CHAPTER 1

BACKGROUND AND ACHIEVEMENTS

Contents

1. Background
2. Achievements

By solid co-operation between national and provincial health departments, supported by others inside and outside government, a national health system has been created.

1.1 BACKGROUND

Prior to 1994 the South African health system was built on apartheid ideology and characterised by racial and geographic disparities, fragmentation and duplication and hospi-centricism with lip service paid to the primary health care approach. There were 14 Departments of Health each having their own objectives. Access to health care for rural communities and those classified as 'black' was difficult. Besides the lack of facilities, the financial burden of finding and financing transport to health facilities and payment for health services acted as barriers to access to care. Many rural hospitals had very limited access to medical doctors and medicines were not always available at public health facilities and expensive.

Over the past few years, our country has been through an exciting process of transformation. During this time we have benefited from the lessons of others and believe that we have also contributed to humanity's common foundation of wisdom.

We have firmly placed before our country a perspective of health that recognises good health as both a prerequisite for social and economic development as well as an outcome of that process. Health must be considered as an investment rather than simply as expenditure. It is also a perspective that sees good health as a product of many determinants - many of which lie outside the formal health sector. For our country to succeed and our citizens to be healthy - government and all associated institutions cannot and should not function in isolation. Our inability to form strong partnerships has been one of our key weaknesses as a government over the past 5 years, a weakness that must be urgently corrected.

It is common knowledge that lack of water and sanitation is a common cause of cholera, diarrhoeal and other illnesses that afflict so many in our country and that there is a relationship between various communicable diseases, including TB, and conditions of squalor. Yet we often have not structured our institutions and service delivery systems in ways that can easily respond to these realities. The adoption by this government of the Primary Health Care Approach forces us to challenge this model. We share the vision captured in the President's "State of the Nation" address - a vision of integrated planning and delivery. This is the only way to optimise use of resources and derive the full utility of our investments.

In spite of these shortcomings, we believe we have made significant gains in the past five years. By solid co-operation between national and provincial health departments, supported by others inside and outside government, a national health system has been created. The policy of Primary Health Care was clearly enunciated and now commands national support. The public health system has been transformed from a fragmented, racially divided, hospital-centred service favouring the urban population into an integrated, comprehensive national service driven by the need to redress historical inequities and to give priority to the provision of essential health care to disadvantaged people, especially those residing in the rural areas.

The public health system can be proud of the structural transformation it has effected. Practical progress has also been made in filling in the details of this transformation. Hundreds of new clinics have been built or rehabilitated, and health care has been made free at the point of delivery for pregnant women, young children and all who use the public primary health care system. New posts have been created at the public primary level of care. The access of poor people to essential health care has thereby been greatly improved. The policy of the delivery of primary health care through the district health system has been clearly formulated and implementation has commenced.

Inevitably, a multitude of challenges remain: planning and management skills are still weak at all levels, but especially in hospitals; management systems need to be upgraded; essential management information is lacking at all levels of the health system; more primary health care nurses need to be trained; the quality of care that is provided in public health facilities must be improved; many clinics are short of equipment; drug procurement, distribution and management must be improved; and the consolidation of the district health system is bedevilled by the continuing territorial divide between provincial and local governments.

We need to focus more attention on the building of a culture of quality and efficiency throughout the health care system. We need to explore possible areas of co-operation between the private and public sectors. Despite these challenges we are certain that we are well on the road to building a health service that all South Africans can be proud of.

1.2 ACHIEVEMENTS

The following summary reflects the key achievements since 1994:

• Outlining of the government's health policies through the tabling of the White Paper on the Transformation of the Health System in April 1997.
• The elimination of discriminatory structures and practices in the public health system.
• Consolidation of fourteen fragmented health administrations inherited from the apartheid system into a national and nine provincial health departments.
• Transformation of the public health system from a fragmented, racially divided hospital-centred service to an integrated, comprehensive national service that emphasises the health needs of disadvantaged people especially those living in rural areas.
• Expansion of the primary care infra-structure:
  • Since 1994 more than 700 new clinics have been built or had major upgrading (495 of which were completely newly built);
  • 2298 existing clinics have received new equipment and were upgraded;
  • 124 new visiting points were built; and
  • 125 new mobile clinics purchased.
• Health care, free at the point of delivery, for pregnant and lactating women, children under the age of six years and all who use the public primary health care system was introduced.
• Introduction of the Integrated Management of Childhood Illnesses (IMCI), with training of health workers.
• The provision of primary school nutrition services through which about 5 million children have benefited and many employment opportunities have been created in communities.
• Major progress achieved with the implementation of the district health system through the demarcation of interim health districts and the setting up of the regional and district offices.
• Launching of the National Drug Policy in 1996 and the development of essential drug lists and standard treatment guidelines for primary health care and hospital levels (paediatric and adult levels of care) and some improvement in the availability of essential drugs in public facilities.
• Realignment of tenders in line with the essential drug lists.
• Introduced the World Health Organisation recommended Direct Observed Treatment Short-course (DOTS) strategy to combat TB in 1996.
• Employment of 402 Cuban and 44 other foreign doctors to strengthen hospital based care for rural communities and to provide proper support to our primary health system.
• The introduction of community service for newly graduating South African doctors.
• An impressive record in transforming health legislation. Acts have been passed to:
  • Rationalise Health Professions Councils and make them more representative of the South African population;
  • Make drugs more available and affordable in the country;
  • Promote the use of generic products;
• More effectively regulate the medical schemes industry;
• Enable safe and legal termination of pregnancies in public and private facilities;
• Warn the public of the dangers of smoking; and
• Limit smoking in public places and ban the advertising of tobacco products.
• Commencement of a system of inquiries into maternal deaths to ensure the prevention of unnecessary deaths.
• Implementation of the Choice on Termination of Pregnancy Act, 1996, with the training of midwives in termination of pregnancy, and in post-abortion counselling.
• Training of advanced midwives and facilitators for most provinces.
• Prioritisation of the health of children has ensured that South Africa is firmly on the road to polio free certification and the achievement of a significant decline in measles due to mass immunisation campaigns.
• Introduction of Hepatitis B vaccine in April 1995 and HiB vaccine in July 1999.
• Advanced preparations for the establishment of a Telemedicine network including 28 pilot sites in the public health system by July 1999 to enhance access to expertise and resources in rural areas.
• Carried out the first ever hospital audit in South Africa in 1996, which resulted in the introduction of the hospital rehabilitation programme.
• Carried out a cost centre study as the first step in the implementation of a system of decentralized management to promote greater efficiency in our hospitals.
• Launch of "Partnerships Against AIDS" by Deputy President Mbeki in October 1998 to intensify efforts aimed at arresting the epidemic and the development of the Government AIDS Action Plan under the auspices of the Inter Ministerial Committee on HIV/AIDS.
• Conducted the first ever "Demographic and Health Survey" in South Africa that provides a reliable baseline for monitoring health status change.