Embed Size (px)
Citation preview
Health in South Africa since 1994 achievements and challenges Will current policy init iatives resolve the crisis
SaSa
A WHO Collaborating Centre for Research and Training in Human Resources for Health
David Sanders Emeritus Professor
School of Public HealthUniversity of the Western Cape
Member of Global Steering CouncilPeoples Health Movement
Member of Steering Committee PHM South Africa
South Africarsquos comparative performance in health Disease pattern and premature mortality ndash levels and
causes Health policy and the health sector advances and
continuing challenges NHI and lsquoRe-engineering PHCrsquo rationale and
challenges to implementation Proposed priority initiatives to address health
challenges including the role of social movements
Democracy so much promise hellipbull Legislation
ndash Constitutionndash UNCRCndash Childrens act
bull Policies amp programmesndash basic servicesndash in social grants ampcndash clinic buildingndash Tobacco controlndash Food fortification ndash PSNP
bull Global ndash Adoption of MDGs
Life expectancy vs wealth
SA
Bangladesh
Cuba
National Health Indicators
bull Life expectancy 4941 (60)
bull Infant mortality 334ndash EC 45 vs WC 18
bull Under five mortality 477- KZN 61 vs WC 25
bull Maternal mortality 300
bull No living with HIV 558 millionSouth African Health Review 2011
Quadruple burden of disease
pre-transitional diseases and poverty related conditions eg childhood undernutrition and infections maternal mortality
emerging chronic diseases eg obesity heart disease diabetes mental ill-health
injuries - including interpersonal violence HIVAIDS and TB epidemics (TB cases increased
from 109000 in 1996 to 341165 in 2006 55 cases also have HIV)
MRC Burden of Disease Unit 2004
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
South Africarsquos comparative performance in health Disease pattern and premature mortality ndash levels and
causes Health policy and the health sector advances and
continuing challenges NHI and lsquoRe-engineering PHCrsquo rationale and
challenges to implementation Proposed priority initiatives to address health
challenges including the role of social movements
Democracy so much promise hellipbull Legislation
ndash Constitutionndash UNCRCndash Childrens act
bull Policies amp programmesndash basic servicesndash in social grants ampcndash clinic buildingndash Tobacco controlndash Food fortification ndash PSNP
bull Global ndash Adoption of MDGs
Life expectancy vs wealth
SA
Bangladesh
Cuba
National Health Indicators
bull Life expectancy 4941 (60)
bull Infant mortality 334ndash EC 45 vs WC 18
bull Under five mortality 477- KZN 61 vs WC 25
bull Maternal mortality 300
bull No living with HIV 558 millionSouth African Health Review 2011
Quadruple burden of disease
pre-transitional diseases and poverty related conditions eg childhood undernutrition and infections maternal mortality
emerging chronic diseases eg obesity heart disease diabetes mental ill-health
injuries - including interpersonal violence HIVAIDS and TB epidemics (TB cases increased
from 109000 in 1996 to 341165 in 2006 55 cases also have HIV)
MRC Burden of Disease Unit 2004
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Democracy so much promise hellipbull Legislation
ndash Constitutionndash UNCRCndash Childrens act
bull Policies amp programmesndash basic servicesndash in social grants ampcndash clinic buildingndash Tobacco controlndash Food fortification ndash PSNP
bull Global ndash Adoption of MDGs
Life expectancy vs wealth
SA
Bangladesh
Cuba
National Health Indicators
bull Life expectancy 4941 (60)
bull Infant mortality 334ndash EC 45 vs WC 18
bull Under five mortality 477- KZN 61 vs WC 25
bull Maternal mortality 300
bull No living with HIV 558 millionSouth African Health Review 2011
Quadruple burden of disease
pre-transitional diseases and poverty related conditions eg childhood undernutrition and infections maternal mortality
emerging chronic diseases eg obesity heart disease diabetes mental ill-health
injuries - including interpersonal violence HIVAIDS and TB epidemics (TB cases increased
from 109000 in 1996 to 341165 in 2006 55 cases also have HIV)
MRC Burden of Disease Unit 2004
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Life expectancy vs wealth
SA
Bangladesh
Cuba
National Health Indicators
bull Life expectancy 4941 (60)
bull Infant mortality 334ndash EC 45 vs WC 18
bull Under five mortality 477- KZN 61 vs WC 25
bull Maternal mortality 300
bull No living with HIV 558 millionSouth African Health Review 2011
Quadruple burden of disease
pre-transitional diseases and poverty related conditions eg childhood undernutrition and infections maternal mortality
emerging chronic diseases eg obesity heart disease diabetes mental ill-health
injuries - including interpersonal violence HIVAIDS and TB epidemics (TB cases increased
from 109000 in 1996 to 341165 in 2006 55 cases also have HIV)
MRC Burden of Disease Unit 2004
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
National Health Indicators
bull Life expectancy 4941 (60)
bull Infant mortality 334ndash EC 45 vs WC 18
bull Under five mortality 477- KZN 61 vs WC 25
bull Maternal mortality 300
bull No living with HIV 558 millionSouth African Health Review 2011
Quadruple burden of disease
pre-transitional diseases and poverty related conditions eg childhood undernutrition and infections maternal mortality
emerging chronic diseases eg obesity heart disease diabetes mental ill-health
injuries - including interpersonal violence HIVAIDS and TB epidemics (TB cases increased
from 109000 in 1996 to 341165 in 2006 55 cases also have HIV)
MRC Burden of Disease Unit 2004
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Quadruple burden of disease
pre-transitional diseases and poverty related conditions eg childhood undernutrition and infections maternal mortality
emerging chronic diseases eg obesity heart disease diabetes mental ill-health
injuries - including interpersonal violence HIVAIDS and TB epidemics (TB cases increased
from 109000 in 1996 to 341165 in 2006 55 cases also have HIV)
MRC Burden of Disease Unit 2004
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Millennium development goal 4
Goal 4 Reduce child mortality
Reduce by two-thirds between 1990 and 2015 the under-five mortality rate
Photo L Rey nolds
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
MDG4 SA progress
httpwwwthepresidencygovzalearningmeindicators2009indicatorspdf
0
20
40
60
80
100
120
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
MRC
ASSA 2002
ASSA 2003
HST
U-5MR projections from various sources
Goal for U-5MR 20 by 2015
Department of Health (2012)
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Health Inequalities in South
Africa
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
0
2
4
6
8
10
12
Ath
lon
e
Bla
auw
ber
g
Cen
tral
Hel
der
ber
g
Kh
ayel
itsh
a
Mit
chel
lsP
lain
Nya
ng
a
Oo
sten
ber
g
So
uth
Pen
insu
lar
Tyg
erb
erg
Eas
t
Tyg
erb
erg
Wes
t
HIV prevalence (estimated)
0102030405060
Athlo
ne
Blaa
uwbe
rg
Cen
tral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plai
n
Nyan
ga
Oos
tenb
erg
SPM
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
unemployed
Cape Town Equity Gauge UWC SOPH 2002
0
10
20
30
40
50
Ath
lone
Bla
auw
berg
Cen
tral
Hel
derb
erg
Kha
yelit
sha
Mitc
hells
Pla
in
Nya
nga
Oos
tenb
erg
SP
M
Tyg
Eas
t
Tyg
Wes
t
Reg
ion
Infant Mortality
0
20
40
60
Athl
one
Blaa
uwbe
rg
Cent
ral
Held
erbe
rg
Khay
elits
ha
Mitc
hells
Plain
Nyan
ga
Oost
enbe
rg SP
M
Tyge
rber
gEa
st
Tyge
rber
gW
est
TOTA
L
households below poverty line
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Causes of under-five deaths in South Africa
bull Neonatal causes pneumonia diarrhoea and other child illness and HIVAIDS each account for 30 of U5 deaths
bull According to Child PIP 60 of children were underweight and a third were severely malnourishedBased on SA Burden of Disease estimates for 2000
Lancet Vol 371 April 12 2008 1294-1304
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Key Determinants of Disease and Death
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Structural Societal
Behavioural Biological
Burden of Disease study PGWC
DOWNSTREAM UPSTREAM
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Diarrhoea and Environmental Factors in South Africa
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Trends in diarrhoea deathsnu
mbe
rs o
f chi
ld d
eath
s
Numbers increasing but fewer die
Source Tony Westwood
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Diarrhoea in the city
Numbers increasing but fewer dehydrated
Source Tony Westwood
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Good paediatrics amp health system performance is not enough
Selective PHC
Access to good health care
Dealing with the causes
These (amp the causes of the causes)
lie outside the domain of the DoH hellip and the dominant narrow paediatric vision of child health
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Table XX Dimensions of deprivation and inequality in South Africa
Dimensions of deprivation Children in
poorest 20 of households
Children in richest 20
of households Income poverty
100 0 Child hunger 28 3 Inadequate water 54 9 Inadequate sanitation 47 9 Overcrowding 28 5 Educational throughputdagger 46 17 Clinic far from home 46 25
Source Statistics South Africa (2011) General Household Survey 2010 Analysis by Katharine Hall Childrenrsquos Institute UCT See Part 3 Children Count ndash The numbers for more information on these indicators dagger Proportion of children aged 16 ndash 17 who have completed compulsory schooling (grade 9)
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Non-communicable Diseases overweight and obesity in South Africa
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Figure 2 Diabetes prevalence based on 1985 WHO criteria presented by age categories for men and women in 1990 and 200809
Peer N Steyn K Lombard C Lambert EV et al (2012) Rising Diabetes Prevalence among Urban-Dwelling Black South Africans PLoS ONE 7(9) e43336 doi101371journalpone0043336httpwwwplosoneorgarticleinfodoi101371journalpone0043336
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
South Africarsquos Double Burden of Malnutrition
NFCS 1999 NFCS 2005 SANHANES 2012
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Determinants of lsquoOvernutritionrsquoin South Africa
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Consumption of sweet beverages and confectionery Compared with a worldwide average of 89 in 2010
South Africans consumed 254 Coca-Cola products per person per year an increase from around 130 in 1992 and 175 in 1997
In 2010 up to half of young people were reported to consume fast foods cakes and biscuits cold drinks
and sweets at least four days a week Carbonated drinks are now the third most commonly
consumed fooddrink item among very young urban South African children (aged 12ndash24 months)mdashless than maize meal and brewed tea but more than
milk Hawkes C (2002) Coca-Cola Company (2010) Theron et al (2007) Reddy et al (2010)
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
26
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
bull There is a shortage of healthy low-fat food and little fresh fruit and vegetables in the townships
bull lsquoLow-fat milk is not available in our shopsrsquo stated one of the CHWs after she had tried to cut down on the fat in her diet
bull lsquoI am scared of exercising because I will lose weight and people may think that I have
HIVAIDSrsquoChopra M Puoane T Diabetes Voice 2003 48 24ndash6
Societal Factors in Obesity
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Bread Pastry Cakes Biscuits and Other Bakers Wares
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Bread Pastry Cakes Biscuits and Other Bakers Wares
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Rapid growth of supermarkets in South Africa
bull Supermarkets now share at least 50-60 of food sales50-60 of food sales in South Africa with the majority of this growth occurring after 1994
bull In a recent study nearly two-thirds two-thirds of households in a rural area in South Africa were now buying their food at supermarkets
Number of households in two rural areas in Transkei Eastern Cape going to supermarkets
Xume Luzie Total
Percent of total
784 500 648
Source DHaese Marijke and Guido Van Huylenbroeck The rise of supermarkets and changing expenditure patterns of poor rural households case study in the Transkei area South Africa Food Policy 30 (2005) 97-113
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Expansion of Supermarkets in Cape Town
Battersby AFSUN
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Total imports of soft drinks and processed snack foods into South Africa and other SADC countries
Source FAOSTAT detailed trade data
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Regional trade and investment policies in SADC since 1990bull early 1990s ongoing liberalization associated with multilateral trade
negotiations
bull 1996 SADC trade agreement signed
bull 1997-2003 South Africa strengthens investment policy and signs 22 Bilateral Investment Agreements
bull 1999 South Africa signs bilateral agreement with European Union (EU)
bull 2000 SADC trade protocol comes into effect Government of South Africa strengthens support for regional export and investment
bull 2002 new Southern Africa Customs Union Agreement completed
bull 2007 Interim Economic Partnership Agreement concluded between EU and Botswana Lesotho Namibia Swaziland and Mozambique
bull 2008 SADC Free Trade Area completed (except for Angola Democratic Republic of the Congo Seychelles)
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
ldquohellip trade policy that actively encourages the unfettered production trade and consumption of foods high in fats and sugars to the detriment of fruit and vegetable production is contradictory to health policy helliprdquo (p 10)
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
From a Nestleacute press releaseVevey February 21 2008
ldquoPopularly posit ioned products (PPPs) Products aimed at lower income consumers in the developing world wil l continue to grow strongly in 2008 and beyond Nestleacute PPPs which mostly consist of dairy products Nescafeacute and Maggi culinary productsgrew by over 25 to reach around CHF 6 billion in sales in 2007 The overall market for such products in Asia Africa and Latin America is estimated at over CHF80 billionrdquo
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Olivier de SchutterUN Special Rapporteur on the Right to Food
March 2012
Felicity Lawrence The Guardian 9 March 2012
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
SA Income share by decile
Leibbrandt Finn amp Woolard (2012) httpdxdoiorg1010800376835X2012645639
5 61 4 732 8 9 10
40
50
20
30
10
60
0
1993
2008
shareof income
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
HEALTH SECTOR DETERMINANTS
Health sector policy funding and performance since 1994
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
ldquohellipthe underlying philosophy for restructuring the health system is the primary health care approach with emphasis on appropriate comprehensive promotive preventive rehabilitative and curative care provided by appropriate PHC facilities with priority for PHC service in rural areas and poor urban areashellipbased on full community participationhelliprdquo
National Health Plan 1994
Policy endorsement of PHC
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Comment
The concept of PHC had strong sociopolitical implications It explicitly outlined a strategy which would respond more equitably appropriately and effectively to basic health care needs and ALSO address the underlying social economic and political causes (determinants) of poor health
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
SELECTED KEY POLICY ADVANCES AND IMPLEMENTATION SUCCESSES
bull Unification of separate health servicesbull Establishment of districtsbull Anti-smoking legislationbull Free health care for mothers and childrenbull Choice on Termination of Pregnancy Billbull Notification of and enquiry into maternal deathsbull Clinic building programme (1800 built)bull Essential drugs listbull Primary School Nutrition Programmebull HIVAIDS programmes expanded (PMTCT amp ART)
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
ADVERSE EFFECTS OF CONSERVATIVE ECONOMIC POLICIES AND BIOMEDICAL DOMINATION
bull Failure to address inequities between public and private sectors
bull Voluntary severance packages and downsizing of health workforce
bull Ringfenced funding of tertiary and academic care but not primary
bull Grossly inadequate funding (until recently) of priority programmes eg HIVTB
bull Failure to implement intersectoral approachesbull Slow transformation of training programmesbull Increasing dominance of managerialismbull Abandonment for 10 years of community health
worker programmes
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Size of private insurance
WHO National Health Accounts database
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Health workforceDrs per 10 000 population
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
SA paediatricians distribution
SA0
10000
20000
30000
40000
50000
60000
WC GP FS KZN EC NC NW MP LP
Number of children age 0-4 per registered paediatrician by province 2006
HPCSA amp Statistics SA Mid-year population estimates 2006
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Currently both the coverage and quality of these priority
interventions are inadequate especially at community
and primary levels and at first-level hospitals in rural and
peri-urban settings Only 35 of young children (12 ndash 59
months) received vitamin A supplements 38 of
pregnant women received antenatal care in the first 20
weeks of pregnancy and only 26 of babies were
exclusively breastfed for the first six months
Department of Health (2012) Strategic Plan for Maternal Newborn Child and Womenrsquos Health (MNCWH) and Nutrition in South Africa 2012 ndash 2016 Pretoria DoH
Shisana O et al (2010) South African National HIV Prevalence Incidence Behaviour and Communication Survey 2008 The Health of Our Children Cape Town HSRC Press
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Immunisation DTP coverage among 1-year olds
SA Rwanda
Average for WHO Africa Region
Country
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
What are the key challenges to improving access to quality health care
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Key actions to strengthen the health system
Dedicated adequate and skilled health workforce
Sustainable and equitable access to health services
Competence and accountability from managers and leaders
Lancet 374 2009 760
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
bull National Health Insurance (NHI)bull Re-Engineering Primary Health
Care
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Health care financing and rationale for NHIMechanism for addressing
bull Existing health system challenges
Ensuring whole population is
bull Able to get care when needed - 166 experience difficulty in accessing health care (Shisana et al 2007)
bull Financially protected from the costs of care (currently 13 of health care spending is out-of-pocket)
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
National Health Insurance Proposal
Recognition of the crisis
Principlesndash Universal coverage
ndash Social solidarityndash Equityndash Accessndash Efficiency
ndash Primary health care
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Increase funding of health services throughbullIncreased allocations from general tax revenuebullMandatory health care contributions by employees and employersbullRemoval of tax subsidies to medical aidsbullPool these funds
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Purchase from accredited providers (public and private)
Medical schemes will remain
Likely that membership will decline
Fewer schemes
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Additional aspects of NHI
bull NHI fund administered separate from DOH
bull Office of Standards Compliance
bull Accreditation of facilities
bull 11 Pilot districts ndash PHC model (current)
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
lsquoRe-engineering PHCrsquo
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
The three key recommendations are essentially
1Strengthen the district health system (DHS)
2Place much greater emphasis on population based health and outcomes which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities
3Pay greater attention to those factors outside of the health sector that impact on health the social determinants of health (ldquoupstream factorsrdquo)
63
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Three streams for Re-engineering PHC
(a) a ward based PHC outreach team for each electoral ward
(b) strengthening school health services and
(c) district based clinical specialist teams with an initial focus on improving maternal and child health
64
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
65
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
PHC outreach teamndash Professional nurse ndash staff nurse and ndash community health care workers
The PHC outreach team will provide comprehensive PHC health care services to a defined number of families Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic
66
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
67
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Global examples of CHW ratiosBrazil bull248000 CHWs bullPopulation of 121 million bull1 CHW for a population of approx 500 people
Thailandbull750 000 village health volunteersbullPopulation of 70 millionbull1 VHV to 93 people 5 per 15 households
Rwandabull60 000 CHWsbull11 million populationbull15th population of South Africa with the same number of CHWs
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Evidence for impact of community health workers delivering curative interventions
Diarrhoea
Pneumonia
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Implementation of CCM in Africa pneumonia
29 countries in sub Saharan Africa have implemented CCM
21 countries
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Evidence for impact and cost-effectiveness of community health workers
bull Recent systematic review including studies from Sub Saharan Africa on impact of CHWs delivering curative interventions for children
bull CHWs in national programmes achieved large mortality reductions of 63 and 36 respectively with curative interventions
Christopher et al Human Resources for Health 2011
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
bull Selectionbull Trainingbull Health system factors ndash esp support amp supervisionbull Community factors bull Political macroeconomic and international factorsbull Financial and non-financial incentives
Factors influencing success of CHW programmes
Lehmann and Sanders WHO 2007 httpwwwwhointhrhdocumentscommunity_health_workerspdf
Haines Sanders et al Lancet 2007 Vol 369 pages 2121-2131
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
RWANDA RWANDA Total health personnel in publicly funded facilities has
almost doubled in 3 years hellip
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Nearly 60 of the existing Human Resources are either nurses or paramedical workers while
doctors contributed to less than 7
Rwanda now has 60000 CHWs
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Trends in Vaccination Coverage
Percentage of children 12-23 months fully vaccinated
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Trend in Early Childhood Mortality
Deaths per 1000 live births
28
MDG
50
MDG
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
U-5 MR Rwanda amp SA
U-5 deaths 1000 live births
Source WHO country profile [httpappswhointnutritionlandscapereportaspxiso=rwa]
Rwanda
SA
MDG goals
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Current CHW training and scope of practice in South Africa
bull Focusses on assessment and referralbull No curative functionsbull Advising families where CHWs could be
delivering the interventions themselves ldquoInform the mothers of deworming at least twice a
year and to ensure the child gets vitamin A and other necessary micronutrient supplementsrdquo
Monitoring of pilot NHI site in NW province shows that most frequent reasons for referral to health facility are to collect Vit A and anthelminthics
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Summary
bull The current CHW programme will not result in desired reductions in child mortality without extending their scope to include some curative functions and improving the ratio of CHWs to househods
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
NHI Pilot Districts12 months progress report
Presentation to the Portfolio Committee on HealthCommittee Room 514 Marks Building
24 July 2013
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Backgroundbull August 2011 NHI Green Paper ndash action plan
bull April 2012 NHI pilot districts to prepare forndash Purchasing of services ndash Engaging the private sector ndash Introducing a district health authority
bull April 2013 Rapid appraisal tondash Assess progress in preparing for NHIndash Provide a framework for monitoring
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
NHI domains appraised
1 NHI management
2 Hospitals
3 Quality
4 Primary Health Care
re-engineering
5 Infrastructure amp
Equipment
6 Human Resources
7 Health information
8 District Management
Teams
9 Conditional Grant
10Referral
11Contracting Private
Providers
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Key
Nearly or completely achieved (where numerical data available gt75)
Partially achieved (where numerical data available 25 - 74)
Minimally or not achieved (where numerical data available lt25)
No data available
Tabular summary per District
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Human Resources for Health
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
NHI COULD be a mechanism to redistribute health care resources BUT some key challenges need to be addressed
Definition of an acceptable lsquopackagersquo of services Development of sufficient CAPACITY and
ENSURING ACCOUNTABILITY in administration of NHI fund
Regulation of private sector ndash to ensure that inequities are not aggravated
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Some key challenges need to be addressed Reconsider ratio of CHWs to households Several
countries have two tiers of CBWs ndash full-time CHWs and part-time CBWs in a ratio of 110 This could generate gt400 000 jobs
Definition of an acceptable lsquopackagersquo of services including CHWs being allowed to undertake treatment
Development of sufficient CAPACITY and ENSURING ACCOUNTABILITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Rapidly increase investment in training re-open nursing colleges increase output and appropriate training by medical schools and other HEIs
Brazil has more than 25 million workers formally employed in the health sector which represents about 13 of the countryrsquos population South Africa has only 150509 health professionals in a population of 51 million (constituting 03 of the population) in 2010
Rapidly increase output of MLWs Reorientate health professionals to be able to
address local social determinants Reorientate specialists in District Specialist Teams
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Reduce power of conservative professional bodies enlarge lsquoscope of practicersquo of non-doctors
Improve incentives and support in rural areas Upgrade infrastructure in ruralperi-urban areas REBUILD AND STRENGTHEN CIVIL SOCIETY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
PEOPLEacuteS HEALTH MOVEMENT
The Peoples Health Movement (PHM) is a large global civil society network of health activists supportive of the WHO policy of Health for All and organised to combat the economic and political causes of deepening inequalities in health worldwide and revitalise the implementation of WHOrsquos strategy of Primary Health Care
wwwphmovementorg
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
Current Situation
bull Awaiting next government draft
bull Planning a coalition of progressive organisations
bull Campaigning around key elements
ndash Free at the point of service
ndash Single payer systemndash Stop private sector subsidiesndash No public funds for private profit
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
EXAMPLE Comprehensive management of diarrhoea
REHABILITATIVE CURATIVE PREVENTIVE PROMOTIVE
NUTRITION
REHABILITATION ORT
NUTRITIONSUPPORT
EDUCATIONFOR PERSONAL
amp FOOD HYGIENE
MEASLESVACCINATION
BREAST FEEDING
WATER
SANITATION
HOUSEHOLDFOOD
SECURITY
