South Africa: Health care overhaul

The looming roll-out of a massive new public health care programme in South Africa, along with several enabling reforms, looks set to provide a healthier future for the country’s citizens. However, financing the scheme to the fullest may be a challenge over the long term.

On April 2, Health Systems Trust, a South African non-governmental organisation supporting the development of the health care sector, published its 2012/13 South African Health Review (SAHR). The report noted that the country is implementing a range of reforms “aimed at transforming the public and private health landscapes and overcoming ever increasing inequities between its society’s wealthiest and poorest.” Among the issues addressed by the review are the planned National Health Insurance (NHI) programme and South Africa’s antiretroviral therapy (ART) scheme.

As the review notes, progress has been made towards implementing the NHI over the past 18 months, particularly through the work of teams established to improve and audit health care facilities. The NHI is a universal health financing system intended to ensure that all South Africans have access to medical services. It is being piloted in 10 districts, while the government is undertaking wide-ranging investments to ensure that facilities and personnel are ready for full roll-out.

The SAHR also hails the antiretroviral programme as a success story, resulting “in dramatic improvements in South African life expectancy”. Under the programme, more than 2m people had accessed ART as of the end of 2012, and the mother-to-child HIV transmission rate has fallen from 30% to less than 3%.

In an interview with OBG, Aaron Motsoaledi, the minister of health, noted that significant progress had been made in the treatment of HIV. “We have made great strides considering that the previous administration did not acknowledge HIV as a problem. Treatment is more widely available today, with some 10,000 nurses able to provide ART, compared to just 250 in February 2010. The number of centres offering ART has also increased, growing from 490 to 3000 over the same period.” However, the minister cautioned that more work needs to be done. “The biggest remaining challenge is to reduce the number of infections and this is why we are mandating that every South African gets tested each year. In 2011 we tested more than 20m people, and while this is a substantial figure, there is still room for improvement.”

The government has directed an increasing amount of funding towards improving the provision of health care services, with the 2013/14 budget allocating R133.6bn ($14.7bn) to the sector. Priorities include building new facilities, expanding ART coverage and providing the groundwork for the NHI.

According to Finance Minister Pravin Gordhan, some of the money will go towards building and renovating nearly 2000 health facilities and 49 nursing colleges. Investment in health care infrastructure has risen from R3.3bn ($363m) in 2009/10 to R5.4bn ($594m) in 2012/13, and will grow to R6.5bn ($715m) over the next three years due to spending linked to the introduction of the NHI.

Upwards of R800m ($88m) of the 2013/14 budget will go towards scaling up ART; the government says that a further R100m ($11m) will be needed in 2014/15 and R384m ($42.24m) in 2015 to fill gaps left by a cut in funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). While PEPFAR had been providing around R4bn ($440m) each year to treat HIV-AIDS and tuberculosis, these monies will be reduced by 50% over the next five years.

Gordhan said that the current health budget is not straining South Africa’s fiscal position, but he added that tax rises might be necessary in the future to fund the NHI’s expansion from its initial pilot projects.

The universal health insurance system is expected to provide opportunities for the private sector, both in terms of the provision of care and supply of medicines and equipment. “Access to medicine to treat and control disease will form a core component of the NHI, and pharmaceutical companies are positioning and readying themselves to play a role,” Luciano Marques, CEO of Novartis South Africa, told OBG. However, he cautioned, “The NHI is a long journey, and will require a lot of dialogue between the government and industry.”

Michael Azrak, the managing director of MSD South Africa, another pharmaceutical manufacturer, agreed, telling OBG that establishing the system would not be easy, or cheap. “The NHI is hugely ambitious. Before it is rolled out, the government must be certain of where the funding will come from.”

South Africa’s health care outcomes have improved in some areas in recent years, thanks to investment and well-targeted projects. The roll-out of the NHI, though still in its early days, is already helping to enhance facilities. Still, provision remains patchy, and extending insurance to all will be a long and challenging process.

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