Hoosen CoovadiaHoosen CoovadiaEmeritus Professor of Paediatrics and Child Health,Emeritus Professor of Paediatrics and Child Health,

Emeritus Victor Daitz Professor of HIV Research,Emeritus Victor Daitz Professor of HIV Research,University of Kwazulu-Natal.University of Kwazulu-Natal.

Director, Maternal Adolescent and Child Health,Director, Maternal Adolescent and Child Health,University of the Witwatersrand.University of the Witwatersrand.

A Vision of Healthcare in South A Vision of Healthcare in South Africa: 2025-2030Africa: 2025-2030

Presentation to the Medical Presentation to the Medical Research Council of South Research Council of South

Africa.Africa.Durban 25Durban 25thth October,2011 October,2011

The Highest PrioritiesThe Highest Priorities

Eliminating Poverty Eliminating Poverty and and Reducing InequalityReducing Inequality are Key are Key

Strategic ObjectivesStrategic Objectives

Reducing inequalityReducing inequality

Eliminating povertyEliminating poverty

Too few South Africans are employed

Poor educational

outcomes

High disease burden

South Africa: A Cocktail South Africa: A Cocktail of Four Colliding of Four Colliding

EpidemicsEpidemicsHIV/AIDS and TB-17% of HIV burden

- 23 times > global average

-5% of TB burden- 7 times > global

average

Non-communicable diseases-< 1% of global burden

- 2-3 times > average developing countries

Violence and injury-1.3% global burden of injuries

- 2 times global average for injuries

- 5 times global average for homicide

Maternal, newborn & child health-1% of global burden

- 2-3 times > average for comparable countries

Government has Broadened Government has Broadened Access to Public and Private Access to Public and Private Services for Many CitizensServices for Many Citizens

Source: Statistics SA: General household survey 1996 and 2007Source: Statistics SA: General household survey 1996 and 2007

Child Health and Child Health and Development in South Development in South

Africa, 2010 - 2011Africa, 2010 - 2011

Source: South Africa Child Gauge 2010/2011. ChildrenSource: South Africa Child Gauge 2010/2011. Children’’s Institute. s Institute. University of Cape Town.University of Cape Town.

• No access to clean water: > a third of all children. In 2009; slightly worse than 2008.

• No access to toilets: >a third [6.8m];> 7m in 2008

• Hunger: 3 million [15.7%] of 18.6 million children in country; 3.3m of 18.8m in 2008.

• Poverty: 61% of children in households with a per capita income <R552/month.

• > 2m [10.9%] children live in back-yards/shacks in informal settlements; 2.3m in 2008.

• Living in households with no adults employed: 6.6m in 2009;6.5m in 2008.

WHYWHY DO DO AFRICAN AFRICAN MOTHERS MOTHERS

DIE?DIE?

WHYWHY DO DO AFRICAN AFRICAN MOTHERS MOTHERS

DIE?DIE?

WHYWHY DO DO MOTHERS DIE MOTHERS DIE

IN SOUTH IN SOUTH AFRICA?AFRICA?

WHYWHY DO DO MOTHERS DIE MOTHERS DIE

IN SOUTH IN SOUTH AFRICA?AFRICA?

Source: Saving mothers report, DOH.

Hypertension, 19%

Haemorrhage, 13%

Pre-existing medical

disease, 6%

Sepsis, 8%

Other, 16% Non-pregnancy

related infections sucAIDS,

TB, pneumonia,

38%

Whydo mothers die in South Africa?

Other, 16%

Non-pregnancy

related infections

sucAIDS, TB, pneumonia,

38%

Hypertension, 19%

Haemorrhage, 13%

Sepsis, 8%

Pre-existing medical disease, 6%

Source: Saving Mothers Source: Saving Mothers Report. DoH.Report. DoH.

Source: Khan KS Source: Khan KS et al.et al. Lancet Lancet 2006.2006.

199176

133

89 8069

55 65

95

67

217

0

50

100

150

200

250

15-19% decline in <5MR between 1980 and 2000

1955-19591960-19641965-19691970-19741975-19791980-19841985-19891990-19941995-19992000-20042008

<5MR South Africa

South African Child Gauge 2005 : 57 and Ahmad OB et al. Bull WHO 2000; 78:1175-1191

<5 MR South Africa<5 MR South Africa

Source: South African Child Gauge 2005:57 and Ahmad OB Source: South African Child Gauge 2005:57 and Ahmad OB et al. et al. Bull WHO Bull WHO 2000; 78:1175-11912000; 78:1175-1191

The Income Gap Between The Income Gap Between Races is Widening and the Gini Races is Widening and the Gini Coefficient is Between 0.58 to Coefficient is Between 0.58 to

0.830.83Mean monthly per capita income(2007 Rand)

Source: IES data; SA development indicators; 2008; S van den Berg CDE.Source: IES data; SA development indicators; 2008; S van den Berg CDE.

87

71

4940

22

Lowest Second Middle Fourth Highest

Under five mortality rate by Quintile, SA

Source Measure DHS STAT Compiler 1998 data :

87

71

4940

22

Lowest Second Middle Fourth Highest

Under five mortality rate by Quintile, SA

Source Measure DHS STAT Compiler 1998 data :

IMR per 1000 live births

Wealth quintile

IMR per

1000 live

births

IMR per

1000 live

births

Wealth quintileWealth quintile

Poverty and Inequity: Poverty and Inequity: Under Five Mortality Rate Under Five Mortality Rate

by Quintile, SAby Quintile, SA

Highest share of hungry households and most extreme levels of hunger occur in urban metros. 36% of all seriously hungry households are found in CT, Ekhurhuleni, Johannesburg and OR Tambo. (GHS 2007)

Highest share of hungry households and most extreme levels of hunger occur in urban metros. 36% of all seriously hungry households are found in CT, Ekhurhuleni, Johannesburg and OR Tambo. (GHS 2007)

Source: Miriam Altman. HSRC, 2011Source: Miriam Altman. HSRC, 2011

Hunger in the MetrosHunger in the Metros

Strategic Outputs for the Strategic Outputs for the Government Programme by Government Programme by

NSDA OutputsNSDA Outputs(By 2014)(By 2014)

Maternal Mortality

Child Mortality

TB Cure RatesNew HIV Infections

ARV Access

Life Expectancy

Innovative and enhanced activities, not Innovative and enhanced activities, not ““business business as usualas usual””

• Anti-Retrovirals [ART]: Services points from490 to 2 205 health centres; ART-certified Nurses from 250 to 2 000;ARV prices slashed by 53%.

• HIV Testing: from 2 million to 12 million PERSONS.

• Persons on ARVs: from 923 000 in 2010 to 1.4 million [by June 2011].

• Human Resources: increase in intakes of students, new infra-structure at existing tertiary hospitals, new medical school in Limpopo, R16.1 billion for next 3 years mainly for new training posts.

““Achievements Over Last Achievements Over Last YearYear””

Chris Bateman. Chris Bateman. ““Motsoaledi declares war on Motsoaledi declares war on disease-causing productsdisease-causing products””. . SAMJSAMJ 2011; 101: 503- 2011; 101: 503-

504504

Source: Ameena Goga. South African AIDS Conference 2011. Durban; HMC. Source: Ameena Goga. South African AIDS Conference 2011. Durban; HMC. Personal Communication.Personal Communication.

Climate Change Climate Change Impacts on HealthImpacts on Health

Budget Speech 2011. “War on Industries: “•Tobacco •Alcohol•Fast-FoodExisting Health System:•Lopsidedly Curative•Hospi-centric•Destructively costly•Unsustainable.

““Motsoaledi Declares War Motsoaledi Declares War on Disease-Causing on Disease-Causing

ProductsProducts””Chris Bateman. Chris Bateman. SAMJSAMJ 2011; 101: 503-504 2011; 101: 503-504

We Need a Development We Need a Development Path That Promotes Growth Path That Promotes Growth

AND Social EquityAND Social Equity

1994

Today

2030

Economic growth

Social equity

Nation: Characteristics

Common historyCommon cultureSimilar ethnic originsUnited by languageReligionLocationSocial and economic

equities

An “Imagined” SASingle geographic spaceSocial and economic

equitiesCommon citizenship

based on “Multiple Identities” but “Uniting Values”.

Build on DiversityAddress concerns of

various layers of SA-”inclusive”

Constructed on our “Interconnected Differences”

Foundations for National Foundations for National Cohesion and a Cohesion and a ““South South

African IdentityAfrican Identity””

“A large part of the financial and human resources for health is located in the private health sector serves a minority of the population. Medical schemes are the major purchasers of services in the private sector which covers 16.2% of the population .

The public sector is under-resourced relative to the size of the population that it serves and the burden of disease it bears.The public sector has disproportionately less humanresources than the private sector yet it has to manage significantly higher patient numbers”.

The Constitution has outlawed any form of racial discrimination and guarantees the principles of socio-economic rights, including the rights to health.

The 2008 World Health Report of The 2008 World Health Report of WHO: Three Trends That WHO: Three Trends That

Undermine the Improvement of Undermine the Improvement of Health Outcomes GloballyHealth Outcomes Globally

Hospital Centrism(Mainly Curative)

FragmentationServices

Programmes

Uncontrolled Commercialism

**Commission on Old Age Pension and National Insurance (1928)**Committee Of Enquiry into National Health Insurance (1935)**National Health Service Commission (1942 -1944)**Health Care Finance Committee 1994**Committee of Inquiry on National Health Insurance (1995)**The Social Health Insurance Working Grou"p (1997)**Comittee of Inquiry into a Comprehensive Social Security for South Africa(2002)**Ministerial Task Team on Social Health Insurance (2002)**Advisory Committee on National Health Insurance (2009)**National Health Insurance

Historical Development of National Health Insurance

Objectives of the NHIObjectives of the NHI

NHI

Improved access and

quality health

services.

Pool risks.

Procure services on behalf of the

entire population and efficiently mobilize and control key

financial resources.

Strengthen the Public

Sector.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Need Total benefits

% s

hare

of

need

/ben

efi

ts

Q1 (poorest) Q2 Q3 Q4 Q5 (richest)

Source: Ataguba & McIntyre Source: Ataguba & McIntyre (2009)(2009)

Imbalances Between Need Imbalances Between Need and Benefits In The SA and Benefits In The SA

Health SystemHealth System

InequitiesInequities

Inequity in FundingInequity in Funding

Differences in Public and Differences in Public and Private Health Sectors in SA Private Health Sectors in SA

(2007)(2007)

Sources: South African Health Review, HST; SA Nursing CouncilSources: South African Health Review, HST; SA Nursing Council

Disparities in Public and Disparities in Public and Private Sector SA Health Private Sector SA Health

Workforce (2008)Workforce (2008)

Trends in Private Hospital & Trends in Private Hospital & Medical Aid Costs Over Past Medical Aid Costs Over Past

Ten YearsTen Years

% C

han

ge o

ver

10 y

ears

Ran

d (

% C

han

ge o

ver

10

years

)

Medical Scheme Contributions as a % of Income according to wealth

INCOME. % CONTRIBUTION

Lowest >14%

Middle +/-12%

Higher > 9%

Richest 5.5%

Intended Relationships in Intended Relationships in the NHIthe NHI

Four Key InterventionsFour Key Interventions

The Breadth, Depth and The Breadth, Depth and Height of Universal Height of Universal

CoverageCoverage

Source: McIntyre, 2010Source: McIntyre, 2010

PaymentFunds from a combination of sources:

*Fiscus

Employers

Individuals

Nominal Per-Capita GDP(US dollars)

0

2000

4000

6000

8000

10000

12000

14000

16000

How Will South Africa How Will South Africa Grow?Grow?20202020

Source: South Africa Budget, 2011Source: South Africa Budget, 2011

Cost of Packages of Care• The model indicates that resource requirements

under this model increases from R125 billion in 2012 to R214 billion in 2020 and R255 billion in 2025 if implemented gradually over a 14-year period.

• The budget is R110 billion in 2012/13. Medical scheme contributions are estimated to total about R92 billion in 2010 . Over R227 billion spent on health services in 2010, equivalent to 8.5% GDP

National Health Insurance will require an increase in spending on health from public resources (general tax revenue and a mandatory National Health contribution) that is faster than projected GDP increases. However, the ultimate spending on a universal health system relative to GDP (of 6.2%) is less than current spending by government and via medical schemes (of 8.5%).

Cost of Packages continued

South Africa – Long-term South Africa – Long-term Budgets 2014 until 2030 – 5% Budgets 2014 until 2030 – 5%

Annual GrowthAnnual Growth

Re-Engineered Re-Engineered Community-Oriented Community-Oriented

PHC-Based DHS ModelPHC-Based DHS Model

Source: Baron and Sasha – Re-engineering for PHC in South Africa Source: Baron and Sasha – Re-engineering for PHC in South Africa (2010)(2010)

Source: Baron and Sasha – Re-engineering for PHC in South Africa Source: Baron and Sasha – Re-engineering for PHC in South Africa (2010)(2010)

Clinic and Community Clinic and Community Primary Health Care Primary Health Care

OutreachOutreach

Governance Governance without without

GovernmentGovernment

The Changing Ontology of The Changing Ontology of PoliticsPolitics

A regulation can claim political legitimation only if it could be based on a rational discourse of those potentially affected by it.

The decision-making process of a democratic government has to reflect the needs, fears, values and aims of the citizens which manifest in a communicatively constructed public sphere.

The linguistic construction of the public sphere is done by more or less spontaneously emerging civil society associations that map, filter, amplify, bundle and transmit problems, needs and values.We owe Jürgen Habermas the idea of rational deliberationDemocracy and its (new) enemies: Guido Palazzo HEC

University of Lausanne

Jürgen Habermas – The Jürgen Habermas – The Convincing Power of the Convincing Power of the

Better ArgumentBetter Argument