Healthcare System and Providers

HEALTHCARE SYSTEM

SPECIFIC LEARNING OBJECTIVES

  • Describe the structure of the South African healthcare system (public and private).
  • Demonstrate the impact of the burden of disease on the health system of the country (e.g. HIV & AIDS, TB and smoking).

STUDY MATERIAL

  • South Africa's health system consists of a large public sector, a smaller but fast-growing private sector, and an NGO sector.
  • The healthcare system in South Africa reflects the country's position as a blend of the First and Third Worlds.
  • Some public healthcare facilities in rural areas are elementary, while other public healthcare and some private facilities (medical research and academic facilities) are cutting-edge.
  • Cutting-edge facilities place South Africa at the forefront of medical advances.
  • The study unit focuses on the public and private sectors, but it is important to note that multiple Non-Governmental Organizations (NGOs) contribute to the health sector by focusing on HIV/Aids and TB.
Public Healthcare System

  • The National Treasury funds the public healthcare sector.

  • It has to serve the majority of the population due to the country's high levels of poverty and unemployment.

  • The public healthcare budget is mainly allocated to the nine provincial health departments.

  • The funds each provincial health department receives and the efficiency of their use vary considerably.

  • To address the shortage of personnel.

  • A shortage of crucial medical personnel hampers the public sector.

  • Foreign medical practitioners have been employed to alleviate a long-standing shortage of medical practitioners.

  • The government has also made it easier for other foreign medical practitioners to practice in South Africa.

  • Newly qualified South African healthcare professionals provide compulsory community service in understaffed hospitals and clinics.

  • The public healthcare system functions according to a referral system:

    • LEVEL 1:

      • Primary Healthcare Clinic: The foundation of the public health system is the primary healthcare clinics that are the first line of access for people needing healthcare services.
      • Primary Healthcare Clinics offer services such as immunization, family planning, ante-natal care, treatment of common diseases, treatment and management of tuberculosis, and HIV & AIDS counseling, amongst other services.
      • These clinics provide their service for free.
      • If the clinic cannot assist, they will refer the patient to a Community Health Centre.
      • Community Healthcare Centre: It is the second step in providing healthcare, but it can also be used for first-contact care.
      • A Community Healthcare Centre offers services similar to a Primary Healthcare Clinic, with the addition of a 24-hour maternity service, emergency care, casualty, and a short-stay ward.
      • The Community Healthcare Centre will refer a patient to a District Hospital when necessary.
      • District Hospital: It is the third step in the provision of healthcare.
      • These hospitals will typically receive referrals from and provide generalist support to community health centers and clinics.
      • These services include diagnostic, treatment, care, counseling and rehabilitation services.
      • Clinical services include Surgery, Obstetrics & Gynecology, Out-Patients Department, Medicine, Pediatrics, Mental Health, Geriatrics, Casualty and Clinical Forensic Medical Services, amongst other services.
      • District Hospital receive referrals from the Community Health Centres and Clinics.
      • Medical practitioners and primary healthcare nurses will mainly deliver care.
      • If the District Hospital cannot help a patient, they will be referred to the local Regional Hospital for treatment.

    • LEVEL 2

      • Regional Hospital: This is the second level of healthcare.
      • These hospitals will generally receive referrals from and provide specialist support to several district hospitals.
      • If the Regional Hospital cannot help, they will refer to the Provincial Tertiary Hospital.

    • LEVEL 3

      • Provincial Tertiary Hospital: These hospitals will receive referrals from and provide sub-specialist, support to several regional hospitals and form the third level of healthcare.
      • Provincial Tertiary Hospitals offer services such as neurosurgery, neurology, plastic & reconstructive surgery, cardiology, urology, pediatric surgery, maxillo-facial surgery, psychiatry, occupational health and orthopedics, amongst other services.
      • Specialists and generalists staff these hospitals.
      • If a Provincial Tertiary Hospital cannot help, they will refer to a National Central Hospital.

    • LEVEL 4

      • Central Hospital: These form the fourth and highest level of healthcare.
      • These hospitals will consist of very highly specialized referral units, which provide an environment for multi-specialty clinical services, innovation, and research.
      • People are referred to these hospitals by Provincial Tertiary Hospitals.
      • Specialized Hospital: These hospitals will provide care only for certain specialized groups of patients.
      • They will include, e.g., chronic psychiatric hospitals, TB hospitals, specialized spinal injury hospitals, and acute infectious disease hospitals.

  • According to research done in 2015, there are 4200 public health facilities in South Africa.

  • Each clinic provides services to 13,718 persons on average (this exceeds the WHO guidelines of 10,000 per clinic).

  • Since 1994, more than 1600 clinics have been built or upgraded.

  • Yet, for 2.5 million South Africans, their nearest clinic is more than 5 kilometers away from their homes.

  • The National Health Laboratory Service (NHLS) provides diagnostic and health research services, the largest pathology service in South Africa, with 265 laboratories serving 80% of South Africans.

Private Healthcare System
  • As in all other countries in the world, the private healthcare system in South Africa serves a much smaller part of the country's population.
  • The private healthcare system comprises healthcare professionals who provide their services on a private basis (e.g., General Medical Practitioners, Community Pharmacies, etc.).
  • Private healthcare practitioners also provide services through private hospitals.
  • The private healthcare system is primarily funded by the subscriptions of individuals to medical aid schemes.
  • By September 2015, South Africa had about 87 medical schemes with around 8.7 million beneficiaries.
  • Referral system is medical aid driven.
  • There is no formal referral system within the private healthcare system.
  • However, certain medical aids will refund the specialist provider only if a general practitioner refers the patient.
  • A motivation system is in place to obtain authorization for chronic medication or specialized medication payment.
  • No 4-level referral system.
Impact of the Burden of Disease on the Health System of South Africa
  • A country's disease burden refers to an assessment of mortality, morbidity, injuries, disabilities, and other risk factors specific to that country.
  • The mortality rate (death rate) measures the number of deaths in a particular population over a specific period.
  • The morbidity rate in a country indicates the frequency or proportion with which a disease appears in the country's population.
  • South Africa's burden of disease can be summarized in 4 groupings:
    • HIV/AIDS & TB
    • Other communicable (infectious) diseases
    • Non-communicable (non-infectious) diseases
    • Injuries
HIV/AIDS and TB
  • A significant challenge for the public health service has been the burden of the HIV pandemic, with more than 70% of all human immunodeficiency viral infections in the world occurring in sub-Saharan Africa and with 6.19 million South Africans living with the disease.
  • South Africa has rolled out the world's most extensive treatment programme.
  • Research into the prevention of HIV is at the center of the government's strategy to end the pandemic that has held the world hostage for many years.
  • TB incidence among people working in mines in South Africa is higher than in any other working community globally.
  • In November 2014, the Prevent, Avoid, Stop, Overcome and Protect (PASOP) Campaign was launched in an effort to call on all communities to join hands with the government in the fight against HIV/AIDS and TB.
  • The PASOP strategy prioritizes specific populations and vulnerable groups such as women, youth, sex workers, and the lesbian, gay, bisexual, transgender, and intersex (LGBTI) community.
  • A high number of women get into the government's Prevention of Mother-to-Child Transmission (PMTCT) Programme.
  • According to the Human Sciences Research Council's National HIV Prevalence, Incidence and Behaviour Survey released in April 2014, maternal and child morbidity declined due to the PMTCT.
Managing communicable and non-communicable diseases (NCDs)
  • The main NCDs in the country include diabetes, cancer, chronic respiratory diseases, mental disorders, and cardiovascular diseases.
  • The main risk factors associated with NCDs are tobacco use, alcohol abuse, an unhealthy diet, and physical inactivity.
  • Targets for reducing non-communicable diseases in South Africa by the year 2020:
    1. Reduce premature deaths (i.e., <60 years) from non-communicable diseases by 25%.
    2. Reduce tobacco use by 20%.
    3. Reduce per-head consumption of alcohol by 20%.
    4. Reduce mean salt intake to less than 5 g/day.
    5. Reduce the prevalence of obesity and overweight by 10%.
    6. Increase the prevalence of physical activity (defined as 150 min of moderate-intensity physical activity per week) by 10%.
    7. Reduce the prevalence of hypertension by 20% through lifestyle modification and medication.
    8. Increase the proportion of people receiving treatment for control of hypertension, diabetes, and asthma by 30% (Increase treatment of hypertension, diabetes, and asthma by 30%.
    9. Offer screening to women with sexually transmitted diseases for cervical cancer at least once every five (5) years or to every woman at least three times in a lifetime.
    10. Increase the number of people screened and treated for mental illness by 30% (by 2030).
Improving health infrastructure
  • The main challenges of the public healthcare sector have been related to the burden of disease and the failures in effective planning for meeting health needs in the country.
  • The public health system has managed to address physical infrastructure development and the provision of medical technologies, medicines, and information systems.
  • The country's infrastructure plans will see 43 hospitals and 213 clinics built by 2020 to meet the needs of the National Health Insurance system.
  • The gross insufficiency of trained health workers adversely affects what can be achieved.

HEALTHCARE PROVIDERS, HEALTHCARE PROFESSIONALS

SPECIFIC LEARNING OBJECTIVES

  • Describe the healthcare provider and healthcare professionals within the South African healthcare system.
  • Explain the functioning of a multi-disciplinary health team.
  • Describe the inter-relationships within the South African healthcare system.

STUDY MATERIAL

The Healthcare Provider and Healthcare Professionals within the Healthcare System
  • No matter how good and workable the details of a health system look on paper, it cannot operate on its own.
  • It needs responsible, motivated, and well-trained healthcare professionals to make it work in practice.
  • These people must have the necessary skills and knowledge and must be able to apply them.
Definitions:
  • Healthcare Professional: A person associated with either a specialty or a discipline and qualified and allowed by regulatory bodies to provide healthcare service to a patient.
  • Healthcare Provider: Any individual, institution, or agency that provides health services to healthcare consumers.
  • A healthcare professional can also be a healthcare provider.
  • However, a healthcare provider is not always a healthcare professional as it might be an organization or grouping of people.
  • In South Africa, there are many different types of healthcare professionals, including, but not limited to, Medical practitioners and specialists; nurses and specialist nurses; pharmacists and registered pharmacy support personnel; dentists; dieticians; physiotherapists; occupational therapists; podiatrists; optometrists; physician assistants; psychologists; counselors; etc.
  • Healthcare provider facilities to be found in South Africa are:
    • Hospitals
    • Outpatient treatment or rehabilitation centers
    • Pharmacies
    • Medical practitioner's practices
    • Nursing facilities
    • Nursing homes
    • Medical Aid schemes
    • NGOs
The Functioning of a Multi-Disciplinary Health Team
  • A multi-disciplinary team may consist of several healthcare professionals within a healthcare environment, each with their own specialty.
  • The combination of team members will depend on the patient and, more specifically, the patient's needs.
  • A multi-disciplinary team for a specific patient in a primary healthcare clinic may typically consist of a medical practitioner, nurse.
  • The ultimate goal of a multi-disciplinary health team is to achieve multi-disciplinary care.
  • Multi-disciplinary care is achieved by professionals from a range of disciplines working together to deliver comprehensive care that addresses as many of a patient's needs as possible.
  • A multi-disciplinary health team can function under one organizational umbrella or as professionals from a range of organizations brought together as a unique team.
  • As a patient's condition changes over time, the team's composition may change to reflect the changing clinical and psychosocial needs of the patient.
The Interrelationships Within The Healthcare System
  • "Interrelationship" is how two or more things or people are connected and affect one another.
  • If you were to look at a primary healthcare clinic, the PAPB and PT responsible for distributing medicine would have an interrelationship with the following people:
    • The visiting medical practitioner prescribing medicine that has to be dispensed by the PAPB or PT.
    • The primary healthcare professional nurse prescribing medicine, within their scope of practice, that has to be dispensed by the PAPB or PT.
    • The pharmacist under whose indirect personal supervision the PAPB and or PT is practicing.
    • In the case where more than one PAPB and or PT is working together, there will be an interrelationship among themselves as well; and
    • The patient to whom the PAPB or PT will dispense the medicine prescribed.
  • It is important to remember that a healthy interrelationship with other healthcare professionals is dependent on open communication channels and that different professionals must work together as a team.
  • It is not productive to have interrelationships in the healthcare system if people keep on referring to them and us.
  • One must aspire to a world where the different players within the health system take hands and work together as a team.