increases poverty, large number of orphans
  and the effect of loss of life on teachers,
  nurses etc

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Recommendations

• Stronger equity/backlogs component to formula for
  allocating global budgets to provinces
• Reviewing provincial processes that determine the
  health allocation within provinces
• Further measures to reduce the inequity between
  the private and public sector. A Social Health
  Insurance that allows for cross subsidising
  between the haves and the have nots

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Recommendations

• Need for a national comprehensive human resource
  strategy
• Attempt to redress urban rural inequity
• Training staff for the level of care that is
  required

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Recommendations

• In addition to above measures intended to
  strengthen the Public Health System as a whole
  there is a need for
• Clarity on the way forward for containing the
  impact of HIV/AIDS especially with regard to ART
  and ensuring access to cheap medicines
• Seeking opportunities to strengthen
  public/private partnerships as a vehicle for
  providing care
• Recognising that our response to HIV/AIDS has to
  be multi-sectoral and include poverty reduction
  strategies as well as measures designed to
  improve access to basic facilities, especially
  sanitation

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THANK YOU