GRAHAMSTOWN, South Africa, May 22 (UPI) -- How does a nation account for its healthcare financing when it refuses to believe why 14 percent of its population, or 30 percent of its workforce, might die by the year 2010?
This is a question that South Africa came closer to answering on April 17, when the cabinet released a policy statement on human immunodeficiency virus, or HIV, and AIDS, which included the statement, "(the) government's starting point is based on the premise that HIV causes AIDS."
Too much of the world these words are common knowledge, but in South Africa, home to approximately 10 percent (nearly 4.5 million people) of the world's HIV-infected people, a statement like this is a godsend.
In spite of the grave economic threat that AIDS presents, President Thabo Mbeki's African National Congress-led government has, until now, questioned the causal link between HIV and AIDS, and blocked the provision of anti-retroviral medications in public health service -- a service on which the majority of the country's 44 million people depend.
The turnabout was in many ways a societal victory over an ideology widely viewed as draconian. The move followed a recent high court order, brought by civil society organizations, that required the government to roll out nevirapine -- a drug proven to minimize mother-to-child-transmission of HIV -- to all hospitals with the capacity to do so.
For the past year, a free, five-year supply of nevirapine, donated by German pharmaceutical Boringer Ingelheim, has been available to South Africa. But the government had only allowed its use at 18 state-run pilot sites.
The media, both local and abroad, were also at odds with South Africa over its HIV/AIDS policy. Newsweek ran a cover story this year questioning Mbeki's logic, while news features about women who could have benefited from nevirapine were the order of the day in South African weeklies. One ran a column referring sarcastically to Mbeki's "avowal that 99 percent of the world's medical specialists are nothing but a bunch of white supremacists who won't listen when he tells them that HIV has nothing to do with AIDS."
But the latest healthcare financing figures on AIDS policy aim to quell this polarized environment somewhat. The government departments of health, social development and education have committed about $100 million to their revised AIDS program for the 2002-03 financial year, up from a meager $35 million in the previous year. In 2004-05, this figure will extend to $180 million, or about 5.5 percent of South Africa's annual healthcare spending.
The funds will primarily be channeled into a nationwide awareness campaign, which acknowledges the HIV-AIDS link. In addition, it supports a universal roll-out of nevirapine where possible; a comprehensive treatment package for sexual assault victims, including HIV testing and counseling; treatment for opportunistic infections that accompany AIDS; and an improvement in home and community-based AIDS care. The latter accounts for almost 10 percent of the new budgetary allocation.
Though the ANC has abandoned much of its dissident AIDS ideology, and even begun to sweep its most vociferous conspiracy theorists under the rug, the inequities in South Africa's healthcare system are enough to make the most sane of the politicians grimace.
Steven Thomas, deputy director of the health economics unit at the University of Cape Town, a think tank that advises the government on health policy, tends to agree.
"Equity is the paramount issue in South Africa's healthcare system, and the question remains whether we're moving closer to it or further away," he says.
The lack of equity, he says, is most renowned in the country's resource allocations to its nine provinces. One doesn't have to look far to see how this problem is manifested.
Last week, Gauteng Province, one of the wealthier provinces that encompasses Johannesburg and the capital city Pretoria, announced that it would start providing anti-retrovirals to rape victims by the end of the year. Concurrent to this, eight state-funded tuberculosis hospitals in the Eastern Cape Province temporarily shut down due to reports that the provincial health department was three months behind on subsidy payments.
"The 3.9 billion rand (about $390 million) that we run our budget on is hardly enough," says provincial health spokesperson Mahlubandile Mageda.
The Eastern Cape, a province with an unemployment rate of 70 percent, is mostly composed of rural areas that were the economically neglected, bantustan homelands of the former apartheid regime. Mageda says that transportation alone is a greater challenge than primary healthcare.
He is also as quick to point out that the Eastern Cape "is no Gauteng" as his Gauteng counterpart, Simon Zwane, is to comment, "We are not like the Eastern Cape."
Another burden on South Africa's healthcare system is the flight of healthcare workers from its borders. According to the Democratic Nursing Organization of South Africa, more than 300 specialist nurses leave the country every month due mostly to pay conditions. Even after six years of service, DENOSA deputy secretary Thembi Mngomezulu said in a report, many experienced nurses in South Africa earn only as much as fresh university graduates, which is usually as little as $296 a month.
For doctors, professional migration is mostly taking place from the public to private sector, according to Dr. Kgosi Letlape, chairman of the South African Medical Association.
In this year's budget, the national health department appropriated about $22.7 million over the next three years to encourage the deployment, retention and training of medical specialists. But according to Letlape, this isn't enough.
"The amount is enough to show that the government acknowledges the problem of retaining public sector specialists, but it isn't enough to address a real solution," he says.
But Thomas believes that the general tenor of South Africa's health policy is going in the right direction. The most progressive aspect is a government proposal, which was presented to the cabinet last month, for a national health insurance system in which everyone, except for the poor, contributes to the cost of providing universal healthcare.
The proposal is for a three-year, four-phased approach that begins in 2003 with reforms aimed at containing costs in the private sector while increasing the quality of public hospital services. By financing a low-cost, state-sponsored scheme that targets the country's six million workers who can't afford medical aid, it is hoped that private medical schemes will be encouraged to make their services more affordable, thus closing the inequity gap.
The second phase seeks to establish a risk-equalization fund aimed at redistributing finances from plans that cover low-risk clients to high-risk ones, namely the elderly and disease-infected. Tax subsidies for the nation's 7 million employers and workers with medical coverage will then be transferred to a risk-adjusted subsidy fund worth $780 million. This amount will then be pooled into a national fund to be disbursed throughout the country. The proposal also recommends a restructuring of the tax system to allow for greater pooling of risk.
The third phase attempts to create a contributory, voluntary scheme for employed people without medical coverage. The contributors, or members, would get enhanced benefits while the poor get basic benefits for free.
In the final phase, low-, middle- and high-income earners would be compelled to contribute to a national health insurance fund mandatory for all income brackets.
Yet the fruits of this proposal are subject to the endorsement of the treasury department, which, according to Thomas, has rejected health insurance initiatives in the past.
"The treasury always has greater control over health policy than the health department," he says.
If this is the case, it seems that South Africa's healthcare system could benefit from more public spending, which currently accounts for only 2.5 percent of the gross domestic product.
Incidentally, member states of the Organization for Economic Cooperation and Development, which consists of some of the world's most developed nations, spend an average of 8 percent of gross domestic product on public healthcare financing.
Last week, a delegation of South African ministers met with their OECD counterparts in Paris for discussions on the New Partnership for Africa's Development. It will be interesting to see if they took notes on healthcare.
