FROM THE EDITOR

Strengthening our health system

Bridget Farham

On 19 - 20 October this year, politicians, academics and leaders in the healthcare world came together for the Presidential Health Summit. South Africa (SA) is in the process of reforming its healthcare system by implementing universal health coverage for all citizens. However, this process has not run smoothly for a number of reasons, some of which look, from the outside at least, like a result of poor planning, with financing far from sorted out and a poor understanding of how exactly the system will be implemented in practice and deadlines constantly (and probably thankfully) being pushed out.

We have a two-tiered health system in SA - the public and the private sectors. The private sector has grown from being a complementary service provider in the 1960s to a significant source of funding and delivery in healthcare since 2000. Whatever you think of private healthcare philosophically, this massive rise in significance speaks volumes about what has happened to the public health system over this time. The private sector is bedevilled with problems - unaffordable prices, maldistribution of providers and facilities, perceptions of over-servicing and perverse incentives and lack of accountability, identified in the draft report of the Health Market Inquiry in July this year.^[1] But for all this, the private sector is perceived as providing better quality healthcare, which, as the Health Market Inquiry showed, may or may not be the case. We simply do not know the outcomes of privately provided healthcare - they are seldom measured.

On the other hand, the public sector has clearly deteriorated badly in the past 20 or so years as a result of poor governance structures, inadequate management capacity and administrative systems, underfunding, human resource shortages and maldistribution, inadequate and poorly maintained infrastructure and equipment, poor information systems, and overall inefficiencies and wastage in the system - and, in my opinion, a complete lack of political will to oversee, monitor and maintain what was, apartheid notwithstanding, a pretty robust public health system up until 1994. Sadly, the evidence of this neglect is everywhere, and is documented in reports such as successive Saving Mothers reports, much of it outlined in the CME section of this issue of SAMJ.

SA now faces a quadruple burden of disease: HIV/AIDS, tuberculosis and sexually transmitted infections; maternal and child morbidity and mortality; non-communicable diseases; and last but by no means least, violence, injury and trauma. The burden on our struggling healthcare sector is huge and is not going to become any less as our population continues to grow and our economy continues to decline.

The purpose of the Presidential Health Summit was to provide an avenue to bring together key stakeholders from different constituencies and to discuss and propose solutions to address what is rightly regarded as a crisis through an inclusive process. Encouragingly, the summit, while recognising the centrality of National Health Insurance, also recognises the combined roles of the public and private health sectors in meeting the goal of universal health coverage in SA.

It is easy to remain critical of these talk shows and cynical about outcomes. But the fact that we now have government recognising and talking openly about 'healthcare in crisis' means that political will is finally there. I hope! Let's go into 2019 each determined, in our own way and through the means available to us, to be part of the solution.

Bridget Farham

Editor

ugqirha@iafrica.com