More than over three decades of Alma Ata PHC declaration, the goal of health for all remain elusive in many countries of Sub – Saharan Africa and a wide gulf exist within and remain in countries such as South Africa. The 1978 Alma Ata declaration underlies the importance of PHC and informs the need for actions to be taken by governments so as to promote the health of the world population. The declaration expressly stated an overall philosophy, strategies for organizing and strengthening the health system, guided by the principles of equity, social justice and health as a right to all. South Africa like any other developing nation faces a wide variety of health-related challenges. The afflictions of waterborne illness and nutritional deficiency are some of the challenges affecting low income communities in the country. Vaccine-preventable diseases impact negatively on the lives of millions of people as well as infectious diseases such as tuberculosis and HIV and AIDS. Thus, it is imperative that in order to improve the health outcomes of a country such as South Africa, social determinants of health should be improved coupled with the standard of living.
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The health system facing developing countries are not only great, the capacity and the wherewithal to address those challenges are lacking and not readily available in most cases. Efforts should be geared towards strengthening the health systems through the provision of adequate resources that should include both human and financial resources. In reality, resources would never be enough to strengthen the health systems, but there is a need to maximize the available resources to bolster the health systems so as to make them operate more efficiently. The only way to ensure that health systems work efficiently is to have a reliable data on its performance. In this way, interventions could be devised and executed based on the results of the data. It is pertinent to say that the data provided should be timely and accurate so that intervention provided could be measured.
Since the advent of democracy in South Africa, efforts have been made to improve and strengthen district health system and primary health care. These efforts include structural and policy changes, removing access barriers through the delivery of free primary health care, the enactment of national health act and execution of priority health programmes. It is pertinent to say that these interventions have made access and care available to the majority of South Africans, the early giant stride have been compromised by South Africa’s burden of disease, lack of management skill, low morale among staff of the health department, and structural defect between policy intentions and outcomes.
The commitment to overhaul the health system made the health minister undertook a visit to Brazil in 2010 with the intention to improve primary health care services. The aim is to address the South Africa’s disease burden, improve health outcome, access and affordability while ensuring responsiveness to the needs of the population. In the light of the visit made to Brazil, a comparative assessment of the health system in Brazil and South Africa will be conducted.
The Brazilian Context
In Brazil, health is a constitutional right and responsibility of the state. After the so called “Big Bang” legislative reform of the new Federal constitution in 1988, the National Health System and the Family health programme were implemented incrementally over the next 20 years (Pan American Health Organization; Health systems and services Profile Brazil. Brasília, D. F., Brazil: Pan American Health organization, February 2008). The Brazilian national health system (Sistema Unico de Saude or SUS) is organized on the principles of universal access, comprehensiveness, decentralization, hierarchization, and community participation. This encompasses public health in general and health care delivery services to individuals.
To execute the lofty programme of the SUS, the Family Health Programme (Programa Saude da Familia, PSF) was created in 1994 and become the national strategy in 2006. The PSF follows a community concept while laying emphasis on the establishment of a close relationship between the health care providers and the community. It serves as a common portal of entry for all primary health programmes and is formed on the beliefs that will ensure continuity, total care and coordination of the health care services. Considerable improvement has been seen in Brazil’s public health in the past decade. These improvement are particularly noticeable in maternal and child health. There is also increase in life expectancy while infant and mortality rates are on the decline. There seems to a pointer that al health millennium development goals will be achieved. It is worth saying that effective steps have been taken to address poverty while improving social determinants of health in once the most unequal country in the world.
A brief description of the Brazilian health care context
A health care reform aiming at achieving equity represented an extraordinary challenge for a country the size of Brazil, with a population of more than 180 million and significant social, economic, cultural, and environmental diversity. The federal constitution of 1988 was enacted after years of militarism. It defined three pillars of health care reform; health as a broad concept that goes beyond the absence of disease; health care as a right of citizens and a duty of the state; and the establishement of the National Health system, the SUS. (Paim JS, Health care reform in Brazil, contribution for comprehension and criticisms. Salvador, Rio de Janeiro. Brazil: Edufba/Editoria FIOCRUZ, 2008).
In Brazil, while public health is provided exclusively by the public sub-sector, individual care is provided by a public-private mix. The public sub-sector has two segments: the SUS for the whole population and another segment whose access is restricted to public employees (civilian and military), and is financed by public resources and contributions from beneficiaries.
Principles and development of the National Health System in Brazil
In the last 20 years the Brazilian health care system has achieved outcomes in realizing its principles. At a glance, universal access and decentralization have been identified as the most implemented principles. Community [articipation has brought about important results. However, the expected social accountability of the health system remains doubtful. Hierarchization, in a nutshell regionalization and coordination among services, has been reinforced since early 2000 and emphasized by the present government. In terms of the universal access the public system offers health care services on a massive scale. In 2006, it provided nearly 2.3 billion outpatients procedures, 300 million medical consultations and 12 million hospitalizations. (Pan American Health Organization. Health systems and Services Profile Brazil. Brazilia, D.F, February 2008).
The growth of a national primary care strategy, the Family Health Programme has demonstrated good outcomes in improving access expecially for the poor. (Rocha R, Soares R. Evaluating the impact of community Based Health interventions: evidence from Brazil’s Family Health Programme. Bonn, Germany: Institute for the study of Labour (IZA), April 2009. For instance, the last national household survey, done in 2008, showed that among an expected 57.6 million households, 27.5 million declared they were enrolled in the Family Health programme. (2008 National Household Survey: An overview of Health in Brazil. Access and utilization of services; population health status; risk factors and health protection) Rio de Janeiro2010).
The development of PHC delivery model
The Family Health programme was initially proposed as an addition to the community health workers programme that had been running in some states of Brazil. The FHP was first officially implemented in 1994 and was based on municipal experiences in experimenting with alternatives to traditional basic care. The establishment of the teams has been the responsibility of the municipalities. However, when the programme begun municipalities as providers received financial resources from the federal government for the maintenance of the team based on a fee for service compensation model.
In 2006 the programme received an important upgrade. The National policy of primary care (PNAB) was published by the ministry of Health, amplifying the PHC concept and scope. (Ministry of Health B. National Primary Care Policy. In: care DoP.Vol. 4 ed. Brasilia, DF, 2007). The family health units (FHU) are under the responsibility of the municipalities. In order to ensre access the PNAB recommends that one family health units with three or four Family Health Teams (FHT) be responsible for PHC provision for a maximum of 12,000 inhabitants of the territory for which it has responsibity.
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However, in a high population density urban areas, this is not always a reality. For rural areas with low density, this number is smaller because teams are distributed in order to facilitate access for dispersed populations. Each FHU must be located within its territory or responsibility.(Ministry of Health B. National Primary Care Policy. In: care DoP. Vol. 4 ed. Brazilia, DF, 2007). All the team members in the programme are required to work full time, but this is not a reality throughout the whole country. According to Barbosa, (2009) only 62% of doctors and 82% of nurses confirmed the work full time nationally. These professionals often work in other settings of the public health care system as well, or sometimes in private practice.
Additional profesionals may integrate with these teams according to the health needs of the local population and the decision of the municipal manager in agreement with the municipal council. In 2007 the federal heath ministry began financing a support group of 5 professionals for every 8 to 10 family health teams including psychologists, social workers, physiotherapist, speech therapist, paediatrician, gynaecologists, homeopathic doctors, psychiatrists, acupuncturists, and physical educators. (more health; a right for all 2008 – 2011. Brazilia; DF Brazil, 2008). The municipal government has to find a better match for the local level needs according to the availability of profesionals
Outcomes and Impact of the Family Health Programme in Brazil
The oucomes and the impact of any programme can be evaluated in several dimensions. The Brazilian health sysystem could be analysed based on starfield’s proposed dimensions: access and first contact, ensuring the principle of of universal care of the system; innovation in the health care provision, ensuring the comprehensiveness and longitudinal of care; and the promotion of equity in health indicators. The expansion of the programme has been remarkable in terms of meeting the ministry health’s goals. In December 2009, the programme got to 30328 teams and 234 767 community health workers covering over 100 million inhabitants in 5349 municipalities in all region of the country. (Ministry of Health B. Department of Primary Care Website Brazilia2012).
It is worth saying that one of the key components of the Brazilian heal system is public support. Studies conducted in different part of the country comparing traditional basic units and Familiy health units shows higher user satisfaction with family health units.(Macinko J, Almeida C, de Sa PK. A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil Health Policy Plan 2007). The coverage extension has moved closer to ensuring universal access to the health system as mandated by the Brazilian constitution. The changes to the teams’ work practices have enhanced comprehensiveness by putting together primary care, public health and health promotion activities. (Peres EM, Andrade AM, Dal Poz MR, Grande NR. The practice of physicians and nurses in the Brazilian Family Health Programme: Hum Resou Health 2006;4:25).
Studies evaluating the family health programme using the infant mortality rate, with ecological designs have shown positive effects on reduction of infant mortality rate. (Aquino R, de Oliveira NF, Barreto ML. impact of the family health programme on infant mortality in Brazilian municipalities; AM J Public Health 2009 ;99(1):87-93). Even though the results are very promising at the national level, there are significant discrepancies between provinces and municipalities. These may suggest the need to better understand the keey components of the programme that are responsible for the results.
Comparative assessment with the South African System
South Africa health system has evolved over the past decade. From a 5 year planning frameworks since 1994 to consolidation of the health system while making substansive inputs to resolving the human resource issues. Although, capacity building programmes for managers were initiated, the bulk of the health professionals other than nurses works in the private sector. This is slightly different from the brazillian context in which majority of health care practitioners are fully involved in the Family health programme.
Primary health care system has always been the focal point of the health system in South Africa over the past decade. A lot of efforts has gone into implementing the programmes in all the pronvinces of the country. Racial and gender bias had been largely eliminated coupled with the provision infrastructues to deal with the burden of the South African disease.Unlike the Brazilian model, sufficient attention has not been paid to its implementation. This includes provision of holistic comprehensive health care services to the communities, emphasizing disease prevention, health promotion and community participation. The Brazilian health programme had been population focussed unlike the South African model. Services has not been taken to the people. Adequate attention has not been given to health measurement outcomes. In other words there has been no basis for improvements coupled with the outbreak of HIV epidemic in the Sub-Saharan Africa.
The district health sysystem has been the focal point through which Primary health care is delivered in South Africa. It comprises of the district hospital, community health centre and clinics with each of those set up having its own target population. The ideal scenario is for each clinic to have its own PHC team the will render services to both the clinic and the community. Faclities should be supported by specialist support teams to cater for the needs of the population. As part of delivering health care, it has been recommended that the district health management team purchse the services of some private health providers where these services are not available to the public sector.
It is a known fact that there has been success stories of the primary health care system. Brazil has been a success story. There has been dramatic improvement in the health oucomes of Brazil compare to that of South Africa. There is a poor health indicators outcomes in the South African health system compared to the resources been invested. This may be due to the overwhelming impact of HIV and AIDS.
Brazil health care system in a three tieir federation comprising of the federal government, state and municipalities. The unified health system is founded on the principles that health is a right and state duty. It is founded on the basis of universal coverage, care and equity which allows most of the population to be covered. The Brazilian health system in not all smooth sailing. Issues such as high cost, scarcity or resources heve bedevilled the system. (Celia R. P. and Ana C. P. G., Human resources for health and decentralization policy in the Brazilian health system, Human Resources for Health, 9(12) (2011).
While South Africa is one of the most developed economies in Africa, its primary health care programme has followed a traditional approach from top to bottom. Unlike Brazil, there are two policies implementation by PHC. There is universal access to health by all South Africans and provision of free health care for pregnant women and children. There are gaps in the implementation of the South Africa Primary health care programme. This gap include migration of health care professionals, lack of resources, the skewed distribution of personnel in public and private sector, lack skill and low morale among staffs coupled with the absence of managerial expertize. (Heunis J. C., Van Rensburg H. C. and Claasens D. L., Assessment of the implementation of the implementation of the primary health care package at selected sites in South Africa. CurationSIS, 29, 37-46 (2006).
In most rural areas of South Africa, health system are not readily availavailable and where it is available, it is purchased at high exhorbitant cost. (De Jager J. and Du Plooy T., Service quality assurance and tangibility for public health care in South Africa, Acta Commercii, 7, 96-117, (2007). One of the challenges facing South Africa health system includes lack of financial resources, dedication of staff implementing the programme, lack of material commitment, How to change management practices, community participation and munltisectoral collaboration. In view of this, there is a need for health system re-engineering
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