Search

Background: National Health Insurance (NHI) is currently high on the health policy agenda. The intention of this financing system is to promote efficiency and the equitable distribution of financial and human resources, improving health outcomes for the majority. However, there are some key prerequisites that need to be in place before an NHI can achieve these goals., Objectives: To explore public perceptions on what changes in the public health system are necessary to ensure acceptability and sustainability of an NHI, and whether South Africans are ready for a change in the health system., Methods: A cross-sectional nationally representative survey of 4 800 households was undertaken, using a structured questionnaire. Data were analysed in STATA IC10., Results and Conclusions: There is dissatisfaction with both public and private sectors, suggesting South Africans are ready for health system change. Concerns about the quality of public sector services relate primarily to patient-provider engagements (empathic staff attitudes, communication and confidentiality issues), cleanliness of facilities and drug availability. There are concerns about the affordability of medical schemes and how the profit motive affects private providers' behaviour. South Africans do not appear to be well acquainted or generally supportive of the notion of risk cross-subsidies. However, there is strong support for income cross-subsidies. Public engagement is essential to improve understanding of the core priniciples of universal pre-payment mechanisms and the rationale for the development of NHI. Importantly, public support for pre-payment is unlikely to be forthcoming unless there is coinfidence in the availability of quality health services.

Without strengthened health systems, significant access to antiretroviral (ARV) therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up ARV access in countries with both massive epidemics and weak health systems. It draws on the authors' experience in southern Africa and the World Health Organization's framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The paper proposes a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, the evaluation of community health workers and their potential role in HIV treatment access, international action on the brain drain, and greater investment in national human resource functions of planning, production, remuneration and management.