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PRIMARY HEALTH CARE IN SOUTH AFRICA Case Study prepared for the PRIMASYS (Primary Care Systems Profile and Performance) initiative of the Alliance for Health Policy and Systems Research and World Health Organization September 2016
AUTHORS Andrew McKenzie,* Helen Schneider, Nikki Schaay, Vera Scott & David Sanders School of Public Health, University of the Western Cape *Health Partners International
Preface Health systems around the globe still fall short of providing accessible, good quality, comprehensive and integrated care. As the global health community is pushing for ambitious goals of universal health coverage and health equity in the post-‐2015 development era, there is increasing interest in frontline healthcare delivery systems, including access to and utilization of primary care in low-‐ and middle-‐income countries (LMICs). A wide array of stakeholders including development agencies, global health funders, as well as policy planners and health systems decision makers, need a better understanding of the primary care schemes, in order to plan and support complex health systems interventions. The knowledge gap concerns strategic information on primary care systems at national and subnational levels in LMICs, providing insights on the entry points into healthcare systems in order to improve implementation, effectiveness and efficiency of health programmes. In addition, there is a need to draw cross-‐cutting lessons across different settings and systems, so as to inform the organization of primary care schemes in LMICs. We need more evidence on successes and failures in improving access to, and performance of primary care. How are primary care systems operating across the globe? What can we learn from different primary care experiences? To bridge the knowledge gap on frontline healthcare delivery systems, the Alliance for Health Policy and Systems Research (HPSR), in collaboration with the Bill & Melinda Gates Foundation, is leading a new portfolio of work entitled Primary Care Systems Profiles & Performance (PRIMASYS). This project aims to develop a set of twenty case studies of primary care systems in selected low-‐ and middle-‐income countries. In order to inform the conduct and reporting of the PRIMASYS case studies, the Alliance convened an Expert Consultation on Primary Care Systems in July 2015, which assembled a set of key global experts on primary care, as well as policymakers and researchers from LMIC-‐ based institutions. The Expert Consultation proposed a framework underpinning the development of the PRIMASYS case studies. This “meta-‐framework” outlines broad categories of elements that collectively describe primary care systems and the dynamic inter-‐linkages between different elements.
PRIMASYS Framework of structure, processes and outcomes of primary care systems (adapted from Kringos et al 2010)i
Following the consultation, country teams were commissioned with the task of developing case studies. Teams were selected based on expertise in primary care and access to key i Kringos DS, Boerma WGW, Hutchinson A, van der Zee J, Groenewegen PP. The breadth of primary care: a
systematic literature review of its core dimensions. BMC health services research, 10:65.
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informants. Each team was provided with a guidance document on development of case studies as well as ongoing support from the Alliance and a project support grant provided by the Bill and Melinda Gates Foundation. Acknowledgements South Africa was selected as one of five countries (with Nigeria, Bangladesh, Pakistan and Tanzania) for a first round of PRIMASYS case studies. The South African case study was conducted as a rapid assessment over a three-‐month period (mid-‐December 2015 to mid-‐ March 2016) by a team from the School of Public Health, University of the Western Cape, in partnership with Andrew McKenzie of Health Partners International, who with Helen Schneider played the main anchoring role for the project. Guided by a template for the case study provided by the AHPSR, we sourced and reviewed a wide range of available documentation and consulted with 29 key players in the field who provided further insights and information. They included national government policy makers (spanning health, treasury and the presidency), provincial, district and programme managers, statutory bodies (research councils, National Institute for Communicable Diseases), NGOs and technical agencies providing support to government and higher educational institutions. We are deeply indebted to all those who agreed to meet us at short notice and who offered inputs and commented on the draft. Thanks in particular go to Peter Barron who read and commented on drafts of the briefing document. Responsibility for the contents, however, remains with the authors. The South African case study will be re-‐issued in 2017 by the Alliance for Health Policy and Systems Research as part of a suite of PRIMASYS products. September 2016
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Abstract The Primary Health Care (PHC) approach as envisioned by the 1978 Alma Ata Declaration on Primary Health Care is enshrined in key health policy statements and legislation in South Africa. PHC is provided in the main through a nurse-‐based, public primary health care infrastructure of around 3,500 clinics and health centres, available within 5 kilometres to more than 90% of the population, and free at the point of use. These facilities provide a comprehensive package of basic services including maternal, child and reproductive health, HIV and TB testing and treatment, screening and care for non-‐communicable diseases and treatment of common ailments. Facilities relate to a large and diverse NGO-‐based community care sector that emerged in response to the HIV and TB epidemics and is being reorganized into a system of “ward based outreach teams” as part of PHC. Per capita funding of PHC has doubled over the last 10 years, largely due to a rapid expansion of access to antiretroviral treatment for HIV, now provided to more than 3 million people, as well as other entitlements (such as pneumococcal and rotavirus vaccines). Despite increasing resources and growing utilization, quality of PHC is a major problem, with drug stock outs common and poor interpersonal quality a frequent complaint. Access to mental health, rehabilitation, oral and eye health care is low. Management capacity at the frontline is weak, and the development of the district health system as the key support to PHC still highly uneven across the country. Training of health professionals in higher education institutions is still hospi-‐centric and curative. In the face of a very high burden of preventable morbidity and mortality, inter-‐sectoral action on the social determinants of health remains under developed. While structures for citizen participation in PHC through clinic committees are mandated in the National Health Act, these are often not functional. A quasi-‐federal system of governance has led to unequal implementation across nine provinces, and a perceived policy-‐implementation gap. A “PHC Re-‐engineering Strategy” is prioritized in South Africa’s proposals for a National Health Insurance. The national “Ideal Clinic” initiative is taking steps to revitalize PHC by standardising the inputs and processes (infrastructure, staffing, records, treatment protocols, governance) of PHC and establishing monitoring and quality improvement mechanisms. A private ambulatory general medical practitioner sector exists in parallel to the public sector, providing regular care to the 16% percent of the population with private health insurance and to the uninsured who can afford out of pocket cash payments. A traditional healer sector is also widely consulted but exists separately and is uncoordinated with the public health system. This report provides an overview of key developments in and features of PHC in South Africa, situated in the socio-‐economic and health system context of the country. It examines the key inputs, outputs and outcomes of this system, summarises its strengths and weaknesses and proposes priorities for further strengthening of PHC. The latter include a major focus on the human resource base of PHC, policy and strategies to address the social determinants of health, developing the District Health System as the key support to PHC, and transferring the lessons learnt from and investments in HIV/AIDS into other areas of the PHC system.
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Contents Preface ................................................................................................................................................................................ ii Acknowledgements ..................................................................................................................................................... iii Abstract ............................................................................................................................................................................. iv Overview of developments since 1994 ................................................................................................................ 1 Macro-‐economic and health sector context ....................................................................................................... 2 Demographic and health profile ............................................................................................................................. 7 Governance of PHC: the District Health System ............................................................................................... 9 Community participation in PHC .......................................................................................................................... 10 PHC financing ................................................................................................................................................................ 11 Human resources for PHC ........................................................................................................................................ 12 Infrastructure, equipment and supplies ............................................................................................................ 15 Access to essential care ............................................................................................................................................. 17 Improving the quality of PHC ................................................................................................................................. 19 Monitoring and evaluating PHC ............................................................................................................................ 21 Strengths and weaknesses of PHC ....................................................................................................................... 22 Going forward ............................................................................................................................................................... 25
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Overview of developments since 1994 South Africa is a middle-‐income country of 55 million people, two-‐thirds of whom are urban dwellers. Since the advent of democracy in 1994, key policy statements such as the White Paper for the Transformation of the Health System (1997),1 and the National Health Act (2003)2 have placed primary health care (PHC) and the district health system at the heart of the transformation of South Africa’s national health system (Figure 1). 1997: White paper: 2011: Office of Health Transformation of the Standards Compliance -‐ health system -‐ National core standards, emphasis shifts from reporting and curative hospital care accreditation process to PHC 1994: end of Apartheid 2003: National Health 2015: NHI White -‐ A racially fragmented Act (61 of 2003) -‐ The Paper -‐ PHC system is united health formalisation of the described as the into legal status of the “heartbeat of the one national and nine provincial health District Health System NHI” departments 2010: PHC re-‐engineering 1996: Free PHC policy Discussion Document -‐ -‐ Implemented first for Reasserting the centrality of women and children PHC and the district health then all users system. 2001: PHC package -‐ Set 2013: Ideal Clinic norms for the provision Initiative -‐ Defining of comprehensive PHC the functions of the (updated in 2010 and PHC clinic currently b eing r evised) Figure 1: Developments in PHC since 1994 South Africa is a signatory to the 2008 Ouagadougou Declaration on Primary Health Care and Health Systems in Africa, commemorating the 30th anniversary of the Alma Ata Declaration on Primary Health Care.3 In 2010, the Department of Health adopted the national PHC Re-‐ engineering Strategy 4 seeking to strengthen, amongst others, community based and preventive strategies. A commitment to PHC is further entrenched in the recently released White Paper on National Health Insurance (NHI), where PHC is described as the “heartbeat” of NHI.5 The PHC Re-‐engineering strategy and the NHI White Paper stress the importance of the PHC approach within the framework of a District Health System. The PHC Re-‐engineering 1 National Department of Health. White Paper on the Transformation of the Health System in South Africa. Pretoria: Department of Health, 1997. 2 National Health Act, No. 61 of 2003. Pretoria: Government Gazette, no. 26595, 2014 3 Ouagadougou Declaration On Primary Health Care And Health Systems In Africa: Achieving Better Health For Africa In The New Millennium, WHO/AFRO, 30 April 2008. 4 National Department of Health. Re-‐engineering primary health care in South Africa: Discussion document. Pretoria: National Department of Health, 2010. 5 National Department of Health. White Paper on National Health Insurance for South Africa. Pretoria: Department of Health, 2015
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Strategy has four priority “streams”: 1) Ward based PHC Outreach Teams consisting of community health workers and a professional nurse as team leader 2) Maternal, Child, Neonatal and Women’s Health District Clinical Specialist Teams 3) an Integrated School Health Programme 4) contracting of private general practitioners to work in public facilities. Public primary health care (PHC) is provided through a nurse-‐based, doctor supported infrastructure of +3,500 clinics and community health centres, available within 5 kms to more than 90% of the population, and free at the point of use.5 Since 1994, there has been a clinic building and upgrading programme involving 1,500 facilities5 and a considerable expansion of resources and entitlements through, and utilisation of, the PHC system. In 1998, there were 68 million visits (1,6 visits per capita) to PHC facilities; by 2015 this had risen to 120 million visits (2,2 visits per capita) (key informant interview). It has enabled access to antiretroviral therapy to more than 3 million people, and reduced mother-‐to-‐child transmission of HIV to 1.5%.17 This PHC system is supported by an emerging system of community-‐based outreach teams consisting of community health workers. In parallel, primary care is also provided by fee-‐for-‐service private general practitioners as well as traditional healers. Reforms to PHC have been implemented with other measures by the state to address absolute poverty – a large programme of social grants (reaching 16 million people), and expanded access to water, sanitation, electricity and housing. However, South Africa faces a formidable burden of disease, disproportionately impacting the poor. It has serious generalized HIV and TB epidemics, a rapidly growing burden of non-‐ communicable disease (NCD), high rates of injury and violence and still unacceptably high levels of maternal and child mortality. The HIV epidemic in particular, has had a devastating effect on the health system and on society at all levels – a rapid decline in life expectancy, overwhelming health care needs, and social and political crises. A concerted national response over the last decade, including a programme of universal access to antiretroviral therapy, has reversed some of these impacts (e.g. by raising life expectancy) and stimulated broader health system strengthening (e.g. increased staffing of PHC) but only recently opened the space to focus on other health care needs (e.g. NCDs). However, there is general consensus that despite a high overall proportion of GDP spent on health, health outcomes are poor. The key issues facing the health sector are the redistribution of resources within the sector, improving the functioning of the public health system, whilst also addressing the social determinants of ill-‐ health, which have their roots in poverty and inequality.
Macro-‐economic and health sector context The achievements of PHC in South Africa occur against a backdrop of significant health system, social and economic challenges. South Africa has one of the highest levels of income inequality in the world, with a Gini co-‐efficient of 0.69.6 Estimates of poverty in South Africa range from 46%6 to 65%. 7 Poverty is particularly severe among the one-‐third of the population that live in rural areas, where estimates of poverty exceed 70%. Agriculture contributes only 2.4% of GDP (2011 data; down from 2.6% in 2006),8 although approximately 8.5 million people, or 17% of the population, depend directly on it.
6 Statistics South Africa. Poverty Trends in South Africa: An examination of absolute poverty between 2006 and
2011. Pretoria: Statistics South Africa, 2014. 7 Noble, M., Zembe, W., Wright, G., Avenell, D. and Noble, S. Income Poverty at Small Area Level in South Africa in 2011, Cape Town: SASPRI, 2014. 8 Source: www.africaneconomicoutlook.org
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In the health sector, inequalities are present in stark differences between a well-‐resourced, insurance-‐based private sector serving only 16% of the population, but consuming half the total funds flowing through the health sector in the country, and a tax-‐funded public health system providing care for the remaining 84% (Table 1).5 In South Africa, spending on private health insurance as a proportion of total health expenditure is the highest in the world, and six times higher than the average in OECD countries.5 The presence of a high-‐tech and costly private health system, characterised by an oligopolistic hospital sector and significant inflationary pressures, accounts for the overall very high proportion of GDP (8.6% in 2015) spent on health.5 Table 1: Health system indicators South Africa Indicator Results Year Source 5 Total health expenditure as % of GDP 8.6% 2015 NDOH Public expenditure as % total health 48.5% 2015 NDOH5 expenditure (including donors) % of total provincial public sector 46% 2015 Padarath et al9 expenditure on District Health Services % total provincial public sector 26% 2015 Padarath et al9 expenditure on PHC Per capita public sector expenditure on US$60 2015 Padarath et al9 PHC Out of pocket payments as proportion 6.4% 2015 NDOH5 of total expenditure on health Voluntary health insurance as 42.8%10 2015 NDOH5 proportion of total expenditure on health Proportion of households experiencing 0.42% 2005/ Ataguba & McIntyre11 catastrophic health expenditure 6 Physicians registered per 1,000 0.93 2014 Padarath et al9 population Nurses registered per 1,000 population 6.1 2014 Padarath et al9 (all categories) As Ataguba and McIntyre12 have shown, the distribution of health benefits relative to need in South Africa is highly inequitable (Figure 2). A household survey found that while total utilization was similar across socio-‐economic groups (2.3–3.7 visits/year), the profile of providers used was different. The poorest (socio-‐economic quintile 1) were the most likely to use public primary health care (PHC) facilities (68.8%), while conversely, 60.8% of the richest (socio-‐economic quintile 5) made use of private primary care providers.13 9 Padarath A, King J, English R, editors. South African Health Review 2014/15. Durban: Health Systems Trust, 2015. 10 Note that public expenditure plus OOP expenditure plus private expenditure = 98.2% with the balance (1.8%) from donors 11 Ataguba J, Day C, McIntyre D. Monitoring and Evaluating Progress towards Universal Health Coverage in South Africa. PLOS Medicine 2014; 11(9)e1001686 12 Ataguba J.E and McIntyre D. Paying for and receiving benefits from health services in South Africa: is the health system equitable? Health Policy and Planning 2012;27:i35–i45. 13 Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S & Chersich M. Inequities in access to health care in South Africa. Journal of Public Health Policy, 2011; 32 Suppl 1(S1), S102–S123.
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% share of benefits or need
100%
80% 60% 40% 20% 0% % share of total benefits Quintile 5 (richest)
Quintile 4
Quintile 3
% share of need Quintile 2
Quintile 1 (poorest)
Figure 2: Comparing health benefits with health needs in South Africa (Source:12 Reproduced with permission) The health system is structured into a National Department of Health, nine Provincial Health Departments and 52 Health Districts. In South Africa’s quasi-‐federal political system, the national sphere sets overall policy and frameworks, and provincial and local authorities are responsible for implementation. The provincial sphere has the main responsibility for service delivery, including PHC and the district health system. Local authorities provide environmental health services and some preventive services. In some metropolitan areas, they also provide clinic-‐based PHC in parallel to that of the provinces. Government revenue is collected nationally and redistributed to provinces in the form of block grants (the so-‐called “equitable share”), based on a needs-‐adjusted, population-‐based formula. This is then allocated to sectors, including health. Certain funds, notably for the HIV/AIDS and TB programme are ring-‐fenced nationally and transferred as conditional grants. Over the last 5 years close to 80% of provincial expenditure has come from the equitable share with the rest from conditional grants and less than 3% from provincial own revenue. 14 Private sector funding flows through a fragmented system of 83 individual medical schemes. The National Health Insurance White Paper outlines proposals to pool these resources with the tax-‐funded base into one National Health Insurance (NHI) fund that will ensure more equitable distribution of resources across the country through purchasing services from accredited public and private sector providers. The overall governing body of the public health sector is the National Health Council (NHC), which links the provincial health Ministers/MEC’s with the national minister. The Director General of the NDOH and the nine provincial heads of department form the Technical Advisory Committee to NHC. Frameworks for financial and performance accountability are provided nationally, and include systems of budgeting, planning and accounting, including reporting on a set of core national indicators. Key regulatory bodies include the Medicines 14 National Treasury. Provincial Budgets and Expenditure Review 2010/11-‐2016/17. Pretoria: National
Treasury, 2014.
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Control Council, which will become the South African Health Products Regulatory Authority (manufacture, registration, distribution and pricing of medicines and medical products), Health Professions Councils (training and professional registration), the Office of Health Standards Compliance (facility accreditation in private and public sectors), and the Medical Schemes Council (regulating private health insurance). Public accountability is through statutorily mandated Councils and Consultative Fora at various levels, Hospital Boards and Health Facility Committees. However, in practice these structures are very unevenly constituted. Figure 3 below provides a map of the health of South Africa’s health system, outlining its architecture and governance.
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South African Health Products Regulatory Authority
GOVERNANCE (in white and blue blocks)
Office for Health Standards Compliance
Health professionals councils Medical Schemes Council
ARCHITECTURE OF SERVICE DELIVERY (in circles) National Health Council
National Department of Health
)
National Consultative Health Forum Provincial Department of Health)
Central) hospitals)
Provincial Consultative Health Forum District Health Council
Regional) hospitals)
)
District Management Team
Hospital Board
Local Government Ward Committee & Subcouncil Community Health Centre/Clinic Committee
Funders:) Third)party) Out
