Equity in Healthcare and Social Delivery: briefing by Health Systems Trust

Meeting report

PORTFOLIO COMMITTEE ON HEALTH
13 November 2001
EQUITY IN HEALTHCARE AND SOCIAL DELIVERY: BRIEFING BY HEALTH SYSTEMS TRUST

Chairperson: Dr A Nkomo

Documents handed out:
Equity Gauge Project Slide Presentation
Equity Issues in Healthcare (HST)
Charts on Equity and Healthcare (HST)
Bringing Health Closer to the People: Local Government and the District Health System
Health System’s Trust website

SUMMARY
The presentations dealt with equity in the healthcare sector in South Africa. The progress of and challenges facing healthcare were extensively dealt with. It was agreed that much improvement was needed to ensure greater equity in healthcare.

There were a number of recurring issues, including public-private partnerships in healthcare; quality of healthcare; viability of medical aid schemes for all citizens; allocation of resources to provincial health departments; personnel and human resource challenges and problems with emergency medical services.

MINUTES
Health Systems Trust
Ms A Ntuli stated that the common objective of the Health Systems Trust was to improve equity in health services. In this regard, the Trust formed the Equity Gauge Project that was created to monitor key issues and facilitate the use of information about the health sector in South Africa. Overall, the Health Systems Trust aimed to support both provincial and national departments and to engage with the media and civil society on important healthcare issues.

Equity Gauge Project
Ms Di McIntyre outlined the key issues regarding healthcare financing in South Africa. Firstly, private sector trends were dealt with. The private sector had experienced a massive increase in contributions and expenditure towards private medical aid schemes since the late 1980s. This increase was estimated at between 20 and 35%. Despite these increases it was shown that there was a decline in benefit packages and a decline in membership to medical aid schemes. Approximately sixteen percent of South African belonged to schemes in 1998.
Other trends in the private sector included decreased expenditure on workplace services and large increases in ‘out of the pocket’ expenditures.

Secondly, public sector trends. There has been a marginal increase in public sector health care funding and an increasing percentage of the population becoming dependent on public sector services.

The Committee needed to ask whether South Africans were getting value for their money in terms of healthcare. Secondly, the government needed to decide whether there was an equitable share of scarce government resources. In terms of medical aid schemes it was pointed out that about 25 percent of medical aid scheme members were civil servants and their families. Interestingly, it was also pointed out that the government spent more per civil servant on medical aid cover than it spent per person dependent on public health services. This demonstrated the problem of equity in the country.

Several other challenges facing the public health sector were also outlined. Firstly, the slow progress on moving towards equity in health care resources between provinces is a major problem. In this regard, there needs to be a thorough review of the formula for resource allocation from central government to the various provinces. It was asked whether the formula adequately addressed backlogs. There needs to be a more equitable distribution of resources to the historically disadvantaged provinces.

A number of potential factors that may increase inequities were also outlined.
These were as follows:
-Differing ability of provincial governments to generate their own revenue.
-Differing capacity to provide primary health care services amongst the various provinces. Again, the historically disadvantaged provinces need more assistance from national government.

Health Systems Trust
Mr Solani Khoza pointed out that equity was the cornerstone of transformation issues within healthcare. There needs to be recognition of the deep structural inequities which prevail. This demanded proper legislation coupled with correct implementation policies.
Some of the achievements in promoting equity in healthcare were outlined:
-Removal of structural racism
-Introduction of primary healthcare
-Building of clinics
-Establishment of district health systems
-Contracting of Cuban doctors
-Improved availability of services

Negative aspects or challenges facing healthcare included:
-Availability of emergency services, especially ambulances.
-Quality of healthcare. This included long waiting lists at hospitals, shortages of drugs, and unacceptable staff behaviour.
-HIV/AIDS – something the government had not come to grips with.
-Personnel issues. Currently the human resource plans were not facilitating transformation. An example of the provincial inequities in terms of personnel was given. In the NorthWest province there are 0.8 doctors per 10 000 people. In contrast, in Gauteng, there are 6,8 doctors per 10,000 people. It was recognised that such a situation was untenable and only exacerbated the split between the public and private sector.

In conclusion it was pointed out that it was now the responsibility of government, and in particular the Portfolio Committee, to oversee the challenges outlined by the presentations. (Presentations attached above).

Discussion
Dr Rabinowitz (IFP) asked whether a more thorough privatisation of health services might assist in meeting the numerous challenges? She also asked whether more competition between various medical aid schemes would result in decreasing the cost of joining these schemes. This would then make them more accessible to the general population.

Dr Jassat (ANC) asked whether it was fair to say there had been a drop in standard and quality of healthcare across all the provinces, in both rural and urban areas.

Members asked a number of other questions.
Why are certain provinces lacking in emergency service transport?
How could provincial MECs ensure they get a more equitable share of the national budget?

With respect to provincial budgetary allocations and relevant problems, provinces must analyse the successes of other provinces when deciding on how to allocate their budgets. On this note there needs to be more cooperation and sharing of knowledge between provinces. Negotiations with the National Treasury over budgetary allocations must focus on the most needy areas.

What should the priority areas for government be? What recommendations can be made?
Is there adequate security at hospitals? Have there been incidents of medicine and linen being stolen?

In response, the key priority areas that government should be focusing on were listed. These areas coincided with those that were to be discussed at the forthcoming Health Summit. These areas were; public-private partnerships; quality of healthcare; human resource challenges and HIV, TB and STDs.

It was pointed out that the strengthening of the public service needed to be a priority area. Furthermore, staff morale and attitudes within the public service needed to be closely examined. Many health workers did not feel empowered, as they had no say in decisions that effected their employment conditions.

In terms of emergency medical services, the provinces need to take more responsibility. Reaction time to emergencies and reliable ambulances were key areas in this regard. Some regions in the more remote provinces were clearly being neglected.

The Chairperson commented that many of the issues discussed would resurface at the forthcoming Health Summit. The meeting was adjourned.