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POPH90209 Comparative Health Systems

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Course Code: POPH90209
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Discuss about the Comparative Health In South Africa.

The health care system of a nation is considered one of the most essential components and it represents the wellbeing of a nation as whole. Health care is considered a basic human right that should be accorded to people across all parts of the globe. Access of health care services is important in ensuring the efficient provision of basic healthcare services. Generally, health care systems are structured with a prime objective to deliver treatment of identified healthcare problems. These services mostly run on taxes paid by citizens since they are run by the state. Although most of healthcare systems are different, they share mutual objectives, results and structures that categorize them with the mutual objectives. Since the end of apartheid in South Africa, 1994, there have been numerous reforms that have been put in place in order to ensure that there is a concrete health care system in the country (Gabriel & Andre, 2016). Has this been achieved? The present paper aims at describing the role of South Africa’s government as well as non-governmental organizations (NGOs) in the efficient delivery of health care. In addition, the paper evaluates South Africa’s health system performance; health policies and initiatives and future health system reforms.
History of South Africa’s Health Care System
The first hospice in South Africa was an impermanent marquee that was constructed at the Cape of Good Hope in 1652, to treat the sick sailors of the Dutch East India Company who suffered from scurvy and typhoid. The construction of a permanent hospital was finalized in 1659 (Gabriel & Andre, 2016). Originally, recuperating soldiers delivered to others any care they afforded until around 1700 when the first Dutch matron, commonly referred to as Binnenmoeder and a male nurse (Siekenvader) were employed to keep the hospital clean as well as to oversee bedside assistants.
The organization subsequently appointed qualified midwives from Holland, who assumed midwifery duties and trained local women who were interested to become midwives. The apprentices included colored and Malay slaves. In 1807, more infirmaries were constructed in King Williamstown, Grahamstown, Queenstown and Port Elizabeth due to rising need of healthcare in the region. Later on, missionary nurses arrived in the region and established more hospitals. These nurses also trained local nurses and lay the foundation of nursing in South Africa. World War 1 greatly affected the provision of healthcare in South Africa. In 1902, the then government introduced formal training of black nurses at Lovedale. In 1912, the military of South Africa introduced military nursing in the Defence Act. The first nursing journal, referred to as the South African Nursing Record was published in the year 1913 and in 1914, The South African Trained Nurses’ Association was founded. The Nursing Act was propagated in the year 1944.
The history of South Africa is infused with discernment on the basis of gender and race. The nation’s infrastructure was influenced by the ferocious suppression of the aboriginal people, seizure of their natural resources and land, and the use of undue laws to force the blacks to work for minimum wages to produce wealth for the minority, the whites (Beck, 2014, n.p.) South Africa is also characterized by political resistance, which ended in 1994 after democracy won against discrimination (Hodes, 2015, p.716). South Africa’s history has had a significant impact on the health of the citizens and the present health policies and services. Before 1994, economic, political and land constraint policies divided the society on the basis of gender, age-based hierarchies and genders, greatly affecting the structure of social life, access to basic health resources and services (Coovadia et al., 2009, p.835). After 1994, the democratic government was determined to improve the uneven healthcare system that was adopted from the apartheid into a single National Health System based on equality and availability to all devoid discrimination. The government made significant advancement made towards the formation of a Primary Health Care System (PHCS) to deliver health care to several areas that had been neglected previously within a District Health Care framework (Van den Heever, 2016, p.1423). Ever since 1994, the government has established and enhanced more than 1600 clinics across the nation. The government also put in place legislations such as National Health Act which have since transformed the health system of South Africa into a non-discriminatory unit.
Role of Government in Health System Delivery, Organization and Efficiency
The government of South Africa government plays a vital role in ensuring that all the citizens access efficient health services. Health care services in the country fluctuates from the basic prime health care that is provided free by the government, to specialized, high-technology services that are offered by the public and private sectors. The roles include:
Provision of expenditure
The government of South Africa provides approximately 40% of all expenses needed in the health sector. The largest part of the health sector expenditure is drawn from the national treasury. In 2012/2013 budget, the government released over R120 billion in a bid to enhance and strengthen the health of the public before the implementation of the National Health Insurance Scheme (Paruk et al., 2014, p.468). In 2011, around 8.3% of the Gross Domestic Product (GDP) was spent in improving the health sector, well above the 5% endorsed by the World Health Organization.
Provision of National, provincial and local health services
Before 1994, hospitals in South Africa were characterized by racism and most were located in white neighborhoods. The health system had 14 departments, characterized by duplication and fragmentation. The disassembling of this structure started soon after the first democratic election in 1994. Nonetheless, due to massive unemployment and poverty, the government bears the burden of most healthcare provision. The Health Department is mandated to control the health system, particularly the public sector.
Provisional health departments deliver and administer inclusive health services, through public health care model that is based in the district.  The local administration of hospitals has delegated power over operative matters, including human resources and budget. This expedites the response to local requirements. The government channels 11% of the total budget to the public health sector which is allotted and used in the nine provinces. The allocation of these resources and the health care standards provided are different depending on the province. The government has formulated a Health Charter aimed at creating a platform for engagement between the public and private sector to address the problems of equity, quality and access of healthcare services.
National Health Insurance
The Health Department of South Africa is determined to ensure that the provision of high quality and efficient healthcare system, particularly public health (Setswe et al.,2016, p.78). This also includes enhancing the management and the functionality of the system via rigorous monitoring of budget and expenditure. Commonly referred to as the ’10-point plan’, the NHI has aided in enhancing the management of human resources, attaining of the required expertise and equipment and hospice infrastructure. Health facilities, for instance tertiary infirmaries and nursing colleges have been improved and reconstructed. The NHI has also brought about reforms that have enhanced efficiency in delivery of healthcare services (Setswe et al.,2016, p.78).. Moreover, NHI has promoted equality to ensure that all citizens receive quality healthcare notwithstanding their household income or monetary support to the NHI fund.
The government is responsible for making and monitoring laws that ensure all the citizens receive efficient and affordable healthcare. One such law is the National health Act of 2003, which gives structure for a single health system in the country (Katuu & van der Walt, 2016, n.p.). The Act caters for several primary health care rights, including the right to have an opinion concerning one’s health and the right to receive urgent treatment. There are also several other legislations all aimed at ensuring health services are affordable, accessible and meet the minimum standards.
Provision of Health Facilities
The government is responsible for the construction and maintenance of health facilities in the nation. Currently, the total number of public health facilities is 4200. Persons per clinic are 13,718, well above WHO recommendations of 10,000 persons per clinic. More than 1600 clinics have been constructed and equipped since 1994. The government provides free medical services to children under the age of six. Free services are also extended to breastfeeding and expectant mothers.
The government also ensures that these facilities are adequately staffed. In an attempt to curb the shortage of doctors in the country, South-Africa entered an agreement with the Cuban government in 1995, which allows importation of doctors from Cuba. In addition, the agreement enables South Africans students to receive affordable medical training from Cuba(Van den Heever, 2016, p.1423).. The country has also partnered with Tunisia and Iran to curb the shortage in the nation.
The Role of NGOs in Health Service Delivery
There are multiple Non-Governmental Organizations in South Africa, which are mainly concerned with the provision of healthcare to HIV/AIDS and tuberculosis patients and victims. The NGOs account for an expenditure of approximately 5.3 million South African Rand. In addition, the NGOs contribute towards providing efficient and quality healthcare to patients suffering cancer, mental health and disabilities. Moreover, NGOs help the government of South Africa in the growth and development of public health services. NGOs therefore play an important role in the provision of both local and provisional level and has aided in the overall functioning of the national healthcare provision system.
Performance of South Africa’s Health System
Due to the complexity of health care systems, it is difficult to measure the performance of the health sector. In South Africa, the measurement of performance is highly challenged by inadequate data and the challenge of defining measurable goals in a manner that is valid and reliable. In this case, the WHO health systems strengthening framework will be used in the evaluation of South Africa’s health system’s performance which comprises of: Health system building blocks, health delivery platform, Health system performance and system performance.
Health System Building Block
As earlier stated, the democratic government of South Africa inherited a fragmented health system which was characterized by inequalities in resource distribution and poor distribution of health care personnel. Since the inauguration of the democratic government, numerous improvements have been put in place to enhance equality and efficiency in health care. Alteration determinations in the health sector over the last 24 years include several policy, legislative structural changes, execution of health programmes for urgent circumstances, enhancement in access of quality healthcare services and eradication of apartheid in the health care sector.  Numerous positive enhancements and developments have been accomplished in the lives of the citizens since independence. Nonetheless, rural/urban, public/private disparities are still severe and are aggravated by frequent health system problems. An empowering legal frame has been established, and there have been many improvements in healthcare provisions. Nevertheless, there are various challenges that still need to be addressed in the six health system building blocks i.e. human resource, leadership and governance, service delivery, finance, medical technology and vaccines and information.
Health Delivery Platform
Resources in South Africa’s health system are used disproportionately and unsatisfactorily particularly in the provision of primary care in district and central hospices. From current statistics, the difference between the highest and the lowest spending districts. For instance, while the highest spending district receives over R633 million, the lowest spending receives only R161M. Statistics also indicate huge differences in patient-day equivalent (PDE) across districts. Considering that district hospices spend 40% of the of total district resources, the variations in PDE should not be high. There are also huge disparities in the cost of healthcare in tertiary infirmaries. High differences in the cost of healthcare provision across districts are indicators of inefficiencies since health facilities are not maximizing their resources Coovadia et al., 2009, p.835). Additionally, it shows that there is poor monitoring and responsibility across all system levels.
Health performance
The overall health performance in South Africa is poor. The public sector is strained and under-resourced in numerous locations. While the government provides approximately 40% of all expenses in the health sector, the public health sector has to provide healthcare services to over 80% of the total populace. On the other hand, the private sector is highly commercialized such that only the middle and high income earners can afford the services. To make matters worse, most health experts are attracted by the high salaries in the private sectors, leaving public hospitals understaffed. This divided system is both inequitable and inaccessible to most South Africans. Moreover, the system has contributed to the poor administration, flagging infrastructure and inadequate funding of the public health institutions. Thus, though the government has increased access to health services, the quality of services has deteriorated.
Health Outcomes
Health results in the country are generally poor and not proportionate with the level of expenditure channeled to the health sector. The South Africans continue to suffer from numerous diseases, both communicable and non-communicable especially HIV/AIDS, chronic diseases, high injury rates and diseases associated with poverty (Coovadia et al., 2009, p.835).. Though South Africa is classified under middle income nations, the health outcomes are lower even compared to low income nations.
Critique of Health System Policy and Initiatives
The district health system adopted in South Africa has been endorsed as the key driver in the execution of prime health care at community levels. Nonetheless, the course of executing and incorporating procedure at the district level has been sluggish and unreliable with some places replicating satisfactorily operational healthcare systems while other places have uneven and insufficiently organized prime healthcare provision systems. Disparities in the coverage and the quality of health services, innate inequalities in the allotment of resources and the chronological encumbrance of illnesses show that districts and provinces are at different levels of healthcare provisions. This is further worsened by the HIV/AIDS plague and other emerging communicable and non-communicable diseases that cause an acute pressure on the limited resources.
From a theoretical perception, community oriented primary care (COPC) is viewed as a connection between the conceptions of primary healthcare and Family Medicine. This delivers a strategic incorporation of public health and prime care in a community, where primacy health scheduling guarantees that the emphasis is on health and not just disease. According to Ried (2010), a population-based methodology, inside a defined community, using the entire primary care team to take care of issues of access and heath care quality would be the better compared to a district-based healthcare policy.
Past and Future Health System Reforms
Since 1994, the South African government introduced numerous reforms in the health sector, which included the abolition of fragmented healthcare system to a single district-based healthcare system and the provision of free prime care to children under the age of six as well as pregnant and breastfeeding mothers. Other reforms include NHI and NHIF which aim at ensuring all South Africans can access quality but affordable healthcare.
Given the huge disparities currently evident in the country, and increased lifestyle diseases due to increased household incomes across Africa, future state-driven reforms of healthcare system are occurring mainly in the country’s public sector, where the primary goal is to develop community amenities that are reachable via the district based primary care approach. This public health system will highlight the advancement of healthy lifestyles, partnership with other public sectors that influence health such as water, housing and sanitation sectors, organization of health services and community participation in planning and provision of free prime health care.
The pedigrees of dysfunctional healthcare and the impacts of the increase of infectious and non-infectious illnesses in South Africa are evident of policies from the times of the nation’s history, from colonial suppression, apartheid withdrawal to the post-apartheid times. Poverty, racism, gender inequalities, migrant labor system, the demolition of family life, extreme violence and inequality in the distribution of resources are all part of the nation’s distressed past, and all have affected health and health services massively. There were numerous challenges that faced the post-apartheid government and most of them continue to affect the current healthcare system. The country introduced macroeconomic policies, which further worsened equitable resource redistribution. Although the public health system has been transformed to an incorporated system, leadership and management problems continue to affect delivery of quality health services and execution of favorable policies. Further, the country’s policy for free primary is strained due to the scarcity of resources. The HIV/AIDS spread has not made matters better either. All these problems therefore require to be addressed by the new administration in order to improve the health system of the country.
Beck, RB 2014, The History of South Africa, 2nd Edition : Second Edition, Second Edition, Greenwood, Santa Barbara, California.
Coovadia, H, Jewkes, R, Barron, P, Sanders, D, & McIntyre, D 2009, ‘Series: The health and health system of South Africa: historical roots of current public health challenges’, The Lancet, vol. 374, pp. 817-834. Available from: 10.1016/S0140-6736(09)60951-X. [2 September 2017].
Gabriel, L, & André, D 2016, ‘The Traditional Health Practitioners Act No. 22 (2007) of South Africa: Its history, resolutions and implementations in perspective (Part 1: History)’, Australasian Medical Journal , Vol 9, Iss 10, Pp 396-401 (2016), no. 10, p. 396
Hodes, R 2015, ‘Kink and the Colony: Sexual Deviance in the Medical History of South Africa, c. 1893–1939’, Journal of Southern African Studies, vol. 41, no. 4, pp. 715-733. Available from: 10.1080/03057070.2015.1049486. [2 September 2017].
Katuu, S, & van der Walt, T 2016, ‘Assessing the legislative and regulatory framework supporting the management of records in South Africa’s public health sector’, South African Journal of Information Management, no. 1. Available from: 10.4102/Sajim.V18i1.686. [2 September 2017].
Paruk, F, Blackburn, J, Friedman, I, & Mayosi, B 2014, ‘National expenditure on health research in South Africa: what is the benchmark?’, South African Medical Journal, no. 7, p. 468. Available from: 10.7196/SAMJ.6578. [2 September 2017].
Setswe, G, Witthuhn, J, Muyanga, S, & Nyasulu, P 2016, ‘The new National Health Insurance policy in South Africa: Public perceptions and expectations’, International Journal of Healthcare Management, vol. 9, no. 2, pp. 77-82. Available from: 10.1080/20479700.2016.1142695. [2 September 2017].
van den Heever, AM 2016, ‘South Africa’s universal health coverage reforms in the post-apartheid period’, Health Policy, vol. 120, no. 12, pp. 1420-1428. Available from: 10.1016/j.healthpol.2016.05.012. [2 September 2017].

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