Equity in national health care: A citizens reflections on South Africa

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Equity in national health care A citizens
reflections on South Africa

• Dr Susan Cleary
• Health Economics Unit
• University of Cape Town
• International AIDS Conference
• 2008

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Background
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• South Africa has 17 of global HIV burden
• Worlds largest treatment programme, BUT
• Delays in starting ART
• Ongoing issues of AIDS leadership or political
  will
  
• Disputes about efficacy/toxicity of treatment
• Battles between civil society, academia and
  government
  
• Diverting energy from responding to the crisis

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SA HIV-treatment strategy
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• Prior to 2003/04
• Programme of treatment and prophylaxis of
  opportunistic and HIV-related infections
  
• Likely that coverage very low
• Operational Plan 2003
• First and second line ART for those with CD4cells/ml or AIDS
  
• Target of universal access to ART by 2009
• Subsequent denial of target by National
  Department of Health
  
• National Strategic Plan 2007-20112
• Universal access only by 2011
• By 2007 only 20 of new need met through ART

South African National AIDS Council (SANAC) HIV
AIDS and STI Strategic Plan for South Africa.
(2007) Pretoria. p. 1-136.
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SA HIV-treatment context
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• HIV treatment
• A classic example of resource allocation in the
  face of highly constrained budgets
  
• A new disease primarily affecting prime age
  adults
  
• Additional 0.5 million need treatment annually
• Effective scale-up means South Africans on ART
• Not about marginal changes to an existing
  programme
  
• Investments in infrastructure (health facilities,
  drug procurement and delivery systems)
  
• Training of health personnel (formal and
  on-the-job)
  
• Without careful long term planning
• ? Achieve equitable access
• ? Sustainable

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Financing1
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• 7.7 GDP in 2005 spent on health care
• Comparable to developed countries high compared
  to countries of similar development
  
• BUT Massively unequal distribution of resources
• In terms of overall funding
• Majority poor (approx 85) access public system
  US200 per annum
  
• Minority rich (approx 15) access private system
  (via health insurance) US1,260 per annum
  
• In terms of human resource distributions
• 1 general doctor per 590 in private sector versus
  1 per 4,200 in public sector
  
• 1 specialist per 500 people in private sector
  versus 1 per 11,000 in public sector

McIntyre D, Thiede M et al (2007) A critical
analysis of the current South African Health
System Health Economics Unit and Centre for
Health Policy, Cape Town and Johannesburg. p.
1-99.
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Majority HIV-positive dependent on
resource-constrained public health systemmajor
implications for scaling up ART
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Costs and outcomes (discounted 3 annually)
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SA GDP per capita US3,000 per capita
Cleary S, McIntyre D, et al. (2008). Assessing
efficiency and the costs of scaling up HIV
treatment AIDS 22 (suppl 1) S35-S42.
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Costs of universal access to ART
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Annual aid flows from GHIs US 10 billion per
annum
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Costs of universal access to ART
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One-third PUBLIC health system spending
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Costs of universal access to ART
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One-third TOTAL health system spending
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Thinking of the next 10 yearshow should we
prioritise?
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Spending one-third public health system
resources on first and second-line ART
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10 m
100
9.4mil
80
Million QALYs
Coverage
13
But we could do better by limiting individual
gains to first-line only
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10 m
100
9.4mil
9.7 mil
80
93
Million QALYs
Coverage
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But we could do better by limiting individual
gains to first-line only
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13 higher coverage 600,000 lives
Another 0.35 million QALYs
10 m
100
9.4mil
9.7 mil
80
93
Million QALYs
Coverage
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If we could draw on the entire health system
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• 16 of total health system resources would
  achieve universal access to first and second-line
  ART
  
• Equitable implementation of more effective models
  of care could be a reality
  
• Starting ART earlier
• Third-line/salvage treatment
• Food support
• Improved quality of care of health system?

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Conclusions
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• Health system, as a social institution, is a
  barometer for the level of solidarity in a
  society
  
• Limited discourse about inequalities between
  public and private
  
• New emphasis on National Health Insurance
  heartening
  
• Equitable access to HIV-treatment depends on the
  extent to which private resources can be
  harnessed