<br>
<p class="MsoNormal" style="text-align:center" align="center"><b style="mso-bidi-font-weight:
normal"><span style="font-size:15.0pt;mso-bidi-font-size:12.0pt;
font-family:Helvetica" lang="EN-GB">National Health Insurance could improve health, create
jobs and mitigate climate change.</span></b></p>
<p class="MsoNormal" style="text-align:center" align="center"><b style="mso-bidi-font-weight:
normal"><span style="font-size:15.0pt;mso-bidi-font-size:12.0pt;
font-family:Helvetica" lang="EN-GB"> </span></b></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">David Sanders
and Louis Reynolds</span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;mso-bidi-font-size:
12.0pt;font-family:Helvetica" lang="EN-GB">[The first of a 2-part series on the NHI, based
on an article written for the One Million Climate Jobs Campaign]</span></p>
<p class="MsoNormal"><span style="font-size:10.0pt;mso-bidi-font-size:
12.0pt;font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">The advent of
the National Health Insurance (NHI) scheme opens up a political space to
campaign for a health service that will best address South Africa’s health
crisis and reduce the extreme inequities between poor and rich, rural and
urban, and public sector and private health service users.</span><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US">Campaigning
is necessary to raise awareness about the problems in our current health system
and the best ways to address them, and to disseminate information about the
most instructive examples globally of health system transformation that have
resulted in impressive advances in health and substantial reductions in health
inequalities. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US">Such
a campaign must counter powerful groups with vested interests who portray
public systems as inefficient and second-best, and see the NHI as an
opportunity to preserve a private health system that is innately inequitable
because of the need to profit from disease.</span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><b style="mso-bidi-font-weight:normal"><span style="font-family:Helvetica;mso-ansi-language:EN-US">Health, health systems
and a new model for health care</span></b></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US">As
we have written before (</span><i style="mso-bidi-font-style:normal"><span style="font-family:Helvetica" lang="EN-GB">NHI key to tackling SA’s health
crisis.</span></i><span style="font-family:Helvetica" lang="EN-GB"> Cape Times,
October 14<sup>, </sup></span><span style="font-family:Helvetica;mso-ansi-language:
EN-US">2010) South Africa’s
health indicators are disturbing.<span style="mso-spacerun:yes">
</span>Despite unprecedented economic growth over a decade, South Africa, (with a GDP/capita of $10 000 per
year) compares badly with other countries of similar wealth such as Cuba, Brazil
and Costa Rica.
In South Africa
under-5 mortality, a sensitive barometer of a country’s health and social
development, has, in contrast to most countries in the world, increased over
the past two decades. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US">South
Africa’s under-five mortality rate (U5MR) of 67 deaths per 1000 live births (75
000 deaths per year) is ten times that of<span style="mso-spacerun:yes">
</span>Cuba at 6 and six times that of Costa Rica at 11 per 1000 live births.</span><span style="font-family:Helvetica" lang="EN-GB"> Similarly, every year 1600 mothers
die from pregnancy or childbirth complications, and 20 000 babies are stillborn.</span><span style="font-family:Helvetica;mso-ansi-language:EN-US"></span></p>
<p class="MsoNormal"><span style="font-family:Helvetica;mso-ansi-language:EN-US"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">Too many live
in conditions that make them sick. Poverty and inequality are key basic
determinants of child deaths: a child belonging to the poorest fifth of the
population is four times more likely to die before turning 5 years old than a
child in the richest fifth. Almost 20% of young children are undernourished,
which predisposes them to infections, many of which spread in unhygienic and
overcrowded environments. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">Though there
has been good progress in increasing the delivery of clean water at an
aggregate national level (although not sufficiently often to individual
households), large gaps and inequalities in water and sanitation exist even in Cape Town: in parts of
Khayelitsha up to 400 people share a single standpipe and 9 percent of
households have no toilets. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">And when
people become sick, they face an inaccessible, understaffed and poorly
managed<span style="mso-spacerun:yes"> </span>health service, characterised by
large inequalities and gaps in distribution of<span style="mso-spacerun:yes">
</span>financial and infrastructural resources between private and public
sectors,<span style="mso-spacerun:yes"> </span>between levels of care
(hospitals vs. clinics), and in human resources. Rural areas house 43.6% of the
population but only 12% of doctors and 19% of nurses work there. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">A minority –
approximately 16% of the population, who are also the healthiest – utilise an
expensive, hospital-dominated, urban private health system accounting for
approximately 60% of health spending and employing just under 50% of the
country’s doctors, approximately 70% of medical specialists, 90% of dentists
and dieticians and almost 40% of all nurses.</span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"><span style="mso-spacerun:yes"> </span></span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">The proposed
NHI scheme pools public and private health resources for health for universal
coverage, increasing the funds available for health significantly, and
restructuring health service delivery. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">There are a
number of other policy initiatives, key amongst which is the proposed
‘Re-engineering of Primary Health Care’. This stipulates that the District
Health System should become the central focus of resources and activity and
that the community level of health care and lower-level facilities (clinics,
health centres and district hospitals) should be urgently strengthened.</span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">It also
outlines a new model for human resources. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">Research and
experience from a growing number of countries shows rapid health improvements
where community-level workers, supported by clinics and health centres and
equipped with basic skills to identify, prevent and treat common<span style="mso-spacerun:yes"> </span>- especially childhood – conditions, visit
households regularly. .<a style="mso-footnote-id:ftn1" href="#_ftn1" name="_ftnref1" title=""><sup><span style="mso-special-character:footnote"><sup><span style="font-size:12.0pt;font-family:Helvetica;mso-fareast-font-family:
"ヒラギノ角ゴ Pro W3";mso-bidi-font-family:"Times New Roman";color:black;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA" lang="EN-GB">[1]</span></sup></span></sup></a></span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">Of the
approximately 65 000 community caregivers (CCGs) in the country, most work in
HIV/AIDS or TB programmes, employed by a myriad of NGOs. Rationalisation,
standardisation and expansion of the skills of this crucial cadre is urgently
needed, as is improvement of their insecure employment conditions. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">This model,
which is similar to Brazil’s
successful Family Health Programme and in line with the revitalisation of
Primary Health Care, would undoubtedly be substantially cheaper than the
current private sector model, and more cost-effective than the current hospital-dominated
public sector. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">Human
resources account for over 70% of recurrent expenditure on health care, and
specialist and general doctors and professional nurses account for a
disproportionate percentage of this expenditure. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">Moreover,
this model should, as in other countries (Brazil, Rwanda, Thailand,
Bangladesh), rapidly increase access to health care by the poor and result in
improved health outcomes, especially if the ratio of CCGs to population were
increased to resemble that of Thailand or Rwanda where the high density of
community-based workers ensures that all households are regularly visited and
health problems detected early. <a style="mso-footnote-id:ftn2" href="#_ftn2" name="_ftnref2" title=""><sup><span style="mso-special-character:footnote"><sup><span style="font-size:12.0pt;font-family:Helvetica;mso-fareast-font-family:
"ヒラギノ角ゴ Pro W3";mso-bidi-font-family:"Times New Roman";color:black;mso-ansi-language:
EN-GB;mso-fareast-language:EN-US;mso-bidi-language:AR-SA" lang="EN-GB">[2]</span></sup></span></sup></a></span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">In several
countries such high ratios are achieved by instituting a ‘two-tier’ system
where full-time CCGs (Community Care Givers) are in a ratio of 1: 300-500
households and part-time CCGs with a more limited training are supervised by
the full-time community workers. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">The ratio of
full-time to part-time CCGs averages 1:10 to 1:20 in countries where such a
system operates successfully. This would mean that South Africa would need a total of
between approximately 700 000 and 1, 300, 000 community caregivers, the
majority of them part-time. </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB">This total
cadre of community-based workers would, undertake a range of health care
activities, spanning the full breadth of rehabilitative/palliative, treatment,
and preventive and promotive interventions. They would form the base of the
health pyramid.</span></p>
<p class="MsoNormal"><span style="font-family:Helvetica" lang="EN-GB"> </span></p>
<p class="BodyA">Thus, in addition to rendering health care more accessible and
equitable, such a PHC-based health system will create many more jobs, and
indirectly improve health by reducing the prevalence and depth of poverty.</p>
<p class="BodyA"> </p>
<p class="BodyA">The next article in this two-part series looks at the critical
interrelationships between climate change and health, and how the NHI provides
the health sector with an historic opportunity to also take a leading role in
addressing climate change.</p>
<p class="BodyA"> </p>
<p class="BodyA"> </p>
<p class="BodyA">Emeritus Professor David Sanders,</p>
<p class="BodyA">School
of Public Health,</p>
<p class="BodyA">University of the Western
Cape.</p>
<p class="BodyA"> </p>
<p class="BodyA">Associate Professor Louis Reynolds,</p>
<p class="BodyA">Health Sciences Faculty,</p>
<p class="BodyA">University
of Cape Town.</p>
<p class="BodyA"> </p>
<p class="BodyA">Both authors are paediatricians and members of the Peoples
Health Movement <a href="http://www.phmovement.org">www.phmovement.org</a></p>
<p class="BodyA"> </p>
<p class="BodyA" style="tab-stops:105.75pt"><span style="mso-tab-count:1"> </span></p>
<p class="BodyA"> </p>
<p class="MsoNormal"><span style="font-size:10.0pt;mso-bidi-font-size:12.0pt;
mso-fareast-font-family:"Times New Roman";color:windowtext;mso-ansi-language:
#0400;mso-fareast-language:#0400;mso-bidi-language:X-NONE"> </span></p>
<div style="mso-element:footnote-list"><br clear="all">
<hr width="33%" align="left" size="1">
<div style="mso-element:footnote" id="ftn1">
<p class="FootnoteText2"><a style="mso-footnote-id:ftn1" href="#_ftnref1" name="_ftn1" title=""><sup><span style="mso-special-character:footnote"><sup><span style="font-size:10.0pt;font-family:Helvetica;mso-fareast-font-family:"ヒラギノ角ゴ Pro W3";
mso-bidi-font-family:"Times New Roman";color:black;mso-ansi-language:EN-US;
mso-fareast-language:EN-GB;mso-bidi-language:AR-SA">[1]</span></sup></span></sup></a>
<span style="mso-ansi-language:EN-GB" lang="EN-GB">Bhutta ZA, Lassi ZS, Pariyo G,
Huicho L. Global Experience of Community Health Workers for Delivery of Health
Related Millennium Development Goals: A Systematic Review, Country Case
Studies, and Recommendations for Scaling Up: Global health workforce alliance:
Health workers for all and all for health workers; 2010<b style="mso-bidi-font-weight:
normal">.</b></span><span style="font-family:"Times New Roman";mso-fareast-font-family:
"Times New Roman";color:windowtext;mso-ansi-language:#0400;mso-fareast-language:
#0400;mso-bidi-language:X-NONE"></span></p>
</div>
<div style="mso-element:footnote" id="ftn2">
<p class="FootnoteText2"><a style="mso-footnote-id:ftn2" href="#_ftnref2" name="_ftn2" title=""><sup><span style="mso-special-character:footnote"><sup><span style="font-size:10.0pt;font-family:Helvetica;mso-fareast-font-family:"ヒラギノ角ゴ Pro W3";
mso-bidi-font-family:"Times New Roman";color:black;mso-ansi-language:EN-US;
mso-fareast-language:EN-GB;mso-bidi-language:AR-SA">[2]</span></sup></span></sup></a>
<span style="mso-ansi-language:EN-GB" lang="EN-GB">Lehmann U and Sanders D.
(2007).Community Health Workers - what do we know about them? The state of the
evidence on programmes, activities, costs and impact on health outcomes of
using community health workers. Evidence and Information for Policy, Department
of Human Resources for Health. WHO: Geneva.</span><span style="font-family:"Times New Roman";mso-fareast-font-family:"Times New Roman";
color:windowtext;mso-ansi-language:#0400;mso-fareast-language:#0400;mso-bidi-language:
X-NONE"></span></p>
</div>
</div>
<br>