Reforming the South African health care system.

The many and varied paradoxes and contrasts that characterize human life around the world manifest in South Africa in a unique combination that has focused international attention on this country. Contrasts between geographic beauty and social ugliness, rich human and material resources and impoverished human development, military power and moral weakness, white freedom and black oppression, wealthy life-styles and grinding poverty, modern industrialized cities and impoverished rural areas, sincerity and hypocrisy in human relations, and potential for progress and wasted opportunities are just some of the features that describe this beleaguered country. Admiration for its support of allied forces in World War II, for some of its scientific and other achievements, and for its official identification with western values contrasts with opprobrium for its oppressive apartheid policies and with concern about the alignment of some of the oppressed with Marxism. These are some of the factors contributing to the paradoxical instability of foreign policies toward a country in slow transition from a destabilizing force in southern Africa to a role with greater potential for driving regional growth and development.

Disparities between the small (5.5 million) white population and the larger (32.5 million) marginalized population range from differences in population demographics, disease profiles, and longevity; through racially discriminatory access to land, education, health care, and employment; to polarization in political, civil, and economic power that have formed the cornerstones of apartheid policies. These disparities have been described in detail elsewhere(1-5) and will be only briefly illustrated here (table 1, page 52).

Transition Challenges

Transformation of the South African health care system must be viewed in the context of the broader transformation process that will shape the future of this country. Such changes in turn need to be seen within the economic and sociocultural developmental process in southern Africa. Although South Africa's per capita GNP is only one tenth that of the United States, it is 10 times that of 10 northern South African Development Coordinating Conference (SADCC) neighbor countries.(6) This economic position between the more developed and the less well-developed countries (table 2, page 53), and the modern economic and industrial infrastructure on which the country stands, provides an intellectual and economic base that could energize and invigorate development in southern Africa. Whether this will be the path into the future or whether the dynamics of the transition process will severely damage the potential for economic growth and human development remains unpredictable. Recent conflict and breakdown in negotiations (mid-1992) would seem to have set back the pace of progress. Given the background to the transition process,(7) it is perhaps not surprising, although of course extremely disappointing, that the road to the future is paved with so many ambiguities and uncertainties.

Van Zyl Slabbert has lucidly described the challenges facing transition toward a democratic society in South Africa.(8) Drawing on examples of pathways to democracy in other countries (through leadership pacts-- e.g., Venezuela, Spain, Uruguay; revolution- e.g., Romania, Nicaragua; imposition from above by military type groups--e.g., Brazil, Portugal, Turkey; reform from below--e.g., Argentina, Poland, Yugoslavia; or combinations of these) and describing the distinction between the democratization process and the practice of democratic government, he outlines modern concepts of the meaning of democracy in the context of industrialized nation states. Because democracy (or a democratic constitution) per se does not guarantee civil stability, eliminate political conflict, or guarantee economic growth and human development when it develops within a shorter time frame and in historical and economic contexts different from those of already consolidated democracies, he emphasizes the need to extend the focus beyond constitutional issues and to simultaneously develop those social structures required to sustain social stability and cohesion--education, health, employment, and social justice.

Loewy has described several different concepts of community and has suggested that it is only in societies that respect the first order biological needs (food and water, clothing and shelter, and sanitation) and the second order sociological needs (education, health care, and the franchise) of its citizens that civil stability, democracy, economic growth, and human development can flourish.(9) Failure to recognize the collective nature of responsibility for these needs inevitably results in a growing disadvantaged class and a spiral of violence.

This is all too evident in South Africa, which has an enormous backlog to meet in all these areas. For example, in relation to first order biologic needs, a considerable proportion of the South African population is considered to be malnourished. Underweight in school children ranges from 5 percent of white children to 25 and 30 percent of African and colored children, respectively. Kwashiorkor and Marasmus account for 5-31 percent of admissions in rural hospitals. The proportion of the population with access to safe water in the rural areas of South Africa ranges from 40 percent in the Northern Cape to 72 percent in the Northern Transvaal when there is no drought. Housing needs remain enormous; only one-third of the population has access to electricity, and the proportion of the rural population with access to adequate sanitary systems ranges from 11 to 37 percent. Regarding second order sociologic needs, there are stark differences in access to educational and health services, and the majority of the population is still disenfranchised.

Although in 1988/89, 61.7 percent (R8.6 billion) of the total expenditures on schools (R14.4 billion) was spent on "other-than-white" schools, these schools housed 91.8 percent of the total school population. Pupils per classroom, teachers per pupil, and the educational level of teachers were thus all much more favorable for whites. To achieve parity at white levels of education would require a three- to four-fold increase in total expenditures on schooling.

Of total expenditures on health, the private sector consumes 50 percent although serving less than 20 percent of the population who carry medical insurance. The public sector (which, in addition to serving more than 80 percent of the population with the remaining 50 percent--R9 billion in 1991--is responsible for training all health professionals and for research and development) has been progressively eroded over the past decade.(2) To achieve parity at private levels for health care would require increments in expenditures similar to those for education.(10) With government expenditures at approximately 30 percent of the gross domestic product (education, health, defense, and interest on debt repayment consuming 20, 10, 16, and 16 percent of government expenditures, respectively), this could only be achieved by an enormous increase in taxation; massive cuts in defense expenditures; (very necessary) reduction in multiple, racially determined levels of bureaucracy; extremely high and sustained (more than 6 percent) economic growth rates; or a rapid and sustained drop in the birth rate. The achievement of parity in social expenditures within current economic constraints would produce only modest increments for the most disadvantaged in the short term, with perhaps subsequent decreases in the long term if such measures (table 3, above) adversely affected economic growth. Working toward achieving some gains for social expenditures simultaneously on all these fronts, together with some redistribution, offers the best opportunities. The hope we all sustain is that sufficient progress can be achieved within a time frame and political legitimation process that can contain violence and promote a culture of peaceful progress.

Evolution of Our Health Care System

The development and reform of national health care systems, their varying ability to meet the growing demand for modern medical services within reasonable economic constraints, and the debate on "curative" medicine for individuals versus "preventive/primary care" for whole populations have been and remain the subjects of intense contemporary debate in many countries, not least in South Africa.

Van Rensburg, a South African sociologist who has made thoughtful and provocative contributions to our understanding of health services in South Africa,(11-13) has recently analyzed trends in the development and structure of health care services during South Africa's 340-year history.(12) He describes how most changes have evolved in a uniform direction that has sustained and fortified major structural disparities inclusive of race, gender and urban/rural distribution of medical practitioners; the black/white bed/population ratios; and marked disparity between expenditures on preventive and curative services and in per capita expenditures on different populations.

Van Rensburg notes three markers of fundamental change that have pointed toward a radical restructuring of the long prevailing system of health care in an opposite direction: the Gluckman Commission of Inquiry (in the early 1940s), the Freedom Charter of the ANC (in the middle 1950s), and renewed pleas from many sources (since the mid-1980s) for a more unified, national, and perhaps even nationalized health service capable of meeting a wider spectrum of needs in our rapidly changing society.(12) He concludes that, despite recent trends toward greater privatization in medicine, further developments will inevitably be in the direction of either a national health service/insurance or a socialist system (table 4, below(14)). Although the broad principles and practical effects of these directions are similar and will require fundamental change of the existing pluralistic system, it is the future of the political economy of the new South Africa that will determine Which system will ultimately be adopted.

From our position at the brink of fundamental societal changes and from the lessons learned from health care systems in highly developed countries,(15) it is clear that health care cannot be left solely to marketplace forces and entrepreneurs. Concern only with short-term individual self-interest will exacerbate inequality, inaccessibility, fragmentation, poor planning, and unnecessary waste. Health care should also not become fully bureaucratized, applied in an authoritarian fashion or totally under central control, with suppression of individual and group medical professional influences. A middle ground-- one that is based on lessons learned from the past and from other systems-must be found. Mechanic, writing about changing the American health care system, notes, "The structure of our health care system reflects our unique social and historical background, our culture and our values. We remain, despite our wealth, the only developed western nation that tolerates the exclusion of a significant proportion of its citizens from the right to health services. We have constructed an extraordinary administrative apparatus to maintain the illusion that health is a private enterprise. We increasingly spend more for less, and disillusionment continues to grow among many important segments of our population. There is need to reexamine basic issues and consider where we as a nation aspire to go in health, and the pathways we propose to take in attaining our objectives." (16)

Successful transition toward a new South Africa could be greatly enhanced by a carefully thought out and implemented transformation of our similarly inadequate health care system. The elements that should be part of this process include:

* Recognition of current strengths built up over many decades within our health care system and efforts to sustain these with maximum efficiency and effectiveness.

* Acknowledgement of weaknesses and implementation of measures to progressively correct them through initiatives at institutional, community, and individual levels.

* Introduction of audit and accountability procedures that will discourage and reduce wasteful administrative and clinical practices.

* Development of a spirit of participation in the process of reconstructing a more comprehensive service that could go a long way toward meeting the aspirations of patients and health professionals.

* Redirection of resources away from wasteful endeavors toward those with potential for human development.

* Promotion of realistic public expectations of what a health care system can deliver, and professional humility regarding cost/benefit balance in a middle-income, developing country in which nutritional, educational, employment, and housing improvements will have a major impact on population health.

* Greater attention to public health measures and to development of primary health care facilities throughout the country.

* An appreciation for the need to sustain scientific and scholarly endeavors as an essential feature of a country aspiring to become developed rather than remain in a dependent, developing state, but within a peer review system cognizant of economic constraints.

* Some restructuring of medical education to include a deeper understanding of population health and medicine and of sociologic, philosophic, and economic aspects of medicine and health care, while sustaining a solid base of scientific knowledge and encouraging better understanding of the scientific method and approach.

* Greater contact between academic institutions and the whole health service on a regional basis, with a view to extending teaching into the primary and community sectors and to improving the quality of practice in these areas.

Although there is widespread agreement on the goals we wish to achieve for health care and academic medicine, there is much less consensus on the ways in which we should set about doing so.(17) There is now a critical need for a penetrating analysis of the structure, function, and funding of our current system and for the development of several models for the future into which could be inserted a range of economic, demographic, and other variables with a view to evaluating realistic means toward practical progress.

In addition to political will, this transformation process will require economic, philosophic, sociologic, anthropologic, and epidemiologic skills. Analysis and modeling will have to be followed by public education and public relations exercises designed to optimize willing participation by all in a transformation process that will be painful, will not meet all the individual aspirations of any group, but will surely offer much more than the continuing greed and polarization associated with the current trend toward privatization without controls.

The Future

Against the background of our current impasse, at least two potential scenarios can be imagined.

A low-road scenario would be characterized by ongoing debate and superficial consensus(17) but no meaningful action; by continued growth-- to a limit--of the private sector with progressive attrition of the public sector and erosion of academic medicine; by further flight of capital and a new wave of brain drain; and ultimately by a very disparate, two-tier health care system with almost the best of everything for those with resources and only the barest minimum for those without. If health professionals work across both systems, this will reduce professional credibility and further erode any conception of medical care as a component of social justice. Litigation will probably increase and, given the limitations of our economy, standards will soon drop, even in the currently well-endowed but already threatened private sector. Within this scenario, South Africa will increasingly come to resemble the rest of sub-Saharan Africa, and the African continent will continue to slide away from and be marginalized by the developed world. The international news media will briefly acknowledge the adverse effects of exploitation but will largely blame the victim. They will smugly recommend that Africa be left alone to develop from where it left off in the 1500s prior to the slave trade,(18) while the developed world continues to exploit human-kind and nature without regard for its humanitarian and physical survival interdependence with poorer nations.(19)

A high-road scenario will include a constitutional solution, an interim government, free and open elections, a return to the world economy and trading system, development of closer trading and other relations with neighboring countries, carefully structured international aid programs, and the creation of civil stability and human development through social and economic growth. Carefully planned, more rational use of health resources, with attention to the requirements outlined above, would be associated with improved national health status; a reduction in the population growth rate(20); a less fragmented, better distributed, nondiscriminatory health care system providing reasonable access to primary, secondary, and tertiary care; preventive and rehabilitation services; and, to some, sophisticated modern medicine. A two-tier system will probably still prevail, with the rich having access to more than others, but the gap will be considerably narrower than at present and will be acceptable politically, economically, and sociologically.(21) This scenario, which would require some short-term sacrifices from all, would predictably pay great dividends in the long run. Such developments could also ignite the flame of progress in a subcontinent filled with despondency and contribute to narrowing global disparities, which is ultimately in the interest of all, even the most developed nations.

Although South Africans must depend largely on themselves and on internal forces to ensure movement toward this high-road scenario, it would not be unreasonable to expect that well-targeted financial, intellectual, and moral support from developed nations could play a critically important role. This will require reversal of some of the economic, military, and moral imperialism of the past and a more humble and beneficent perspective on the interdependent nature of survival on a threatened planet.(22,23)

If this high-road scenario could be achieved, it would not only reflect the potential for South Africa and sub-Saharan Africa, but could also provide an example to other countries and help sustain the idea that rationality, human fights for all, and commitment to more than one's own personal/national short-term interests, pave the path to a better future for all. The spirituality and magnitude of the challenge are awesome. Regrettably, in the context of recent developments both within South Africa and at a global level, the probability of moving toward such a scenario seems low.

Conclusions

Meaningful discussion of a better health care system in our rapidly changing society will demand great intellectual honesty and a realistic view of what has been achieved elsewhere and of what can be achieved within a reasonable time in our socioeconomic, political, and geographic context. The possible directions toward which we can choose to develop include:

* A divisive, two-tier health care system dominated by a wasteful private sector.

* A totally socialized health service with a predominance of primary health care and little tertiary medicine or medical research.

* Some form of national insurance health service that, through an appropriate mix of private and public primary, secondary, and tertiary services, could sustain and improve the health of all citizens without reducing them to the lowest common denominator.

Commonly held aspirations for our future are for a just, democratic society in which human rights would be upheld and achieved and in which respect for every individual would be a high priority; for an economy with sufficient resources to provide basic social services for the disadvantaged; and for an educational environment conducive to a healthy, happy childhood that would provide individuals with the opportunities to reach their potential as involved citizens actively contributing to the further development of their society and its citizens.

The complexity of the many interlinking tasks involved in working toward these goals should not be underestimated. Even if they can be achieved, given the vast economic growth required, the time frame will be considerably longer than desired by most.

The new South Africa will require more than a political solution. Without economic growth, the development of a culture of democracy, more equitable and nondiscriminatory access to educational and health care systems, respect for human rights, civil stability, and peaceful approaches to conflict resolution,(24) the victory over apartheid will be hollow and characterized by continuing wide disparities, conflict, poverty, and suffering for many generations. Given the goodwill that continues to exist both within South Africa and toward this country (despite its tragic history) and the human and natural resources available to us, we should optimistically conclude that it is indeed possible to generate the convergence of forces necessary to constructively transform our society. Every South African and the many others who wish to assist have a vital role to play in this process. Only by recognizing the importance of cumulative individual efforts on a daily basis can we overcome the inertia that accompanies despair. Living professional and personal lives that set examples and inspire others remains a powerful social force. Hardin's classic article reminds us of the profound adverse evolutionary effects associated with greed and short-term self-interest.(25) Averting the "Tragedy of the Commons" is a collective task that can only be achieved through multiplied individual efforts, encouraged and sustained by appropriate social structures and international support. One of these social structures is a health service that sustains the belief of all citizens in society's respect for their human dignity. Living and practicing medicine in South Africa fosters, for those with some conscience, an awareness (through the effects of racist policies) of man's inhumanity to man and (from the many examples of dedicated care for fellow humans and achievement of excellence in the face of constraints and adversity) of the potential to advance through hope and high aspirations. Altering the balance toward the latter is a challenge for South Africa and for Africa that calls for concerted national and international endeavors.(22)

[TABULAR DATA OMITTED]

References

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2. Benatar, S. "Medicine and Health Care in South Africa--Five Years Later." New England Journal of Medicine 325(1):30-6, July 4, 1991.

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18. "The Agony of Africa." Time, Sept. 7, 1992, pp. 26-39.

19. Human Development Report 1991. United Nations Development Programme. London, England: Oxford University Press, 1991.

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21. Benatar, S. "A Unitary Health Service for South Africa." South African Medical Journal 77(9):441-7, May 5, 1990.

22. Benatar, S. "A Global Perspective on Health and Human Rights." (Submitted for publication.)

23. Gillis, J. (Ed). The Militarization of the Western World. New Brunswick, N.J.: Rutgers University Press, 1989.

24. Schlemmer, L. "Violence--What Is to Be Done?" South Africa International 23(2):60-4, Oct. 1992.

25. Hardin, G. "The Tragedy of the Commons." Science 162:1243-8, Dec. 13, 1968.

Solomon R. Beatar, FRCP, FACP(Hon.) is Head of Department and Professor of Medicine, Department of Medicine, Medical School, University of Cape Town, South Africa.