Strengthening health systems for equity and social justice in South Africa: The 24th anniversary of the Centre for Health Policy
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Almost two decades after the end of apartheid, South Africa, with a population close to 50 million,1 continues to be viewed as a model of peaceful, democratic transition in a world marred by conflict and violence. In addition to South Africa's rights-based constitution,2 notable achievements since democracy include bold steps to improve overall population health and well-being, increased access to education and health services, and the largest social grant assistance program in sub-Saharan Africa.1, 3, 4, 5, 6
Despite significant progress, huge inequalities remain, illustrated by a 2010 Gini index of 57.8 (with 0 representing absolute equality and 100 absolute inequality).7 Gender and race remain the key markers of vulnerability to economic disadvantage and poor health outcomes in South Africa.3, 8 The country has a huge and complex disease burden, life expectancy has declined over the last decade largely because of HIV and AIDS, there is insufficient progress towards the achievement of the Millennium Development Goals, and health systems performance is sub-optimal.3, 7, 9, 10, 11, 12
This Special Issue focuses on different aspects of South African health sector reform designed to improve population health outcomes, and is in commemoration of more than two decades of the existence of the Centre for Health Policy (CHP), a university-based research unit established in 1987 during the final years of the anti-apartheid struggle. The issue brings together six commentaries and eight scholarly articles that explore themes that have captured global attention in recent years: improving population health; reducing health inequities; enhancing the influence and impact of research on health policy in low- and middle-income countries; and optimizing health systems performance.
Approach and Process
In December 2009, the CHP obtained funding from the University of the Witwatersrand, Johannesburg, for a special journal issue. Preparing this Special Issue allowed us to share and reflect on CHP's evolution over two decades in tandem with South African health sector reforms, but with relevance to an international audience. In December 2009, we contacted past and current CHP staff, associates, and partners, inviting them to submit abstracts in line with the theme of ‘Strengthening health systems for equity and social justice’.
Between February and November 2010, we reached an agreement with the Journal of Public Health Policy (JPHP), selected abstracts, commissioned additional commentaries, and supported authors to write their papers. For each paper we selected peer reviewers from within South Africa and internationally to ensure that local content would be accurate and that papers would be sound, relevant, and interesting to an international audience as well. All authors revised the papers between January and February 2011, following receipt of reviewers’ comments. We edited the papers during March and April 2011 for quality assurance and to comply with JPHP guidelines.
Themes and Focus of the Special Journal Issue
In the first paper, Research in support of health systems transformation, Rispel and Doherty describe the role and experience of CHP in influencing and supporting health systems transformation both during the transition to democracy and in a democratic South Africa. The paper is based on key informant interviews and a review of CHP publications and other documents. The authors highlight lessons for other countries, namely to: conduct good quality, relevant research based on strong ethical values; build and maintain open and honest relationships with government; recognize and adapt to changes in the policy environment; develop capacity as part of a continuous program; and seek core funding that ensures research independence and public accountability.
Many themes highlighted in this first paper are common strands running through the subsequent papers: policy-implementation gaps; concerns with policy design, processes, and relationships; empirical evidence illustrating problems in availability of and barriers to health services, both among the general and most-at-risk populations; and lessons for impending health sector reforms.
Notwithstanding these commonalities, the papers can be grouped into four clusters on the basis of their dominant focus: population health imperatives and improving health systems performance; gaps between research or well-intentioned health policies on the one hand and implementation on the other; users’ perspectives, health-care access, and utilization; and finally, potential challenges of future health sector reform, including collaboration between the public and private health sectors.
Population health imperatives and improving health systems performance
Three commentaries (Kahn, Mathee, and Fonn) and one article (Goudge and Ngoma) highlight the need for a public health approach to population health and well-being. In light of South Africa's rapid and complex health transition over the past two decades, worsening mortality, and a morbidity profile that comprises co-existing infectious and non-communicable diseases, Kahn's commentary argues for strong government leadership, targeted efforts within the health and social sectors, and broader development initiatives that are evidence-based.
Mathee's commentary highlights a range of preventable environmental hazards to the health of South Africans, many of which are rooted in the country's colonial and apartheid past, and persistent poverty and inequality. She suggests strengthening institutional capacity to enforce the existing environmental legislation, and ensuring that health is placed at the center of sustainable development and planning.
Fonn argues that Schools of Public Health in Africa should respond to the many systemic issues that confound improvements in population health by incorporating a public health approach to the training of all health professionals, enhancing indigenous health systems research capacity; collaboration, advocacy, and networking; and strengthening health systems management. She emphasizes the importance of two-way exchanges between public health faculty in universities and government officials in national health systems.
In a qualitative study that explored the reasons for poor anti-retroviral treatment adherence, Goudge and Ngoma found that patients lacking stable food sources faced significant barriers in adhering to treatment regimens and remaining sufficiently healthy to search for, obtain or retain a job. The authors propose addressing treatment adherence through multi-dimensional, inter-sectoral programs that tackle the social determinants of health, such as food insecurity, poverty, and gendered inequities.
One commentary (Murray et al) and two papers (Ditlopo et al and de Wet et al) examine the relationship between research (or well-intentioned health policies) on the one hand, and implementation on the other.
In a sobering review of occupational lung diseases, Murray et al found that despite extensive research on silicosis, tuberculosis, HIV and AIDS, and compensation for occupational disease, there has been limited policy implementation, reflected in high levels of occupational diseases. Key messages to other countries are to: monitor dust and disease levels reliably, evaluate the impact of policy and regulatory reforms, and define the roles and responsibilities of various stakeholders.
Using a policy analysis framework, Ditlopo et al analyzed the implementation and perceived effectiveness of a rural allowance policy and its influence on the motivation and retention of health professionals in rural hospitals in the North West province of South Africa. The authors found policy design and implementation weaknesses and recommend that government take more account of contextual and process factors to ensure that policies have the intended impact.
De Wet et al studied task-shifting from nurses to community health workers (CHWs) for HIV treatment and care at 12 primary health-care clinics in the Free State Province, South Africa. They found inefficiency in nurse deployment and many tasks that could be shifted to CHWs. The authors recommend that task-shifting from nurses to CHWs will require the South African Ministry of Health to recognize CHWs formally within the health system.
Users’ perspective, health-care access, and utilization
The third cluster of papers provides empirical evidence of inequitable access to health services and access barriers experienced.
In the first paper, Inequities in access to health care in South Africa, Harris et al provide empirical evidence of markedly inequitable health-care access, 17 years into democracy, with black South Africans, poor, uninsured and rural respondents, experiencing the greatest barriers. The authors highlight the importance of understanding access barriers from the user-perspective for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.
In the second paper, Nxumalo et al report on the utilization of traditional healers. Although reported utilization was low, almost three quarters of the poorest quintile spent more than 10 per cent of their household expenditure in the previous month on traditional healers. The authors propose that policy-makers should develop strategies to protect poor South Africans from out-of-pocket payments for health care.
Rispel et al describe the utilization of health services by men who have sex with men (MSM) in South African cities. The study found that targeted public health sector programs for MSM were limited, and MSM experienced stigma, discrimination, and negative health worker attitudes. The authors recommend that the public health sector in South Africa should provide responsive and appropriate HIV services for MSM.
Munyewende et al's commentary explores perceptions of HIV risk and health service access among Zimbabwean migrant women, and identified several access barriers. The authors recommend that migrant-health rights be placed on South Africa's health policy agenda.
Potential challenges of planned health sector reform
The final group of papers anticipates the planned implementation of financing reforms and discusses the challenges of reform and collaboration between the public and private health sectors, while ensuring that the goals of public health policy are met.
The first paper entitled Social solidarity and civil servants’ willingness for financial cross-subsidization in South Africa draws on a survey of civil servants from the health and education sectors. One-third of civil servants reported willingness to cross-subsidize others and half favored a progressive financing system, with differences by seniority, race, and education level. The authors conclude that understanding social relationships, identities, and shared-meanings is important for any health reform striving for universal coverage.
A final commentary by Ruff et al argues that funding is not the central problem of the South African public health system but rather the enormous management inefficiencies and low productivity. They argue that reform initiatives should build on the strengths of both the public and private health sectors in South Africa.
South Africa stands as a touchstone of hope to many transitional and conflict-ridden countries in her quest to improve population health and to transform health systems to achieve equity and social justice. In this Special Issue we have tried to capture some of South Africa's successes and shortcomings from the perspective of a university-based health policy research unit. What then are the concluding lessons for public health practitioners and policy-makers in other countries?
First, the aspirational goals of equity and social justice offer a useful normative framework within which to undertake health sector reforms. At the same time any country seeking to reform its health-care system to achieve equity, must take into account dimensions of both horizontal and vertical equity to ensure that the health needs of disadvantaged and vulnerable groups are considered.
Second, there is value in an independent health policy and systems research unit, one that is able to contribute to health systems transformation through long-term research, training of researchers, collaborative networks, and peer-reviewed publications. Independence and integrity are critical to the success of such a research unit, because they influence the space between research and policy implementation and provide continuity and coherence during times of political change.
Third, strong government stewardship and leadership, and a culture that recognizes the value of research, is needed to improve population health, strengthen institutional capacity, and to enforce enabling legislation.
Fourth, a robust information and evidence base is indispensable for monitoring both progress towards reducing health and health-care inequities, and the impact of public health policy initiatives. However, the existence of information in itself is not sufficient to ensure implementation of research or policies. Public health professionals also take on important advocacy and networking roles, and the facilitation of partnerships with policy-makers and implementers. Finally, research units and public health professionals need to be able to recognize changes in the policy environment and find ways to adapt to new demands, while providing honest critique, encouraging transparency, and protecting and lobbying for research independence, and public accountability.
The University of the Witwatersrand's Strategic Planning and Allocation of Resources Committee (SPARC) funded this Special Issue. We are indebted to numerous individuals, without whose assistance, the publication would not have been possible:
• Professors Phyllis Freeman and Anthony Robbins, the editors of JPHP, for their incredible support, encouragement, and insightful advice over the past nine months.
• Professor Matthew Chersich assisted with internal review of papers and with editing of the final manuscripts.
• Professor Sharon Fonn, the Head of School of Public Health at the University of the Witwatersrand, for her encouragement and support.
• Our reviewers whose insightful comments helped to strengthen the commentaries and papers significantly:
○ Professors Peter Berman, Carlos Cáceres, Richard Clapp, Rodney Ehrlich, John Eyles, Melvyn Freeman, Leah Gilbert, Charles Hongoro, Lenore Manderson, Anne Mills, Daniel Ncayiyana, Erick Nyambedha, Karl Peltzer, Stephen Reid, Helen Schneider, David Serwadda, Zena Stein, Mervyn Susser, Myra Taylor, Eric Udjo, Alex van den Heever, Dingie van Rensberg, Kuku Voyi, Gill Walt, David Wegman;
○ Doctors Jo Barnes, Peter Barron, Francoise Barten, Susan Cleary, Mardge Cohen, Sharon Friel, Robert Fryatt, David Harrison, Louise Ivers, Catherine Joyce, Stephen Knight, Newton Kumwende, Tim Lane, Christian Laurent;
○ Ms Mary Crewe and Mr Robin Hamilton.
• Dr Neil Henderson and Dave Williams from Palgrave Macmillan for their professionalism and support, and for turning a ‘gracious blind eye’ to the inevitable deadline slippages.
• Ms Jeanette Hunter and the Health Systems Trust for willingness to provide editorial assistance at short notice.
Finally, we acknowledge the Heads of the School of Public Health at the University of the Witwatersrand over the past two decades: Professors John Gear, William Pick, and Sharon Fonn, and the directors of CHP Professor Eric Buch; Mr Cedric de Beer; Dr Max Price; Professor Helen Schneider; Drs Nzapfurundi Chabikuli; Duane Blaauw and Jane Goudge, for their vision and passion in ensuring the survival of CHP.
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