Health Systems Trust Equity Gauge Project A Partnership between the Health Systems Trust and South African Parliamentarians Presented by Antoinette Ntuli

Objectives To actively monitor equity in health and health care; Support legislators in utilising equity oriented information and analysing health policy especially with regard to budgeting and resource allocation; Instil the notion of monitoring equity as a key strategy for the promotion of equity among the media and the general population of South Africa; Strengthen the accessibility and quality of health data; Pilot mechanisms whereby disadvantaged communities can utilise information to better advocate for improvements in equity and the meeting of their health needs; Stimulate responsiveness of legislators, local councillors and service providers to needs identified by their communities.

Key Equity Promoting Achievements Since 1994 Equity enshrined in SA constitution Equity underpins policy development Unitary Public Health System Progress with the establishment of a District Health System Free Primary Health Care and free care for children and pregnant mothers Upgrading of existing and building of many new clinics Introduction of community service for newly qualified health personnel

Promulgation of Legislation Health Specific Legislation impacting on: Medical Schemes Medicines and related substances Mental health Tobacco products Professional Councils Laboratories

Value for Money? Some International Comparisons Country South Africa Botswana Thailand Venezuela GDP per capita in $ 8908 6872 6132 5495 Under 5 mortality per 1000 69 59 30 23

Public/Private Divide Private sector expenditure in 2000 was R3898 per person, almost five times Public sector expenditure of R779 per person Less than 1 in 5 people have medical aid coverage Almost 70% of whites having medical aid coverage while less than 10% of Africans have medical aid

Health Status in South Africa Infant mortality rate – 47 for Africans and 11 for whites Under 5 mortality rate – 64 for Africans and 15 for whites Provincial as well as racial inequities – stunting twice as prevalent in Mpumalanga where it is 30% as in the Western Cape where it is under 15%

Public Sector Expenditure Per capita expenditure is below R650 in four provinces while it is more than R1200 in the Western Cape. Sometimes inequity within provinces is even greater, with some districts spending as much as four times more than others per person on health care

Trends in Government Financing of Health Care 1992/3 to 1997/8 Growth in Government Financing Move towards greater provincial equity Shift of resources to primary health care 1998/9 Reversal of redistribution between provinces Limited growth in PHC expenditure

Health Sector Financing 10 20 30 40 50 60 70 80 R billion (1999/00 prices) Government finances 29 31 Households 23 25 27 Employers 11 12 Total 61 67 1996/97 1997/98 1998/99 Doherty et al. 2002.Health financing and expenditure in the post-apartheid era. 2002 SAHR

Household Spending on Health Care A survey of households affected by AIDS found that they spent on average a third of their income on healthcare with some rural families spending half of their income on health care. 54% of income of rural households was spent on health care compared to 26% for urban households From: ‘ A Survey of Households impacted by HIV/AIDS in South Africa: What are the Priority Responses?’

Inequity in Provincial Health Spending 250 200 150 100 50 1996/97 - Rands 1997/98 (50) (100) 1998/99 (150) (200) (250) (300) Free State Gauteng Mpumalanga Northern Cape Eastern Cape Western Cape Northern Province KwaZulu-Natal Doherty et al. 2002.Health financing and expenditure in the post-apartheid era. 2002 SAHR

Personnel In Eastern Cape and Northern Province 12 medical practitioners per 100 000 people as compared with 32 in the Western Cape Between 60% and 70% of spending is on salaries

Health Care Personnel in the Private and Public Sectors 1999 Source: National Health Accounts, The private sector report 2001

HIV/AIDS Difficult to monitor impact of HIV on equity. However it is expected that those areas already most disadvantaged are likely to be more disadvantaged by HIV. This is born out by a recent study among families affected by AIDS: “There is also evidence that AIDS is making this poverty worse. It is difficult to imagine a response to this epidemic that does not in some way try to alleviate poverty and address the lack of basic services like sanitation” From ‘A Survey of Households impacted by HIV/AIDS in South Africa: What are the Priority Responses?’

Household Sewerage Disposal Facility Used Urban   National Urban Data* Rural National Rural data* N % Flush toilet 363 75.5% 42% 50 20.2% 5% Chemical toilet 4 0.8% 36% 1 0.4% 7% Pit latrine with vent 30 6.2% 10% 29 11.7% 67% Other pit latrine 36 7.5% 71 28.7% Bucket toilet 35 7.3% 11% 14.2% 2% Non/open veld 9 1.9% 1% 61 24.7% 19% Communal toilet 0.0% Total 481 100% 247 From ‘A Survey of Households impacted by HIV/AIDS in South Africa: What are the Priority Responses?’

Impact of HIV/AIDS Estimates as to HIV related bed occupancy in hospitals are as high as 60% Life expectancy to drop by as much as 20 years by 2010 Social impact may be devastating as a result of the increases poverty, large number of orphans and the effect of loss of life on teachers, nurses etc

Recommendations Stronger equity/backlogs component to formula for allocating global budgets to provinces Reviewing provincial processes that determine the health allocation within provinces Further measures to reduce the inequity between the private and public sector. A Social Health Insurance that allows for cross subsidising between the “haves” and the “have nots”

Recommendations Need for a national comprehensive human resource strategy Attempt to redress urban – rural inequity Training staff for the level of care that is required

Recommendations In addition to above measures intended to strengthen the Public Health System as a whole there is a need for: Clarity on the way forward for containing the impact of HIV/AIDS especially with regard to ART and ensuring access to cheap medicines Seeking opportunities to strengthen public/private partnerships as a vehicle for providing care Recognising that our response to HIV/AIDS has to be multi-sectoral and include poverty reduction strategies as well as measures designed to improve access to basic facilities, especially sanitation

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