Transcript View our presentation to the National Health Insurance

Conference on NHI – Lessons for South Africa
Ministry of Health – Gallagher Estate,
Johannesburg
7-8 December 2011
Elroy Paulus – Advocacy Programme Manager,
Black Sash
The uniqueness of the SA context
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Important context
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51.0
Share of income in South Africa
50
40
30
20
17.8
10.3
10
0
0.2
Poorest
10%
1.2
2.2
2.9
3.5
4.7
6.4
Middle
10%
Income groups (from poorest to richest 10% of population)
Richest
10%
Figure 1:
At least 1 in 4 of
working age in SA is
unemployed or
working poor
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South Africa
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• Share the methodology of these consultations with a
sector of civil society organisations
• Highlight key findings and recommendations
• Link to current work and initiatives of civil society
organisations in South Africa
• Highlight aspects of insights learnt from a current
project – CMAP (Community Monitoring and
Advocacy Programme)
Eliciting public preferences for health system
reform including the National Health Insurance in
South Africa
• Disseminate information on current health system
challenges and health system reform options;
• Provide regional civil society platforms for
information sharing and preference elicitation with
respect to national health system reform
• ensure that these preferences are taken into account
in policy deliberations
• Intended impact - that the policy proposals for
health system reform will reflect public values and be
in line with public preferences
Organisational Mission and Project Design
• Collaboration between three organisations: the Black
Sash, the Health Economics Unit of the University of
Cape Town and Health-e News Service
• Holding public consultation workshop with civil society
groupings in all provinces, and using informed
deliberation approaches to elicit public views on the
values that should underlie the SA health system and
the priority health system changes desired
• Submission of findings to wide range of policy actors
and public dissemination of findings
Timeline of consultations
• Public Consultations held in each of 9 provinces during
May 2010 to June 2011, viz. Eastern Cape; KwaZulu
Natal; Western Cape; Mpumalanga; North West;
Limpopo, Gauteng; Northern Cape and Free State.
• Intention was to, as rapidly as possible, elicit public
preferences on the core values that should underlie
health system reform in South Africa and on key
aspects of the proposed NHI (focussed on broad policy
options  feed that information into the policy
process while it is still in its initial stages.
Broad strokes of methodology
• Used broad approach of informed public deliberation
in these workshops  Deliberative processes used to
elicit public views to establish the values that citizens
want to underlie their health systems and the
priority issues for health services to address.
• Workshop representatives/participants were:
– provided with relevant information, i.e. their discussions
are informed;
– given an opportunity to deliberate on the information and
the specific questions posed to them, so that the pros and
cons of different decisions can be discussed; and
– reached decisions on specific issues and explained the
basis for the decisions they reached
Broad strokes of methodology
• Facilitators were trained (language, context), careful
recruitment and selection of participants –
geographically and sectorally
• Human rights organisations; health – health affiliated
organisations; local advice offices; traditional health
practitioners – emphasis on CBO’s – rural, peri-urban and
urban
• 360+ participants from each of the 9 provinces in
workshops ranging from 45 – 65 participants in each of
the 9 provinces
• Trained facilitators fluent in local languages
The Right to Health:
Rights and responsibilities –
developments in health policy (incl NHI)
Free State Consultative Workshop
6-8 June 2011
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Current Context and Recent Policy
Developments
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Vulnerable communities and social
determinants of Health in SA
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Health and the Constitution
27. Health care, food, water and social security
(1) Everyone has the right to have access to (a) health care services, including reproductive health care;
(b) sufficient food and water; and
(c) social security, including, if they are unable to support
themselves and their dependants, appropriate social
assistance
(2) The state must take reasonable legislative and other
measures, within it’s available resources, to achieve the
progressive realisaiion of each of these rights.
(3) No one may be refused emergency medical treatment.
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Health and health
services in the Free
State: Key issues
Overview
• The Free State in the context of South
Africa overall
• Between districts in the FS
Number of people per province
Million people: total and those not on medical schemes
[CMS data]
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Infant deaths (less than 1 year)
Infant deaths per 1000 live births
70
60
50
40
30
20
10
0
Children who die before age 5
Under 5 mortality rate [ASSA 2003 projections]
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Access to piped water
Percent households with access to piped water by province
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Households with no toilet
Percent households without a toilet
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Number of people per province
Million people: total and those not on medical schemes
[CMS data]
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Government spending on health per person
Government health spending
2500
2000
1500
1000
500
0
Public sector doctors & specialists
General doctors & specialists per 100000 uninsured population
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Adults & children getting ART
Number on ART by province
Source: Day C, Gray A. Health & related indicators. SAHR 2010
Private hospitals
Public hospitals
= District hospitals
= Regional hospitals
= Provincial or
national hospitals
Findings
Black Sash, along
with its partners,
published these
reports for public
information – every
provincial report, a
final synthesis
report and a midterm review is
posted on our
website – see
www.blacksash.org.
za – search Sash in
Action – Health and
NHI Consultations
Final Synthesis Report
Consultations
THE KEY PRIORITIES THAT COMMUNITIES (WE CONSULTED)
IDENTIFIED AS NEEDING TO BE ADDRESSED IN ORDER TO
FACILITATE ACCESS TO HEALTH CARE
• Addressing inadequate access to health care
facilities
• Addressing the shortage of staff, skills and improving staff
performance
• Increasing access to ambulances
• Improve monitoring and evaluation of health care
• Improving access to medication
• acilitating partnership with health facilities and
participation in health
Addressing inadequate access to
health care facilities
“ Accessibility of hospitals was less significant
than that of clinics, demonstrating that clinics
(and as such primary health care) remain the
main access point of health care for people. As
one participant indicated improving access to
health care facilities includes “…building more
clinics that are ‘closer to the people’, are multipurpose and have longer hours”
Addressing the shortage of staff, skills and
improving staff performance
• In the Northern Cape for example, one group
noted that staff use colour coded folders that
categorise the different health issues and that
this indiscreet conduct often denies patients
their right to confidentiality, with variations
thereof in other provinces. Participants from
all provinces suggested that, as a priority staff,
need to be sufficiently trained on patient
rights and Batho Pele principles.
Increasing access to ambulances
• …..in the Free State as an example,
participants report that ambulances do not
collect seriously ill patients from their point of
call and people are expected to travel to a
central point such as a police station for
collection. As one participant indicated,
“…ambulances have had fatal results for
communities”
Improve monitoring and evaluation of
health care
•
“where a system is in place, it is rendered
ineffective through incompetence or lack of
implementation”
• Northern Cape participants report that area
managers are not aware of challenges
experienced at an implementation level and
that monitoring and evaluation of services is
“completely” absent.
Improving access to medication
• was widely reported in the nine provinces
where consultations were held that access to
medication remains an obstacle to people
accessing quality health care
• Limpopo Province, Waterberg District, it was
reported that some patients struggle to access
chronic medication such as ARV’s, and either
share these with other patients or use less
than the prescribed amount per day in order
to “stretch the medicine” till the next clinic
visit.
On the NHI and funding options
• The majority of participants across all nine
provincial consultations supported the
introduction of a tax funded National Health
Insurance system on condition that it would
be able to provide a substantially improved
and quality health care system which is
accessible to everyone.
NHI and funding options
• Participants recognized key values that need
to inform a health care system, including that:
• South Africa’s social context must be
considered in any health reform initiatives:
there is a high rate of unemployment and
most people live under poverty line and are
dependent on social grants.
NHI and funding options
• The Bill of Rights and Constitution are
fundamental: everyone has a right to access
quality health care.
• Health is a constitutional right and therefore the
government is responsible for ensuring access to
health services.
• There are social determinants of health in South
Africa, which imply responsibility of the state and
wealthier households and companies for the
health care of impoverished people.
NHI and funding options
• Given the socio-economic factors in South
Africa, in general participants suggested that it
would be unfair to expect everyone to pay the
same amount towards a health care
contribution.
• Participants suggested a variety of solutions
including contributions which are based on a
percentage of a person’s salary: “Everyone
who is earning an income should pay a
nationally prescribed PERCENTAGE of this to
health care”.
NHI and funding options
• Participants were also presented with
different options of taxation with which health
care can be funded – including Value Added
Tax (VAT), Pay As You Earn (PAYE) and
employer payroll tax.
• The majority of participants suggested that
NHI should be funded either through PAYE or
employer payroll tax or a combination of both.
Other innovative sources of funding were also
raised in some provinces.
NHI and funding options
•
The principle of ownership of the health
system was associated with contributing towards
it.
• Participants suggested that it was necessary for
everybody to contribute to the health system so
that they could play an active and recognised role
in it.
• However, the majority of participants also
suggested that VAT should not be used to fund
the health system, since it would
disproportionately the poor.
NHI and funding options
• Any increase in VAT was perceived by
participants to affect impoverished people
negatively.
• Therefore, there is recognition of three clear
principles that need to inform any health care
system in South Africa:
• Although people may not be able to
contribute towards a health system, they
should have equal access to health.
NHI and funding options
• Therefore, the health system should endorse
cross-subsidization of health care as an
important value that ensures equal access to
health.
• It is suggested that wealthier individuals and
companies cross-subsidize those who are less
fortunate and unable to pay for health care.
• Everyone who can contribute to the health
system should do so, but this needs to be
linked to how much a person earns or can
afford.
NHI funding options
• Sick people should be afforded the dignity of
health care even if they cannot afford to pay
for it. Therefore, everybody has a right to
health regardless of their ability to pay.
• There was broad agreement on categories of
people who should not be asked to contribute
to a health system. These categories included:
NHI funding options
• people who are unemployed
• those who access social grants or who are
included in indigent policies
• children
• the elderly
• the poorest proportion of the population (at least
the poorest 10% according to income distribution
in South Africa), and
• those who earned an income which fell under the
tax bracket.
Advocacy (local and national)
• We have made several submissions on these
findings to Parliament
• Assisting local communities to follow up –
especially in rural areas
• Working with CSO/NGO networks to realise
the right to health with partner organisations
– especially social determinants – local govt,
water, sanitation
• Calling for a Chronic Illness Grant
CMAP – monitoring health
• Through our Community Monitoring and
Advocacy Project (CMAP) we are working with
community monitors who wish to monitor
health care facilities and we will publish and
disseminate these findings in the public
domain
CMAP – Community Monitoring and Advocacy
Programme
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CMAP – Community monitoring and advocacy
programme
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The need for ongoing community monitoring
and advocacy as a preventative and preemptive strategy
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WORK done to date and future plans
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•
•
•
SASSA paypoints and application points
Monitoring of Health clinics
Monitoring of other service points
Submission of reports to government,
Parliament and Chapter 9 Institutions
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Municipalities in crisis – the de Doorns Experience
Walkabout and meeting in de Doorns – #1 13 Dec 2009
Gathering in Stofland, de Doorns 13 Dec 2009 09h15
Community Leaders Government Officials and Monitors
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Walkabout and meeting in de Doorns – #2 13 Dec 2009
Dumpsite at entrance to Stofland as at 13 Dec 2009
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Visit by senior municipal leaders to Stofland and De Doorns
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Walkabout and meeting in de Doorns – #6 13 Dec 2009
No tap(broken off) at standpoint in Stofland, de Doorns
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Walkabout and meeting in de Doorns – #8 13 Dec 2009
Highly unhygienic conditions in Stofland prevails
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Walkabout and meeting in de Doorns – #9 13 Dec 2009
Local Leaders explaining a point 13 Dec 2009
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Walkabout and meeting in de Doorns – #10 - 13 Dec 2009
Ward Councillor Lubisi explaining flood plains
and settlement pattern disputes
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Walkabout and meeting in de Doorns – #17 - 13 Dec 2009
Evidence of shacks built in flood plain –
Maseru, de Doorns
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Engaging government
• SASSA – and received formal responses from
them (in writing) and formal permission to
monitor their sites under certain conditions
• Seeking permission and support from DoH
• Brokering permission from municipalities
"The
day will come when nations will be judged
not by military or economic strength, nor by the
splendour of their capital cities and public
buildings, but by the well-being of their people: by,
among other things, their opportunities to earn a
fair reward for their labour, their ability to
participate in the decisions that affect their lives;
by the respect that is shown for their civil and
political liberties; by the provision that is made for
those who are vulnerable and disadvantaged“
-
UNICEF Progress of Nations Report (1998)
Contact details
Black Sash www.blacksash.org.za
Elroy Paulus: Advocacy Programme Manager
072 382 8175
Email: [email protected]
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