Di McIntyre

The health and health system of South Africa: historical roots of current public health challenges

The roots of a dysfunctional health system and the collision of the epidemics of communicable and non-communicable diseases in South Africa can be found in policies from periods of the countrys history, from colonial subjugation, apartheid dispossession, to the post-apartheid period. Racial and gender discrimination, the migrant labour system, the destruction of family life, vast income inequalities, and extreme violence have all formed part of South Africas troubled past, and all have inexorably affected health and health services. In 1994, when apartheid ended, the health system faced massive challenges, many of which still persist. Macroeconomic policies, fostering growth rather than redistribution, contributed to the persistence of economic disparities between races despite a large expansion in social grants. The public health system has been transformed into an integrated, comprehensive national service, but failures in leadership and stewardship and weak management have led to inadequate implementation of what are often good policies. Pivotal facets of primary health care are not in place and there is a substantial human resources crisis facing the health sector. The HIV epidemic has contributed to and accelerated these challenges. All of these factors need to be addressed by the new government if health is to be improved and the Millennium Development Goals achieved in South Africa.

Removing user fees for primary care in Africa: the need for careful action.

Current calls for the removal of user fees respond to evidence of their regressive impacts and their role in enhancing social exclusion—but removal must be carefully managed because this action may have negative impacts on the wider health system User fees are once again a topic of hot policy debate in Africa. They were introduced relatively recently in many countries (box 1), but the current call is for their removal, particularly at primary care level.2 As analysts who have consistently argued against user fees, we broadly support this call. However, we recognise that this action cannot be introduced overnight and, if weakly implemented, may exacerbate the problems facing African health systems. We outline both why we believe African countries should move away from user fees, and what actions should accompany their removal to ensure that this policy change strengthens rather than undermines healthcare provision. Our suggestions are based on the experience of countries such as South Africa and Uganda that have already removed some or all fees, as well as wider experience of policy change. User fees are the most regressive form of healthcare financing available; they contribute to the unaffordable cost burdens imposed on poor households; and they represent one facet of the social exclusion experienced by these households. Out of pocket payments (which include user fees at public sector facilities) are more regressive than any other method of financing health care, capturing a higher proportion of income among poor households than wealthier ones.3 Thus, simply on the basis of the equity principle that those with the greatest ability to pay should make appropriately larger contributions, out of pocket payments are the least desirable way of financing health services. At primary care level, fees are relatively low. None the less, such fees can encourage inappropriate self treatment …

Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage

BACKGROUND Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of financing mechanisms, especially to protect people outside the formal employment sector. Crucial issues are the equity implications of different financing mechanisms, and patterns of service use. We report a whole-system analysis--integrating both public and private sectors--of the equity of health-system financing and service use in Ghana, South Africa, and Tanzania. METHODS We used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. We collected qualitative data to inform interpretation. FINDINGS Overall health-care financing was progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries. INTERPRETATION Analyses of the equity of financing and service use provide guidance on which financing mechanisms to expand, and especially raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality. FUNDING European Union and International Development Research Centre.

The cost-effectiveness of antiretroviral treatment in Khayelitsha, South Africa--a primary data analysis.

BackgroundGiven the size of the HIV epidemic in South Africa and other developing countries, scaling up antiretroviral treatment (ART) represents one of the key public health challenges of the next decade. Appropriate priority setting and budgeting can be assisted by economic data on the costs and cost-effectiveness of ART. The objectives of this research were therefore to estimate HIV healthcare utilisation, the unit costs of HIV services and the cost per life year (LY) and quality adjusted life year (QALY) gained of HIV treatment interventions from a providers perspective.MethodsData on service utilisation, outcomes and costs were collected in the Western Cape Province of South Africa. Utilisation of a full range of HIV healthcare services was estimated from 1,729 patients in the Khayelitsha cohort (1,146 No-ART patient-years, 2,229 ART patient-years) using a before and after study design. Full economic costs of HIV-related services were calculated and were complemented by appropriate secondary data. ART effects (deaths, therapy discontinuation and switching to second-line) were from the same 1,729 patients followed for a maximum of 4 years on ART. No-ART outcomes were estimated from a local natural history cohort. Health-related quality of life was assessed on a sub-sample of 95 patients. Markov modelling was used to calculate lifetime costs, LYs and QALYs and uncertainty was assessed through probabilistic sensitivity analysis on all utilisation and outcome variables. An alternative scenario was constructed to enhance generalizability.ResultsDiscounted lifetime costs for No-ART and ART were US

The economics of health equity

2,743 and US

Socioeconomic-related health inequality in South Africa: evidence from General Household Surveys

9,435 over 2 and 8 QALYs respectively. The incremental cost-effectiveness ratio through the use of ART versus No-ART was US

The Economics of Health Equity: Exploring the dimensions of access

1,102 (95% CI 1,043-1,210) per QALY and US

Artemisinin-based combination therapy reduces expenditure on malaria treatment in KwaZulu Natal, South Africa

984 (95% CI 913-1,078) per life year gained. In an alternative scenario where adjustments were made across cost, outcome and utilisation parameters, costs and outcomes were lower, but the ICER was similar.ConclusionDecisions to scale-up ART across sub-Saharan Africa have been made in the absence of incremental lifetime cost and cost-effectiveness data which seriously limits attempts to secure funds at the global level for HIV treatment or to set priorities at the country level. This article presents baseline cost-effectiveness data from one of the longest running public healthcare antiretroviral treatment programmes in Africa that could assist in enhancing efficient resource allocation and equitable access to HIV treatment.

Redressing dis-advantage: promoting vertical equity within South Africa.

This book is about equity in health and health care. It explores why, despite being seen as an important goal, health equity has not made more progress within countries and globally, and what needs to change for there to be greater success in delivering fairness. An international team of eminent experts from primarily the field of health economics describe how equity in health and health care might develop over the next decade. They examine existing and past barriers to promoting equity, citing case examples, and covering issues including access to health services and inequalities between and within countries. The analyses are detailed, but the issues are approached in an accessible fashion, highlighting the factors of common international relevance. This book provides a manifesto for achieving health equity for the future. It will be essential reading for health and social policy makers, and health academics nationally and internationally.

Exploring SWAp's contribution to the efficient allocation and use of resources in the health sector in Zambia

BackgroundInequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s.MethodsSeveral rounds (2002, 2004, 2006, and 2008) of the South African General Household Surveys (GHS) data were used, with standardized and normalized self-reported illness and disability concentration indices to assess the distribution of illness and disability across socio-economic groups. Composite indices of socio-economic status were created using a set of common assets and household characteristics.ResultsThis study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008. These results have also been confirmed internationally.ConclusionThe current burden and distribution of ill-health indicates how critical it is for the South African health system to strive for access to and use of health services that is in line with need for such care. Concerted government efforts, within both the health sector and other social and economic sectors are therefore needed to address the significant health inequalities in South Africa.