Health and Health Care in South Africa

748 Pages·2012·17.37 MB·English

by  H.C.J. van Rensburg (ed.)

Health and
Health Care
in South Africa
Second edition
HCJ van Rensburg
EDITOR
JE Ataguba • SR Benatar • JE Doherty • MC Engelbrecht
• JC Heunis • AP Janse van Rensburg • NG Kigozi
• DE McIntyre • AJ Pelser • E Pretorius
• N Redelinghuys • F Steyn • E Wouters
Van Schaik
PUBLISHERS
Published by Van Schaik Publishers
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First edition 2004
Second edition 2012
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P R E F A C E
RATIONALE FOR THIS BOOK
For both those inside and those outside the South African health care system, the
changes that have taken place (and are still taking place) in the post-1994 health
sphere are often difficult to comprehend. Often these reforms are confusing, even
bewildering. What is the essence of the transformation? Where are the reforms head-
ing? This book portrays a coherent “big picture” of health and health care in the coun-
try. Chapter by chapter, Health and health care in South Africais taking stock of the
evolving health system, along with the ensuing changes and challenges in the health
sector. Throughout, it attempts to contextualise these developments historically and
globally, and to critically assess them.
The book has its origin in the early 1980s with the publication of Profiles of disease
and health care in South Africa (Van Rensburg & Mans 1982). Ten years later, just
before the country’s transition to full democracy, Health care in South Africa –
structure and dynamics (Van Rensburg, Fourie & Pretorius 1992) was published.
Then followed the first edition of Health and health care in South Africa(Van Rens-
burg (Ed) 2004) – a book that retained the historical perspective of its predecessors,
but at the time focused specifically on the nature, accomplishments and failures of
the first decade of health reforms. This 2012 edition of Health and health care in
South Africabuilds further on the work and developments of the past three decades
in this field.
PURPOSE AND AIMS OF THE BOOK
The general purpose of the book is to present a coherent picture of the current state
of health and health care in the country, and of how these nestle in the larger histori-
cal, societal and global contexts. More specific aims are, first, to construe a sociohis-
torical perspective of the recent and long-term developments in the health system
with a view to better understand current and future developments and challenges;
second, to analyse post-1994 reform policies and legislation, and the ensuing new
structures and directions in South African health care, and; third, to review progress
and achievements, but also to better comprehend contemporary constraints and defi-
ciencies in health performance. Over and above these aims, the book strives to be an
authoritative reference source on health and health care in South Africa and as these
relate to the global context.
FOR WHOM THE BOOK IS MEANT
The book serves as a reference source on health and health care in South Africa for
diverse interest and stakeholder groups. Firstly, it is meant for researchers and lec-
turers in the domains of the history of health care, public and community health,
health policy and systems, health economics, medical sociology and other health-
related social sciences, social epidemiology, and bioethics. Secondly, the book tar-
gets managing and practising health professionals (nurses, doctors, dentists, pharma-
cists, supplementary and allied health professionals), as well as health planners, poli-
cy makers and managers. Thirdly, it is meant for senior and postgraduate students in
the health and health-related professions, the social sciences, and those studying in
the health planning, policy and management-related disciplines.
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THE INDIVIDUAL CHAPTERS, THEIR SEQUENCE AND
INTERRELATEDNESS
Although all the chapters can be approached as stand-alone entities – and thus may
be read separately and independently from one another – the sequence of the chap-
ters nevertheless follows a particular logic. Together the chapters form a coherent
whole that portrays the complexity and diversity of South African health and health
care. As the title suggests, the chapters focus on two broad themes: the health care
system and the health of the population. Apart from Chapter 1 (a conceptual and
global framework) and Chapter 12 (on bioethics), seven chapters deal – from various
angles – with the South African health care system, its composition, operation,
dynamics and recent reform. The remaining three chapters cover the health and
health status of the South African population and its subpopulations, and the sur-
rounding environment as the ultimate source of determinants that affect the health,
disease and ill-health of its inhabitants.
South African health care in global context
Chapter 1 presents a conceptual framework and the tools for analysing and inter-
preting the nature, functioning and dynamics of health systems. Specifically, the com-
ponents of health care systems, the environments in which they function, and the
clientele they serve, are described. It then reviews the nature and diverse types of
health systems of countries and the ensuing typologies of national health systems.
Attention is also paid to the global and international health system, globalising, con-
verging and diverging trends in health care, the two main thrusts in health care (high-
tech medicine and primary health care), reforms of national health care systems on
the globe, and the main propellers driving change and reform. A special focus is the
nature, dynamics, mixes and reforms of health care systems in Africa.
The South African health care system and its transformation
Chapter 2 has a historical focus: it reconstructs the evolution of the South African
health care system from its earliest documented origins, through the colonial and
apartheid phases, and up to the prelude to the reforms that commenced in 1994.
Attention is paid to the evolving nature of the health system, the rise of the health
professions and health institutions, the policies and legislation that shaped the health
system, and that eventually instigated the trends and contours responsible for the
notorious policies of exclusion and discrimination clearly reflected in grave race and
class disparities and inequities in health care and in the health status of the different
population groups. Also documented are the sporadic official and non-official reform-
minded attempts to redirect the system with a view to manage structural and func-
tional inefficiencies.
Chapter 3 takes the development of the South African health care system further
by reconstructing its transformation since 1994. It reviews the rationale for reform,
the post-apartheid reform policies and legislation in the health sphere, the reorganisa-
tion of the spheres of government in health, and the rise of the district-based PHC
system as the post-apartheid government’s solution to past inequities, inaccessibility
and inefficiencies in health care delivery. Despite remarkable progress in restructur-
ing the health care system and services, the transformation has still a long and diffi-
cult way to negotiate in order to overcome the many unresolved issues and to deal
with new challenges, inter alia, persisting disparities and inequities, poor steward-
ship, policy–implementation gaps, a growing burden of disease, and poor perfor-
mance of the health system.
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The health conditions, health and health status of South Africans
Three chapters of Health and health care in South Africa(Chapters 4, 5,6) focus
on the health, health conditions and “ill health” of the population – a population in
numerous respects under serious and increasing stress. The analyses are done
against the backdrop of the broader South African environment and the unique so-
cietal context with its compounding conditions of unequal distribution of develop-
ment and wealth. These directly and indirectly lead to unequal exposure and to grave
disparities in human development, health status and life expectancy. In turn, amid
gross discrepancies in the provision for basic needs, significant differences in suscep-
tibility to disease and death prevail.
Chapter 4 explores the links between health, environment and development as
well as strategies to manage ensuing challenges, both globally and in South Africa.
Three main dimensions form the crux of the analysis. The first is the structure and
dynamics (size, composition, distribution, growth, migration) of the population and
the diverse implications of these for human development and health. The second is
the changing biophysical or “green” environment (climatic changes, deteriorating
fresh water resources, soil degradation, pollution, loss of biodiversity) and its impact
on the health of the population. The third dimension is the social or “brown” environ-
ment (the socioeconomic landscape, social inequalities, poverty, unemployment) that
poses conditions that profoundly affect the health and well-being of people.
Chapter 5explains the variety of indicators used to measure health, ill-health and
the health status of populations. It describes the health status of the world population
and the propellers of the health transition, and analyses the morbidity and mortality
patterns in developed and developing nations. Against this global background, the
health and health status of South Africans are reconstructed in terms of the current
trends in morbidity, mortality, fertility and life expectancy. Prevailing disease and
death profiles are reconstructed according to the prevalence of prominent infectious
diseases and chronic diseases of lifestyle, especially as these conditions and risks
result in a quadruple burden of disease which has serious ramifications for health
care in the country. Specific attention is also paid the health and vulnerability of
women in South Africa.
Chapter 6deals with the origins, growth and burdens of the HIV and AIDSand TB
epidemics globally, in sub-Saharan Africa and especially in South Africa. In recent
years, these diseases have become major threats to human development, health and
wellbeing. Attention is given to the social epidemiology of the diseases, factors
fuelling them, and the manifestation of these epidemics according to geographic and
social differentials. Past and current HIV and AIDSand TB policies and strategies to
control the epidemics are reconstructed and appraised. The recent confluence of the
two diseases into the TB-HIV and AIDS co-epidemic considerably aggravates the dev-
astating effects of both epidemics. The disruptive impacts of the epidemics on broad-
er society, societal sectors and social institutions, and on communities, families and
individuals are reviewed.
Main components of South African health care and their
transformation
Several chapters (especially Chapters 7, 8, 9, 10) deal with specific components of
the South African health care system, including the composition and dynamics of
these components, the challenges to these components posed by the new dispensa-
tion, and efforts to reform the legislation and policies that govern and guide the struc-
ture and operation of these components.
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Chapter 7reviews human resources for health in South Africa against a global and
historical backdrop. Attention is given to human resource shortages and their
inequitable distribution along geographic, sectoral and socioeconomic lines, as well
as to post-1994 reform strategies to redress disparities and inequities. The organisa-
tion and regulation of the health professions are analysed, along with recent trends in
the supply of health professionals. Four hard-core issues persist in South Africa’s
human resources for health: geographical shortages and distributional disparities;
private–public disparities and inequities; loss of large numbers of health profession-
als via emigration; and low worker morale and suboptimal productivity. The chapter
concludes with the demands that the planned re-engineering of PHC will place on the
human resource corps.
Chapter 8 describes the nature of health care financing and expenditure in South
Africa, and past and present strategies to deal with challenges in this domain. The dif-
ferent sources of health care funding, the relative contributions of these sources as
well as allocation mechanisms are analysed. Special focus is placed on health care
expenditure, and on post-1994 progress in addressing previous inequities and ineffi-
ciencies in the distribution of resources among provinces, at different levels of care,
within public sector facilities, in the private sector and in the public–private mix.
Challenges requiring urgent attention are the sustainability of health care financing,
the expenditure spiral in the private sector, and the inequitable public–private mix.
Lastly, the planned NHI is analysed in terms of funding requirements and as a mecha-
nism to secure universal access to health care.
Chapter 9deals with the nature and status of PHC, both as an international thrust
since Alma-Ataand as a strategy ardently pursued by the post-1994 government. PHC
in South Africa is explored, from its relative neglect by previous governments up to
its rise to centre stage in health care. The essence of the 2001 Service Package for
PHC facilities and the contents of the subsequently revised 2010 PHC Package are
reconstructed, and so are the types, numbers, distribution and trends regarding pub-
lic PHC facilities. Post-1994 achievements and gains in service delivery and in equi-
table care are recorded, but amid successes, the approach to PHC remains selective
and many backlogs and inequities at various levels still prevail. To address these
remaining shortcomings, a major effort is currently under way to revitalise PHC as
part of a comprehensive re-engineering of the entire health care system.
Chapter 10 portrays the development of hospitals, globally and locally, and docu-
ments hospital reforms and reform strategies in post-1994 South Africa. The supply of
hospitals – in both the public and private sectors – is analysed in terms of their
nature, numbers and trends. Persistent inequities and the dominance of commer-
cialised, private-for-profit hospitals are depicted. Strategies to improve hospital ser-
vices, the essential linkages between hospitals, PHC, the DHS and the crucial role of
district hospitals in the public service chain, expenditure on district hospitals, and
the District Hospital Service Package are duly considered. In addition, the social
dynamics of hospitals are covered, also as manifested in the role of hospital man-
agers, industrial action in hospitals, patients’ experiences of hospitalisation, and the
say of communities in the governance of hospitals.
Chapter 11 describes the divergent modes, principles, methods, and use of com-
plementary and alternative healing globally, and specifically their rise, status and
coexistence with Western allopathic medicine in South Africa. The advantages of
these healing forms are appraised and so are prospects of integrating these forms of
medicine with biomedicine. Subsequently, extensive attention is devoted to the
nature and extent of African ethnomedicine in South Africa, the types and training of
traditional practitioners, and the methods and means of diagnosis and treatment.
Contemporary challenges are discussed; inter alia, the position of African traditional
healers vis-à-vis Western counterparts; organisation and control in own ranks; intel-
viii
lectual property rights, as well as developments in legalisation, legislation, profes-
sionalisation, and closer collaboration.
Ethical perspectives on health care in South Africa
Chapter 12is a contribution in its own right. It explains what ethics in health care at
different levels and in different spheres mean and require. From a different angle, it
spans most of what has been presented in the preceding chapters. In a different man-
ner, it again touches on the key questions and issues raised in the foregoing chapters,
and takes a step-back stance to appraise – through the ethics lens – what is happen-
ing around, within and to South African health care. It does so against the backdrop
of global developments and culturally diverse contexts. The author identifies the key
challenges, unsettling dilemmas, and topical choices that confront health profession-
als, managers, policy makers and politicians, and that they should come to terms with
in order to remain humane and to secure fairness in administering, allocating and dis-
tributing health and health care.
THE AUTHORS
Various authors from diverse backgrounds and disciplines wrote the different chap-
ters of the book. Among them count seasoned and prolific academic writers, but
upcoming researchers in the domains of health and health systems research were
also deliberately involved. All these authors contributed in significant ways to the
production of this publication.
ACKNOWLEDGEMENTS AND APPRECIATION
I owe a debt of gratitude to the various contributors who made the book possible and
who ensured its quality and value. First and foremost, sincere gratitude needs to be
conveyed to all the authors and co-authors, in particular for their willingness to make
an indispensable contribution, and, then, for the time and energy they devoted with
such remarkable dedication to completing the task.
I also want to warmly thank those people who took care of the linguistic, artistic,
editorial and secretarial aspects that formed and formatted the book in these essen-
tial respects: Marius Pretorius, for investing so much time, energy and patience over
a protracted period of time in the linguistic editing and for securing acceptable levels
of uniformity amid the obviously diverse writing styles and skills of the authors in the
2004 edition; Belinda Jacobs, for taking care of editing and controlling the vast num-
ber of references and the bibliographies of the twelve chapters in an effort to secure
correctness, uniformity, consistency and completeness. In similar vein I convey my
sincere gratitude to all those dedicated people at Van Schaik Publishers who ren-
dered the publication of this book a reality. The following need to be mentioned by
name: Lydia Reid, Daleen Venter, Werner von Gruenewaldt, Estian Behrens and Ron-
nie Dombai for their expertise and enthusiasm in different domains of this endeav-
our.
In conclusion, I gratefully acknowledge and appreciate the understanding, support
and sacrifices of those people in the close surroundings of the authors during the
writing of the book.
Dingie van Rensburg
Bloemfontein
August 2012
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