Part $3$ Complementary Content

Consider the content that we covered around the History of Health Systems in South Africa. Having read two chapters of Van Rensburg and linking the material that were presented class, trace a timeline of important events in the history of health systems in South Africa:

Democratic Era: $2003-2020$

The purpose of this session is to discuss the persistent challenges that have faced the health system since the start of democracy. We will also look at the District Health System, and at the development of the National Health Insurance Bill.

Describe the persistent challenges faced by the health system in South Africa.

Define and describe the District Health System.

Discuss the key challenges affecting the District Health System.

Link the principles of the Gluckmann Commission to those of the National Health Insurance Bill.

Democratic Era: $2003-2020$

In this session, we will look at three key areas:

Persistent challenges facing the health system

District Health System $($DHS$)$

National Health Insurance Bill $($Universal Health Coverage$).$

Persistent Challenges Facing the Health System

South Africa$$s healthcare landscape continued to be faced with many challenges. Often, just as solutions emerged in one sector, further challenges required responses in yet another.

During this time, the struggle between the various camps of people who held very different positions around the best response to HIV$/$AIDS continued. There was a large group who insisted South Africa take the HIV health crisis seriously and provide antiretroviral $($ARV$)$ therapies as well as tackle prevention; there were those who were concerned about the pharmaceutical burden on our country with any right to ARV treatment $--$ as they predicted the skewing of resources away from the other areas of primary health; and those, including the then$-$president Thabo Mbeki, who remained in the camp of HIV$/$AIDS denialism, focused on HIV$/$AIDS as either a fabrication or a cluster of conditions, caused by hunger and poverty.

After the landmark Constitutional Court Judgement of $2002,$ which, after hearing detailed evidence from all sides, then mandated ARV treatment availability in South Africa for all who qualified, this specific debate was largely put to rest. But it took two years of immense effort and work across civil society and every state sector as well as from the academic community and donor groups to manage the rollout of the national programme in $2004.$

In the midst of this, South Africa$$s health authorities and planners were continuing to develop the National Health Act, which sought to outline the reorientation of South African$$s expenditure towards more focused spending at the preventative level of Primary Health Care. However, to re$-$structure expenditure in a country that had been so fragmented during the Apartheid era, in the midst of a pandemic, proved a huge challenge. Part of the solution to this was the creation of the District Health System $($DHS$).$ The requirement that antiretroviral therapies needed to be rolled out urgently necessitated a top$-$down approach and this was in tension with the District$-$led approach as outlined in the DHS and compromised some of the principles of the National Health Plan of $2003.$

These persistent challenges faced the country with a deep conundrum $--$ balancing emergency health interventions based on treatment with broader goals directed towards preventing disease and attending to a wider view of health in a primary setting, with preventative models in place.

District Health System

The District Health System $($DHS$)$ was created in line with the Reconstruction and Development Programme $($RDP$).$ The principles, therefore, that the DHS were founded on include:

Overcoming fragmentation

Equity

Provision of comprehensive services

Effectiveness

Efficiency

Quality

Improved access to services

Local accountability and community participation

Decentralisation

Developmental and intersectoral approach

Sustainability

The demarcation of the health regions and the health district boundaries presented challenges. Two fundamental criteria were used for this process: these boundaries had to be coterminous with local government boundaries and contiguous. Other issues that provinces took into consideration were: financial viability; existing health services; transport routes; sites of economic activity; and physical geography.

$$One of the cornerstones of health system reforms was the development of the district$-$based PHC system as the framework for managing and delivery of health care. The DHS geared the state machinery towards decentralising powers and functions to local governments, health institutions and communities. To this end, metropolitan and district council areas and sub$-$districts$/$local municipal areas were demarcated, and district management teams were appointed and capacitated to manage and deliver PHC$.$