Equity is the cornerstone to the Department of Health's transformation of the health system and therefore central to the committee's work
The equity vision is simple in concept and theory but more challenging to bring into fruition. This is becoming more evident to all of us working within the health sector as we face the daily challenge of improving the health of our nation, especially the poor.
A review of progress towards equity must first recognise that deep rooted structural and service inequities have existed for decades cannot be turned around overnight.
The achievement of equity is a process that requires first and fore most:
Unwavering Commitment
Understanding of the problems and environment
Legislation
Transformation and implementation
Monitoring and evaluation accompanied by revisions where necessary
(These stages overlap)
Good progress has been made since 1994. The achievements highlighted below are not exhaustive. There are many facets and determinants of health and simply impossible to encapsulate them all. It is probably fair to say that the laws of every Ministry in government have a bearing on health or health status in some way or another.
The focus here is on initiatives within the health sector that were intended to promote health systems development and equity.
Achievements include: The removal of structural racism
The establishment of a unitary health system
The introduction of free primary health care
The upgrading of many clinics and health centres and building of approximately 500 new ones, in under-served communities.
The establishment of a District Health System (DHS), although progress is variable, the efforts need to be commended.
Provinces and local authorities starting to pool their resources and integrate care, offering a more comprehensive service under one roof.
Community service for newly qualified doctors and contracting Cuban doctors strengthening services in the poorest parts of the country
A massive primary school nutrition programme, which even with implementation difficulties, meant that many children were no longer too hungry to learn greater effectiveness
Transformation of health governance institutions, such as the professional bodies
Important efforts to improve public health, including measures to curtail use of tobacco
In most instances, legislation has been promulgated to provice an enabling environment to facilate the move towards equity.
So what has been the overall effect of all these changes? (From the The National Health Care Facilities Survey 2000, HST)
Greater access and availability of health services
See figure on availability of services at fixed clinics
Improved availability of health professionals
Availability of doctors at fixed clinics improved to 63% in 2000 compared to 54% in 1997
The provision of Primary Health Care services have improved coupled with the provision of intergrated services
For 2000 between 80% and 90% of all clinics offered comprehensive care on a daily basis
Vulnerable groups like children and women and the disabled have been prioritised their health service needs improved
Show Figure on Availability of selected services in rural facilities
Legislation put in place to facilitate necessary changes to the health system
Pharmacy Amendment Bill, Medical Schemes Act to point out just a few
In general drug availability especially at clinic level seems to have improved, facilitated by the introduction of the Essential Drugs List
See figure on Drug availability in rural areas
With respect to some of the Department’s public health efforts.
Prevalence of smoking has decline from 34% to 24% (that’s with a little help from Mr Manuel taxes) between 1992 and 1998.
Also recently on the news, 76% reduction in Malaria cases in KwaZulu-Natal
But, not all has been positive. The negative aspects include:
Emergency services The availability of emergency services remains a problem at clinic level but also with respect to ambulance availability, and where available the response time is simply not acceptable.
The survey revealed that 13% of all clinics in Northern Province, 26% in North West and 37% in Eastern Cape had no transport on any kind available for medical emergency referral. In all 42% of response time, where an ambulance was available, was over an hour. What is more disturbing in the fact there has been little change in response time since 1997. This problem has also been highlighted in recent site visits where patients voice their dissatisfaction with the availability of ambulances.
Quality of care While general access to facilities seems to have improved there are still grave concerns about the quality of care received in public health care facilities. These range from long waiting time to drug shortages and some times unacceptable staff behaviour towards patients. Understaffing and lack of proper equipment all contribute to poor quality of care.
HIV/AIDS A relentlessly worsening AIDS epidemic which government has not sufficiently got to grips with
Personnel While the availability of funds and their equitable distribution between provinces, sectors and health needs will provide the impetus to any move towards equity, it is the human resources that will largely determine the success of most of the objectives and goals that the Department of Health has set for the country. Health personnel are the heart of the entire health system. It matter where they are, what they do, the knowledge they have how many they are, how they are trained.
The first and most pressing issue is that there still exist great inequities in the distribution of health personnel among provinces.
"The inability to enforce fair transfers on public servants or to follow up declines of transfers with retrenchment, has effectively blocked key aspects of transformation. It has prevented balanced workloads and proper staffing of PHC services.
Current human resource model not suitable for middle income country like South Africa, we inherited it but the question is are we doing enough to facilitate the necessary changes. Large number of mid-level health workers (e.g. assistant categories in pharmacy rehabilitation environmental health) need to be effectively retrained and deployed. National intervention is required to drive this.
Large proportion of human resources is tied-up in administration and the fact that salaries tie up a substantial proportion of health sector expenditure, limits the potential for redistribution of resources.
Inequities exist between provinces raging from 0.8/10 000 population in North West to 6.8 in Gauteng. KZN has a 2.2/10 000 ratio of doctors
Retention of skilled staff at hospital level is also a challenge. Voluntary severance packages combined with active recruitment of nurses by private and overseas countries contribute to this.
There are concerns that not enough nurses are being trained. For example between 1996 and 1998 the number of registered nurses only increased by 1 197 not much more than the number or doctors in the same period.
Filling vacant post remains one of the key frustrations
Shortages of allied health personnel impacts negatively on staff morale as it encourages resentment on the part of nurses at having to perform tasks that they saw as the role of support staff.
While the introduction of community service and contracting of foreign doctors has led to the provision of needed services to many rural areas the question remains is enough being done to attract health professionals to rural areas overall. Where are the incentives to facilitate this?
The Private Sector
Shortages of staff in the public sector is further exacerbated by the fact that most personnel with the exception of nurses are concentrated in the private sector.
See figure on Health care personnel in the private and public sectors 1999
The inequity between the two sectors extends beyond human resources. Many of the inefficiencies found in the public sector are fueled by these inequities
General access to the private sector needs to be increased. While this has been recognised by the Department of health the objective is far from being met.
Another major problem is that the sector is poorly regulated. There is appreciation of Legislaiton like the Medical Schemes Act, however there is more that needs to be done.
In short, unless there are proper regulatory mechanisms and access to the private sector remains a privilege of the few. Both the human resource challenges and the inequities between the private and public sector will prove to be the Achilles heel of all our efforts to bring about equity within our health care system.
In concluding, it’s been seven years that we have set out against inequities in our health system. The honeymoon is over. The role of this committee becomes even more critical in monitoring and overseeing the achievements and non-achievements of the Department of Health’s efforts and of the many stakeholders within our health system.
The committee therefore needs to be constructively critical and also give credit were it is due.
See figure on Stunting ask why is stunning still at 23% in 1999 but at the same time credit the Eastern Cape for managing to reduce it in their province.
Make sure that gains are not made at the expense of other areas.
See figure on Urban fixed clinic availability of selected services. While in many rural clinics the availabitility of these services has improved (as seen in figure on Availability of selected services in rural facilities earlier on) in urban areas there seem to have been a stagnation of services and 46% availability of ante-natal care is low even given the fact that there are more private sector services available in urban areas.
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Look beyond overall achievements for problem areas and pockets of non-delivery.
See figure on Immunisation coverage. Why is KwaZulu-Natal having such a low immunisation coverage?
Keep a vigilant eye on inequities that are simply not acceptable.
See figure on Infant mortality
But most of all this committee needs to help stir and guide the equity boat that we all are trying to come to terms with by monitoring, inspecting, questioning, encouraging and motivating all those genuinely seeking to achieve equity in our health system.