The shift of resources from hospitals to primary health care

14 June 2016

The purpose of this brief is to evaluate the shift of resources to primary health care services in accordance with the White Paper on National Health Insurance. Expenditure on primary health care and hospital services using the 2015 and 2016 national budget and the 2015 provincial budget is considered. These sources provide information on actual and projected expenditure from 2011/12 to 2017/18.

District health services in each province of the country provide primary health care (PHC) services as well as district hospital services. PHC aims to reduce the burden of disease and provide quality care. PHC is central to the implementation of National Health Insurance.

PHC has the following sub-programs within districts:

- Community Health Clinics: offers a nurse driven primary health care service at clinic level including visiting points and mobile clinics.

- Community Health Centres: offers primary health service with full-time medical officers based on mother and child, health promotion, geriatrics, occupational therapy, physiotherapy, psychiatry, speech therapy, communicable diseases and mental.

- Community based services: Offers a community based health services at non-health facilities in relations with home based care, abuse and victims, mental and chronic care, school health and so on.

- Other community services: Offers environmental, port health and part-time district surgeon services.

- Nutrition: Offers a nutrition service directed at specific target groups and combines direct and indirect nutrition interventions to address malnutrition.

Hospital services, on the other hand, are classified into three levels:

1. District Hospitals

2. Provincial Hospitals, which provide accessible and appropriate hospital services including a specialized rehabilitation service and offer a platform for training health professionals and for research. Provincial hospitals are of three types: General/regional hospitals, tuberculosis hospitals and psychiatric hospitals.

3. Central Hospitals, which provide tertiary health services and create a platform for the training of health workers, and serve as specialist referral centres from provincial and district hospitals..

The graphs below represent the real expenditure per capita on primary health care and hospitals with 2014/15 as base year, as well as the ratio of expenditure on PHC to expenditure on hospital services.

Figure 1 shows that real expenditure per capita by the government on primary health care increased from 2011/12 to 2015/16. It is expected to be stable for the next two years. Real spending per capita on hospital services increased gradually from 2011/12 to 2014/15. It is expected to drop between 2014/15 and 2017/18.

The White Paper on National Health Insurance (2015) describes the four streams of primary health care re-engineering that are being implemented. These are: the municipal ward-based Primary Health Care Outreach Teams (WBPHCOT), the Integrated School Health Programme, district clinical specialist teams, and the contracting of private health practitioners at non-specialist level.

The WBPHCOTs are in charge of a given number of households in a municipal ward. The outreach team will be connected to a primary health care facility. The community health workers will evaluate health status of people in the households and provide health promotion education. They will also identify individuals in need of preventive, curative or rehabilitation services and refer them to relevant primary health care facility.

The integrated school health program (ISHP) provides health promotion, preventive and curative services, focusing on examining the health-related barriers to learning such as vision, hearing, cognitive and development impairment. The school services are provided to improve the physical, mental and general well-being of children. 70 school mobiles have been deployed by the department in all pilot districts to provide general oral health services, eye health and audiology services. The ISHP will be expanded beyond the pilot district in the next phase of implementation.

District clinical specialist teams (DCST), have been appointed to improve capacity building and mentorship and 228 health professionals have been delegated to do this task. In the next phase of implementation provincial specialists in obstetrics, gynecology and pediatrics will be appointed in provinces that have not yet appointed them.

The contracting of general practitioners to provide PHC at clinics located within the pilot district was implemented in the 2014/15 financial year, and this will be expanded to include other health specialists such as audiologists, optometrists, speech therapists. Pharmaceutical services will be contracted to facilitate the access to medicine in community pharmacies, churches and schools.

There is a sharp mismatch between the goals of expanding PHC and the static real resources per capita for PHC in the next three years. Hospitals will be under pressure as real resources per capita decline. Slow growth and fiscal austerity are taking their toll on improvement of publicly provided health care.

Agathe Fonkam is a Researcher at the Helen Suzman Foundation.

This article first appeared as an HSF Brief.