Our weak economy threatens to undermine the significant progress made in the public health sector over the past decade, including a 10-year increase in life expectancy, reports Health-e News. The SA Health Review 2017, released last week, paints a sober picture of a sector battling to deliver services as well as contain costs in the face of low economic growth.
Health expenditure will increase in this financial year by a mere 1,1%. By next year, this increase will be a miniscule 0,8% and in 2018/19, there will be a cut in spending of R142m (0,1%).
“The slowdown in growth may last for a long time, impacting on health budgets negatively, but the National Health Insurance (NHI) has the potential to reverse this trend through additional revenue streams to fund health services,” write Treasury official Mark Bletcher and colleagues in the SAHR.
The report says Health Minister Aaron Motsoaledi has been casting around for some years now, trying to find more resources to ensure that poor people have access to better quality healthcare. Proposed financing for the NHI is from a reduction in tax breaks for medical scheme members, a VAT increase, payroll tax and personal income tax surcharge.
The report says the 38% depreciation of the rand against the US dollar between 2012 and 2016 has posed a huge challenge for the price of medicines. At the same time, an extra 400,000 patients per year are joining the HIV treatment programme and a number of new children’s vaccines have been introduced.
Luckily, “control of medicine price increases has generally been one of the Department of Health’s greatest successes,” Bletcher and colleagues note. This has been done largely through the central procurement of medicines. “Prices of ARVS are generally considered the lowest in the world and overall public sector medicine prices have been said to be 87% lower than average OECD prices,” they say.
Staff costs are the biggest expense, with national salary increases for certain categories of health professionals resulting in increases of 38% between 2005 and 2012. Despite ongoing official denials that health posts in provinces have been frozen, almost 5 500 public sector positions have been lost over the past four years, although most of these jobs have been nursing assistants and student nurses.
“Most provinces have imposed some form of restriction in terms of filling vacant posts,” says Bletcher, with posts declining by around half a percent a year since 2012.
Some 300 medical specialists left between 2015 and 2016 alone. The Western Cape suffered the greatest loss, losing 200 specialists. This province was also the only one to lose doctors (down by 63 to 1500). While Limpopo only lost 12 specialists in the past year, it means that the province now down to 68 specialists. This translates into 1,3 per 100,000 people, the lowest ratio in the country and way below the country average of 10.
The report says spending on infrastructure has been cut, and more patients are being channeled to clinics rather than hospitals to cut costs. At the same time, clinic visits have been cut by 3m over the past two years, in part due to the introduction of a new medicine dispensing programme that enables stable chronic patients to get their medicines from designated pick-up points such as private pharmacies and schools.
The report says clearly, both provincial and national health departments are straining to contain costs but this requires considerable management skill – something that is in short supply in the sector, particularly at lower levels of management. In the meantime, the looters who have captured large parts of the state are lining their own pockets with impunity.
Death rates have declined, largely due to successes in HIV, but a lot more needs to be done to defeat its “terrible twin”, tuberculosis (TB). Health-e News reports that according to the review, life expectancy, which rose from its lowest levels in the mid 2000s, has been maintained. In 2006, due to the explosion in new HIV infections and little access to treatment, life expectancy was 52 years but in 2015 it had risen to over 63 and remains stable. This increase was driven by a massively scaled-up antiretroviral programme: the largest in the world.
It noted that the prevention of mother-to-child transmission (PMTCT) of HIV, another big driver in helping people live longer, “is one of the success stories of the 21st century in South Africa”.
There have also been successes in prevention. Since 2010, an estimated 10m HIV tests and half a million medical male circumcisions are done every year, while 750m male and over 25m female condoms are distributed.
Despite this, the report says, many gaps remain. Key populations, those at higher risk of HIV infection, “pose particular challenges in the South African context”, noted the review. These include sex workers, people who inject drugs, transgender people, prisoners and men who have sex with men.
According to the Joint United Programme on HIV/AIDS more than 20% of new infections in sub-Saharan Africa were in key populations and more targeted interventions are needed to reach these communities who are often stigmatised and struggle to access services at traditional health facilities.
The report says the review also noted that more needs to be done to address drug-resistant TB (DR-TB) as it is “a significant threat to end TB efforts in South Africa”. It has implications for the fight against HIV as up to as many as 60% of TB patients are co-infected with HIV. Although just under 20,000 patients were diagnosed with DR-TB in South Africa in 2015 the numbers continue to rise and there are concerns that a significant number of cases are undiagnosed.
While the country has recently expanded access to newer drugs for DR-TB the review noted that there are variations in available DR-TB services across different provinces. For example the national policy of decentralising DR-TB services, out of hospitals and into communities, has not been implemented evenly across provinces.
“HIV has been a black cloud dominating the health landscape over the past 25 years,” note Professor Peter Barron and Ashnie Padarath in the review’s editorial. They said that the most important success in reflect on is the response to HIV which has been “instrumental in improving the key health indicators relating to death rates, life expectancy, and maternal, child and infant mortality”.
“Nonetheless, it is also very clear that challenges remain and that much needs to be done to improve governance, leadership and accountability at strategic, district and facility level, as well as in terms of the overall planning and implementation of the health workforce.”
The increase in life expectancy means that HIV patients are living longer and many are experiencing other health problems as well. Health-e News reports that the review noted that South Africa has the highest prevalence of diabetes on the continent affecting about 4m people. Rates of high-blood pressure are also high in many communities: one study found that almost half of Durban Indians have hypertension.
Many patients have more than one non-communicable disease (NCD) at a time and most diseases are preventable through lifestyle changes. “Prevention and early detection measures are therefore crucial for the control and management of NCDs, and failure to implement such interventions can be costly,” it noted.
The report says most NCD care is done at the facility level and a chapter in the review argued that community health workers (CHWs) are under-utilised in the management of patients with NCDS. Research has shown that CHWs can deliver services in communities, especially in rural communities where transport costs are a barrier to health care, efficiently and effectively. These services could include weight, blood sugar and blood pressure checks.
“Although prevention of NCDs should be part of (primary health care) services, these services are still weak in many places in South Africa,” noted the authors. Utilising CHWs, or ‘task-shifting’, to promote prevention and awareness, including about healthy eating and physical activity, would further unburden public facilities that are struggling to cope with high patient loads.
Policy initiatives, including the proposed tax on sugary beverages, will help, the review noted, but more needs to be done to adequately manage patients, especially those with multiple chronic conditions for which they will likely need treatment for life.
The report says the costs of treating this disease burden in the future will be significant as will be the costs to the economy of early deaths. Although it is not clear how much is spent on community services, funding for NCDs in total forms less than 0.1% of the national health budget.
To control the growing burden, and offset the costs, the authors noted that a new approach needs to be taken and the “importance of health financing for management and control of NCDs at community level cannot be overemphasised.”
[link url="https://www.health-e.org.za/2017/08/24/weak-economy-compromises-health-service-delivery-sahr/"]Health-e News report[/link]
[link url="http://www.hst.org.za/publications/South%20African%20Health%20Reviews/HST%20SAHR%202017%20Web%20Version.pdf"]SA Health Review 2017[/link]
[link url="https://www.health-e.org.za/2017/08/23/deaths-rates-declined-due-hiv-success-report/"]Health-e News report[/link]
[link url="https://www.health-e.org.za/2017/08/23/non-communicable-diseases-threat-health-system/"]Health-e News report[/link]