PANOS London - Monday, May 19, 1997
Janine Simon

"Aah," she says, "there are a lot of patients." Like many others in the health care sector in South Africa, Khanye -- a tuberculosis controlnurse -- knows that when user fees are scrapped more patients turn up for care.

She learned that in 1994, when free primary health care was introduced as part of the new government's ambitious attempt to make accessible and equitable a health system which, by the early 1990s, was noted only for its ability to widen the gap between b lack and white patients.

When the government came to power, headed by President Nelson Mandela, seven times as many black infants were dying as white, with the classic preventable conditions of poverty -- like malnutrition, diarrhoeal diseases and measles -- taking a heavy toll.

Nationally, each doctor had to care for 1,340 patients. But in the ten black homelands some 15,000 people had to share one doctor.

Moreover, two-thirds of the country's total spending on health, and nearly two-thirds of the country's doctors were devoted to a tiny one-sixth of the population -- almost entirely white -- who could afford private care. On top of all this, the state ser vices were concentrated in cities, leaving rural areas unserviced.

Plans to overhaul the system had been brewing for two years in Mandela's African National Congress party. And the first action came within a month of Mandela taking office.

In his state of the nation speech, Mandela declared all health care for children under six and pregnant omen would be free at state facilities and district surgeries. Later, the health policy was extended to everyone at the primary care level -- and beca me law.

The previous fees were small - diagnosis and treatment at Soweto clinics cost eight Rands (1.80 dollars), and income-based fees were as low as R 20 (4.50 dollars) for surgery and hospitalisation. But for the poorest, even these sums were prohibitive.

The policy prompted a rush of patients -- especially children -- in hospitals and clinics across the country. In the densely- populated Gauteng province, for instance, free care saw child outpatient attendance at some clinics almost double overnight befor e levelling off at between 30,000 and 40,000 patients a month.

By the end of 1995, two out of three people in a national survey said they enjoyed easier access to health care, with patients in rural and informal settlements the happiest. The South African Health Review of 1996 said the rise in attendance figures con firmed that user fees in the state sector had been a barrier to health.

Now, harder information is appearing.

Two new midwife obstetric units rendering free services at the Western edges of Gauteng have drastically cut infant mortality and morbidity in the area and vindicated te accessile free primary health care approach, according to provincial health authorit ies.

Nurses at anothr clinic, the newly-expanded Hikensile Clinic in Northeast Johannesburg, provide services to the 5,000 under- fives in the area with pride.

"We've had still-births, but we have not heard of any deaths of preventable disease among children last year," chief community nurse, Nellie Shongwe, said.

But some serious problems have been uncovered following the policy changes.

Medical Research Council staff tracking the impact of the free health care policies in the Hlabisa district of Northern KwaZulu Natal say the population there seems to be so sick, that the demand for cures is rocketing and overstretching the health servi ce.

As a result, its crucial preventive work such as childhood immunisation, care for pregnan women, and HIV/AIDS education is suffering.

"The fine balance between important preventive services, and demand for curative services is in danger of being lost unless more resources are made available," said researcher David Wilkinson.

There also are complaints from the country's renowned academic hospitals which train medical staff. Teaching hospitals, which represent half of all the tertiary-level care in South Afric grumble that they may end up footing the bill of Mandela's free pri mary health care scheme.

The fact remains tht free primary health care will cost the govrnment only about R 680 (153 dollars) million in the coing year -- a tiny proportion of the total health budgt.

But teaching hospitals claim that they provide a considerable amount of primary health care in urban areas -- and they used to be able to charge for that care.

And, in the first two years of the new policy, the teaching hospitals, which are clustered main ly in Gauteng and the Western Cape, took a seven percent budget cut to fund the building of more than 100 primary health clinics.

In addition, the health budgets of Guateng and the Western Cape were slashed as the government shifted money to poor provinces like the North West and Eastern Cape.

With what little was left, the Western Cape and Gauteng provincial governments had to fund both academic hospitals and the shift within their own provinces to create new primary care facilities.

There is another issue at play here -- a legacy of apartheid.

Teaching hospitals in Western Cape and Guateng provinces mostly trained white students and catered to white patients. Mandela, it appears, is trying to undo some of that wrong by shifting resources from urban teaching hospitals to health services in poor provinces.

His critics however say he should have consulted teaching hospitals. (END/PANOS/JS/DDS/97)

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