CHAPTER 1: INTRODUCTION AND BACKGROUND
1.2 Background
1.2 Background
1.2.1 Historical Context of Health Care Financing Reforms
27. South Africa has a rich history of several proposals and attempts to implement health financing reforms namely: the 1928 Commission of Old Age Pension and NHI; 1941 Collie’s Committee of Inquiry into NHI; the 1943 African Claims that proposed equal treatment in the scheme of Social Security; the Dr Henry Gluckman National Health Services Commission of 1943 to 1944 that proposed NHI; The Freedom Charter as adopted by the Congress of the People, 1955; the 1994 Ministerial Committee on Health Care Financing; the 1995 Ministerial Committee of Inquiry into NHI (Broomberg and Shisana Report); the 1997 Social Health Insurance Working Group; Professor Taylor’s 2002 Committee of Inquiry into a Comprehensive Social Security System; Ministerial Task Team on Social Health Insurance and the 2009-2014 Ministerial Advisory Committee on NHI.
28. Under the African Claims in South Africa the Charter on Health states :
“a drastic overhauling and re-‐organisation of the health services of the country with due emphasis on preventive medicine with all that it implies in modern public health sense.., strongly urged the establishment of free medical and health services for all sections of the population; …the establishment of a system of School Medical Service with full staff of medical practitioners, nurses and other health visitors… increased hospitals and clinic facilities both in the rural and in urban areas; Increased facilities for the training of African doctors, dentists, nurses, sanitary inspectors, health visitors (and) a coordinated control finance of health services for the whole Union” (14 December, 1943).
29. From this Health Charter in the African Claims, it is apparent that the problems faced in the 1940’s are still with us today and require even more urgent attention. The reforms
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described in the African Claims were envisioned to address institutionalised challenges in the health system, particularly through the establishment of a coordinated funding mechanism. The African Claims proposed the introduction of school health services and community based care services coupled with improved staffing. The aim of such a system was to end inequalities in access to care between the rural and urban areas amongst others.
30. At the Congress of the People in Kliptown in 1955 the same problems were identified and articulated in the Freedom Charter, which was adopted then as follows:
"A Preventative health scheme shall be run by the state.
Free medical care and hospitalization shall be provided for all with special care for mothers and young children”.
1.2.2 Progress since the advent of Democracy
31. Prior to the 1994 democratic breakthrough, South Africa had a fragmented health system designed along racial lines. One system was highly resourced and benefited the white minority. The other was systematically under-resourced and was for the black majority.
The Constitution has outlawed any form of racial discrimination and guarantees the principles of socioeconomic rights including the right to health. In 1994, a new single de-racialised public health system was born with national, provincial and local government services to provide comprehensive health care as stipulated in the White Paper on the Transformation of the Health Care System (Department of Health,1997) and the National Health Act (Department of Health, 2003). These changes were aimed at improving quality, equitable access, efficiency and effectiveness of the health system.
32. Attempts to deal with the abovementioned disparities and to integrate the fragmented services that resulted from fourteen health departments (serving the four race groups, including in the ten Bantustans) did not fully address the inequities. Problems linked to health financing biased towards the privileged few have still not been adequately addressed. Post-1994 attempts to transform the healthcare system and introduce healthcare financing reforms were thwarted. This has entrenched a two-tiered health system, public and private, based on socioeconomic status and this system continues to perpetuate inequalities in the current health system.
33. Primary health care, delivered through the district health system, was made the cornerstone of the health policy, beginning a shift from the earlier hospital-based curative approach. All user fees were abolished for pregnant women, children under six years of age and people living with disabilities. Access to primary health care services, measured in terms of visits per year, increased from 67 million in 1998 to 129 million by December 2014, with the desired concomitant decline in utilisation of public hospitals observed.
34. After 1994, the government implemented a massive infrastructure programme that saw more than 1,500 new and revitalised health facility infrastructure projects being completed, to facilitate access to healthcare facilities within a five kilometre radius of where people live. This was coupled with community based services and outreach services in underserved areas.
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35. During this period efforts were also made to enhance human resources for health. To date, more than 44,000 health professionals have been deployed for community service especially in rural and underserved areas. From 1996, a large number of doctors were recruited from Cuba to further expand coverage to these underserved areas. In subsequent years more doctors were also recruited from countries such as Iran and Tunisia.
36. Government also expanded the national training platform for medical students in South Africa. Through the Nelson Mandela-Fidel Castro collaboration, a medical training programme was established in Cuba alongside the recruitment programme. As a result of this collaboration there are 3,344 medical students training in Cuba as at 2014. The domestic training platform has been expanded since 2011 by increasing student intake and plans to build new medical schools or to expand existing ones are in place.
37. Nursing remains the backbone of the South African health system. A Primary Health Care (PHC) category for nursing was introduced to support the PHC system. From 2009 to 2013, the number of nurses trained on Nurse Initiated Management of Anti-Retroviral Therapy (NIMART) increased from 250 to 23,000. This increase contributed to the massive roll out of Anti-Retroviral Therapy (ART) resulting in the largest ART programme in the world.
38. The process of strengthening the nursing colleges as the primary training platform is underway. This has been undertaken in order to reverse the trend that started in 1987 which has undermined nursing colleges through a policy which favoured universities as primary training platforms, resulting in disinvestment in nursing colleges.
39. The changes achieved in the management of health services were also accompanied by changes in procurement of medicines. In 1994 the pharmaceutical sector was characterized by lack of equity in access to essential drugs, with a consequent impact on quality of care. The introduction of a series of reforms including the development of a new drug policy, which included an Essential Drug List (EDL), standard treatment guidelines and improved affordability of medicines contributed to improved access to medicines. The public sector procurement systems were reorganised to achieve the best prices. In the private health sector a transparent pricing system has been implemented, which regulates the price of medicines in the supply chain system from manufacturer through to the patient. This system reduced the cost of medicines in the private sector by over 20% with a compound reduction of the annual price increases as regulated through the Single Exit Price (SEP) mechanism.
40. Over the period since the advent of democracy, South Africa has been able to reduce poverty-related diseases like measles, malnutrition, and malaria and improve the management of non-communicable diseases. The HIV and AIDS epidemic peaked in the 1990s. Initially, government's response to the HIV and AIDS epidemic was ambiguous but has in recent years turned the corner. During the same period the incidence of tuberculosis increased concurrently. In partnership with civil society and development partners, the country has made significant strides in reducing the tide of HIV and AIDS and tuberculosis. This has contributed to the increase in life expectancy.
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41. Despite the progress that has been achieved so far including improved life expectancy, the health system's effectiveness and efficiency still remains a huge challenge. These challenges are more pronounced in relation to the inequitable financing of the health care system whereby the poor are still largely marginalised and many other South Africans are at risk of catastrophic health expenditure3.
42. Given the history outlined above, and the need to improve health system’s effectiveness and efficiency, South Africa must implement NHI in line with provisions of the NDP. The NDP proposes that an NHI system needs to be implemented in phases, complemented by a reduction in the relative cost of private medical care, improved quality and supported by better human capacity and systems in the public health sector.
43. If the above measures and other interventions are implemented, the NDP envisages that in 2030 “South Africa will have a life expectancy of at least 70 years for men and women;
the generation of under-20 should be largely free of HIV; the quadruple burden of disease will have been radically reduced compared to the two previous decades, with an infant mortality rate of less than 20 deaths per 1000 live births, and the under 5 mortality rate of less than 30 per 1000 live births”. Furthermore, the NDP envisions that by 2030 there should have been a significant shift in equity, efficiency, effectiveness and quality of healthcare provision and that universal coverage is available. The risks posed by the social determinants of health and adverse ecological factors should also have been reduced significantly.
44. It is imperative that South Africa implements NHI to achieve the goal of an integrated health care system that serves the needs of all, regardless of race, socio-economic status and ability to pay for services.