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- Volume 2000, Issue 1, 2000
South African Health Review - Volume 2000, Issue 1, 2000
Volume 2000, Issue 1, 2000
Author Patiswa Zola NjongweSource: South African Health Review 2000 (2000)More Less
The year 2000 was a significant one in terms of developments affecting the health sector. Local Government elections in December heralded the beginning of the final stage of the transformation of Local Government, paving the way for the full implementation of the District Health System. The National Health Accounts were undertaken, providing an overview of financing and expenditure in both private and public sector care. And, as can be evidenced by the frequent references to HIV/AIDS in many chapters of this Review, the impact of the epidemic began to be felt in almost every aspect of the health system.
Author Antoinette NtuliSource: South African Health Review 2000 (2000)More Less
During the 1980's many South Africans spent the greater part of their weekends at funerals. As we move into the first decade of the 21st Century this pattern is re-emerging, although for entirely different reasons. Every South African is becoming increasingly intimate with the effects of the HIV/AIDS epidemic, and, as with most preventable diseases, it is the most vulnerable and poorest communities whose lives are most adversely affected. The attention given to HIV/AIDS by many chapters in the 2000 South African Health Review reflects the seriousness of the disease and the widespread impact that the epidemic is already having. Previous South African Health Reviews have highlighted that in most areas of our health system excellent policies are now in place, and the challenge is to ensure implementation. In contrast, what is disturbing in relation to HIV, is that in some critical areas including Mother to Child Transmission and HIV and breastfeeding, there are not even clear policy guidelines.
Author Annalize FourieSource: South African Health Review 2000, pp 3 –50 (2000)More Less
Notable moves, either towards or away from equity in Primary Health Care (PHC) provision in South Africa, are observed when comparing the 1997/98 and the 2000 PHC Facility Surveys. Significant strides towards improvement have undoubtedly been accomplished. Sadly there are also areas in which inequity has increased. Given the supposed increased prioritisation of and budgetary allocation to PHC in South Africa in recent years, improvement across the spectrum of indicators measured in this survey could have been expected. Sadly many areas of PHC remainin dire straits. Undoubtedly there have been marked changes for the better in PHC provision; equally true is that such improvements seem to come at the expense of other areas of PHC.
Author Eric BuchSource: South African Health Review 2000, pp 53 –74 (2000)More Less
The Department of Health's 1999 - 2004 Strategic Framework focuses on accelerating quality health service delivery. This chapter addresses the broad question : Where does the Strategic Framework take us and are we getting there? It systematically reviews the situation pertaining to each of the ten components of the Framework and concludes that on the whole government is on track, but in a number of areas the pace will need to improve and the emergence of a ""policy to implementation gap"" be overcome. It suggests that the Department should not make the assumptions it does on financial resources, health personnel, management systems, co-operation by stakeholders and reversal of the HIV/AIDS epidemic, but should pro-actively address these and include them as part of its Framework. It also argues for a more concrete expression of the vision for the health system, both public and private, and for maximum attention to be given by top management to interventions that are key to overall acceleration.
Author Andy GraySource: South African Health Review 2000, pp 75 –88 (2000)More Less
This chapter draws attention to the health-related legislation emanating from the national and provincial legislatures in 2000. It also looks more broadly at other legislation passed this year that has an impact either on the health of individuals or communities or on the way that the health system operates. New national legislation discussed includes the Pharmacy Amendment Act, the two Chiropractors, Homeopaths and Allied Health Service Professions Amendment Acts, the National Health Laboratory Services Bill and the Council for Medical Schemes Levies Bill. The recent laws of broader impact are the Public Finance Management Act, the Skills Development Act and Skills Development Levies Act, the Promotion of Access to Information Act, the Promotion of Equality and Prevention of Unfair Discrimination Act and the Local Government: Municipal Structures Amendment Act. In addition, regulations to and interpretations of earlier legislation (descriptionbed in previous editions of the Health Review) are outlined. The efforts of provincial legislatures to produce laws that define the operation of the health system are descriptionbed. Finally, the chapter reviews important Constitutional Court rulings with health implications, these being the SAMMDRA, Hoffman and Grootboom decisions.
Author Nadine NannanSource: South African Health Review 2000, pp 89 –124 (2000)More Less
South Africa is undergoing a demographic transition with declining fertility. However, compared with other middle income countries, the health status is poor. This is due to a triple burden of disease from a combination of poverty-related diseases, emerging chronic diseases and injuries. The HIV/AIDS epidemic has exacerbated this in recent years resulting in increased child and young adult mortality and reduced life expectancy. It is estimated that in the next 10 years 6 million South Africans will die from AIDS. However, even at this late stage of the epidemic, there is scope for reducing the impact. There is an urgent need for people to change their behaviour, the management of STD's needs to be strengthened and the transmission of HIV from mother to child needs to be prevented. Anti-retroviral drugs need to be made affordable in the public sector and it is essential to develop appropriate guidelines for the treatment of opportunistic infections. Much could be done to reduce the overall burden of disease through health promoting and disease preventing strategies. These need to target the youth and focus on promoting safe sexual practices, preventing smoking, alcohol abuse and violence. Secondary prevention strategies are also important and the limited control of hypertension suggests that there is much room for improvements in primary care. Extensive inequalities in health status by population group, urban/rural area and province have been observed. Social interventions are necessary to overcome the extensive levels of poverty and unemployment in South Africa. While some of the disparities in health reflect the underlying economic inequalities, the health sector needs to find ways to redress these inequalities. The national epidemiological database has clearly improved over the last few years. Government needs to continue its efforts in this regard. In particular, mortality statistics need to be compiled more rapidly and the disease notification system needs attention. It is timely for South Africa to undertake a national burden of disease study to assess the coherence of the different data sources and provide consistent estimates of the health of the nation and subgroups.
Author Charlotte MuhekiSource: South African Health Review 2000, pp 127 –147 (2000)More Less
The funding of the public health care system in South Africa has reached a critical juncture. While much was done to improve equity in the funding of public health care in the first few years of democratic government, this trend appears to have reversed. Data on public health expenditure and human resources, from a recent National Health Accounts Project, are presented. They reveal that from 1997 there have been declines in the public per capita funding of health care, increased inequity in provincial resource allocation and even a decline in per capita funding of primary health care. Furthermore, projections of future revenue availability suggest a continued decline in per capita funding of the public health sector. All these factors should sound alarm bells for a government committed to the equitable provision of primary health care through the district health care system. In response, the chapter concludes by examining possible policy options for government to renew its attack on inequity in health funding.
Author Peter BarronSource: South African Health Review 2000, pp 149 –167 (2000)More Less
This chapter demonstrates the value of a District Health Expenditure Review (DHER) as part of a district manager's tool kit. DHERs provide a picture of how resources are allocated and used and assist district management teams in becoming better planners and spenders. The initial five DHERs conducted in South Africa are compared showing differences across and within provinces, as well as within districts. The most salient features are the under-resourcing of primary health care and poor staff utilisation and deployment in the district health system.
Author Lucy GilsonSource: South African Health Review 2000, pp 169 –181 (2000)More Less
It was in the 1980s that social health insurance was first proposed as a key mechanism for extending health care coverage and promoting equity in South Africa. More than a decade later, and despite intensive investigation by three government committees since 1994, social health insurance is no nearer implementation. Lack of policy action on this front means that the wide disparities between health care in the public and private sectors remain untouched. What lessons does this experience teach us? This chapter explains why consensus was never reached on the exact form social health insurance should take, and suggests strategies for building support - and offsetting opposition - amongst important stakeholders. The chapter also critiques features of the government's most recent proposal, published in 1997. It is argued that this proposal will have a limited impact on equity and is not sufficiently robust to generate the 'virtuous cycle' of improvements in resource availability and quality of care so badly needed by the public sector. Technical analyses are suggested that might resolve disputes about the fundamental principles underlying social health insurance in the South African context, thereby strengthening the design and acceptability of the policy. The chapter also highlights the importance of both hospital management transformation and fee policy reform as precursors to the successful implementation of social health insurance. It is crucial that these issues be understood by more than a small circle of senior policy makers and academics. Social health insurance is a wide-ranging reform that seeks to translate societal values into real changes in access to health care on the ground: this makes it a policy worthy of extensive public debate. The resurgence of public discussion is warranted now, in particular, as social health insurance has been tabled once again for consideration by government, this time as part of a Cabinet-sponsored process to develop a co-ordinated social security system for the entire country. Given past experience it is important to ensure that social health insurance emerges from this process as an equitable and sustainable policy and that, this time around, it stands a chance of implementation.
Author Debbie PearmainSource: South African Health Review 2000, pp 183 –200 (2000)More Less
There have been extensive changes to the law governing medical schemes in the last two years. Implementation of much of that law only began in January 2000. The legislative changes represent underlying changes in government policy in favour of increased regulatory control, not only of medical schemes but also contractors to medical schemes such as medical scheme administrators, managed care organisations and brokers. The chapter explores these legislative changes, issues surrounding their implementation and responses by the medical schemes industry to date. Initially the legislation, the Council for Medical Schemes and even the Minister of Health were all challenged by a number of powerful stakeholders within the industry on a few important issues, namely, the lines of demarcation between insurance business and the business of a medical scheme, re-insurance of medical schemes, and the promulgation of additional regulations relating to waiting periods. This chapter examines the changes in the functions of the Council for Medical Schemes in the light of the legislation's more consumer-oriented approach. The effect of the legislation on medical scheme contributions is discussed and some scheme membership figures are presented. It also offers a brief look at the implementation of the prescribed Minimum Benefits Package by schemes from a consumer's point of view.
Author Thulani MatsebulaSource: South African Health Review 2000, pp 201 –217 (2000)More Less
Improving access to necessary drugs requires attention to all four component parts of the access equation - ensuring rational selection, providing sustainable financing and efficient systems to distribute and use the drugs but also making sure that prices are affordable. However, comparing drugs prices across countries and health systems is not always easy. Methodological pitfalls abound, and have in the past ensnared the South African Ministry of Health. The National Drug Policy contains a variety of proposed strategies to reduce the price of medicines in South Africa. This chapter considers the complex issue of drug pricing, the policy options outlined and available, and provides recommendations on steps that will advance the implementation of such policies.
Author Urmila SankarSource: South African Health Review 2000, pp 221 –230 (2000)More Less
The Minister of Health and Members of the Executive Council (MEC's) for Health of the nine provinces have reiterated the vision of a district health system (DHS) being the cornerstone of a national health system. They have also reiterated the view that the final home of the DHS is with local government. Therefore, the developments that took place in the local government sector in the year 2000 have had and will continue to have, a profound impact on the establishment of the DHS. One of the major developments in 2000 was the demarcation of new local government boundaries. The total number of municipalities in the country was reduced from 834 to 285. Health district boundaries are being re-aligned to correspond with the boundaries of Metropolitan and District Councils. Although this will ensure that all government departments have the same managerial area of operation, it has caused major disruptions in terms of staff who have been working in the interim health districts. It is also a problem in terms of the concept of the DHS - many of the new ""health districts"" are now too large to be manageable and will have to be divided into smaller sub-districts. These problems are further elaborated on in this chapter. Community participation and inter-sectoral collaboration are cornerstones of the DHS. This chapter looks at how the pursuit of these goals in the functioning of local government will facilitate their expression in the district health system. The issue of municipal financing is also discussed. In addition, a number of key unresolved issues in local government which will affect the establishment and functioning of the district health system are highlighted. These include the necessity for a strategic framework to guide the implementation of the DHS, the role of national and provincial Health Departments, and capacity development within the newly created municipalities.
Author Nicholas CrispSource: South African Health Review 2000, pp 251 –261 (2000)More Less
A comprehensive clinical laboratory service is indispensable to proper patient care. It plays a part in making a diagnosis and influencing treatment decisions in patient care and has public health value. Public health sector laboratory services are very fragmented and range widely in quality. There have been attempts over the years to rationalise and restructure these services and to upgrade the quality where it is poor but there have always been reasons why this has not occurred. The fragmentation of the services has resulted in a loss of economies of scale, especially where highly specialised equipment, expensive reagents and unique skills are concerned. In this chapter, the history of the many players in the provision of the services that is relevant to the developments and the failure to rationalise the services in the past is briefly discussed. For many years all roleplayers have recognised the need to improve the whole laboratory system. Immediately after the 1994 elections the Minister of Health established a commission to investigate the rationalisation and reorganisation of the laboratories. One issue was the joint ownership of the South African Institute for Medical Research (SAIMR) by the Chamber of Mines (CoM). In October 1998 the CoM unconditionally donated their interests in the SAIMR to the government. A Transformation Task Team (TTT) was appointed to make new recommendations for the restructuring of the public health laboratory services. The TTT recommended the establishment of a new parastatal (public entity) and for all public health laboratory services to become a part of that entity. Since May 1999 a Project Implementation Team has been designing the new entity in earnest. The vision is for a single entity that is large enough to derive benefit from economies of scale and therefore to ensure that services can be provided even where they are not independently viable. The control over purchasing services will remain with the clinicians that request laboratory tests. The new entity will employ about 4 500 employees and will have an annual turnover that is expected to be close to R1bn within the next two years. The National Health Laboratory Service Bill has been adopted by Parliament.
Author Julia MekwaSource: South African Health Review 2000, pp 271 –283 (2000)More Less
This chapter examines progress made in the transformation of nursing education with respect to relevant changes that are currently taking place in South Africa and within the framework of the Department of Health's White Paper for the Transformation of the Health System in South Africa. The chapter outlines basic nursing education and training programmes available in South Africa immediately prior to 1994, and addresses transformation targets envisaged by the role players involved with transforming nursing education.The content presented is derived from a variety of official discussion documents, publications, reports and submissions from various stakeholders, among them the South African Nursing Council and the Democratic Nurses Organisation of South Africa (DENOSA).
Author Dawn BetteridgeSource: South African Health Review 2000, pp 287 –299 (2000)More Less
South Africa has one of the highest incidence and prevalence rates of HIV/AIDS in the world. The fact that these numbers have been increasing during the period when the national AIDS response was being mustered and implemented is of particular concern. This chapter looks at some of the reasons why efforts to stem the epidemic have not been as successful as hoped. The HIV/AIDS and STD Strategic Plan 2000 - 2005 is analysed, as are issues such as access to treatment, voluntary testing and counselling, confidentiality and notification, and the controversial debate around the link between HIV and AIDS. Recommendations are given regarding the way forward from here.
Author Shaun ConwaySource: South African Health Review 2000, pp 301 –326 (2000)More Less
Using data obtained from annual surveys of pregnant women attending public sector antenatal clinics, this chapter attempts to estimate the current and future size and impact of the HIV/ AIDS epidemic by means of projection models. The chapter looks at the possible impact of HIV/ AIDS on the economy of the country as well as the economies of households, the capacity of traditional coping mechanisms to deal with ill and dying people and orphans, future health care costs in both the public and the private sectors, and the possible impacts of various interventions on the growth of the epidemic. This paper is adapted from a report published by loveLife with support from the Henry J. Kaiser Family Foundation. Demographic projections were undertaken by Metropolitan Life AIDS Research and Consulting.
Author Helen SchneiderSource: South African Health Review 2000, pp 327 –333 (2000)More Less
Over the past few years, the previously largely silent epidemic of HIV in South Africa has shifted to a visible epidemic of AIDS. The impact of this on health services, families and communities are emerging at a rapid pace. In an attempt to deal with this impact, it is common practice for health care facilities to ration services to people with HIV, with much of the burden of caring for the ill falling onto households and communities. In South Africa, ""home-based care"" has become a national policy priority. This chapter presents the findings of a review of various NGO, community and religious-based projects which are involved in helping people infected and affected by AIDS. The chapter looks at programmes which provide funding, technical assistance and support to communities, those which are involved in advocacy and community mobilisation, drop-in centres and support groups, home visiting and comprehensive home-based care as well as the care of orphans. The challenges to these programmes are listed and discussed, as are the factors which promote their success.
Author Samson KirondeSource: South African Health Review 2000, pp 335 –349 (2000)More Less
Despite sustained progress in control since the formulation of new policy guidelines in 1996, tuberculosis still remains a major public health threat in South Africa. The effects of the rapidly growing concurrent HIV epidemic further compound the prominence of the tuberculosis epidemic and the proportion of TB patients co-infected with HIV is increasing. There is an urgent need to hasten the integrated management of these two epidemics.The promotion of voluntary counselling and testing (VCT) for HIV in TB treatment centres, provision of materials for advocacy and health education for TB/HIV/AIDS as well as the development of training and management guidelines for dually infected patients will go a long way towards achieving this goal. The introduction of combination anti-TB drugs during 1999 will assist in improving adherence to treatment as well as reduce the occurrence of drug resistant strains of tuberculosis. However, in order to achieve this, there is need to further the progress already made in delivering directly observed supervised treatment to TB patients, particularly within the context of community-based care.Improvement within the computerised recording and reporting system to make it simpler and uniform for all the provinces will further assist in more accurate documentation of the tuberculosis burden in the country and lead to targeted interventions where necessary. The National Tuberculosis Control Programme hopes to achieve its objective of reducing the tuberculosis burden in the country through increased collaboration with other role players at local and regional levels as will be discussed in this report.
Author Immo KleinschmidtSource: South African Health Review 2000, pp 351 –364 (2000)More Less
Malaria has devastating effects on African communities and economies. South Africa is not exempt, illustrated by the high poverty and unemployment rates in the most affected districts. In the early decades of this century malaria was much more widely distributed and much more severe than it is now. This reduction has been due to intensive control activities that have targeted both the Anopheles vector and the Plasmodium parasite. Unfortunately recent developments, such as resistance of the parasite to drugs, re-emergence of an eradicated vector species and its resistance to insecticide, have resulted in considerable resurgence of malaria. The number of malaria cases started rising in the mid-1980's, when chloroquine resistance was first detected, and has continued to rise exponentially ever since. The 1999/2000 malaria season saw close to 40 000 cases, concentrated mainly in a small number of districts of the three north-eastern provinces and along the Mozambique border. Spatial analysis has confirmed a spread to previously low-risk areas. While the situation is far from that in the early 1930's, the trend is likely to continue unless radical steps are taken to stop the spread of the disease. Efforts to overcome the escalating problem have involved a range of activities. To keep pace with changes in drug efficacy, drug policy has been updated repeatedly. Insecticide usage has been changed recently in an attempt to once more eliminate the dangerous vector An. Funestus. The wider implementation of insecticide treated bed nets is under discussion. A major regional control effort - the Lubombo Spatial Development Initiative - is underway, and better malaria reporting and information systems have been introduced. The national policy, in line with international malaria control strategies, and guided by the National Malaria Advisory Group, addresses specific situations in each province. Future priorities should focus on appropriate control strategies, using effective drugs and insecticides, both within South Africa and, through collaboration, within the SADC region; adequate information flow to drive evidence-based policy decisions, again both nationally and regionally; ongoing monitoring of control operations; ongoing surveillance of drug and insecticide efficacy; and ongoing research into key areas.