Chapter 9 Access to healthcare

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Contents

• Unit 19: Access to healthcare and the “right to health”
• Objectives
• Case studies
• Unit 20: Primary healthcare and South Africa’s district health system
• Objectives

Unit 19: Access to healthcare and the “right to health”

Objectives

When you have completed this unit you should be able to:

• Describe the factors that limit an individual’s access to healthcare.
• Explain what is meant by universal health coverage.
• Explain what is meant by the right to health.
• Raise a concern about healthcare delivery while protecting yourself.
• Find outside help for issues you cannot resolve at your workplace.

19-1 What does “access to healthcare” mean?

Access to healthcare means having the opportunity to use healthcare. A good way of thinking about access is in terms of affordability, availability and acceptability.

• Availability refers to whether:
  • Services are close by
  • The opening hours are appropriate
  • The staff have the right mix of knowledge and skills
  • The appropriate equipment is present and working
  • Drugs and disposables are on hand.

• Affordability refers to how much somebody has to pay to use health services and whether this payment means the household has to go without other essential items. Costs to patients involve more than facility fees. When thinking about affordability it is necessary to consider how much somebody must pay for transport, whether they will lose income as a result of having healthcare, or whether they might have to pay for something else – for example childcare – while they are in a health facility.
• Acceptability refers to the match between the expectations and values of the person seeking healthcare, and the facility and person providing that healthcare. Trust is an important part of acceptability.

Good access to healthcare means that healthcare is available, affordable and acceptable.

19-2 What is meant by universal health coverage?

Universal health coverage means that:

• Health services are available to all who need them, regardless of financial situation.
• Health services are of good quality.
• Health services do not expose households to financial hardship.

In most countries, universal health coverage is seen as something to work towards rather than something that can be achieved in the short-term. Importantly, if a country has made a commitment to universal health coverage, it is committed to:

• Finding ways of health financing that protect the poor.
• Making good quality services widely available.

Most low- and middle-income countries and some high-income countries such as the USA have not been able to implement universal health coverage. South Africa is still to achieve universal health coverage.

Universal health coverage means everyone has access to good quality healthcare.

19-3 What is a “right”?

A right is something that wider society has recognised should or should not happen to somebody. There are 2 important characteristics to a right:

• A person or community can assert (demand) their right.
• Wider society supports that person or community in asserting their right because we collectively believe it is a good thing.

There are 2 categories of rights:

• Civil and political rights, such as the right to free speech and the right to vote are individual rights and must be protected by governments who either adopt them in their national constitutions, or who sign international charters such as the United Nations Universal Declaration of Human Rights.
• Social, economic and cultural rights, such as the right to health, education, food and safe water, are the rights of peoples. In many countries, these rights are far from being realised. That means that they are still aspirations, and that governments are committed to the “progressive realisation” of the right. Progressive realisation means that governments have committed to providing these rights for as many people as possible in a way that is as fair as possible.

19-4 What does the “right to health” mean?

The “right to health” does not mean that everybody has a right to be healthy; it means that everybody has the right to achieve the “highest possible standard of health”. A paraplegic cannot assert the right to be able to walk again, but can assert the right to rehabilitation services that will let them have optimal mobility and social engagement. A child with TB meningitis cannot assert the right to be uninfected, but communities can assert the right to be protected from TB by well-functioning community health services.

“Right to health” means the right to achieve the highest possible standard of health.

19-5 What does the South African Constitution say about the right to health?

Section 27 of the Bill of Rights in the Constitution states:

• Everyone has the right to have access to
  • Healthcare services, including reproductive healthcare
  • Sufficient food and water
  • Social security, including, if they are unable to support themselves and their dependents, appropriate social assistance.
• The state must take reasonable legislative and other measures, within its available resources, to achieve the “progressive realisation” of each of these rights.
• No one may be refused emergency medical treatment.

The immediate realisation of the right to health may be limited by the resources available. Therefore there should be progressive realisation of the right to health.

19-6 What does progressive realisation “within available resources” mean?

Although somebody can assert their right to a particular service, this can be challenged when the service is expensive and has to be rationed to those who will be able to make best use of it. For example, the Constitutional Court has ruled that the government has a duty to “progressively realise” access to kidney dialysis but that it cannot be forced to provide access to kidney dialysis for every individual. On the other hand, most people would agree that a woman has a right to control her fertility using contraception.

19-7 What does the human rights approach to health mean in practice?

Legal arguments for the right to health can be taken to the highest court in South Africa (the Constitutional Court). However, the human rights approach is only effective when individuals and communities are informed of their rights and willing and able to assert their rights. Otherwise a court judgement is sometimes ignored and not carried out, particularly if there is no organised civil society and people feel powerless to hold government to account.

Case study 1

A clinic in a low-income community has a plentiful stock of condoms that are provided free of charge to anybody who requests them. The clinic is open in the afternoons until 6pm. A student asks a group of teenage girls who are sexually active why they are not using contraception. The girls say that the nursing sister will look at them as if they are dirty and they believe she told the mother of a friend that she was using condoms.

1. Is there an access problem here?

Yes. There seems to be no problem with availability or affordability of condoms. However, the girls are not using the service because they think the nursing sister disapproves of them and tell their parents. Whether or not this is true, there is a mismatch in values and expectations between the girls and the health provider that is proving a barrier to access to condoms.

Unit 20: Primary healthcare and South Africa’s district health system

Objectives

When you have completed this unit you should be able to:

• Explain what is meant by primary healthcare, and why it is an important part of the health system.
• Explain what is meant by health promotion.
• Identify the goals of the district health service.
• Explain the role of ward based outreach team and the district clinical specialist team in meeting the goals of the district health system in South Africa.

20-1 What is primary care and what is primary healthcare?

Primary care is not the same as primary healthcare:

• Primary care refers to the first point of contact between a patient and the health system. This is usually via a general practitioner (family doctor) or clinical nurse practitioner, but can also be used to refer to emergency room visits.
• Primary healthcare is a broader concept. It means the provision of health services, including prevention and health promotion, to a particular community in order to have better health for all. With good primary healthcare citizens tend to have good health with lower total health spending. In South Africa, primary healthcare is delivered through the district health system.

The goal of primary healthcare is to bring better healthcare services to everyone in a community.

20-2 What is health promotion?

Health promotion is “the process of enabling people to increase control over, and to improve, their health”. Health promotion includes:

• Supportive social environments for health such as “sex education” at schools.
• Healthy public policies such as no VAT on essential food items.
• Strengthening community action for health such as no “junk food” in school “tuck shops”.
• A stable eco-system such as no smoking in public spaces.
• Equity in healthcare.

Health promotion helps people to control and improve their health.

Note

In 1986, the World Health Organisation (WHO) had a conference and produced the Ottawa Charter on health promotion. The process of empowering individuals and communities is at the heart of the Ottawa charter.

20-3 What is equity in healthcare?

Equity means something is fairly distributed. Therefore equity in healthcare means that people are given fair opportunities to use good quality health services. It is not the same as being equally distributed. It is quite easy to say that something is unequal as you just have to measure who has what, such as their homes, cars or financial income.

To say that something is inequitable means also making some value judgments. For example, a person having a motor vehicle crash in a large city is more likely to be admitted to a major trauma centre than somebody having a crash in a remote, rural area. You could argue that this is inequitable (unfair) access to healthcare. However you could argue that it is not reasonable to expect major trauma centres in remote regions and that access is fair as long as the patient could be transferred if necessary. Empowerment of individuals and communities is an important step towards equity.

20-4 What is empowerment?

Empowerment is a process that allows people to take control over their own lives. It is an idea that is central to the definition of health promotion. There is a saying that “knowledge is power”, but knowledge by itself does not lead to power. Power is mostly about relationships between people. For most people, their understanding about their own power has been conditioned throughout their life. The term “empowerment” is a popular one, but health professionals should be aware that they may not by themselves be able to empower another person if that person has spent a lifetime being powerless. One way of empowering people is to give them access to health education.

20-5 What is health education?

Health education to the public is the process of providing health related information and understanding while trying to motivate people to take the necessary actions to improve their health. Health education can be provided on an individual level during a consultation, or it can be provided to groups of people such as schools, workplaces and community groups. The media can also be used to provide health education. Health education contributes to health promotion.

20-6 Why is primary healthcare important?

In countries where primary healthcare works well, citizens tend to have good health and there is lower total spending on healthcare. Cuba is a good example of a country that has introduced primary healthcare.

20-7 What is South Africa’s primary healthcare services history?

South Africa is known for sophisticated hospital care such as heart transplants. It has also been at the forefront of some important primary healthcare innovations.

• One of the best known and earliest examples of Community Orientated Primary Care was the Pholela Health Centre founded in rural Natal in 1940 by Sidney and Emily Kark, and Edward and Amelia Jali. Pholela was revolutionary in the way they looked at the underlying determinants of health for the whole population, focussed on prevention and health promotion, and empowered individuals and households to plan their own care.
• One of the first training programmes for clinical nurse practitioners was developed in South Africa. When many doctors left the country in the 1970s after the Soweto Uprising several clinics had to close. Clinical nurse practitioners were trained at Baragwanath hospital and were able to staff many of the clinics within months.
• Similarly in the 1980s primary healthcare for children was provided throughout the “Ciskei” by well-trained clinical nurse practitioners.

20-8 What were the main health service reforms after 1994, and how does primary healthcare “fit in”?

Before 1994, health services in South Africa were racially divided, fragmented and inefficient. There were 14 different Departments of Health, one for each racial group and one for each ethnic “homeland”. In addition, municipalities managed most clinics and health services. Resources were concentrated in large hospitals that provided sophisticated care and there was limited access to people not classified as white. Health service reforms after democracy brought 2 big changes.

• The multiple departments of health were disbanded and brought together under a single National Department of Health.
• The new National Department of Health made a commitment to provide primary healthcare through a District Health System.

20-9 What does a district health system consist of?

In the South African district health system (DHS), a province is divided up into smaller, well-defined areas (health districts). There are 44 municipal health districts outside large urban areas in South Africa and 8 metropolitan health districts (“metros”) that serve the larger urban areas. The area governed by metropolitan municipalities therefore also function as health districts. In the 8 “metros” primary healthcare services in the metropolitan district is managed by the metropolitan municipality through the health district office.

Each health district is divided up into a number of sub-districts. In the 44 smaller municipal districts it is the sub-district that is responsible for day-to-day management of primary healthcare services, while the district office provides planning and coordination.

Primary healthcare services provided by the district health system consist of:

• Preventive services
• Community based services
• Clinics
• District hospitals
• Sometimes specialist hospitals such as TB and psychiatry hospitals are managed by the DHS

Regional and tertiary hospitals are not part of the district health system. They are run by a medical superintendent or chief executive officer who reports to a provincial manager.

Note

The term health region is no longer used as these areas are now called districts.

20-10 What are the goals behind the district health system?

A district health system aims to:

• Decentralise healthcare by letting decisions about budgets be made locally and address local priorities.
• Allow local people to have a say in the services they use.
• Make health services responsible for all people in their area, not just those who are coming for care.

20-11 How well is primary healthcare working in South Africa?

Primary healthcare in South Africa is not working as well as it could, despite good intentions, allocation of resources, and a lot of hard work by many individuals:

• When healthcare spending in South Africa is compared with life expectancy, South Africa compares poorly to other countries. To some extent, the HIV epidemic has greatly impacted the health system, but other countries, such as Rwanda, have also faced the HIV epidemic, spend much less on healthcare and yet have longer life expectancies.
• Clinicians working in South African hospitals find that much of the caseload is made up of people needing treatment for the complications of uncontrolled chronic disease.

20-12 How well has the district health system succeeded in decentralising management?

Decentralised management has had limited success. A health district can be quite large and the district office can be several hundred kilometres from health facilities. Reporting to district and subdistrict managers who are not physically present at healthcare facilities can create paperwork at facilities that takes clinicians away from clinical work.

20-13 How well has the district health system succeeded in allowing management decisions to be taken more locally?

District managers may be reluctant to take decisions. They receive policies from the National and Provincial Departments of Health and may be uncertain of their authority to adapt and change them. The presence of multiple levels of management at provincial, district and subdistrict levels, and within departments, contributes to this uncertainty.

20-14 How well has the district health system succeeded in allowing people to have a say in the services they use?

Health service reforms have made provision for community participation in health services through hospital boards, clinic committees and district health councils.

• Hospital boards tend to be quite well established but are primarily concerned with the quality of hospital services and the use of donated funds for patient benefit.
• Community clinic committees have been established in some sites, but they often get bogged down in dealing with specific complaints rather than representing more general community needs. Participation by local representatives has not been good, and meetings can be somewhat irregular because there is no reimbursement for travel costs and no stipend for representatives.
• District health councils have been slow to get off the ground and it is difficult to find reports of functional district health councils that represent the needs of health users.

20-15 How well has the district health system succeeded in making health services responsible for all people in their area, not just those who are coming for care?

There have been some important successes in providing health for all people in health districts, for example immunisation coverage. However, in most health districts, very little is known about the individuals who live there, what their needs are and what their barriers to care are. Without this information, it is not possible to know how well community needs are met. This information is the first step in providing good, community level primary care.

Because of the many challenges still facing the formation of an efficient district health system there is a need for “primary care re-engineering”.

20-16 What is “primary care re-engineering”?

The limited way in which the district health system has been able to identify and meet needs at community level has been recognised and there is a policy to re-engineer primary healthcare in South Africa. There are 2 main approaches:

• The ward based outreach team
• The district clinical specialist team

20-17 What is a ward-based outreach team?

The most effective people for identifying community level needs are community health workers, who are community members with a basic healthcare training. The plan in the future is to have a ward-based outreach team (WBOT) consisting of 6 community health workers and a primary care nurse. These primary healthcare teams will be responsible for each health (electoral) ward, although more than one team will probably be required for larger wards. They will be responsible for visiting homes, mapping health problems, providing preventative care and health promotion, and providing home based care. How they will fit into the current, district health management structure is not yet clear.

A ward-based outreach team is a team of community health workers led by a primary care nurse that brings primary healthcare to all people in an electoral ward.

20-18 What is a district clinical specialist team?

District clinical specialist teams (DCST) are in the process of being appointed in all 52 health districts. A district clinical specialist team consists of a:

• Family physician
• Primary healthcare nurse
• Paediatrician
• Obstetrician-gynaecologist
• An anaesthetist
• Advanced midwife
• Paediatric nurse

The goal is for each district clinical specialist team to provide leadership, evaluation, support, clinical guidance and governance for district services and, in particular, to improve the care of mothers and children. For example the team should ensure that staff can correctly diagnose and manage common and important problems during pregnancy.

The aim of the district clinical specialist team is to improve the delivery of health services in that district.

20-19 Does primary healthcare involve just managing the “easy” things?

Many people think that primary healthcare involves only prevention, health education, picking up the easy to treat cases such as urinary tract infections and referring other cases. This is not true. Increasingly, doctors and nurses in primary care settings are expected to manage people with complex chronic diseases and difficult social problems. It is important that clinicians in primary care are given adequate support and information to help them manage complex patients.