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Building an equitable health system is a cornerstone of the World Health Organization (WHO) health system building block framework. Public participation in any such reform process facilitates successful implementation. South Africa has embarked on a major reform in health policy that aims at redressing inequity and enabling all citizens to have equal access to efficient and quality health services.
This research is based on a survey using Mxit as a mobile phone–based social media network. It was intended to encourage comments on the proposed National Health Insurance (NHI) and to raise awareness among South Africans about their rights to free and quality health care.
Data were gathered by means of a public e-consultation, and following a qualitative approach, were then examined and grouped in a theme analysis. The WHO building blocks were used as the conceptual framework in analysis and discussion of the identified themes.
Major themes are the improvement of service delivery and patient-centered health care, enhanced accessibility of health care providers, and better health service surveillance. Furthermore, health care users demand stronger outcome-based rather than rule-based indicators of the health system’s governance. Intersectoral solidarity and collaboration between private and public health care providers are suggested. Respondents also propose a code of ethical values for health care professionals to address corruption in the health care system. It is noteworthy that measures for dealing with corruption or implementing ethical values are neither described in the WHO building blocks nor in the NHI.
The policy makers of the new health system for South Africa should address the lack of trust in the health care system that this study has exposed. Furthermore, the study reveals discrepancies between the everyday lived reality of public health care consumers and the intended health policy reform.
In the South African health system, there is a severe divide between the public and private sectors [
The South African health system is characterized not only by a two-tiered system, but also by escalating costs [
The NHI of South Africa seeks to provide universal access to health care, as is promoted by the WHO [
According to Frogner [
A government’s effectiveness is linked to its ability to develop, implement, and enforce measures that ensure the enforcement of policies [
Public consultations not only constitute a civil right in terms of the South African Constitution [
The WHO proposes a “building blocks” framework for health systems strengthening (HSS) [
The study analyzed the views on a health system policy of consumers—as the system’s major stakeholders. Health systems are meant to be complex adaptive systems that aim to provide improved health as well as social and financial protection as they respond to the expectations and current needs of a population [
Despite consensus on the need of HSS worldwide [
Public consultation and participation are valuable tools to draw on in support of the successful implementation of new policies and in order to reduce any disparities between intended policies and everyday lived reality. Up to the present, only a few electronic public consultations related to health policies have been published [
Mobile devices that provide social interaction technology applications are ideal for regions such as South Africa with its low Internet and computer penetration, but high coverage on mobile phones [
The objective of the study was to understand the experiences and perceptions of public health care users regarding the current health care system and to relate these to the intended reform. The six WHO building blocks were employed as an overarching framework for HSS, and a qualitative research approach was adopted by using a theme analysis to illustrate and interpret the survey data.
This paper outlines health consumers’ views of the current system and whether they are congruent with the proposed improvements of the NHI and the six building blocks for HSS. Since findings may be deployed by policy makers to fine-tune implementation of policy and to fill gaps between public concerns and policy reform, they should facilitate the process of the consumer-orientated overhaul of the health system.
Due to the high coverage of mobile phones in South Africa [
The Green Paper was made available on the South Africa National Health Insurance website so as to raise awareness and stimulate public feedback. Mxit donated free advertising for the NHI consultation. An advertisement was sent to 60,000 Mxit users. Nearly 900 participants showed interest in contributing towards the NHI policy. The survey was carried out between November 30 and December 24, 2011. In total, 582 people participated in the survey by submitting answers to the six questions. The questions asked, and their linkage to the six building blocks of the WHO, are illustrated in
Overview of the questions and statements addressing the South African health care consumers in the survey.
WHO building block | Survey question |
Health Service Delivery | The South African Constitution protects the right to health for all people living in SA. Free access to health care services is your right. |
Health Workforce | Do you spend hours waiting in line at the clinic every month? South Africa’s public hospitals/clinics need more staff, for example, nurses, doctors, and pharmacists. |
Health Information | Prevention is cheaper than treatment! The SA government must provide more health promotion and illness prevention education. |
Medicine and Technology | Please give suggestions on how you would like health care services in your community to be improved through the NHI? |
Health Care Financing | In SA, over 85% of the population relies on public health care, while only 15% can afford private health care. Yet each sector has almost the same amount of money to spend! |
Leadership and Governance | Corruption is a major problem everywhere! How can we prevent corruption from happening in the NHI? |
Semi-quantitative analysis.
Building block and related question | Obtained answers | Ranking of major themes |
Service delivery: SA constitution right to free health care | 522 | 1 Good quality of health care provision |
2 Equal health care for all | ||
2 Treated with respect and dignity | ||
3 Trust in government | ||
Workforce: waiting times hospitals and shortage of staff | 534 | 1 Waiting time too long |
1 Improve attitude of staff | ||
2 Improve training of staff | ||
Information: prevention is cheaper than treatment | 496 | 1 Information campaigns (pros and cons) |
2 Affordability of prevention | ||
3 Better education of people | ||
Medicine and technology: suggestions for improvement | 516 | 1 Improved infrastructure |
1 Improved staff performance | ||
2 Accessibility of health care providers | ||
Financing: public versus private health care | 494 | 1 Allocation of funds for public health care |
2 Quality of public versus private health care | ||
2 Affordability of health care | ||
Leadership and governance: Corruption | 524 | 1 Prevention of corruption, law enforcement |
2 Request for reduction of corruption | ||
3 Introduction of ethical standards for health care professionals | ||
3 Emphasis on right job qualification |
A qualitative analysis [
Data were analyzed in the light of the research questions: (1) What are the experiences and perceptions of health care users in South Africa?, (2) How would health care users like to see the system improved under the NHI?, and (3) What are the strengths and weaknesses of the WHO building blocks in the light of the answers obtained from the public consultation?
WHO building blocks of a health system [
The results are linked to the WHO’s six building blocks of a health system. The consumers’ perspectives are analyzed according to whether the claims of health care users are included in the NHI scheme as planned and if these demands are addressed in the WHO building blocks.
Health service delivery is a key element in a health care system and a fundamental contributor to the health status of a population [
The NHI does provide a leadership concept to address the existing inequalities and poor health outcomes in the country as stated by health care consumers in the survey: “Some clinics are dirty and people also suffer from all those germs”, “As South Africans we need to get the right treatment to stay alive”, “They do provide it but the quality is extremely poor”, and “Government must improve health condition in rural areas”. The survey leads the respondents to the matter of human rights, so that some responses read “I have a right for healthy living” or “a healthy country equals to a healthy economy, more jobs are created and less poverty”. Comments such as “the right of health care must be provided by public institutions and not by private ones” or “If it is a free medical services why do we have to pay medical expenses at hospitals?” expressed the view that government is responsible for providing health care for free without charging service fees. Critical voices raise the concern: “What is a right when you are treated with no respect and humanity”, “How reliable is the confidentiality between the patient and the health practitioner?”, and “It is true, but the government still lacks to find people who really care about our health and who do not judge”.
According to the WHO, accountability involves enforcement, such as the imposition of sanctions, the provision of rewards for performance, performance around the actual supply of services, evaluation and monitoring of performance, and financing to ensure that adequate resources are available to deliver essential services [
The NHI demonstrates leadership and governance by emphasizing existing inequalities and how to overcome them in a certain timeframe. Yet an existing lack of confidence in the health system is expressed by the respondents: “This statement is our right but I find the government is failing to do this” and “It is a right but everybodies rights are being abused”. This failure of trust will have to be remedied.
The workforce is a key element in a health system. It is defined as “people engaged in actions whose primary intent is to enhance health” [
The analysis of responses revealed that the attitude and training of the health workforce as well as the waiting time are major concerns. The attitude of employees regarding their workplace environment relates to the emotions, level of satisfaction, and their overall outlook. It is often directly related to a high or low level of morale in the workplace. Respondents targeted different disciplines: administration (“The receptionist must always be there”), doctors (“Doctors are more occupied with their own affairs than to treat patients”), and nurses (“The rude treatment [by] the nurses is unethical”). Nurses are more widely discussed, probably because respondents have more intense contact with nurses than with other staff members. The responses express the desire for a more patient-oriented service. From some of the respondents’ points of view, the staff seem to be more focused on their own affairs than on reacting to the patients’ needs.
A good health outcome is largely dependent on the knowledge, motivation, and skills of the health care workforce [
A number of responses relate to the training of staff as in the following quote: “Nurses should be trained to take care of patients”. Health care users insist that staff have to receive proper and regular training to fulfill their duties. They also believe that only health workers with a high level of job satisfaction can deliver the best outcome for patients: “The government should keep health workers happy”. Other statements, such as “Health care service is insufficient and [so is] the level of training of health care workers”, suggest that South Africa is not investing enough money to train health professionals and needs to upgrade the quality of service [
The importance of waiting times for the health care consumers is underscored by the following two quotes: “In public sector patients wait over 12 hours”, and “I never spend less than 4 hours in a clinic”. Different explanations are given for lengthy waiting times: “Long waiting time due to break time for staff”, “The waiting time is too long because the shortage of staff”, and “Long waiting time because everything is free”.
Yet a few respondents report no waiting time. As the data were anonymized, we do not know if this applies to private or public facilities or if the respondents live in a well-serviced area. Waiting times between 4 hours and 12 hours and more are not acceptable to health care users, especially when people are severely sick and urgently need attendance and treatment [
Interestingly, health care consumers asked for the implementation of ways to improve treatment efficiency. Separate queues for different diseases are suggested: “for eg influenza in the winter, HIV and TB”. Related to this matter of efficiency, triaging scales are not mentioned as a tool, in the NHI or in the WHO building blocks. Yet they could prove useful in reducing waiting times for severely sick patients and offer more rapid and adequate treatment [
According to the NHI guidelines, managers should be allocated the necessary authority to achieve planned objectives and should also be held accountable for overall performance and results [
The attitude of the staff is addressed in the Green Paper of the NHI, where it is portrayed as less service- and patient-oriented than is desirable [
Clearly the delivery of health care service through the health workforce needs improvement and scaling up, but it remains traditionally driven, with a paternalistic approach [
The NHI aims to establish a higher quality of service through compliance with the Office of Health Standards: “It will have three units, namely: inspections, norms and standards [...]. It will set norms and standards and undertake the inspection of all health facilities” [
To estimate if the number of health professionals is adequate, a more thorough analysis must be done by calculating the number of health workers available in a region relative to the total population. The WHO recommends at least 23 health care professionals (physicians, nurses, midwives) per 10,000 people for selected primary health care interventions [
In the relevant WHO building block, high-quality health services are mentioned, centered on the patient’s need and given in a timely fashion [
The survey question, “Prevention is cheaper than treatment! The South African government must provide more health promotion and illness prevention education”, is linked to the theme of health information. Analysis revealed a number of concerns: affordability (“Prevention should be affordable”), government involvement (“The government is doing enough but the people are ignorant”, “The government is not doing enough”), and the need for a better information policy (“People have less knowledge about prevention”, “The government must try hard to inform the people comprehensively”). Youth are also a matter of concern (“Most of the youth is illiterate”, “Teenagers do not use condoms”).
For people coming from a lower socioeconomic background, resources for obtaining information are scarce. Consequently, they have to rely on whatever information is provided by the municipality or government. Health care users should have access to reliable, usable, understandable, and comparative data and information [
Affordability for the sake of prevention was raised by the respondents. The provision of prevention must be offered based either on the individual’s ability to pay or be free of charge [
According to the NHI Green Paper [
Participants also conveyed their belief that “the government is doing enough to educate the people”. They point out that a range of prevention programs has been carried out, but people still do not behave accordingly. Hence, they conclude that people cannot be educated and prevention campaigns are a waste of time and resources. Comments like these should sensitize the government to the need to demonstrate the results of prevention campaigns by publishing and advertising data about achieved goals [
The question “Please give suggestions on how you would like health care services in your community to be improved through the NHI” was related to the building block for medicine and technology. Analysis of responses revealed the respondents connecting primary and secondary health care (“24 hours emergency ambulances and emergency rooms”), recognizing intersectoral health care (“Government must provide educated social workers”), and special care (“Employ counsel[l]ors”). They envisage health care through the life course with improved accessibility (“A bus service for pensioners”), besides hospitals’ diverse health care settings (“Provide a nurse at each school”), and improvements in existing services (“ambulances must better work together and be better organized”), and staff performance (“By training the nurses to take good care of patients”, “Would like the nurses to work with their hearts”).
They requested the scaling up of services and medication availability (“Enough medication in hospital is needed”). Even intersectoral cooperation between public and private health care providers was suggested to achieve a better quality of care (“private doctors should work together with normal doctors”).
The maintenance of hospitals and “cleaner hospitals” are frequently mentioned together with the demand for a broad scaling-up initiative of health care facilities. Responses focus on existing clinics (“Better care and longer opening hours”), mobile clinics (“Providing everywhere mobile clinics”), as well as new facilities (“More hospitals are needed because public and private hospitals are full”). Access barriers emerge as another topic: “People in rural areas are not taken care of”, “There is no clinic close to them and there is a lack of water and electricity”, and “A basic health care facility should be in every community”. These demands refer to the need for capacity enhancement [
The respondents expressed wishes similar to those of patients from developed countries, such as the United Kingdom [
Most of the public health care consumers’ requests are taken up in the NHI and the WHO building blocks. Under the question “suggestions”, people asked for better access to basic medicines and adequate equipment. Also requested were additional service provisions such as mobile ambulances and better logistics such as the management of ambulance vehicles.
A well-functioning health system ensures equitable access to essential medical products, vaccines, and technologies [
The mismatch of resources between private and public sectors is addressed in the question regarding health care financing and is also elaborated in the Green Paper of the NHI [
The consumers surveyed for this study describe the purpose of public health care as follows: “Public health care is important for poor people who cannot afford private health care”. Responses touched on matters of affordability (“A lot of people cannot afford health care”), equality (“If the quality of the health care would be equal, no private health care would be needed”), and funding (“money for the public sector should be reallocated”). The service quality of private health care is regarded as superior to public health care (“People that can afford private health care get better services and are treated better”, "Private health care has a higher standard. So most people do prefer it”, “Public health care has always been a mockery to us because of its poor standards”).
Concerning out-of-pocket payments and service fees
The implementation of the NHI should achieve universal coverage, aiming to allow health care users the access to affordable health care services [
The topic of equality was raised concerning income groups, disease groups (HIV- not HIV-infected), and public and private health care providers having an unequal distribution of financial and human resources. The separation of funds between private and public health care and the contribution to the health care system, depending on personal income are discussed in the survey. Some of the respondents stated that they were not aware of the huge difference in health care expenditures between the private and public sector (“Did not know before how funds are spent”). They requested that people be informed about the existing differences and how to overcome them. Some respondents said that “we all have to get private health care”, as the quality of private health care is considered to be better than in the public sector.
This becomes evident in statements such as “The government should improve the standards for public health care”. Reasons for this, among others, can be seen in the underfunding of public health care: “The public health care does not get enough funds” and the fact that more professionals per patient are working in the private sector than in the public sector [
According to the WHO, health financing refers to the “function of a health system concerned with the mobilization, accumulation and allocation of money to cover the health needs of the people [...] to ensure that all individuals have access to effective public health and personal care” [
The WHO, defining the role of the government and the relationship of other actors in order to protect the public interest, describes it as stewardship [
Health care consumers were asked how to prevent corruption in the health system and their responses raised concerns regarding the corruption they are experiencing. They said, for instance, “Reduction of corruption is necessary”
According to the study’s results, a new ethical approach for those employed in the health care sector should be introduced, with its stated values demonstrating a high standard of ethical commitment. Some respondents commented that the current state of the health system mirrors the corruption taking place in government: “Prevention by starting at the government”, “Hire qualified people and not politicians”, “Eliminate nepotism and corruption will disappear”, and “Hire people who know the job and are not your relatives...in this corrupt system of government”. A lack of trust in government emerged, thus indicating that it is believed that a change in society would have to take place [
The participants asked for the employment and selection of people who were more honest. In order to make people accountable for their actions, they suggested additional audits to expose corruption. The responses display a clear understanding of what actions health care users expect to be taken to address this problem. The majority expressed the feeling that corruption could probably be reduced if the necessary steps were taken but that it cannot be eliminated.
The Green Paper of the NHI does not explicitly address corruption, and consequently, there are no measures described to deal with it. The reform of governance, the autonomy of hospital management as well as overall and individual accountability are mentioned, but outlines on how to provide more efficient supervision of staff and management are missing. Ethical values might be included in the final bill, but it is vital to also incorporate means to reduce corruption, improve surveillance, and to hold individuals to account since corruption is regarded by consumers as a serious problem in the SA health system.
The analysis of the answers to the survey answers revealed a public request for improved service efficiency, equity, affordability, and equal allocation of resources between the public and the private sector. These findings substantiate the need for reform and fit with the aims of the NHI. The current state of the health system is described from the patient’s perspective as neither accountable nor efficient. There is a shortage of medicines, uneven distribution of health services, and poor availability of equipment and of intersectoral services. Basic service management appears to be inadequate. The respondents in this study are concerned about the quality of care they are receiving. In general, people judge the quality of care to be better in private hospitals with quicker treatment and less waiting time. The staff in private health care is described as being better organized, more attentive, and more patient oriented in comparison to staff in public health care.
The expectations of health care users are in accordance with those of other countries [
The WHO’s six building blocks identify the key elements of a health system to strengthen health systems. They should lead to improved health, equity, responsiveness, social and financial risk protection, and more efficiency. These building blocks were used as a lens to analyze responses and relate them to the reform of the South African health systems. However, while a health system embraces all organizations, institutions, resources, and people whose primary purpose is to improve health [
The building blocks provide a description of tools that are necessary to strengthen health systems; however, they provide no outline of the soft skills and measures such as values and norms. This is the underlying capital on which a health system runs efficiently and successfully. Each country is asked to implement these soft skills and norms. From the consumers’ perspective, soft skills, interaction techniques, and training of health care professionals need improvement in South Africa. The application of measures for monitoring performance would also prove helpful in enhancing overall performance. Public consultation processes are not often applied in health policy processes, although they constitute a civil right in terms of the South African constitution [
Some limitations arise regarding the study design: the survey is not representative of the South African population as Mxit is mainly used by a younger population (average 15-35 years) with a different race stratification than in the South African population. For example, there was a higher number of colored people (colored is one of four population groups used by Stats SA, with the others being black African, Indian/Asian, and white): 26% colored people as Mxit users versus 8.9% of the total population. We have no insight into the number of different races that participated in this survey.
The data obtained in the survey of the People’s Health Movement are useful for further studies and provide insight into the public’s views.These data have been used according to Robson [
disability adjusted life years
health systems strengthening
non-governmental organization
National Health Insurance
South Africa
World Health Organization
The authors would like to thank Cell Life, Cape Town, South Africa, and in particular Dr Victoria Nembaware for generating the dataset and her dedicated work to realize the electronic survey. In addition, the authors thank Mas’ud Parker for the information he provided on Mxit and Prof Leslie London for his support.
None declared.