Legal vacuum hampers health for all

The common lament running through the South African Health Review (SAHR) for 2002 is government?’s failure to provide the country with the legal tools to guide the transformation of healthcare services.

Seven years after the National Health Bill was first drafted, it is still mired in bureaucracy. The Bill, which sets out mechanisms and structures to achieve healthcare for all, is sitting with the state law advisors and is only expected to reach parliament by the end of the year or early 2004.

The SAHR notes that while provinces have tried to interpret national policy based on various drafts of the Health Bill, "swings in policy direction have left managers confused and wary. It?’s now safer to await the Act than to predict direction".

All provinces have passed their own laws to fill the legal vacuum, but these will all have to be amended once there is a national Act, a time-consuming and costly exercise.

Progress has been made at a local level, however. According to the Constitution, municipalities are required to deliver "municipal health services" but these were never defined. But last year, the definition was clarified to mean "environmental health services". However, the SAHR notes that environmental health is "one of the most neglected spheres of health management". About a quarter of all posts are vacant, mostly in rural areas and small towns.

It will take great effort to make environmental officers proactive in identifying environmental health hazards ?– such as dirty water and no sanitation -- rather than simply acting as traditional "health inspectors".

Last year, the Health Minister and her provincial counterparts also resolved that responsibility for primary healthcare delivery should remain with provinces, although provinces are likely to sign service agreements with various municipalities. While South Africa?’s health spending is relatively high (8.8 percent of GDP), government health spending dropped in 1998/99 and "this trend is likely to continue", mainly because government has decided to keep the rate of public spending below that of economic growth.

However, government regulations aimed at getting more people out of state healthcare and into private health have failed ?– mainly because medical schemes are too expensive. The key reason for the expense, argues the SAHR, is that medical schemes are run on a fee-for-service basis, which means that health providers can milk consumers by giving them unnecessary procedures and medicines.

Unless there is "managed care" to curb over-servicing, argue researchers Jane Doherty and Prof Heather McLeod, premiums will continue to skyrocket and more people will be forced to abandon their schemes and join the queue for State health.

The review calls for a comprehensive human resource (HR) strategy to address the brain drain and the impact of HIV/AIDS, in terms of infected staff and staff burnout from dealing with AIDS patients.

The lack of a human recourse strategy is also evident in the management of the one-year compulsory community service (CS) for newly qualified doctors, dentists and pharmacists. Most reported inadequate supervision, particularly in rural areas where a quarter of community service officers said in their exit interviews that they had had no supervision at all.

The community service dentists were also frustrated by a lack of equipment, which meant that many could not perform basic tasks such as fitting dentures. A staggering 43 percent (up from 34 percent in 1999) of community service doctors said they were planning to work overseas once their service year was over.

With regard to HIV/AIDS, Dr Patiswa Njongwe, Chairman of the Board of Trustees of HST, said that the year had seen an increasing number of AIDS patients seeking health care from already over-stretched public sector facilities, particularly clinics in under-serviced communities. "Many households had to dig deeper into their pockets to care for loved ones," said Dr Njongwe.

The SAHR Report found that the toll of HIV/AIDS on households is worsening as infected people begin to get sick, a trend that will only get worse. A study of 728 AIDS-affected households showed that 34 percent of monthly income is spent on healthcare (54 percent in rural areas).

The SAHR urges businesses to be proactive against HIV/AIDS, as absenteeism and death begin to bite at industry, also affecting benefits such as pensions, life cover and medical aids.

Researchers Prof Alan Whiteside and Gavin George point local companies to Debswana Diamond Company in Botswana as a good example of how to deal with HIV/AIDS. The company covers 90 percent of the cost of anti-retroviral treatment for employees and their spouses and has a comprehensive management system.

The World Health Organisation ranked South Africa as having the ninth most serious tuberculosis epidemic in the world last year. While real progress is being made to extend TB treatment, the cure rate for new patients last year was 64 percent far lower than the national target of 85 percent.

Overall, progress has been slow and piecemeal. Hopefully, next year?’s review will show more progress on legal guidelines and certainty on issues such as anti-retroviral treatment.

The aim of South African Health Review is to provide a long-term review of the development and implementation of South African public health policies. The review is published annually by the Health Systems Trust, a non-governmental organisation funded by the Rockefeller Foundation, the Commission of the European Union, the Henry J. Kaiser Family Foundation (USA), the Department for International Development (UK) and the Department of Health (SA). It is essentially aimed at policy-makers, planners and managers in the health sector.