This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. John E. Ataguba and colleagues illustrate progress towards UHC and its monitoring and evaluation in South Africa. Please see later in the article for the Editors' Summar

Ataguba, John E

Day, Candy

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John E Ataguba

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Monitoring and evaluating progress towards Universal Health Coverage in South Africa.

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Monitoring and Evaluating Progress towards Universal Health Coverage in South Africa

<p>Monitoring and Evaluating Progress towards Universal Health Coverage in South Africa</p

John E. Ataguba (632386)

Candy Day (632387)

Di McIntyre (632388)

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Collection ReviewMonitoring and Evaluating Progress towards UniversalHealth Coverage in South AfricaJohn E. Ataguba1*, Candy Day2, Di McIntyre11Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa, 2Health Systems Trust, Durban, South AfricaThis paper is part of the PLOS Universal Health CoverageCollection. This is the summary of the South Africa countrycase study. The full paper is available as SupportingInformation file Text S1.BackgroundSouth Africa’s colonial and apartheid inheritance is one ofsubstantial social, economic, and health inequalities [1]. Sincethe first democratic elections in 1994, the human developmentindex has declined considerably, largely because of the HIVepidemic, which has reduced life expectancy. The South Africangovernment has committed to a universal health system, whichis seen as critical to improve population health and redressinequalities [2].Universal Health Coverage: The Policy ContextSouth Africa (SA) has a divided health system, with theminority of the population using private health services,particularly if covered by private voluntary health insurance(approximately 17% of the population), and the remainder ofthe population relying mainly on tax-funded health services[1,3]. Many South Africans face health service accessconstraints.A green paper published in late 2011 mapped out policies tomove towards universal health coverage (UHC) over a 15-yearperiod [2]. In the first phase, the emphasis is on investing inimproving access to and the management and quality of publicsector health services, particularly at the primary health carelevel. A range of activities has been initiated, driven by thevery active leadership of the current minister of health. Thesecond phase is intended to introduce a strategic purchasingmechanism, by establishing a semi-autonomous NationalHealth Insurance Fund (NHIF). Although termed a NationalHealth Insurance (NHI), it would be tax funded, throughallocations from general tax revenue and possibly additionalearmarked taxes. It is envisaged that the NHIF will create auniversal entitlement to comprehensive health services, to beaccessed through primary health care (PHC) gatekeepers andfollowing referral routes.Monitoring and Evaluation for UHCAs SA is at an early stage in its UHC reforms, it does nothave an explicit UHC monitoring and evaluation frameworkor system. While there are a number of administrative systems(such as the District Health Information System) and house-hold surveys that can be used for UHC assessment, there areseveral challenges and deficiencies with the data [4]. Datafrom routine administrative systems are frequently inaccessibleoutside of government departments and of questionable dataquality. There are also limitations in terms of equity analyses;most indicators of relevance to monitoring UHC progress canonly be disaggregated by geographic area (province andsometimes district), with few indicators able to be disaggre-gated by other equity stratifiers, such as income and gender.Progress towards UHC in South AfricaGiven that UHC reforms have only recently begun to beimplemented, it is not feasible to assess progress in this regard.We were, however, able to assess South Africa’s status relativeto the goals of UHC, by drawing on some suggestedinternational benchmarks. In relation to service inputs, SA iswell below the WHO’s Service Availability and ReadinessAssessment (SARA) benchmark for inpatient beds (17 beds per10,000 population in SA; 25 per 10,000 recommended bySARA). While SA is slightly above the SARA benchmark forcore personnel (25 per 10,000 population in SA; SARA, 23 per10,000), there are considerable variations in the distribution ofhealth workers among geographic areas. There are alsodisparities across geographic areas in other inputs (e.g., percapita public spending on PHC services), outputs (such asutilisation rates), and health outcomes [4].From a UHC perspective, an indicator of particularimportance is that of health service utilisation, as it providesinsights into the extent to which people have access to care.The SARA benchmarks are five outpatient visits per personand 100 inpatient discharges per 1,000 population per year.Collection Review articles synthesize in narrative form the best availableevidence on a topic. Submission of Collection Review articles is by invitation only,and they are only published as part of a PLOS Collection as agreed in advance bythe PLOS Medicine Editors.Citation: Ataguba JE, Day C, McIntyre D (2014) Monitoring and EvaluatingProgress towards Universal Health Coverage in South Africa. PLoS Med 11(9):e1001686. doi:10.1371/journal.pmed.1001686Published September 22, 2014Copyright:  2014 Ataguba et al. This is an open-access article distributedunder the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided theoriginal author and source are credited.Funding: The paper was funded through the World Health Organization’sUniversal Health Coverage case studies. No funding bodies had any role in studydesign, data collection and analysis, decision to publish, or preparation of themanuscript.Competing Interests: The authors have declared that no competing interestsexist.Abbreviations: SA, South Africa; SARA, Service Availability and ReadinessAssessment; UHC, universal health coverage.* E-mail: John.Ataguba@uct.ac.zaProvenance: Not commissioned; part of a Collection; externally peer reviewedPLOS Medicine | www.plosmedicine.org 1 September 2014 | Volume 11 | Issue 9 | e1001686While overall utilisation rates in SA appear to be in line withthese benchmarks (4.2 outpatient visits and 95 inpatientadmissions in either public or private facilities), Figure 1highlights substantial differences across provinces. Utilisationrates are also lower than the SARA benchmarks for thepopulation dependent on publicly funded services (4.1 outpa-tient visits and 89 inpatient admissions) yet well above thesebenchmarks for those with private insurance coverage (5.5outpatient visits and 139 inpatient admissions) [5]. Disparitiescreated by fragmented funding pools are such that the privateinsurance pool has per capita spending levels that are 6.2 timesgreater than the tax-funded pool [3].Financial protection is also of importance from a UHCperspective. Although levels of impoverishment from out-of-pocketpayments in SA are low (Figure 2), they are far greater in thepoorer than richest provinces.Figure 1. Health facility utilisation rates by province, South Africa, 2008. Outpatient and inpatient utilisation are visits per person andadmissions per 1,000 population per year, respectively. The provinces are Eastern Cape (EC), Free State (FS), Gauteng (GP), KwaZulu-Natal (KZN),Limpopo (LP), Mpumalanga (MP), Northern Cape (NC), North West (NW), and Western Cape (WC). Source: Alaba and McIntyre [5].doi:10.1371/journal.pmed.1001686.g001PLOS Medicine | www.plosmedicine.org 2 September 2014 | Volume 11 | Issue 9 | e1001686Conclusions and RecommendationsTo evaluate a country’s status relative to UHC goals, it is criticalto have UHC-related international benchmarks against whichto compare country data. While some benchmarks have beensuggested recently, more debate and a consensus on a widelysupported set of benchmarks are needed.It is important for SA to develop an explicit UHC monitoringand evaluation system at an early stage of reform implementationto support the refinement of reforms over time. Given itsinheritance of pervasive inequalities, reducing inequalities shouldbe emphasised while moving to UHC. Improvements in informa-tion systems and surveys are required to improve data quality, andto allow for disaggregation of indicators by a range of equitystratifiers. In addition, routine administrative data should be mademore widely available.Supporting InformationText S1 The full country case study for South Africa.(DOCX)Author ContributionsAnalyzed the data: JEA CD DM. Wrote the first draft of the manuscript:JEA CD DM. Contributed to the writing of the manuscript: JEA CD DM.ICMJE criteria for authorship read and met: JEA CD DM. Agree withmanuscript results and conclusions: JEA CD DM.References1. Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D (2009) The health andhealth system of South Africa: historical roots of current public healthchallenges. Lancet 374: 817–834.2. Department of Health (2011) National Health Act (61/2003): Policy on NationalHealth Insurance. Government Gazette 34523. Pretoria: National Departmentof Health, Republic of South Africa.3. Ataguba JE, McIntyre D (2012) Paying for and receiving benefits from healthservices in South Africa: is the health system equitable? Health Policy Plann 27:i35–i45.4. Day C, Gray A (2013) Health and related indicators. Padarath A, English R,editors. South African Health Review 2012/13. Durban: Health Systems Trust.5. Alaba OA, McIntyre D (2012) What do we know about health service utilisationin South Africa? Dev Southern Afr 29: 704–724.6. Statistics South Africa (2008). Income and expenditure of households 2005/2006dataset. Pretoria: Statistics South Africa.Figure 2. Impoverishment associated with out-of-pocketpayments by province in South Africa, 2005/2006. The provincesare Eastern Cape (EC), Free State (FS), Gauteng (GP), KwaZulu-Natal(KZN), Limpopo (LP), Mpumalanga (MP), Northern Cape (NC), NorthWest (NW), and Western Cape (WC). Source: Authors’ analysis ofStatistics South Africa’s Income and Expenditure Survey [6].doi:10.1371/journal.pmed.1001686.g002PLOS Medicine | www.plosmedicine.org 3 September 2014 | Volume 11 | Issue 9 | e1001686

Monitoring and evaluating progress towards universal health coverage in South Africa

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Monitoring and evaluating progress towards universal health coverage in South Africa

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