Primary healthcare - People's Health Movement

Universal Coverage And Equity In
Integrated Health Governance Systems
Director General Health
Peoples Health Assembly
South Africa 09 July 2012
Outline of the Presentation
• Background
• Pillars
• Opportunities
– Renewed interest in PHC
– Crises
– Various perspectives
• A response-Comprehensive PHC
• Lessons from other countries
• SA Response, 10 point plan, NSDA
Universal Coverage
• This principle is based on the understanding
that the progressive development of a health
system, including its financing mechanisms,
should be founded on the principles of
access to quality needed health services and
protection from financial hardships
• It implies that everyone must be given an
equitable and timely opportunity to access
needed health services, which must include
n appropriate mix of promotion, prevention,
curative and rehabilitative care.
Crises and social spending
• Financial crisis and rising unemployment,
cannot be basis for cutting allocations for
social services
• Most countries have seen a decline in public
health expenditure and increase in inequities,
deterioration in health
• Can be minimised, or impact can be reduced
through a comprehensive primary health care
and universal coverage
Various perspectives on the
importance of health
• Commission on Macroeconomics and Health (2001 )health has been considered a central goal of
development and an instrument to enhance other
welfare outcomes
• Amartya Sen (1999) presented a philosophical
perspective , that health is an essential element of the
human capabilities needed for development
• Bloom and Canning (2000), an economic perspective,
consider population health as key in contributing
towards economic growth at a national level
• Liu et al (2003) on poverty , poor health is linked to
poverty and household distress
• Access to healthcare is a human right enshrined in the
Renewed interest on PHC
• Thirty four years ago- Alma Ata declaration
• Four years ago WHO World Health Report 2008
devoted to PHC, “ Primary Health care, Now More
Than Ever”
• The Lancet 2008 series- “30 years after Alma-Ata: has
primary health care worked in countries”
• Commission on Social Determinants on Health
• The Lancet (Julio Frenk, 2009) “Reinventing Primary
Health Care: the need for systems integration”
• Subsequent declarations, e.g. RIO Declaration on the
Social Determinants of Heath, and RIO 20+
Comprehensive primary health care
• Elements of a comprehensive approach
include equity, high coverage, governance,
effective inter-sectoral action, the
responsiveness of the non-health sector and
community participation
• Comprehensive primary health care must be
an integration of preventative, promotive,
therapeutic and rehabilitative
International Experiences
• Many governments have made attempts to
reform health
• Some have created new insurance schemes,
others have changed how primary healthcare
is delivered, restructured hospital governance,
decentralised service delivery
• Many of the reforms have yielded mixed
results, a combination of successes and
failures, improvements in some areas and
slow progress in others
Success stories
• Common features among countries
with experiences in rolling out PHC
are, in an integrated manner, with
community participation, use of
community health workers, focus on
social determinants of health
(Thailand, Rwanda, Brazil)
Lessons for South Africa
• Countries differ in their level of
development, social conditions, value
systems, disease profiles, effectiveness
of their governance structures and
• Every country must reform its health
system with the involvement and
participation of its citizens, mobilisation
of its communities, the beneficiaries
Pillars for an integrated approach
• Health Financing
• Health Service Provision
• Governance and Institutional
• Regulatory environment
Health Financing
• Countries do not finance healthcare
through a single mechanism
• There are a combination approaches:
– Public
– Private
– Combination of both
– Multiple health plans
Health Service Provision
• Predominantly publicly provided servicesScandinavian countries
• Combination of government care and
private health providers (UK)
• Predominantly private providers (Swiss)
South Africa
• Nationally agreed prioritised and phased
primary health care, with special attention to
strengthening district health system
• Individual private insurance, that may
– community based health insurance, or
– medical savings account, or
– private health insurance e.g. medical
• Payment through taxes or compulsory
health insurance:
– Social health insurance,(contributions from
employer and employee, it is limited to the
formal employment sector),
– National health insurance, (prepayment
scheme that is mandatory and is a
compulsory health insurance)
– Tax-based finance system (government
revenue the main source)
(Source: Global Health Watch 3, 2011)
Social Health Insurance
• Limited to the formal employed sector
• Excludes a significant proportion of the
informal employed and self employed
• It has a small pool and hence universal
coverage may not be achievable
• It is socially acceptable to the employed
• May contribute to higher labour costs
Tax-based finance system
• It is a form of prepayment and government
is the main source of funding
• It does not link payment to risk and
detaches payment from the experience of
• It has better potential in achieving
universal coverage and financial protection
• It may promote social cohesion across
different groups
Tax-based finance system
• It requires both fiscal and social contract
between the state and society
• It must be the means by which the state
can be made accountable to society
Private Health Insurance
• Self financing scheme for the affluent
• It is highly selective and universal coverage
may not be achievable as it only covers a
small proportion of the population
• Requires robust regulatory systems
• Countries with predominantly private health
insurance schemes are Netherlands,
Switzerland and USA
• In the US, 50 million people are uninsured
despite the fact that 2,3 trillion is spent on
healthcare ( G. Halvvorson, 2009)
Community Based Health Insurance
• A scheme that is operated by organisations
other than government of private for profit sector
• It may cover part of or all of the healthcare costs
• It is voluntary and is low cost, with administration
managed by the communities themselves
• It largely provides cover for the socially excluded
or populations in the informal sector
• the schemes have a potential to reduce financial
burdens on individuals and reduce out of pocket
Community Based Health Insurance
• Those without income may not benefit, and thus
universal coverage may not be possible without
government subsidy
• The biggest challenge is long term sustainability
• The Chinese and Indian schemes benefit from
government subsidy:
– Rural Mutual Healthcare (China)
– Self Employed Women association (India)
South African inequities
Reminder: The People we Serve
Middle-Low Income
±11.5 million
Public Sector-Low Income
±37 million
per capita
Often used as
of inequity in
absolute and
in trend terms
Medical Scheme
Public Health
Council for medical schemes reports, National and Provincial budget statements
South African inequities
• The skewed distribution of financial resources
between the public and private sectors in
relation to the population served has led to
inequities in the health system because the
better-off segments of the population have
better access to health services
What is needed for South Africa?
• Fair financing means that the risks that each
household faces due to the cost of healthcare
are distributed not according to the risk of illness
• Will need trade offs if fairness is to be achieved
• Will need involvement of communities and all
stakeholders across all spheres
• Will need improved governance structures and
transparent, responsive and accountability
systems across all spheres of government
What is needed for South Africa?
• A shared value of universal coverage based
on principles of
– Fairness and without barriers
– Social solidarity, promoting unity and ownership
– Financial risk protection
– Access, availability, acceptability, affordability, and
• What should be the uniting and core
– Solidarity: the young must subsidise the old, the
healthy must subsidise the sick and the rich must
subsidise the poor
South Africa needs a healthcare house to
accommodate all its citizens
An estimated
8.2 million citizens
have a private one
The remaining estimated
41 million citizens
cannot afford a private one
What is needed for South Africa?
• Universal coverage so as to
– provide a better level of financial risk protection against
out-of-pocket payments and user fees at the point of
utilizing needed health services for the entire
– address the burden experienced by South African
households of high medical scheme contributions and
high out-of-pocket payments (including co-payments).
– reduce health-related catastrophic expenditures that
lead to household impoverishment.
– address inequities in the health system this through
pooling of resources.
• NHI will be phased-in over a period of 14 years
• Will include piloting and complete overhaul of the health system in the
following areas:
Quality improvement
PHC Re-engineering
Management of health facilities and health districts
Infrastructure development
Medical devices including equipment improvements
Human Resources planning, development and management
Improving Access to medicines
Strengthening of information management and systems support
Public sector health finance reform
• Establishment of the National Health Insurance Fund in the latter years of the
1st phase
• The 1st phase occurring in the 1st 5years of
rollout includes:
– Strengthening of the health system and
– Improving the service delivery platform
– Addressing human resource for health gaps
NHI PILOTS IN 2012 / 2013
• The first steps towards implementation of National
Health Insurance in 2012 will be through piloting
• Pilots commenced on the prioritized health districts
• 10 (+ 1) districts have been selected for piloting
• They extend coverage for 11 million people
• Pilot district selection has been based on the following
Demographic profile
Socio-economic profile
Burden of diseases using (MDG Proxy indicators)
Service delivery platform and health system performance
District management capacity to conduct pilots
Eden NHI Pilot District and the
role of partners
Demographic profile of the District
• Eden is one of the 6 districts in the Western
• The District covers a geographical area, of
22,720 square kilometres
Population Pyramid of the District
Demographic Data
• Total Population (Midyear 2011 DHIS) 558,950
• Population density (Midyear 2011) 24.6/Km2
• Percentage of population with medical
insurance (General Household Survey 2007)
• 49.5% of the population is in the age group
40-64 yrs followed by 25-39 yrs (31%)
Social Determinants of Health
Social Determinants of Health
Indicators for Basic Services
Percentage traditional and informal dwelling, shacks and
squatter settlement
Community Survey
Percentage households without access to improved
Percentage households without Access to Piped Water
Percentage households without access to electricity for
Percentage households without refuse removal by local
authority/private company
Socio-economic indicators
• According to the Community Survey 2007,
12.2% of the population are unemployed and
5% of households live with an annual income
below R4, 800 or less than R400 per month.
• The Deprivation Index of the district is 1.3