the Health Information and Management System Society Conference, San
Diego
14 February 2006
AN OVERVIEW OF THE SOUTH AFRICAN HEALTH SYSTEM
Introduction
In South Africa one finds the worldâs strangest and most dramatic
landscapes, a unique wealth of animals and plant life, a treasure of gold,
diamonds and other minerals and a kaleidoscope of many cultures. South Africa
occupies the southern most part of the African continent stretching latitudinal
from 22 to 35 degrees south and longitudinal from 17 to 33 degrees east. Its
surface area is 1 219 090 square kilometres. It has common boundaries with the
republics of Namibia, Botswana, Zimbabwe, Mozambique and the Kingdoms of
Swaziland and Lesotho.
History of the Department of Health
The Department of Health is responsible for policy, legislation, national
programmes and international liaison. The major delivery responsibility rests
with the provinces. The population of South Africa is 44,820 million according
to the latest census conducted in 2001. The urban population is more than the
rural population with an increase in informal settlement.
History of SA health system
During the apartheid era, the health system had 14 departments of Health,
which were created along racial lines. The institutions and facilities were
built and managed with the specific aim of sustaining racial segregation and
discrimination in healthcare. This resulted in systems that were highly
fragmented, biased towards curative care and the private sector, inefficient
and inequitable.
Challenges of the past
The challenge was for the democratic South Africa to design a comprehensive
programme to redress social and economic injustices. This involved the complete
transformation of the national healthcare delivery system and all relevant
institutions.
Current system
The healthcare system ranges from highly specialised urban academic centres
to rural small clinics through out the country. Health practitioners and
expertise are concentrated in major urban cities while people in rural areas
have limited access to basic healthcare because of geographical isolation and
poor public transportation.
Main health problems
South Africa has a complex and heavy disease burden. The challenge in
reducing infant mortality rate is great especially in our black communities.
The disease pattern amongst children under five years in South Africa is
similar to those in developing countries. Diarrhoeal diseases, respiratory
infections, malnutrition and increasingly HIV/AIDS are major contributors to
the burden carried by our children. Measles once a major factor has had minimal
impact in recent years.
The relatively low incidence of various vaccine preventable diseases is due
to a fairly robust immunisation programme. In accordance with this disease
pattern our strategy is to sustain and build the immunisation programme,
improving nutrition and managing disease burden as effectively as possible.
Tuberculosis (TB) crisis
The incidence of TB in South Africa is now at 550 cases/100 000 population.
There has been a significant increase in the number of cases reported over the
past eight years. The table below shows the number of reported cases from
2001-2004 in all provinces. In 2004 there were 279 260 reported TB cases out of
which 117 971 were new infectious cases. The provinces most affected are
Eastern Cape, KwaZulu-Natal, Gauteng and Western Cape which contribute about 80
percent of the total TB burden in the country. These provinces have had higher
TB notifications historically and continue to have higher notifications rates
than other provinces.
Major factors affecting high incidence rates in these provinces include
inadequate implementation of the Directly Observed Therapy Short-Course (DOTS)
strategy, increasing number of patients with resistant strains and HIV/AIDS,
limited or poor access to laboratories for microscopic services among others.
The TB cure rates for new smear positive cases remain low at 50.1 percent with
a successful treatment completion rate of 62.9 percent. The proportion of TB
patients who default treatment is high (11.5 percent) and the proportion of
patients transferred to other districts with no documentation that the patient
continued treatment in another district is also high at 9.8 percent this
translating to a quarter of TB patients lost to follow up out of all those
registered in 2003.
This is despite progress achieved in decentralisation of TB services,
ensuring uninterrupted drug supply and high coverage with DOTS. A national
surveillance study done by the Medical Research Council (MRC) in 2001 showed
multi drug resistant strains in 1.6 percent of new cases and 6.7 percent of
previously treated patients, returning for treatment. It also confirmed the
association between previous TB treatment and drug resistance, which has been
well documented. About 4500 cases of multi-drug resistant tuberculosis (MDR-TB)
were reported in 2003. It is documented that 55 percent of TB cases are
co-infected with HIV. (Survey of Tuberculosis drug resistance in South Africa
2001-2002)
TB crisis plan
We have developed a TB crisis plan to be launched by the Minister next
month.
The key elements of the plan include strengthening of TB service delivery
systems and processes at community and facility levels:
* Active community involvement;
* Intensive communication strategy highlighting TB as a crisis in the
country;
* Ensure that there are adequate personnel;
* Ensure access to laboratory services; and
* Improve management of co-infected patients in order for them to be provided
with appropriate drugs.
HIV/AIDS
In his State of the Nation Address last Friday, President Thabo Mbeki
announced that the Operational Plan for Comprehensive Prevention, Treatment and
Care of HIV and AIDS has resulted in the upgrading of hundreds of facilities.
To date, over 100 000 patients are receiving Antiretroviral Treatment (ART) and
combined with patients in the private sector, South Africa has one of the
largest such treatment programme in the world. For 2005/06 our budget for
HIV/AIDS was R1.5 billion, a R3 million increase from the previous year.
Accelerated HIV prevention
With the increasing challenge of HIV/AIDS in South Africa, the national
Department of Health (NDOH) has developed and accelerated HIV prevention plan.
This plan will include the following:
* Increase voluntary counselling and HIV testing (VCT) coverage including opt
out strategy (which needs wide consultation and preparation before
implementation)
* Increase coverage of preventing mother to child transmission (PMTCT),
including opt out strategy
* Social mobilisation is the backbone of the accelerated HIV prevention
programme
* Communication strategy to be finalised by the end of March
* Include greater focus on life skills in schools, especially primary schools
in the prevention plan (also youth clubs, tertiary institutions)
* Prevention programme needs to be focused, target vulnerable groups such as
women with targeted messages; and
* Need to better understand what levels of awareness exist and how to translate
knowledge and awareness into behaviour change.
Bringing healthcare closer to the people
Since coming to power of the new government, over 1 300 clinics have
benefited from the upgrading programme and more have received additional
equipment and the programme to revitalise hospitals is proceeding apace. The
extension of community service to a range of health professionals has ensured
that at any one time over 2 000 such professionals are available in public
health institutions.
Our future plans in this area include the further expansion of the health
infrastructure, the refurbishment of existing clinics and hospitals and the
re-opening of nursing colleges to increase the numbers of these important
professionals. To improve service delivery in our hospitals by September this
year we will ensure that hospital managers are delegated authority and held
accountable for the functioning of hospitals with policy issues regarding
training, job grading and accountability managed by provincial health
departments which themselves will need restructuring properly to play their
role.
NDOH priorities for 2006/2007
Human resources (HR), as personnel consumes over 60 percent of the budget
consistently across all parts of the health system, the HR plan is the most
important part of the service transformation plan. The objective is to
restructure the service platform and the modes of delivery in such a way to
achieve 100 percent staffing in all disciplines (clinical specialties) in all
facilities offering tertiary, secondary and primary healthcare (PHC)
services.
Service transformation plan, the core message that comes out of the review
of outcomes is the need for a comprehensive review of the service delivery
platform and the development of service transformation plans in each province.
This will be achieved through the strategic planning and budgeting process in
2006/07 leading to allocations for activities from 2007/08.
Physical infrastructure, as the distribution of facilities fundamentally
affects the staffing requirements, rationalisation of the service delivery
platform and matching these two resource components is the next priority.
Quality of care, improved quality of care in the restructured service platform
is essential to the delivery of the required outcomes and the Departmentâs
vision and mission.
Priority health programmes, whilst efforts will continue to strengthen all
health programmes the two critical communicable disease programmes should enjoy
additional priority during the next two to three years. These are accelerated
prevention of HIV and implementation of the TB crisis plan. In addition the key
preventative initiatives relating to illnesses of lifestyle must also receive
special attention. âMove for Healthâ was launched last year to mobilise South
Africans to adopt healthy lifestyles and thus improve their health and prevent
lifestyle diseases such as diabetes Type II, obesity, some cancers, heart
disease, hypertension and arthritis.
Health Charter
As part of transforming our country the past few years have seen the
development of various Charters in South Africa with a view to transform
ownership to include those who were economically marginalised and disadvantaged
such as blacks, women and people living with disabilities.
NDOH has also developed the Health Charter in partnership with various
stakeholders:
* It seeks to facilitate and effect transformation of the health sector in the
following key areas;
* Access to health services;
* Equity in health services;
* Quality of health services;
Broad Based Black Economic Empowerment (BBBEE)
* It seeks to ensure the urgent transformation of the national health system
in a cooperative, constructive and mutually beneficial relationship in such a
manner as to reflect the diversity and meet the various healthcare needs of
South Africans.
* We hope to rectify the injustices of the past and the restoration of
imbalances between previously disadvantaged and privileged people.
* The Charter will ensure that health providers conduct their business in a
manner that is ethical, honest, fair and satisfy the needs of consumers. This
includes the issues such as over-servicing or overcharging, exploiting
healthcare professionals for ends that might contradict their ethical codes and
etc.
The charter also covers the issue of foreign owned multinationals in terms
of the implementation of BBBEE. The foreign owned multinational pharmaceutical
and medical devices sub-sectors may contribute to the objectives of both the
BBBEE and those of the NDOH through a series of replacement offerings. They can
include the following:
* The enterprise to demonstrate a true commitment to transformation of the
health sector and BBBEE;
* Exemptions from ownership requirements in terms of BBBEE are applicable only
to the extent of the demonstrable inability of the enterprise to comply and
shareholding transfer requirements must be offset against equivalent acceptable
replacement offerings;
* A replacement offering must be rationally related to the objectives of the
BBBEE Act or the Charter requirements as regards access, quality and equity in
health care;
* The replacement offerings can be delivered by individual enterprises
independently or jointly across a sub-sector; and
* It may not be less than the value of the equity interest it seeks to replace
calculated as the date when the replacement offering is made.
ICT and health
The information and communications technology (ICT) revolution brings
opportunities and particular challenges to health systems. These challenges can
be divided into two broad areas. The first has to do with participation in the
information society; the second considers how ICT impacts on access, cost
effectiveness and quality of information. The context within these challenges
present themselves is that of globalisation and polarisation in a world of
increasing disparities between the rich and poor and within nations.
The notion of the so called âdigital divideâ is therefore an appropriate
warning that the ICT is from neutral. It is fitting also to recall that the
term was first coined in the United States (US) rather that in some
impoverished less developed country. The digital divide does not only have to
do with who has a personal computer (PC) linked to the internet or who has a
cellular phone it is about how the digital technologies are a core feature of
innovation and competitiveness. The world development report of 1999, notes,
âKnowledge is like light, weightless and intangible; it can easily travel the
world, enlightening the lives of people everywhere. Yet billions of people
still live in the darkness of poverty, unnecessarily.â
There are disparities in all countries, what is different about the
disparities in South Africa is that they were legislated into practice for the
purpose of racial dominion. We have therefore to overcome one divide while a
new one looms. The scale of the disparities in basic social services remains
daunting and is exacerbated by the growing impact of the HIV and AIDS pandemic.
Bringing ICT connectivity to our health sector needs to happen. It is a task
that needs to occur alongside the provision of basic health information
infrastructure which is the responsibility of the government. Extensive
provision of ICT is, however, beyond the financial resources of the government
alone and the partnership with donors and the private sector will therefore be
a critical success factor.
According to the declaration made by the World Summit on Information Society
(WSIS) in Geneva 2003, our challenge is to harness the potential of Information
and Communication Technology (ICT) to promote the development goals of the
millennium declaration, namely the eradication of extreme poverty and hunger;
achievement of universal primary education; promotion of gender equality and
empowerment of women; reduction of child mortality; improvement of maternal
health; to combat HIV and AIDS, malaria and other diseases.
E-Health
E-Health may be described as the combined use of electronic communication
and information technology for the health sector. E-Health can be considered to
be the health industry's equivalent of e-commerce. Because the Internet created
new opportunities and challenges to the traditional health care information
technology industry, the use of a new term to address these issues seemed
appropriate.
These ânewâ challenges for the health care information technology industry
were mainly:
* The capability of consumers to interact with their systems online (B2C =
"business to consumer")
* Improved possibilities for institution to institution transmissions of data
(B2B = "business to business")
* New possibilities for peer to peer communication of consumers (C2C =
"consumer to consumer")
SA perspective to E-Health services
In 1997 the White Paper on the Transformation of the Health System in South
Africa was published. In terms of Chapter 6, which deals with health
information, proposed the establishment of the National Health Information
Systems Committee of South Africa (NHIS/SA). The Committee developed the
National Strategy for the implementation of a comprehensive National Health
Information system.
The NHIS/SA Committee consists of NDOH, reps of provincial MECs for Health,
other relevant government departments, academic and research institutions as
well as the private sector. In terms of the Health Act No. 61 of 2003, NDOH is
responsible for coordinating the establishment, implementation and maintenance
by provincial departments, district health councils, municipalities and the
private sector of health information systems in order to create a comprehensive
health information system.
Telemedicine
NDOH has adopted a telemedicine strategy in the use of ICT for the provision
of health care services. A National Telemedicine Strategy for South Africa
(NTSSA) was established in 1998. In 1999 we established 28 pilot sites in six
provinces. The initial applications were tele-radiology, tele-ultrasound for
antenatal services, tele-pathology and tele-ophthalmology. ISDN lines were used
to network the telemedicine sites. Now we have 57 telemedicine sites.
Telemedicine achievements
The system facilitates frequent contact between doctors in underdeveloped
and developed centres. It also provides the academic professionals from major
South African medical academic institutions to extend their educational
capabilities to healthcare professionals throughout the rural communities of
South Africa without having to provide facilities and teachers in every rural
location. The initial telemedicine evaluation done by the medical research
council found that access to specialist radiologist reporting was possible
within an hour, compared to five to seven days in the past. Telemedicine
improved medical ability to diagnose and manage various medical conditions
particularly those related to trauma and chest diseases and reduced
professional isolation.
In 2001, closed head injury referrals between Witbank and Pretoria Academic
Hospitals were an average of 10 referrals per month compared with an average of
48 per month in the absence of telemedicine. A telemedicine research test-bed
was set up between Tonga Hospital and three clinics in Mpumalanga for clinical
research and the development and evaluation of new telemedicine technologies,
preliminary results showed that the number of referrals dropped.
Thank you.
Issued by: Department of Health
14 February 2004
