Burden of Disease

                     Source: McIntyre and Ataguba (2012)

94. To exacerbate the inequities in health financing, both government and state owned enterprises as employers contribute significant amounts of public funds to medical schemes. Preliminary estimates indicate that the contribution by government to medical schemes (open and restricted) in 2015 is well-in-excess of R20 billion annually and these funds are mostly spent within the private health sector. This creates a fiscal problem for government as public funds are used to subsidies state employees to meet the rising costs of health care in the private sector.

95. South Africa also has weak purchasing mechanisms. At present, there is a relatively passive relationship between purchasers (i.e. those who hold a pool of funds and transfer these funds to providers) and service providers. Existing ways of paying providers in both the public and the private health sectors are inefficient. The current system of line-item budgeting in the public sector does not provide incentives for efficiency or for providing good quality care. Fee-for-service payments, as used within the private sector environment, create an incentive to provide as many services as possible, even where these may not be medically necessary or appropriate, again generating inefficiencies.

3.2 Burden of Disease

96. South Africa is faced with a quadruple burden of disease in the form of communicable diseases such as HIV and AIDS and TB; maternal and child mortality¹⁸; NCDs such as                                                                                                                          

18Maternal  mortality  –  This  is  the  number  of  women  who  die  due  to  pregnancy  related  causes  and  is  measured  per  100,000  live  births  in  a   given   population.   It   includes   any   pregnancy   related   death   and   is   measured   from   the   beginning   of   pregnancy   to   six   weeks   after   birth   or  

0%  

20%  

40%  

60%  

80%  

100%  

%  share  of  benefit   %  share  of  need  

Poorest  20%  of  populagon   Second  poorest  20%  

Middle  20%   Second  richest  20%  

Richest  20%  

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hypertension and cardiovascular diseases, diabetes, cancer, mental illnesses, chronic lung diseases such as asthma; as well as Injury and Trauma. The combined impact of these epidemics has had an effect on the doubling of death rate between 1997 and 2006 in South Africa.

97. HIV, AIDS and TB have significantly contributed the most in this increased death rate. In 2012, an estimated 6.4 million people living with HIV resided in South Africa. The estimated number of new infections in South Africa was 1.08% in 2012. The number of newly infected children aged 0 – 14 years fell by 56.2%, from 66,000 in 2008 to an estimated 29, 000 in 2011. More than 85% of women in need of Prevention of Mother to Child Transmission (PMTCT) services were estimated to be covered in 2014. According to the UNAIDS estimates, the national HIV prevalence among the general adult population aged 15 – 49 years old has remained stable at around 17.3% since 2005. The WHO Global TB Control report of 2012, estimates that South Africa has the third highest TB incidence rate and the second highest Multiple-Drug Resistant or MDR-TB incidence globally. The TB incidence has decreased in South Africa over the last few years from being third to sixth highest globally.

98. Maternal and child mortality still contributes significantly to overall mortality even though the specific contributions to overall mortality have decreased over time. The Medical Research Council’s (MRC) Rapid Mortality Survey in 2014 reports that the Maternal Mortality Ratio (MMR) has reduced from 281 per 100 000 live births in 2008 to 197 per 100 000 live births in 2011. The Neonatal Mortality Rate (NMR) has also declined from 14 deaths per 1000 live births in 2009 to 11 deaths per 1000 live births in 2011. Under-5 Mortality (U5MR) rate has reduced from 56 deaths per 1000 live births in 2009 to 41 deaths per 1000 live births in 2013. Infant Mortality Rate (IMR) has reduced from 39 deaths per 1000 live births in 2009 to 29 deaths per 1000 live births in 2013.

99. There is an increased need for services for speech, vision, audiology, oral health and psychological services including cognitive assessments for school-going children. The increased prevalence of NCD’s globally and in South Africa is contributing at least 33% to the burden of disease. Common risk factors for NCD’s include tobacco use; physical inactivity; unhealthy diets, and excessive use of alcohol. The South African National Health and Nutritional Health Survey (SANHANES)-1 published by the Human Science Research Council (HSRC) in 2013 reflects that Government’s tobacco control policy has succeeded in reducing adult smoking by half, from 32% in 1993 to 16.4% in 2012.

100. The need to address social determinants of health is highlighted by increasing healthcare costs, morbidity and mortality associated with the management and treatment of communicable and non-communicable diseases impacting adversely on the affordability of the health system.

101. Violence and injury also contribute significantly to the burden of disease. South Africa has an injury rate of 158 per 100 000. The most recent South African Burden of Disease data indicates that road traffic accidents and interpersonal violence are the leading causes of Years of Life Lost (YLL).

termination  of  pregnancy.  Child  mortality  includes  peri-­‐natal  and  neonatal  mortality.  Peri-­‐Natal  Mortality–is  the  death  of  a  baby  who  was   born  live  after  20  weeks  of  pregnancy  or  dies  within  7  completed  days  after  birth  measured  per  1000  births.  It  includes  stillbirths.  Neonatal   mortality–  refers  to  the  death  of  a  live  born  baby  within  28  days  of  birth  and  is  measured  per  1,000  live  births.  

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102. The recent increase in life expectancy and reduction in mortality rates cannot be sustained under the present health care system that is mainly curative, fragmented and unaffordable.

The high burden of disease, mal-distribution and inadequate human resources as well as the poorly financed health system has contributed to the inability of the health system to maintain the above gains on a sustained basis.

103. The move towards National Health Insurance must therefore be informed by a deliberate effort to eliminate this fragmentation from the health system. The policy trajectory must be based on the clear objective of entrenching income and risk cross-subsidisation mechanisms that will ensure that all citizens are provided with (1) adequate financial risk protection; (2) an opportunity to equitably benefit from the health system; and (3) the ability to contribute towards the funding of the health system based on their ability to pay.

104. The solution to these structural shortcomings in health financing will be outlined in subsequent chapters that deal with NHI coverage and healthcare financing.

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