1. Background and Introduction
On 16 April 1997, the Minister of Health Published the White Paper on the Transformation of the Health System in South Africa in Government Gazette #17910. This White Paper presents the policy objectives and principles upon which a unified health system of South Africa will be based. In addition, the document presents various implementation strategies to meet these objectives. It contains many significant revisions from an earlier policy document released by the Department of Health in December 1995 and again in May 1996. It incorporates many elements of the Restructuring the National Health System for Universal Access to Primary Health Care. This White Paper document presents a comprehensive picture of the Department's vision for the creation of a unified National Health System. It should be read in combination with the National Drug Policy that was released in February 1995.
Within the 225 pages, there are countless policy proposals that have more or less relevance for the various stakeholders. The White Paper consists of 21 separate chapters on different aspects of the Department of Health's control. Phila plans to issue a series of summary briefs on other chapters in the White Paper in the next few weeks. Thus, this brief will highlight the major policies contained in the document.
2. Founding Principles
The central issue within the White Paper is the restructuring of the health sector. The Department has identified the following aims for this process:
Additional goals and objectives for the Department include:
3. Specific Issues
3.1 Reorganisation of the Health Sector
The new Constitution stipulates that certain powers and functions within the health sector should be devolved to the provincial and local levels. The Department has adopted the district health system model to give effect to this mandate. Each level of government will have certain responsibilities and functions within the National Health System.
The functions of the National Department of Health broadly speaking will be:
Provincial health departments will promote and monitor the health of the people in the province, and develop and support a caring and effective provincial health system through the establishment of the district health system based on the principles of primary health care (PHC). During the period of transition required to establish the DHS, provincial authorities will perform functions that will be devolved to districts at a later stage.
The country will be divided into geographically coherent, functional health districts. Within each health district, a team will be responsible for the planning, management, and evaluation of health services for a defined population. Because of the diversity among provinces, three governance options for the district system are suggested:
The DHS represents the core strategy of the reorganisation of the health sector, therefore its rapid implementation should be given the highest priority. In terms of the practical steps of implementation, each province will be divided into functional districts. Peri-urban, farm, and rural areas will fall within the same health district as the nearest town. Parity in salaries and conditions of service will be established throughout the country. Incentives will be provided to encourage health providers to work in underserved areas. Financing mechanism will be established to ensure that district level health services are funded in an equitable and sustainable manner.
Once established, the district will serve as the purchaser and provider of health services. The functions of the district level are to provide and coordinate the delivery of all health services, to ensure community participation, to ensure the provision of support services, establish and manage its budget, planning, monitoring and evaluating health services, and providing for adequate human resource development.
3.2 Financing of the Health Sector
Currently financing of the health sector is skewed toward high technology hospitals located in urban settings. In order to correct these financial inequities, the Department has developed the district health system mentioned above. It has also developed a medium term expenditure framework designed to provide basic health care to all South Africans within 10 years if two conditions are met. First, there must be a redistribution of public health resources. Second, new sources of public health revenue must be identified over and above general government allocations.
The Department recognises the need to protect funding for the district health system at the expense of hospitals. The Financial and Fiscal Commission proposed conditional minimum standard grants to provinces for district health services and real growth in district level spending. In the absence of such a conditional grant, other provisions must be made to ensure that adequate funds are earmarked for the DHS.
3.2.1 Hospital Revenue Retention
The Department suggests two mechanisms to raise additional funds for the health sector. The first is the retention of revenue by secondary and tertiary hospitals. Currently, revenue generation at these facilities is quite low because there is little incentive to collect fees. All monies are transferred to the provincial treasuries. In addition, the quality of care currently provided at public hospitals is quite low and paying patients are often transferred to private hospitals for better care.
The proposal is that individual hospitals would be able to retain some the revenue generated. This proposal must be viewed in the context of decentralised management that is being introduced within hospitals. Hospital managers would have flexibility to spend this additional money to improve the quality of care delivered. It is envisaged that revenue retention would be phased in over time. A greater proportion of funds from higher level hospitals would be forwarded to the province while lower level hospitals would be able to retain higher levels at the hospital.
3.2.2 Social Health Insurance
The other major financing proposal under consideration by the Department is the introduction of a social health insurance scheme. Many employed individuals and their families attend public hospitals without paying for services. Medical scheme beneficiaries also use public hospitals after their cover has run out and may not pay any fees. To address this situation, the Department will introduce a social health insurance scheme which will require all formally employed people to be insured for the cost of treatment for themselves and their families at public hospitals. Contributions will be split between employers and employees and related to income and family size.
3.2.3 Funding of Highly Specialised Services
In the future, the Department anticipates that many tertiary services will be provided at some regional hospitals. In the interim, provinces without these tertiary services must continue to refer patients to those provinces which can provide them. The 'client' province is expected to pay the 'provider' province for these services. The level of charges over the next few years will take into account that provinces do not yet receive equitable funding.
Highly specialised services that are very expensive and needed by a small percentage of the population will not be provided in every province. They are currently being provided at academic hospitals in urban centres. These services will become a national resource available to all people in the country. The location and development of these services in the future will be planned and funded by the Department of Health.
3.2.4 Funding of Academic Health Service Complexes
Beyond the cost of providing services, academic health service complexes incur extra costs training students. Currently, the Department provides a separate ' national increment for teaching, education and research' (NITER) grant to these institutions. Historically, the NITER grant has been payed in one lump sum based on historical expenditures. A more rational funding system will be introduced. The proposed system will be based on the number of enrolled medical students as an indicator of the academic activity of the institution. It is envisaged that the revised system will address the imbalances in health training institutions caused by apartheid policies.
3.3 Redistribution of Physical Resources
The Department is currently engaged in a policy to redress imbalances in the distribution and condition of health facilities within South Africa. It has conducted an audit of community health centres and hospitals that will form the baseline for future capital expenditure. Through the Clinic Upgrading and Building Programme (CUBP), hundreds of new clinics are being built and existing structures upgraded.
The Department has several proposals to improve the public/private mix of health services. The revenue retention scheme and the social health insurance proposal should reverse the flow of money from the private to the public sector. In addition to these financial arrangements, the Department will use licensing, regulations, and contracts to increase utilisation of private sector resources by the public sector. Finally, the Departments presents a potential framework for the contracting out of selective clinical and non-clinical services.
3.4 Human Resource Development
Human resources development is one of the critical factors in determining the success of the health system. A national policy should provide guidelines for the recruitment, selection and placement of health personnel based on needs and affirmative action. The Department has identified three principles that create the framework for its human resource development policy.
Audits of the number and distribution of health personnel and training institutions will be conducted by the Department. On the basis of these audits, comprehensive guidelines for future training of health workers will be developed, based on the principles of excellence.
The skills, experience and expertise of all health personnel should be used optimally to ensure maximum coverage and cost-effectiveness.
The Primary Health Care Team (PHCT) should contain a mix of health workers with different skills to deal with common conditions and refer to the appropriate level. It should be based at a clinic, community health centre, or doctor's suite and include: community health nurses, midwives, doctors, primary health care nurses, enrolled nurses and nursing auxiliaries, oral hygienists/therapists, clerical and support staff and rehabilitation personnel. The existing PHCT ratio of 1:30,000 should be reduced to 1:15,000 during the next five years.
The referral team should consist of medical and nurse practitioners, clinic nurses with advanced training, pharmacists, dentists, clinic psychologists, environmental health officers and assistants, enrolled nurses and nursing auxiliaries, advanced midwives and supplementary health personnel according to the needs of the community. Specialists will be stationed at secondary and tertiary hospitals.
Community health workers, traditional healers, and traditional birth attendants should not be incorporated into the public service at this stage. Training for CHWS should take place at the district level with accountability to the provincial health authority. Community rehabilitation workers should only be trained through the addition of skills to physiotherapists or occupational therapists assistants, where a distinct career path has been identified and not on an a hoc basis. The regulation of traditional healers should be investigated for their legal empowerment.
Health personnel should be distributed throughout the country in an equitable manner.
A national planning system for the distribution and financing of health workers should be developed. Maldistribution of human resources will be addressed through an incentive driven process, which requires a maximum of two years in underserved areas after completion of their studies. Incentives should be developed based on the level of inhospitality of the working environment. In addition, all health professionals, generalists and specialists, should spend at least two years in a public sector non-tertiary institution before entering health practice.
3.4.1 Education and Training
Health Education and training programmes need significant restructuring to make them appropriate for the proposed health system. These programmes must become refocused on recruiting and developing people who will be competent to respond appropriately to the people that they serve. Training should be coordinated and geared to empower health workers to deliver PHC services. Training for certain professions such as PHC nurses, advanced midwives, community psychiatric nurses, psychologists, and paediatric nurses among others should be prioritised. Continuing education opportunities should be promoted and re-certification for safe practice should be the responsibility of professional councils.
Health sciences curricula should be restructured to meet community needs more accurately. All health workers should be empowered with an understanding of PHC through reorientation programmes. The training of generalists should receive greater emphasis than specialisation with academic health services complexes. The Department will support the establishment of a national School of Public Health without walls.
3.4.2 Creating a Caring Ethos
All people using the health system should find it to be caring and compassionate. The Department recommends that a Charter of Community and Patient's Rights should be designed in consultation with health workers to support democracy within society. Likewise, the rights of health workers should be identified and respected. In order to bring about a culture of caring in the health services, an active national campaign will be undertaken by the Department.
3.4.3 Changing the Nature of Management
The guiding principle in terms of health management will be maximum decentralisation of authority to allow for greater autonomy. At the district levels, management teams will be fostered to develop comprehensive, integrated services. Throughout the health system, a participative, democratic management style and management by objectives should be encouraged. The Department recognises the deficiencies that currently exist in health management and has proposed a skills development programme to address this issue.
3.4.4 Affirmative Action
The Department believes that affirmative action policies should be aimed at transforming the public health service into a non-racial, non-sexist organisation. It should broadly reflect the composition of the population in the labour market. A realistic and comprehensive affirmative action policy should be linked to recruitment of personnel, job descriptions, career advancement, performance appraisal, training, study programmes, and promotion. Efforts should be made to ensure that health educational and training institutions begin to produce graduates to meet the goals of affirmative action.
3.5 Community Involvement in Health
The Department has identified three principles to involve the community in the health sector.
All South Africans should be equipped with the information and the means for identifying behavioural change conducive to improving their health.
As many health interventions rely on individual behaviour, a healthy environment, and positive lifestyles to improve health status, it is essential to actively involve individuals, families and communities in the health promotion process.
People should be afforded the opportunity to actively participate in various aspects of the planning and provision of health services.
In line with the deepening of democracy brought about by the 1994 elections, the health sector will establish structured opportunities for communities to be involved at all levels. Clinic, health centre and community health committees should be established to allow users of the service and communities to participate in the planning and provision of services. The essential PHC package will be negotiated between communities and facilities to ensure that health priorities are met and expectations are clearly understood. Simple community-based information systems should be established to identify the needs of the community and monitor progress. Women should be enabled and supported to play a major role in local health committees.
The Department of Health should provide the public with regular updates on progress, results and emerging issues related to its work, and should ensure that people participate in the development of national policy.
Periodic national, provincial and district health summits should be established to give the public opportunities to make policy recommendations and identify new priority issues. National, provincial, and district annual reports should be compiled and distributed widely. The Minister of Health must provide parliamentarians and other elected officials with information to respond to questions raised by constituents.
4. Way Forward
No comment period was given for this document. It was released as the official policy of the Ministry of Health. In addition, it is not clearly stated how this document will be taken forward in relation to the National Health Bill. Finally, time frames for implementation have not been provided for the majority of strategies. Based on this document, the implementation status of many of these policies is not clear. One cannot tell how much progress has been made in a particular area. A forthcoming report from the Health Portfolio Committee will provide a comprehensive assessment of the Department's progress over the past three years.
Phila is funded by a grant from the Henry J. Kaiser Family Foundation.
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