South African Health Sector: Presented to Budget committee By Dr. Olive Shisana CEO Human Sciences Research Council

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1 South African Health Sector: Presented to Budget committee By Dr. Olive Shisana CEO Human Sciences Research Council

2 Vision of the Department of Health An accessible, caring and high quality health care system 2006 Department of Health, annual report This presentation aims to assess if this vision is being realised and the challenges the health system faces.

3 Successes of the Department of Built clinics and health centres to increase access to health care In 1996 PHC fees were removed Health Increased visits 1998: 67 million 2002: 85 million 2004: 98 million Increase in the number of visits from 1.8 pp in 1998 to 2.1 in 2004.

4 Successes of Department of Health 249 hospitals out of >400 were rehabilitated 18 new hospitals were built, including 3 major teaching hospitals continued

5 More examples of revitalised hospitals

6 Increased access to medicines in the public sector 16.6% (or 5 million) SA had difficulty accessing medicines Room for major improvement in access to medicine: 36.6% PH vs 39.5% PrH

7 Poor pharmacy stock management Drugs dumped in passage way accessible to public July 2005

8 Access to services Earlier we saw that visits for PHC have increased. While this is true, the HSRC study found in 2005 that 16.6% (or 5.2 million South Africans 15 years and older) faced affordability difficulties.

9 Quality of Care

10 Quality of health care Patient Rights Charter exists, but are patients satisfied with services provided? 51.9% of South Africans using public hospitals and more 54.9% using the private sector say the health system needs a lot of improvement; people wait too long before being served. Satisfaction levels: 16% in public hospitals and 13.3% in private hospitals Same results found for public clinics (42.9%) and private clinics or GPs (54.5%) are dissastisfied HSRC Survey, 2005

11 Care: low satisfaction rate with treatment by health workers Service by Clerks- of 28.9% public hospital users say they are satisfied/feel very good in the way clerks treat patients compared with 22.5% of those using the private hospitals Service by Nurses- public hospitals: 32.4% satisfactory or very good in the public hospitals and 28.3% in private hospitals Service by doctors- public hospitals: 53.4% satisfactory or very good; 43.5% in private hospitals

12 Wet bed in a hospital

13 Examples of incidents reported by Maternity departments during the period September 07 March 2008

14 Item Knowledge versus clinical practice in dental facilities in the Free State, 2004 (Methar, Shisana, Mosala, et al: Hospital infections ) Protective clothing used during procedure and hand washing Knowledge (%) N = 28 Clinical practice (% ) N = 23 P value Use of gloves Masks < 0.05 Washing hands between patients < 0.05 Changing gloves between patients Critical equipment processing Inspection-Visibly clean < 0.05 Soaking in disinfectant Item sterilized between patient New needle for each patient Fresh vial for each patient Sterile drill for each patient Sharps and waste disposal Appropriate discard of sharps < 0.05

15 Poor facility practices put communities at risk Food waste infested with cockroaches and flies File Clinical waste mixed with food, left for weeks, and now difficult to find contractors willing to undertake removal Contractor terminated agreement because needles and syringes were found in food

16 Example of a contravention of the Asbestos Regulations also indicative of a lack of maintenance and ineffectual SHE representatives.

17 Health and safety risk oil and oxygen fire/explosion hazard indicative of a lack of risk management and negligence on the part of the SHE representatives.

18 Health and safety risk fluorescent tubes mercury and broken glass indicative of a lack of risk management and negligence on the part of the SHE representatives.

19 Environmental drying of washed, disposable tubing, catheters and endo tracheal tubes

20 Quality Improvement Programme

21 Quality standards should provide an comprehensive, integrated hospital environment and effective efficient patient care Management Security OPD Casualty Technology maintenance CSSD Theatre PAMS Labs Nursing Radiology Patients Pharmacy Wards Laundry Doctor s input Kitchens Infection control Facility maintenance Administration

22 Standards for health care These standards have been developed in conjunction with South African professional bodies e.g. DENOSA, Society of Surgeons and Society of Anaesthesiologists, ICSSA, etc and are recognised as meeting ISQua s International Principles for Standards. Management Clinical and clinical support Technical Hotel (food, laundry, hotel) Professional allied to medicine

23 Quality improvement is beginning to be implemented in the public health sector The National District Hospital in Bloemfontein has received full accreditation recently. The Free State Department of Health is very proud of this achievement in quality of care.. declared the MEC for Health in the Free State. South African Government Information 2 October 2008

24 Compliance scores achieved by public hospitals participating in the QI Programme Baseline Progress External Re-Entry 17 Trigger Trigger Hospital a Hospital b Hospital c Hospital d Hospital e Hospital f Hospital g Hospital h Hospital i Hospital j Hospital j Hospital k Hospital l Hospital m Hospital n Hospital o Hospital p Hospital q Hospital r Hospital s Hospital t Hospital u Hospital v Hospital w Hospital x

25 Human Resource Challenges Shortage of health workers Medical Practitioners Nurses HIV among health workers

26 Medically equipped hospital, but no trained ICU staff

27 Human Resource Challenge medical doctors are registered with the Health Professions Council Western Cape 14.7 per population Gauteng 12.6 Limpopo 1.8 North West 2.3 Eastern Cape 2.7 Mpumalanga 3.0 Private sector: 60% Rural areas are underserved Migration of doctors to developed countries is a problem The programme to recruit foreign doctors is working

28 Human Resource Challenge, continued nurses are actively working in South Africa Inequitable distribution of nurses in the public and private health sector Inequitable distribution of nurses between provinces Large attrition of nurses

29 HIV among health workers 16% of health workers tested positive for HIV Health workers with CD4 cell counts < 200 cells/μl is large (18.9%), an estimated are succumbing to AIDS and DoH says combined nursing colleges produce professional 424 nurses per year, The supply is not meeting the demand; target for training is by 2011 clearly DoH did not take evidence into account. Shisana O, Hall EJ, Maluleke R, Chauveau J, Schwabe C. HIV prevalence among South African health workers. S Afr Med J 2004; 94: Connelly D, Veriava Y, Roberts S, et al. Prevalence of HIV infection and median CD4 counts among health care workers in South Africa. S Afr Med J 2007; 97: Shisana: High HIV/AIDS prevalence among health workers requires urgent action: February 2007, Vol. 97, No. 2 SAMJ

30 Health Outcomes

31 General Health Status of the South African population, 2005 A total of South Africans were asked a question in general, would you say your health is excellent, good, fair or poor? 21.2% excellent, 59.6% was good, 16.7% was fair and only 2.4% said it was poor

32 Disease 2005 national household survey: Do you currently have any of the following illnesses? (Diagnosed with the illness) Overall Prevalenc e Black Coloured Indian White Diabetes (N=15860) 3.4 % 3.2 % 3.0 % 8.9 % 3.4 % Cancer (N=15851) 0.6 % 0.6 % 0.4 % 0.5 % 1.1 % High blood pressure (N=15960) 14.5 % 14.0 % 13.9 % 14.7 % 18.6 % Tuberculosis (N=15860) 2.1 % 2.4 % 1.3 % 1.0 % 0.4 % Pneumonia (N=15852) 1.0 % 1.0 % 0.7 % 0.7 % 0.7 % Malaria (N=15842) 0.5 % 0.5 % 0.3 % 0.2 % 0.5 %

33 MDG 4,5 & 6 Goals and targets Indicators Goal 4: Reduce child mortality Target 5: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Goal 5: Improve maternal health Under-five mortality rate Infant mortality rate Proportion of one-year-old children immunised against measles Target 6: Reduce by three-quarters, between 1990 and 2015, the maternal mortality rate Maternal mortality ratio Proportion of births attended by skilled health personnel Goal 6: Combat HIV and AIDS, malaria and other diseases Target 7: Have halted by 2015, and begin to reverse the spread of HIV and AIDS HIV prevalence among 15- to 24-year-old pregnant women Contraceptive prevalence rate Number of children orphaned by HIV and AIDS

34 MDG 4 - child survival Registered deaths, <5 years Deaths Registered deaths increased from in 1997 to in Source: Statistics South Africa Difficult to assess completeness of registration for children Year - and it is not yet possible to distinguish increases in death rates from improved registration.

35 MDG 5 maternal mortality Reported maternal deaths Deaths Stats SA - plus pregnant Confidenitial enquiry Stats SA - underlying Year Source: Saving mothers report, DOH. Stats SA. Own analysis of the cause of death statistics

36 HIV prevalence by sex and age: 2005 HIV Positive (%) and above 17.5 Age group (years) Males Females

37 HIV incidence estimates by single year of age in year old age cohorts Age cohort incidence (%) Males Females Age group (years)

38 TB cure rates The national cure rate :54%, target: 85% A large number of patients fail to complete treatment or move between provinces and health districts and are lost to the TB control programme Dept of Health, annual report 2006

39 Health Care Financing

40 Escalating cost of health care Public vs Private Public sector serves 40 million people spending 3.5% of the GDP (R53.2 billion in 2007/08)- UNDERFUNDED public sector Private sector serves 7 million people-spending 5% of GDP About R10 billion of the medical aid scheme is through tax concession by state (public funds) R59.36 was spent on drugs per person in the state sector as opposed to R on drugs per person in the private sector (2006)

41 Why NHI in South Africa? To fundamentally redress inequities in access to health care services and ensure the progressive realisation of the right to health care To achieve fairness in financing and improve the insurance function (protection against catastrophic costs and its consequences) of the health care system Reduce fragmentation of the health care system thereby avoid waste (e.g. suboptimal use of beds and high cost technology), variable quality of services, administration costs and general escalation costs of health care Use the public and private resources to serve all South Africans

42 Principles underlying NHI policy 1. Health is a right; universal access 2. Free at the point of use 3. Choice of provider within the district 4. Mandatory contribution to pay, but according to ability to pay (Social solidarity) 5. Access to services on the basis of need 6. The state bears a constitutional obligation to provide access to health services; 7. State is obliged to attend to the needs of those with the most urgent needs for health care; 8. Funding of services is based on an assessment of needs 9. NHI will be publicly funded and administered

43 Funding of NHI Allocations from general tax revenue and a dedicated health tax (or mandatory health insurance contribution)= single NHI Fund Require progressive real increase in allocation for health No one eligible will be allowed to opt out of NHI Contribution will be shared between employer and employee Contribution will be progressively structured Collected by SARS

44 Funding of NHI, continued The financing process will involve growing the public sector budget on a gradual basis and introducing a mandatory NHI contribution for all people above the income tax threshold; the size of this contribution will increase over time. Funding for infrastructure in the public health sector will be stretched over a period of 15 to 20 years by using innovative ways of financing eg PPPs and borrowing which allow for rapid improvement of physical facilities, while spending less per year.

45 Respondents opinions on providing health care coverage for all South Africans vs holding down taxes, South Africa, 2005 Race Coverage for all N (%) Holding down taxes N (%) No opinion N (%) TOTAL African 5390 (58.8%) 1808 (18.8%) 2321 (22.4%) White 940 (47.8%) 585 (34.2%) 358 (18.0%) Coloured 1554 (52.0%) 659 (22.0%) 730 (26.0%) Indian 916 (55.3%) 347 (17.7%) 465 (27.0%) TOTAL 8800 (56.9%) 3399 (20.7%) 3874 (22.3%) HSRC, 2005

46 Conclusion Vision of the DoH is partly realised Lots of successes, but also Lots of Challenges in Improving health outcomes Increasing access to health care Human resources Quality of services Financing of health care NHI should be funded to permit sharing of resources in both the public and private health care and increasing access to quality health care for all

47 Thank you

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