In order to address fragmentation in the healthcarefinancing system, mandatory prepayment funding mechanisms in form of general tax revenues and mandatory health insurance would have to be probably considered to be efficiently implemented as principal healthcarefinancing mechanisms. Furthermore, budget allocations in the public health sector from nationally raised revenue sources would not need to be conducted largely based on the incremental budget approach, but rather based on differentials in healthcarefinancing needs of healthcare institutions and facilities on a realistically justifiable case-by-case criterion, as well as healthexpenditure needs of populations.
Thus ―market mechanism‖ which operates based on profitability will not produce (enough of) them. In most cases the ―primitive accumulation‖ has happened via policy measure forced by the state, in favor of capital and against labor. Mercantilist policies of 17 th Century England in protecting capital both internally against British workers, and externally at the expense of people of colonial lands is the classic example, but by no means the only one. Historically such policies have been more of a rule than exception. 1970s South Korean ―garrison factories‖ and Chaebols (large, usually family-owned business group) are a more recent example. Case of China, a state capitalism without Dutch Disease, thus relying on ―blood, sweat and tears‖ of workers for ―primitive accumulation,‖ is another major recent example.
Dibb and Lee have extensively studied China‘s economy and compare it to the economy of Japan of about forty years ago. In their article, ―Why China Will Not Become the Dominant Power in Asia,‖ Dibb and Lee (2014) state that China has entered into a similar pattern with that of Japan and may soon share with Japan an extended period of economic downturn. In particular, they note that ―there are only three ways to grow an economy—add more labor, increase capital outputs, or become more productive with the inputs‖ (p. 2). China may be constrained in all three areas. China grew its economy by 162% between 2004-2014, where ―additional labor inputs contributed 6% of that increase and capital investments to infrastructure amounted 136% of that increase‖ (p. 3). But, at what cost? The economic plans adopted by successive Chinese governments during this period, however, also increased China‘s national debt from 147% of GDP in 2008 to 250% of GDP at the end of 2014. Dibb and Lee (2014) provide additional indicators of China‘s deficiencies, but the essence of their analyses is that China, despite its emergence as the ―world‘s factory,‖ will be unable to dominate Asia economically. Watkins (2015) notes that China will not supplant the United States in military presence in the Pacific Region in the near future, despite China‘s forceful use of its military to claim the natural resources of the South China Sea (see Tonnesson, 2015).
Despite the importance of patterns of health service utilization in determining healthcarefinancing and delivery, there is a limited literature on the role of travel costs in developing countries. The major chal- lenge is obtaining reliable measures of travel time and monetary travel cost to access health services. This requires information on the precise location of the household and the health facility, network of roads, availability of and waiting time for public transporta- tion, and reliability of self-reported data. In SouthAfrica, studies have been conducted in a Demographic Surveillance Site in rural KwaZulu-Natal; however, it is unclear whether these estimates can be generalized to the rest of the country [11,12]. Indeed, there are few large-scale studies of this sort in developing countries and the existing nationally representative studies rely on self-reported estimates of distance or time to the nearest clinic [3,6].
the total healthexpenditure is substantial in the world. For instance according to World Bank data 5 for the year 2014 developed nations like United States, Germany, Japan, Australia etc. spends more than 8 per cent of their GDP on public healthexpenditure. However for developing nations like India, Bangladesh and Afghanistan the corresponding figure is only 1.4, 0.8 and 2.9 per cent respectively in the year 2014 5 . However, owing to the differentials in the income levels of different countries, the spending also varies across different countries. Cevik & Tasar, 2013 mentions that the proportion is as high as 8.2% in OECD countries and as low as 2.9% in sub- Saharan countries which accounts for the lowest level of government health spending standing far below the world average (Cevik & Tasar, 2013) 4 . Owing to such high expenditure on healthcare in high income countries, Or, z (2001) observes that in OECD countries, health status indicators like life expectancy, infant and perinatal mortality, and potential years of life lost from various causes have seen improvement over time particularly from 1960s. Over the past three decades, health status in all OECD countries has improved significantly. The results confirm that there is a significant potential for public health initiatives such as anti- smoking and anti-drinking campaigns to improve health status. Thus an effective health policy framework has to recognise the role for public health with well defined objectives to attain a decent standard of health in a country. (Or, 2001) 6 . Contrary to high income OECD countries, a study by Novignonet. al concluded that majority of the countries in sub Saharan Africa (SSA) rely on donor grants for financinghealthcare as healthcareexpenditure has been low in this region which may be due to the poor tax systems and social security structures. This could be seen from poor health infrastructure and workforce in the light of resource constraints, high catastrophic expenses
It is evident that the non-governmental health and advocacy organisations in this context have taken the initiative to provide healthcare access to FSWs through peer-led SRH care and psychosocial services. These organisations have ensured that they provide ser- vices to FSWs in a way that fosters a trusting and respecful interaction between FSWs and healthcare pro- viders. The power imbalances that characterise the healthcare provider and patient dynamics in most pub- lic health facilities have been replaced with a system where FSWs communicate freely with healthcare pro- viders about their sex worker identity, as well as receiv- ing a service tailored to the complex challenges they experience in sex work. However, it is important to note that these organisations are limited in their reach and are not available to sex workers operating outside of the metropolitan municipalities; thus, sex workers who oper- ate in townships or rural settings may rely heavily on public clinics and hospitals enforcing a sense of power- lessness and lack of well-being among some members of this population, fostering health disparities due to the in- accessibility of supportive services. In its quest for healthcare reform, the South African health sector should en- gage with these organisations and aim to design government-led parallel services that have a wider reach, and with sensitised healthcare staff so as to gradually cater for key populations.
Since a landmark publication by Prince et al. , the notion of “no health without mental health” has stimu- lated policy-makers in all countries to consider mental health and the treatment of mental disorders as a key priority in the pursuit of equity in health and health ser- vice access. This has become particularly pertinent in recent years with the emergence of universal health cov- erage goals and the need to provide broad-based, con- text- specific primary healthcare (PHC) [1, 2]. In 2018, the Lancet Commission on Global Mental Health and Sustainable Development reaffirmed and expanded these sentiments, emphasizing that a global response to mental health necessitates “promoting mental health, prevent- ing mental disorders, and including mental healthcare in universal coverage…agenda[s]” as a humanitarian and development priority, providing evidence that mental health is indeed at the centre of sustainable development . These goals have been embraced by the South Afri- can government through the adoption of the National Health Insurance Policy (2017) and the South African National Mental Health Policy Framework and Strate- gic Plan 2013–2020 (MHPF) [4, 5]. Despite compelling evidence supporting the case for investment in mental health systems and strong national policy commitments [6, 7], it is essential that the plans and policies developed to address the mental health burden in SouthAfrica reflect an increased recognition that financing is a critical factor, not only in the realization of a viable mental health system but also for the long-term development prospects of the country.
To minimize HW attrition and the resultant negative effects, innovative efforts are required to address the causes of HWs’ dissatisfaction and to further identify the nonfinancial factors that influence HWs’ choices, especially given the inability to increase remuneration within a constrained fiscus. The South African Strategic Plan for HIV, tuberculosis and sexually transmitted infections 2012 to 2016 does call for the need to explore ‘innovative financing’ as a mechanism for raising additional resources for the public healthcare system . Fryatt suggests a number of avenues that SouthAfrica could explore to raise funds and whilst these resources will not solely be allocated to HRH, they could be used to fund efficacious attraction and retention strategies . The Government of Malawi responded to their HW crisis by increasing salaries by 50%, improving working conditions, re-enrolment of retired HWs and investment in training for HRH, all of which yielded positive results . Ghana, for their innovative education and training strategies, were recognized with an award from the Health Worker Migration Policy Council . Limited resources, inadequate education and career opportunities along with weak management systems leads to a shortage of HWs . Further research is needed in those countries that have successfully addressed these issues. SouthAfrica, through policy, has set out ways to address the HRH shortage, but implementation is key to ensure there are adequate staffing levels across cadres and in traditionally under-resourced areas.
This paper has examined the overall costs of scaling up access to ART from 2010 to 2020 within the context of the proposed UC system. Coverage has been defined fol- lowing the National Strategic Plan for HIV&AIDS and STIs to be meeting 80% of new need for ART on an ongoing basis. The costing of ART is subject to a num- ber of key uncertainties including those related to the data requirements of the study, extrapolation of data and generalizability of results. Uncertainty relating to data requirements has previously been assessed using probabilistic sensitivity analysis (PSA) while generaliz- ability has been assessed via multi-way sensitivity ana- lyses . While these analyses lend some support to the overall robustness of the lifetime costs of care used in this current analysis, it is nevertheless the case that this costing is based on a relatively efficient model where care is delivered via community health centers and treatment is handled by both doctors and nurses. This model of care is cheaper than a number of alterna- tives that have been evaluated in the South African pub- lic  and private healthcare sectors . It should therefore be borne in mind that the ART costs pre- sented in this paper could be underestimated, given that a scaled up response is likely to require delivery of ART through all possible models of care. It is also likely that costs would increase following any decision to change the CD4 initiation criteria from <200 to <350 cells/ μ l. While starting ART at CD4<350 cells/ μ l will be likely to be associated with lower costs during the first year on treatment , cost-effectiveness analyses have shown that lifetime costs would increase, primarily owing to
To minimize HW attrition and the resultant negative effects, innovative efforts are required to address the causes of HWs’ dissatisfaction and to further identify the nonfinancial factors that influence HWs’ choices, espe- cially given the inability to increase remuneration within a constrained fiscus. The South African Strategic Plan for HIV, tuberculosis and sexually transmitted infections 2012 to 2016 does call for the need to explore ‘innova- tive financing’ as a mechanism for raising additional re- sources for the public healthcare system . Fryatt suggests a number of avenues that SouthAfrica could explore to raise funds and whilst these resources will not solely be allocated to HRH, they could be used to fund efficacious attraction and retention strategies . The government of Malawi responded to their HW crisis by increasing salaries by 50%, improving working condi- tions, re-enrolment of retired HWs and investment in training for HRH, all of which yielded positive results . Ghana, for their innovative education and training strategies, were recognized with an award from the Health Worker Migration Policy Council . Limited resources, inadequate education and career opportunities along with
The right to access healthcare services in SouthAfrica is guaranteed by Section 27 of the Constitution, but consid- erable inequities still remain, largely due to discrepancies in resource allocation [32, 33]. In their study on access to healthcare in SouthAfrica, Harris et al.  concur with previous SouthAfrica studies, confirming that poor, uninsured, Black Africans and rural groups have poorer access to healthcare than do other members of South African society [32, 33, 35, 36]. Only a few studies have looked at disability issues in rural SouthAfrica [14, 37–40]. These studies focused specifically on disability and access to healthcare. More large scale quantitative research contributing to assessing and improving access to healthcare for persons with disabilities needs to be prioritised – especially in South African rural areas.
ance, prevented consultation for highly vulnerable house- holds. The findings show the monthly cost burdens for repeated trips can be exceptionally high. Those house- holds with income, strong social networks, receiving social grants, or exemptions from public hospital fees were able to seek care regularly, incurring much lower cost burdens. Although there is a growing international litera- ture on the affordability of heath care [40-44], as well as literature on the household impact of illness and death as a result of catastrophic diseases such as HIV, there is little published evidence on the cost burdens of recurring chronic care. In a review of studies on the economic bur- den of HIV, TB and malaria in low and middle income countries, the direct costs incurred due to TB, requiring regular chronic care, were considerably higher (8–20% of annual income) than the costs incurred as a result of malaria (2–3% of monthly income). The review showed the largest cost from HIV were those associated with death, indicating regular treatment was not com- monly available. Disease specific studies from SouthAfrica have broadly noted that the lack of finances was an impediment to regular clinic visits , and following a prescribed diet. The cost of traveling to hospital was also found to be prohibitive, and consequently many patients ran out of medicines between hospital visits . However, there are few detailed South African studies of the costs of chronic care.
The same interviewers conducted a group discussion among medical students in a South African medical school comprising 6th year students training in South Af- rica (n = 10) (see Additional file 4). Owing to continued student unrest on most university campuses during the field work it was not possible to gain access to other med- ical schools. Informed signed consent was obtained from participants. Similar themes were discussed as detailed above. The transcripts from the interviews and focus group discussions were analysed by a single investigator using themes that arose from the data and pre-existing themes that were derived from previous research and a stakeholder meeting . Verbatim quotations were se- lected from the transcripts to illustrate the opinions and experiences of faculty members, students and recently qualified doctors.
1291 hospital sector is vital to improve patient and population health and enshrine their role in enhancing the determinants of health, medical and non-medical. The Health System Trust in 2012 noted that public hospitals performed poorly in positive and caring attitudes, and performed relatively well on waiting times and intermediately on patient safety, cleanliness and availability of medications . Managers are often not allowed to manage. The Development Bank of Southern Africa (DBSA) in 2011 also reported that many of the traditional functional roles of CEOs are housed within the administrative chain above the CEO, including finance, Human Resources and stra- tegic matters. In the strictest sense, the CEO’s role is often reduced to managing the day to day running of a hospital . Hospitals are a minor part of the NHI reforms with their being required to provide services based on their category of hospital. Oth- ers are linking to private providers in public-private partnerships to maintain benefit and lower cost . Perhaps the most important development is the creation of the Academy for Leadership and Management in HealthCare, established by the Health Minister, to overhaul dysfunctional and often inept leadership at public hospitals. In an op-ed, written after many CEO meetings across the country, Bateman noted that “the most valuable (and loudest) feedback from the national CEO group was that their success relies on having appropriately qualified, properly appointed managers below them, and the leadership and management chain above them being competent and functional”  . Jacobs [Academy Chair] summarized: “They asked us to make sure that the nature and competencies of all managers in the system were aligned with their qualifications—and to look at the line going up to provincial and national le- vels—and also the teams within these institutions. Other critical issues they wanted addressed were on-the-job support and mentoring, peer networking and a clear de- termination of their own ‘delegations’ [job descriptions]” . This provides a solid start for ensuring two of the core health competencies, leadership and corporate gov- ernance and operational management .
Status. As with the Health Status, women were more likely to report poorer functionality (WHODASi) than men. Age significantly affected functionality only from 70 years of age. People aged 80 and over had a threefold increase in risk of reporting poorer functionality. Pro- gressively lower levels of education related to a gradual increase in functional problems. Being single or ‘not working at present’ were also associated with worse functionality. There was no gender difference in QoL. However, our analysis showed the following factors related to lower QoL: older age group, no formal education, being single and currently not working. Table 6. WHODASi a by demographic variables [n, (%)] for 4,085 adults aged 50 and over in Agincourt sub-district, 2006
In order to improve compliance with the PHC STGs/EML, we believe it is important that health professionals, especially clinical nurse practitioners are inducted on the use of STGs/EML as soon as possible after their finalisation and publication. This sentiment has been echoed by the National Commissioner of DCS when he highlighted the need to provide healthcare workers with the necessary training to enable them to execute their duties appropriately . We believe regular refresher training courses should also be conducted to ensure prescribers are continuously sensitized on using the PHC STGs/EML. This is especially important in the PHC model that places clinical nurse practitioners at the centre of health provision , similar to other countries .
The role of government expenditure at both sectoral and aggregate levels in improving economic performance and social welfare cannot be understated. The recently introduced ARDL methodology was applied to investigate the impact of government expenditure on agricultural productivity. Urbanization was included in the agricultural productivity model in order to address biases associated with bivariate models due to omitted variables. Prior testing for long run relation among chosen variables, the Augmented Dickey-Fuller (ADF) test was used to examine stationarity characteristics of the variables. The Bounds cointegration test confirms the existence of long run relationship between agricultural productivity and independent variables examined. The study reemphasised that SouthAfrica government expenditure has not in been accordance to the threshold that was signed at Malabo Declaration in 2014 by African heads of state and government. Estimations of ARDL model support the fact that government expenditure is important for agricultural productivity in SouthAfrica despite the fact that the sector is dominated by private commercial farmers. However, the current expenditure pattern will only lead to a minute increase in agricultural productivity. Moreover, results show that about 91.1% deviations from long-run stable equilibrium would be corrected annually. Overall, the study finds government expenditure on agriculture in SouthAfrica to be of significant effect on agricultural productivity.
cohort was 60 years, and thus represented an older population that would be expected to have a higher prevalence of co- morbidities. This disparity may have been driven by differences in the definition of co-morbidities but may also be a result of an increased burden of HIV in SouthAfrica. There was a significant difference in co-morbidities between the elective and emergency cohorts, with 85% of elective patients having at least one co- morbidity as opposed to 50% of emergency patients. This was driven by a significantly higher prevalence of cardiovascular disease and metabolic disease (mostly diabetes mellitus) in the elective cohort, which is expected as most of these patients were undergoing coronary artery bypass grafting. HIV disease was the second most common co-morbidity in the entire cohort (19.3%). In the emergency population the prevalence of cardiovascular disease (20.8%) and HIV disease (20.2%) was similar, highlighting the burden of HIV disease in KwaZulu-Natal. In contrast, international studies report a prevalence of HIV of 0.3–1.0%. 19–21
health services in England, Canada and the USA showed that admission rates for people with mental disorders decreased significantly . A consumer satisfaction survey among group home residents 12 months before and 12 months after a strike by HCWs showed no dif- ference satisfaction level with the community mental health services . Other studies, which investigated the impact of doctors, strike on different socio-economic strata of Israeli society, showed that patients from lower socio-economic groups coped less effectively with strikes and complained of a higher impact on their health as opposed to patients from higher socio-economic strata, perhaps because of affordability of alternative healthcare services. It was further reported that patients from the lower socio-economic classes were less likely to condemn either party in the strike action [14,41]. Perhaps observed low impacts of HCW strikes on service delivery in devel- oped countries could be related to the ready availability of alternative channels for obtaining healthcare such fee- for-service private care and emergency services. Contrary to the low impact of HCW strikes in developed countries, anecdotal evidence from newspaper reports and research seem to suggest that strikes by HCW in developing coun- tries are associated with more patient deaths and have a more severe impact on the general population [17,20,21, 23,47]. This is not unexpected considering that these communities may be considered vulnerable populations groups in accordance with UNAIDS criteria for vulner- ability [30,31]. This evidence buttresses the need for implementation of minimum service agreements in less developed countries to mitigate the impact of doctor and HCW strikes on the local population, a measure which has been advocated by some local doctors in SouthAfrica [18,19,28,49-51].
People that work in the home-based care programme are referred to as home-based caregivers . They are generally physically fit middle-aged women from the community . The home-based caregivers do not have medical training but undergo home-based care training . The training introduces them to various aspects of home-based care such as diseases and disability, management of patients’ condition and treatment, assisting patients with mobility and preventing complications, and patient referral . The training offered is focused on nursing care, life skills, counseling, case-finding, and record-keeping . It is designed to capacitate and equip caregivers to provide necessary help for the community they serve . The services provided by home-based caregivers yield numerous benefits . However, home-based caregivers face the challenge caused by the generation of healthcare risk waste . There are large volumes of healthcare risk waste arising from care given by home- based caregivers and currently there are no arrangements made to correctly manage the generated waste . The management of healthcare risk generated by home-based caregivers is a mounting problem, especially in developing countries such as SouthAfrica that have inadequate resources and lack of cost-effective waste disposal processes . Healthcare risk waste is defined as the waste that is generated during the process of providing healthcare services to patients . The waste is considered to be very hazardous and is ranked the second most hazardous after radioactive waste because it has the potential to cause adverse health effects and significant pollution in the environment . In SouthAfrica, the waste generated by home-based caregivers is managed in the same manner as general domestic waste . The waste is either discarded in an open field, burnt, buried in shallow graves or collected by or on behalf of the local authority to be disposed of in solid waste land fill sites .