1. Conference on NHI – Lessons for South Africa Ministry of Health – Gallagher Estate, Johannesburg 7-8 December 2011 Elroy Paulus – Advocacy Programme Manager, Black Sash

2. The uniqueness of the SA context 2

3. Important context

4. 4 Figure 1: At least 1 in 4 of working age in SA is unemployed or working poor

5. 5 South Africa

6. Share the methodology of these consultations with a sector of civil society organisations Highlight key findings and recommendations Link to current work and initiatives of civil society organisations in South Africa Highlight aspects of insights learnt from a current project – CMAP (Community Monitoring and Advocacy Programme)

7. Eliciting public preferences for health system reform including the National Health Insurance in South Africa Disseminate information on current health system challenges and health system reform options; Provide regional civil society platforms for information sharing and preference elicitation with respect to national health system reform ensure that these preferences are taken into account in policy deliberations Intended impact - that the policy proposals for health system reform will reflect public values and be in line with public preferences

8. Organisational Mission and Project Design Collaboration between three organisations: the Black Sash, the Health Economics Unit of the University of Cape Town and Health-e News Service Holding public consultation workshop with civil society groupings in all provinces, and using informed deliberation approaches to elicit public views on the values that should underlie the SA health system and the priority health system changes desired Submission of findings to wide range of policy actors and public dissemination of findings

9. Timeline of consultations Public Consultations held in each of 9 provinces during May 2010 to June 2011, viz. Eastern Cape; KwaZulu Natal; Western Cape; Mpumalanga; North West; Limpopo, Gauteng; Northern Cape and Free State. Intention was to, as rapidly as possible, elicit public preferences on the core values that should underlie health system reform in South Africa and on key aspects of the proposed NHI (focussed on broad policy options  feed that information into the policy process while it is still in its initial stages.

10. Broad strokes of methodology Used broad approach of informed public deliberation in these workshops  Deliberative processes used to elicit public views to establish the values that citizens want to underlie their health systems and the priority issues for health services to address. Workshop representatives/participants were: – provided with relevant information, i.e. their discussions are informed; – given an opportunity to deliberate on the information and the specific questions posed to them, so that the pros and cons of different decisions can be discussed; and – reached decisions on specific issues and explained the basis for the decisions they reached

11. Broad strokes of methodology Facilitators were trained (language, context), careful recruitment and selection of participants – geographically and sectorally Human rights organisations; health – health affiliated organisations; local advice offices; traditional health practitioners – emphasis on CBO’s – rural, peri-urban and urban 360+ participants from each of the 9 provinces in workshops ranging from 45 – 65 participants in each of the 9 provinces Trained facilitators fluent in local languages

12. The Right to Health: Rights and responsibilities – developments in health policy (incl NHI) Free State Consultative Workshop 6-8 June 2011 12

13. Current Context and Recent Policy Developments 13

14. Vulnerable communities and social determinants of Health in SA 14

15. Health and the Constitution 27. Health care, food, water and social security (1) Everyone has the right to have access to - (a) health care services, including reproductive health care; (b) sufficient food and water; and (c) social security, including, if they are unable to support themselves and their dependants, appropriate social assistance (2) The state must take reasonable legislative and other measures, within it’s available resources, to achieve the progressive realisaiion of each of these rights. (3) No one may be refused emergency medical treatment. 15

16. Health and health services in the Free State: Key issues

17. Overview The Free State in the context of South Africa overall Between districts in the FS

18. Number of people per province [CMS data] Source: Day C, Gray A. Health & related indicators. SAHR 2010 Million people: total and those not on medical schemes

19. Infant deaths (less than 1 year)

20. Children who die before age 5 Source: Day C, Gray A. Health & related indicators. SAHR 2010 Under 5 mortality rate [ASSA 2003 projections]

21. Access to piped water Source: Day C, Gray A. Health & related indicators. SAHR 2010 Percent households with access to piped water by province

22. Households with no toilet Percent households without a toilet Source: Day C, Gray A. Health & related indicators. SAHR 2010

23. Number of people per province [CMS data] Source: Day C, Gray A. Health & related indicators. SAHR 2010 Million people: total and those not on medical schemes

24. Government health spending

25. Public sector doctors & specialists General doctors & specialists per 100000 uninsured population Source: Day C, Gray A. Health & related indicators. SAHR 2010

26. Adults & children getting ART Source: Day C, Gray A. Health & related indicators. SAHR 2010 Number on ART by province

27. Doctors working for public sector

28. Private hospitals

29. Public hospitals = District hospitals = Regional hospitals = Provincial or national hospitals

32. Findings Black Sash, along with its partners, published these reports for public information – every provincial report, a final synthesis report and a mid- term review is posted on our website – see www.blacksash.org. za – search Sash in Action – Health and NHI Consultations www.blacksash.org. za

33. Final Synthesis Report

34. Consultations

35. THE KEY PRIORITIES THAT COMMUNITIES (WE CONSULTED) IDENTIFIED AS NEEDING TO BE ADDRESSED IN ORDER TO FACILITATE ACCESS TO HEALTH CARE Addressing inadequate access to health care facilities Addressing the shortage of staff, skills and improving staff performance Increasing access to ambulances Improve monitoring and evaluation of health care Improving access to medication acilitating partnership with health facilities and participation in health

36. Addressing inadequate access to health care facilities “ Accessibility of hospitals was less significant than that of clinics, demonstrating that clinics (and as such primary health care) remain the main access point of health care for people. As one participant indicated improving access to health care facilities includes “…building more clinics that are ‘closer to the people’, are multi- purpose and have longer hours”

37. Addressing the shortage of staff, skills and improving staff performance In the Northern Cape for example, one group noted that staff use colour coded folders that categorise the different health issues and that this indiscreet conduct often denies patients their right to confidentiality, with variations thereof in other provinces. Participants from all provinces suggested that, as a priority staff, need to be sufficiently trained on patient rights and Batho Pele principles.

38. Increasing access to ambulances …..in the Free State as an example, participants report that ambulances do not collect seriously ill patients from their point of call and people are expected to travel to a central point such as a police station for collection. As one participant indicated, “…ambulances have had fatal results for communities”

39. Improve monitoring and evaluation of health care “where a system is in place, it is rendered ineffective through incompetence or lack of implementation” Northern Cape participants report that area managers are not aware of challenges experienced at an implementation level and that monitoring and evaluation of services is “completely” absent.

40. Improving access to medication was widely reported in the nine provinces where consultations were held that access to medication remains an obstacle to people accessing quality health care Limpopo Province, Waterberg District, it was reported that some patients struggle to access chronic medication such as ARV’s, and either share these with other patients or use less than the prescribed amount per day in order to “stretch the medicine” till the next clinic visit.

41. On the NHI and funding options The majority of participants across all nine provincial consultations supported the introduction of a tax funded National Health Insurance system on condition that it would be able to provide a substantially improved and quality health care system which is accessible to everyone.

42. NHI and funding options Participants recognized key values that need to inform a health care system, including that: South Africa’s social context must be considered in any health reform initiatives: there is a high rate of unemployment and most people live under poverty line and are dependent on social grants.

43. NHI and funding options The Bill of Rights and Constitution are fundamental: everyone has a right to access quality health care. Health is a constitutional right and therefore the government is responsible for ensuring access to health services. There are social determinants of health in South Africa, which imply responsibility of the state and wealthier households and companies for the health care of impoverished people.

44. NHI and funding options Given the socio-economic factors in South Africa, in general participants suggested that it would be unfair to expect everyone to pay the same amount towards a health care contribution. Participants suggested a variety of solutions including contributions which are based on a percentage of a person’s salary: “Everyone who is earning an income should pay a nationally prescribed PERCENTAGE of this to health care”.

45. NHI and funding options Participants were also presented with different options of taxation with which health care can be funded – including Value Added Tax (VAT), Pay As You Earn (PAYE) and employer payroll tax. The majority of participants suggested that NHI should be funded either through PAYE or employer payroll tax or a combination of both. Other innovative sources of funding were also raised in some provinces.

46. NHI and funding options The principle of ownership of the health system was associated with contributing towards it. Participants suggested that it was necessary for everybody to contribute to the health system so that they could play an active and recognised role in it. However, the majority of participants also suggested that VAT should not be used to fund the health system, since it would disproportionately the poor.

47. NHI and funding options Any increase in VAT was perceived by participants to affect impoverished people negatively. Therefore, there is recognition of three clear principles that need to inform any health care system in South Africa: Although people may not be able to contribute towards a health system, they should have equal access to health.

48. NHI and funding options Therefore, the health system should endorse cross-subsidization of health care as an important value that ensures equal access to health. It is suggested that wealthier individuals and companies cross-subsidize those who are less fortunate and unable to pay for health care. Everyone who can contribute to the health system should do so, but this needs to be linked to how much a person earns or can afford.

49. NHI funding options Sick people should be afforded the dignity of health care even if they cannot afford to pay for it. Therefore, everybody has a right to health regardless of their ability to pay. There was broad agreement on categories of people who should not be asked to contribute to a health system. These categories included:

50. NHI funding options people who are unemployed those who access social grants or who are included in indigent policies children the elderly the poorest proportion of the population (at least the poorest 10% according to income distribution in South Africa), and those who earned an income which fell under the tax bracket.

51. Advocacy (local and national) We have made several submissions on these findings to Parliament Assisting local communities to follow up – especially in rural areas Working with CSO/NGO networks to realise the right to health with partner organisations – especially social determinants – local govt, water, sanitation Calling for a Chronic Illness Grant

52. CMAP – monitoring health Through our Community Monitoring and Advocacy Project (CMAP) we are working with community monitors who wish to monitor health care facilities and we will publish and disseminate these findings in the public domain

53. CMAP – Community Monitoring and Advocacy Programme 53

54. CMAP – Community monitoring and advocacy programme 54

55. The need for ongoing community monitoring and advocacy as a preventative and pre- emptive strategy 55

56. 56

57. WORK done to date and future plans SASSA paypoints and application points Monitoring of Health clinics Monitoring of other service points Submission of reports to government, Parliament and Chapter 9 Institutions 57

58. 58 Walkabout and meeting in de Doorns – #1 13 Dec 2009 Gathering in Stofland, de Doorns 13 Dec 2009 09h15 Community Leaders Government Officials and Monitors Municipalities in crisis – the de Doorns Experience

59. 59 Walkabout and meeting in de Doorns – #2 13 Dec 2009 Dumpsite at entrance to Stofland as at 13 Dec 2009

60. 60 Visit by senior municipal leaders to Stofland and De Doorns

61. 61 Walkabout and meeting in de Doorns – #6 13 Dec 2009 No tap(broken off) at standpoint in Stofland, de Doorns

62. 62 Walkabout and meeting in de Doorns – #8 13 Dec 2009 Highly unhygienic conditions in Stofland prevails

63. 63 Walkabout and meeting in de Doorns – #9 13 Dec 2009 Local Leaders explaining a point 13 Dec 2009

64. 64 Walkabout and meeting in de Doorns – #10 - 13 Dec 2009 Ward Councillor Lubisi explaining flood plains and settlement pattern disputes

65. 65 Walkabout and meeting in de Doorns – #17 - 13 Dec 2009 Evidence of shacks built in flood plain – Maseru, de Doorns

66. Engaging government SASSA – and received formal responses from them (in writing) and formal permission to monitor their sites under certain conditions Seeking permission and support from DoH Brokering permission from municipalities

68. " The day will come when nations will be judged not by military or economic strength, nor by the splendour of their capital cities and public buildings, but by the well-being of their people: by, among other things, their opportunities to earn a fair reward for their labour, their ability to participate in the decisions that affect their lives; by the respect that is shown for their civil and political liberties; by the provision that is made for those who are vulnerable and disadvantaged“ - UNICEF Progress of Nations Report (1998)

69. Contact details Black Sash www.blacksash.org.zawww.blacksash.org.za Elroy Paulus: Advocacy Programme Manager 072 382 8175 Email: elroy@blacksash.org.zaelroy@blacksash.org.za 69