Are Community Care Givers the Answer to Better National Health Insurance in South Africa?

Understanding South Africa’s National Health Insurance (NHI) scheme is almost as daunting and confusing as trying to grasp our system (?) in the US where health insurance rates continue to climb but quality is not improving. Like the US, South Africa is searching for a way to cut the “extreme inequities between poor and rich, rural and urban, and public sector and private health service users”. A recent article in The Cape Times authored by David Sanders and Louis Reynolds addresses “campaigning to raise awareness about the problems in South Africa’s health system and the best way to fix them, and give information about the most instructive global examples of health system transformations that resulted in impressive advances in health and substantial reductions in health inequities” – now that’s a mouth full!

Despite South Africa’s economic growth over recent years it fares poorly when compared to other countries “of similar wealth”, such as Costa Rica, Brazil, and Cuba. During the last 20 years SA’s under-five mortality rate increased to 10 times that of Cuba and 6 times that of Costa Rica! Too many South African children “live in conditions where they are undernourished and predisposed to infections, many of which spread in unhygienic and overcrowded environments”.

Although more clean water is available to these communities now, “large gaps and inequalities in water and sanitation” exist in Cape Town. For example, in Khayelitsha township “up to 400 people may share a single stand-pipe and 9 percent of households have no toilets”!

Cape Town’s rural areas house almost 44 percent of the Western Cape’s population, but only 12 percent of doctors and 19 percent of nurses work there. The healthiest 16 percent of the Cape’s population use the urban hospital-dominated private system which accounts for almost 60 percent of health spending and employs:

• 50 percent of doctors
• 70 percent of medical specialists
• 90 percent of dentists and dietitians
• 40 percent of nurses

South Africa’s proposed NHI scheme “restructures health service delivery” to increase funds available by pooling public and private health resources and making them universally accessible.

A major policy initiative discussed in The Cape Times article proposes “re-engineering primary care at the community level with district-level health systems becoming the central focus of health resources and activity”. Lower-level health facilities (clinics, health centres, and hospitals) also need strengthening. This policy initiative outlines a “new model for human resources”. Similar global communities saw significant health improvement occur when a sufficient number of community care givers (CCGs) with basic skills received support from clinics and made regular visits to disadvantaged households.

Currently NGOs employ most South African CCGs and they primarily work in HIV/Aids or TB programs. Sanders and Reynolds advocate the urgent need for “rationalizing, standardizing, and expanding the skills of the crucial CCG cadre of health care workers and improving their insecure employment conditions.”

Sanders and Reynolds conclude that revitalization of a program where trained CCGs offer primary health care would “undoubtedly be substantially cheaper than the private sector model and more cost-effective than the current and costly hospital-dominated public sector”. Increasing the ratio of CCGs to population ensures that households are visited on a regular basis so health problems are detected early. Similar programs succeeded in increasing access to health care in Brazil, Rwanda, Thailand, and Bangladesh.

As the base of a “health pyramid” a strong CCG program would also create jobs and “indirectly improve health by reducing the prevalence and depth of poverty in these communities”.

David Sanders is Professor and Director of the School of Public Health at the University of the Western Cape, Cape Town, South Africa. Louis Reynolds is Associate Professor of the School of Child and Adolescent Health, University of Cape Town. Both authors are pediatricians and members of the Peoples Health Movement – PHM The PHM’s Right to Health Commission evaluating the Right to Health and Health Care Campaigns (RTHC) recently identified themes that are common among the many campaigns that are under way in 17 PHM circles around the globe.

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