Special Report
Health Care Reform in the New South Africa
N Engl J Med 1997; 336:891-896March 20, 1997
- Article
The social transition that must follow the political transition in South Africa will pose major challenges for many decades. The need to reduce inequities is undisputed. However, the means of effectively and sustainably achieving this reduction are less clear, especially in the face of rapid population growth and minimal additional resources in an economy that is growing less rapidly than hoped for by the new government. Health care reform exemplifies the many challenges facing South Africans. Profound shifts in thinking about the social forces influencing health and disease underlie the shift from the conventional biomedical model of health care to the primary health care approach within a fixed or even diminishing public health budget. The move toward a primary care approach in South Africa is not the same as a shift in emphasis toward primary care in highly industrialized nations. An attempt is made here to provide some insight into this process by describing the dilemmas facing health care reform in South Africa and the threats to academic activities that will be central to future progress.
In the 1930s it was recognized that health care could not be provided for the growing and diverse South African population by allowing entrepreneurial medical services to develop haphazardly. The plea for a national health service by the president of the Medical Association of South Africa in 1931 was echoed by the government-appointed National Health Services Commission in 1944. The rejection of this proposal, the subsequent election of a Nationalist government in 1948, and the institution of apartheid were associated with the development of a health service characterized by racial discrimination, fragmentation, poor coordination, duplication of services, and a predominant focus on hospital-based care rather than primary care.1-3
Privately financed medicine flourished, providing excellent primary and community-level care for patients (predominantly white) who had health insurance through more than 200 private insurance companies. Tertiary services, which were largely confined to government-financed academic hospitals, were available free of charge to the indigent as well as to those with private insurance. As a result of this focus on hospital-based care, academic medicine thrived — allowing, for example, innovative research on malnutrition and iron metabolism, and the capacity to perform the first heart transplantation — but primary care and community facilities for poor patients (predominantly black) remained woefully inadequate.1,2
In the late 1970s, overall funding for health services in South Africa (both the public and private sectors) was about 5 percent of the gross national product and had remained at that level for about 10 years. At that time, a private sector, comprising about 40 percent of the physicians in the country, accounted for about 30 percent of the health care expenditures and provided excellent care to the 20 percent of the population that had insurance. Many private-sector physicians supported academic and government-financed medicine (in which the remaining 60 percent of the nation's physicians worked full time) by working part time in public institutions for minimal compensation.1
The 1980s and 1990s
Between 1980 and the early 1990s, health care expenditures increased to about 8 percent of the gross national product. Despite many warnings, private medicine grew into a large, uncontrolled entrepreneurial industry with no public accountability. By 1992 it took 64 percent of national health care expenditures for 60 percent of the nation's doctors to provide medical services, often lavish and wasteful, to about 17 percent of the population — those with insurance.2,4,5 Not only was the private sector expanding, but its demographic features were also changing, with many blacks joining the middle class and acquiring private medical insurance. Academic medicine came under increasing strain as teaching hospitals faced the demands of a growing and more urbanized population, the private sector recruited medical and nursing staff into more lucrative positions, and physicians in full-time private practice became less interested in doing part-time work in the public institutions. In the 1980s these trends gave rise to renewed, but unsuccessful, advocacy for a national health care system.3,6
Three statistics show the extent of the disparities in health care at the end of the apartheid era. First, the infant mortality rate in 1990 was 7.4 per 1000 live births among whites, as compared with 48.3 per 1000 among blacks, with malnutrition, diarrheal diseases of childhood, and measles contributing a heavy burden of morbidity and mortality. Second, infectious diseases continued to account for about 13 percent of all deaths among blacks, as compared with 2 percent among whites, with approximately 90,000 new cases of tuberculosis, mainly among blacks, reported annually. Third, the life expectancy at birth in 1990 was 60 years and 67 years, for black male infants and female infants, respectively, as compared with 69 years and 76 years for whites.3 The growth of the AIDS epidemic is reflected by the results of prevalence surveys at antenatal clinics that show a progressive rise in human immunodeficiency virus seropositivity from 0.73 percent in 1990 to 2.15 percent in 1992 and 10.44 percent in 1995.
Political and Social Transition
South Africa's political transition from apartheid to a fledgling democracy through negotiations and a peaceful election in 1994 has been a source of great inspiration to South Africans and, indeed, to the world.7,8 That such a change could take place without a violent revolution amazed those who believed that power would be transferred only through a bloody civil war. In the third year of the new South Africa, however, justified jubilation over the transition is being tempered by a realization of the magnitude of the challenges that the new government faces — initiating and sustaining a social transformation that could appreciably reverse the legacy of inequities bequeathed by decades of apartheid and the discriminatory “colonial” mentality.7-9 The African National Congress's Reconstruction and Development Program and National Health Plan, which have a district-based approach to primary care as their framework, offered ambitious approaches to these daunting social problems.10,11
Health Care Reform since 1994
Government-driven reform of health care is taking place predominantly in the public sector, where the chief focus is on developing community facilities accessible through the district-based primary health care approach.3,11 This public health system will emphasize the promotion of healthy lifestyles, the coordination of health services, collaboration with other public sectors affecting health (for example, housing, water, and sanitation), community participation in planning and delivering free primary care, environmental health services, efficient administration, and effective systems of referral to secondary and limited tertiary levels of care. Intellectual backing is provided by research emphasizing population-based epidemiology, the formulation of health policy, studies of health services and health economics, and a wide-ranging program of education on public health.
Providing free primary health care for all with no increase in spending involves redistributing the public health budget on the basis of the official census of each province (Table 1Table 1
Distribution of Spending for Public Health Care among the Provinces of South Africa.), as well as creating a new balance between hospital-based services and primary care clinics. Given the economic and demographic disparities among regions and the maldistribution of health services, with medical schools clustered in certain provinces, this will be a daunting task for decades. To build and staff primary care clinics in poor areas within a fixed budget (actually, in real terms, a shrinking one), resources are being withdrawn from academic medical centers, and many of their services are being curtailed. Almost 100 new primary care clinics were opened in the country by the end of 1996, funded by a cut of about 7 percent in the budget for teaching hospitals. This is the first step toward the building and staffing of 780 such clinics over the next three years. Such restructuring offers many potential benefits, but clearly at the cost of hospital-based services, particularly in the academic centers.The effects of these shifts are already evident, especially in the Western Cape, where the largest budget cuts are being made in order to shift resources toward the provinces (such as the Eastern Cape) with fledgling medical schools or the most meager rural health care facilities. These shifts have resulted in the progressive reduction of staffs and hospital beds,3 with erosion of the critical mass of staff needed to sustain many of the usual services of academic medical centers.
Since there are no provincial taxes, the country's public health care system is funded entirely from federal taxes. The central government retains control over planning, legislation, and funding, with responsibility for the delivery of care devolved to the nine provincial administrations, which have no mechanism by which they can be remunerated for the care of patients from other provinces or by which they can generate any substantial amount of resources through private work.
The private sector has been largely untouched by these efforts to restructure the public health care system and provide free primary health care for all. In the private sector, the organization and delivery of care remain predominantly under the influence of entrepreneurs and market forces. The rapid escalation in the cost of private health care, resulting in increases in contributions to private insurance funds at a rate almost double the consumer price index, has, however, provoked a drive toward containing costs through the development of managed care.3
Academic Medicine and Medical Education
All eight medical schools in South Africa are publicly supported, but in recent years limited private practice by the faculty has been allowed in an effort to retain staff. These institutions have been subject to increasing strain for several reasons. Private practice has expanded and recruited away some of their staff over the past 10 years; permission for limited private practice has been abused by some physicians, with the resulting neglect of public patients; many young professional staff members have emigrated to seek academic and economic advantages; national resources for hospital-based health care have been reduced in line with the national plan; and macroeconomic policy has imposed progressive reductions in all government expenditures for health care, education, and welfare. The pace and extent of budget cuts threaten the sustainability of all our medical schools. For example, recently announced cuts affecting the medical schools of the Western Cape over the next four years will reduce real funding by 25 percent in the 1996–1997 fiscal year and cut it in half by 2001.
What these changes imply for academic medicine in South Africa can be shown by describing their likely effects on the Department of Medicine at the University of Cape Town and Groote Schuur Hospital. With difficulty, this department, perhaps the largest and most active in sub-Saharan Africa, retains the ability to carry on all its current functions, whereas other previously strong medical schools have lost that capacity and newer schools have not been able to develop it.
The department, which now has about 12 percent less staff than it did five years ago, has 35 full-time faculty members, 80 residents (in postgraduate years 1 through 6), 12 fellows (in postgraduate years 7 and 8), and a loyal cadre of part-time physicians. They staff a busy emergency unit (serving more than 44,000 patients per year), an acute care unit (with more than 12,000 admissions per year), four general medicine services (with more than 6000 admissions annually), and cardiology, clinical immunology, endocrinology, gastroenterology, geriatrics, hepatology, nephrology, neurology, pulmonology, and rheumatology services with heavy inpatient and outpatient responsibilities.
An average of three full-time faculty members serve in each subspecialty. They cover most areas of special interest in their disciplines, sustain undergraduate and postgraduate training and continuing medical education across a large part of sub-Saharan Africa, undertake some research, keep up with international advances, and introduce these advances into practice in the context of local constraints on resources. All the full-time faculty members teach and care for inpatients and outpatients throughout the year, with at most a month or two away from their clinical duties for research. They work closely together on collaborative projects, undertake some general medical duties, and participate in national and international medical organizations. Over the past year, agreements to allocate up to 30 percent of the staff's time to regional health care — to consult on patient care and assist in developing community services — are being implemented.
The 25 percent budget cut in the coming fiscal year and the planned further reduction by another 25 percent over the following two to four years will radically compromise the structure and function of this department and others, as well as their potential for leadership and training in the future.12 Physicians in wealthy countries may better appreciate the challenges facing academic medicine in South Africa through a comparison with some social, economic, and medical statistics for the United States (Table 2Table 2
Comparison of the South African and U.S. Health Care Systems.).One reason for the shift to primary care is the claim that the bulk of expenditures in public academic institutions are for high-technology medicine. This is misleading, however, because so-called high-tech academic hospitals in South Africa deliver a relatively small volume of high-technology services and a considerable volume of community services. They do the latter effectively because they have well-organized infrastructures and sufficient staff members to provide 24-hour coverage for a wide range of needs. It is also not sufficiently appreciated that all health care professionals in the public and private sectors are trained in academic institutions. Also, it is the poorest members of the population who are served by public institutions and from whom services are being withdrawn to build primary care clinics, albeit for the advantage of future generations of the poor. Furthermore, our academic institutions both underpin the future of medical education in the country and have wide-ranging outreach programs that support and sustain the community medical services on which primary care will also depend.
Choices Facing Society
South African society now needs to decide whether, while developing a more equitable system of primary care, all medical schools should reduce their activities or whether certain special functions should be preserved by merging some schools and encouraging others to focus on the education of primary care physicians. Taking the former course could result in the demise of all the schools, especially if they try to emulate past models that even the most successful schools cannot realistically aspire to. The alternative of explicitly adopting different goals for undergraduate and postgraduate education may permit the preservation of some tertiary care for the poor in the public sector while encouraging the diverse spheres of excellence that South African society will require during a challenging transition.
From Political Apartheid to Economic Apartheid
While public and academic services erode, private for-profit hospitals are being allowed to flourish,5 and drug companies (whose products consume 30 percent of expenditures in the private health care sector3) are directing more of their funds into product-oriented research. This thrust toward private medicine may seem attractive in the short term, but it will almost certainly jeopardize further our already fragile public medical facilities and academic centers.4 As funding for medical schools (all in the public sector) is cut back and they become more focused on primary care, educational and health care facilities for modern scientific medicine may be increasingly diverted to the private sector. The growth of private medical schools will be encouraged, and their fees for students will rise in keeping with market forces.
The previous inequity in access to universities that was based on political apartheid could be replaced by an inequity due to economic disparities. Medical students, except for those aspiring to deliver only primary care, will need to have rich parents or be willing to accumulate large debts. This may be appropriate in affluent societies, and it may be seen as appropriate for South Africa by some who consider it the only way to retain modern medical skills, but the danger it poses of re-creating a new form of two-tier system for “haves” and “have nots” will frustrate efforts to reduce inequities in the nation. It will also, I anticipate, threaten the social stability needed for long-term economic growth and the development of a civil society.
Public Awareness
The public is largely unaware of the repercussions of this civil war in health care. Hospital services are being increasingly withdrawn from some of the most vulnerable members of the society. The ability of medical schools to give disadvantaged students the quality of education they were previously denied, when at last they are gaining access in increasing numbers, is being eroded. The possibility of sustaining secondary and tertiary care services in the public sector is being diminished; such services may not be available for the patients who will emerge from improved primary care to expect the next level of care. Finally, the enthusiasm of young medical practitioners for careers in academic medicine or the public sector is being dampened, and they are being driven to seek economic opportunities in private medicine or academic opportunities in other countries.
The enthusiasm of our Health Ministry for staffing rural clinics and hospitals with physicians from Cuba, who are inadequately trained for conditions in South Africa (there are about 200 such physicians already here, and recruitment continues), and the apparent intention to reintroduce coercive measures to send medical graduates to rural areas (measures that resemble military conscription, which drove many young physicians out of the country) seem shortsighted and inadequate solutions. An alternative with more potential for sustainable progress would be to develop financial and educational incentives for work in rural areas and to couple them with well-structured vocational training that is carefully planned in association with medical schools. Ambitious goals cannot be achieved by government edict alone, however well intended.
Conclusions
The cooperation of professionals, the public, and government is essential if the efficient and fair use of health care resources is to be achieved. At least one or two medical schools will need to be capable of meeting the full range of needs for health care and postgraduate education in South Africa and sub-Saharan Africa. Other schools should focus on education and training for primary care. The private sector must be incorporated constructively into the transformation process. A deeper understanding of the need to move toward a just health care system,13 acknowledgment of the political responsibility to inform the public of the tradeoffs involved in withdrawing existing services in order to benefit future generations, and an attitude that encourages public deliberation on cost-containing policies will all be vital aspects of progress.
The complexity of a successful transformation of society generally and of health care specifically precludes any simple plan,14-16 particularly in view of the demographic transition in South Africa.17 Extensive research on health services3,18 reveals both the willingness and the knowledge base necessary for evolution toward a system that could satisfy the reasonable expectations of patients and the appropriate aspirations of health care professionals in a middle-income country. The realities of our economic status and the prospects for economic growth in the context of our demographic transition call for the re-education of both the public and health care professionals about their expectations of medicine and the role of professionals in our society6 (and unpublished data). This reorientation should involve the private and the public sectors constructively, without sacrificing the medical schools that have a crucial role in sustaining our progress.
The important achievements of South Africa's new government12,19 and the difficulty of building a society that respects the law in the wake of apartheid20 should not be eclipsed, either by the criticisms outlined here or by high-profile reports in the media of the escalating crime, violence, and fraud that may follow the unleashing of freedom in societies that were formerly oppressive. Shaping a future in which freedom will be used responsibly will take many decades, during which tolerance, hard work, patience, and support for the concept of civic citizenship, as well as valid criticism of current policies that could lead to new directions in planning, will all be essential. Achieving tough goals requires great resolve, perseverance, and some sacrifice — but also flexibility. The uncertain and tumultuous nature of the pathway into the future will be recognized by those who understand the complexity of social transformation in a country such as South Africa at the dawn of a new millennium.21,22 Having avoided a bloody civil war to achieve political change, we now face the challenge of averting a civil war over resources and access to the social services required in a society that aspires to democracy.
Source Information
From the Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa, where reprint requests should be addressed to Dr. Benatar.
- References
References
1
Benatar SR . Medicine and health care in South Africa. N Engl J Med 1986;315:527-532
Full Text | Web of Science | Medline2
Benatar SR . Medicine and health care in South Africa: five years later. N Engl J Med 1991;325:30-36
Full Text | Web of Science | Medline3
South African health review 1995. Durban, South Africa: Health Systems Trust and Henry J. Kaiser Family Foundation, 1995.
4
Benatar SR ,van Rensburg HC . Health care services in the new South Africa. Hastings Cent Rep 1995;25:16-21
CrossRef | Web of Science | Medline5
McIntyre D ,Valentine N ,Cornell J . Private sector health care expenditure in South Africa. S Afr Med J 1995;85:133-135
Medline6
Benatar SR . A unitary health service for South Africa. S Afr Med J 1990;77:441-447
Medline7
Adam H, Moodley K. The negotiated revolution: society and politics in post-apartheid South Africa. Johannesburg, South Africa: J. Ball, 1993.
8
Sparks AH. Tomorrow is another country. Sandton, South Africa: Struik, 1994.
9
Van Rensburg HCJ ,Benatar SR . The legacy of apartheid in health and health care. S Afr J Sociol 1993;24:99-11110
African National Congress. The reconstruction and development programme. Johannesburg, South Africa: Umanyano Press, 1994.
11
A national health plan for South Africa. Johannesburg, South Africa: African National Congress, 1994.
12
Cherry M . Change comes slowly to South Africa. Nature 1996;384:11-15
CrossRef | Web of Science | Medline13
Buchanan A . Privatization and just healthcare. Bioethics 1995;9:220-239
CrossRef | Web of Science | Medline14
Malcolm L . Primary health care and the hospital: incompatible organisational concepts? Soc Sci Med 1994;39:455-458
CrossRef | Web of Science | Medline15
Rifkin SB ,Walt G . Why health improves: defining the issues concerning “comprehensive primary health care“ and “selective primary health care.“ Soc Sci Med 1986;23:559-566
CrossRef | Web of Science | Medline16
Coughlan FJ . Primary health care in South Africa: some conceptual issues. S Afr J Sociol 1995;26:9-1417
Van Rensburg HCJ. Demographic transition, social security and health care: the South African case. In: Yang W-S, Lee M-L, eds. Demographic transition, health care and social security. Academia Sinica book series. Taipei, Taiwan: Sun Yat-Sen Institute for Social Science and Philosophy, 1996:363-403.
18
Directory of health systems research, 1995. Durban, South Africa: Health Systems Trust, 1995.
19
Lyman PN. South Africa's promise. Foreign Policy. Spring 1996:105-9.
20
Lewis A . South Africa: building a culture of law. Annu Surv Int Comp Law 1995;2:1-1421
Braudel F. A history of civilizations. Mayne R, trans. New York: Allen Lane, 1994.
22
Hobsbawm EJ. The age of extremes. New York: Pantheon, 1994.
- Citing Articles (12)
Citing Articles
1
Enoch N. Kwizera, Jehu E. Iputo. (2011) Addressing social responsibility in medical education: The African way. Medical Teacher 33:8, 649-653
CrossRef2
Z. R. Kon, N. Lackan. (2008) Ethnic Disparities in Access to Care in Post-Apartheid South Africa. American Journal of Public Health 98:12, 2272-2277
CrossRef3
Charles E. Begley, Gus A. Baker, Ettore Beghi, James Butler, Daniel Chisholm, John T. Langfitt, Pierre Levy, Christoph Pachlatko, Samuel Wiebe, Karen Lee Donaldson, . (2007) Cross-Country Measures for Monitoring Epilepsy Care. Epilepsia 48:5, 990-1001
CrossRef4
Benatar, Solomon R., . (2004) Health Care Reform and the Crisis of HIV and AIDS in South Africa. New England Journal of Medicine 351:1, 81-92
Full Text5
Melanie E. Campbell, Peri J. Ballantyne. 2004. WHO ADVOCATES FOR PATIENTS WHEN HEALTH CARE SYSTEMS FAIL? ENSURING ACCESS TO ESSENTIAL MEDICINES IN SOUTH AFRICA (AND THE U.S.). , 239-260.
CrossRef6
Paula Braveman, Eleuther Tarimo. (2002) Social inequalities in health within countries: not only an issue for affluent nations. Social Science & Medicine 54:11, 1621-1635
CrossRef7
Susan L. Beck. (2000) An Ethnographic Study of Factors Influencing Cancer Pain Management in South Africa. Cancer Nursing 23:2, 91-99
CrossRef8
Susan L. Beck, Aocn. (1999) Health Policy, Health Services, and Cancer Pain Management in the New South Africa. Journal of Pain and Symptom Management 17:1, 16-26
CrossRef9
Alexander R.P. Walker. (1998) Epidemiology and health implications of obesity, with special reference to African populations. Ecology of Food and Nutrition 37:1, 21-55
CrossRef10
S R Benatar. (1998) Global disparities in health and human rights: a critical commentary.. American Journal of Public Health 88:2, 295-300
CrossRef11
StÉPhanie Oddou, Norbert Vey, Patrice Viens, ValÉRie Jeanne Bardou, Catherine Faucher, Anne Marie Stoppa, Christian Chabannon, Jacques Camerlo, RÉDa Bouabdallah, Jean Albert Gastaut, Dominique Maraninchi, Didier Blaise. (1998) Second Neoplasms Following High-dose Chemotherapy and Autologous Stem Cell Transplantation for Malignant Lymphomas: A Report of Six Cases in a Cohort of 171 Patients from a Single Institution. Leukemia & Lymphoma 31:1-2, 187-194
CrossRef12
Biebuyck, Julien F., . (1997) Ratio of Specialists to Family Practitioners in the United States. New England Journal of Medicine 337:4, 282-282
Full Text
- Letters
