The term health care delivery means the major components (characteristics) of the system and processes that enable people to be provided or receive health care or services. In this paper, one will read about two countries and how they have organized their health care delivery; statistics that inform policy and programming; measures to improve on health care; a glimpse into culture of provision and demand;the challenges unique to each country; and summaries unique to the two countries.
The United States of America, commonly referred to as the United States or America, is a federal republic composed of 50 states, a federal district, five major territories and various possessions. At 3.8 million square miles and with over 320 million people, the country is the world's third or fourth-largest by total area and the third most populous. It is one of the world's most ethnically diverse and multicultural nations, the product of large-scale immigration from many countries. South Africa, officially the Republic of South Africa, is the southernmost country in Africa. It is the 25th-largest country in the world by land area occupying 470,693 square miles and with close to 53 million people, is the world's 24th-most populous nation (bing.com). USA is almost 9 times the size of Republic of South Africa (RSA).
|Dr. Aaron Motsoaledi (in black suit) during World AIDS Day Event in South Africa. Photo courtesy of National Health Department of RSA.|
Both the Republic of South Africa and United States of America value their populations. Healthy populations are an asset to any given country; vast and complex networks of government, private institutions, non-governmental organizations (NGO’s) and community initiatives create structures through which healthy outcomes are achieved; public health is structured according to existing social-political-cultural structures; the authority granted to health professionals; funding provided for social services and programmatic emphasis; and manipulating factors that influence health and illness play an important role on delivery and accessibility of health services. The information garnered can be used to assess population and community health status and develop effective health interventions and public policy (Turnock, 2015). The relevance of these factors “resides in their focus on causes or influence of particular health outcomes” (Page 22). Data on mortality, morbidity, medical records and population assessments are utilized as measures to gauge health outcomes. Information on health status of a population can be collected and compared to study differences between one country and another. This can offer valuable information about the comparative state of health of a population or about disease trends (American Medical Association, 1989). Crude mortality rates count deaths within the entire populations; age-adjusted mortality rates show age-related factors that influence health (e.g., stroke, heart disease, HIV infections, infant deaths, tuberculosis, influenza, pneumonia, malaria, URTIs, UTIs, syphilis, cancer); age-specific mortality rates relate the number of deaths to the number of persons in a specific age group ( e.g., infant-mortality rate describes number of deaths of live-born infants occurring in the first year of life per 1,000 live births and maternal-mortality describes number of death by mothers during or after delivery); age-adjusted rates are calculated by applying age-specific rates to a standard population ( the year 2000 is used in USA). “This adjustment permits more meaningful comparisons of mortality experience between populations with different age distribution patterns” (Page 26); Life expectancy, is a computation of the number of years between any given age (e.g., birth or age 75) and the average age of death for that population; and Years of Potential Life Lost (YPLL) is a mortality-based indicator that places greater weight on deaths that occur at younger ages. An arbitrary or given age is used as a threshold e.g., 65. Together with infant mortality rates, life expectancies are commonly used in comparisons of health status among nations. These two mortality-based indicators are often considered to be general indicators of the overall health status of a population. Comparisons between the two different countries for causes of death for say, cancer, heart disease, unintentional injuries, suicide, homicide, cerebrovascular diseases, chronic obstructive lung disease, diabetes mellitus, HIV infections and chronic liver disease and cirrhosis, offer insight into magnitude and impact of problems. This in turn will inform policy, investments and interventions needed. But before one collects the information, it would do to understand the characteristics or structures that influence particular health outcomes.
|Integrated Care for Mothers and Children is an important health approach. Photo courtesy of World Bank.|
Characteristics of US Health Care System:
The total population (2013) of USA is 320,051,000; Life expectancy at birth m/f (2013) is 76/80; and total expenditure on health as % of GDP (2013) is 17.1 (WHO, 2013). The infant mortality rate per 1,000 live births for 2011 was 6.05 (Child Health USA, 2013). The health system in USA is complex and decentralized, having a combination of national, state and local public health services. The private sector is responsible for the delivery and production of most care in USA. The department of health and human services is similar to a ministry of health. An individual can gain access to needed services, including specialized care through hospitals and organizations that supply health services, medical equipments, pharmaceuticals, supplies, health insurance and training work force. Healthcare services are paid for through insurance and out-of-pocket. The U.S has a national health system with tax-funded coverage, a health insurance system with a single payer and a health insurance system with multiple insurers. There are different hospitals, health centers, government insurance programs such as Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP) and these provide vulnerable populations with access to health care services. These are benefits that people in this country experience because of the health system’s characteristics. People are guaranteed access to healthcare services. Medicare is one of the largest sources of health insurance in U.S. serving nearly 39 million people who are either 65 years old or older and who are suffering from certain disabilities or are diagnosed with end-stage renal disease. This is managed by Health Care Financing Administration (HCFA). Medicare has four parts (A, B, C & D). Medicaid is the third largest health insurance in U.S. providing coverage for low-income women, children, elderly people and individuals with disabilities covering 12% of U.S. population. The program provides outpatient care and prescription drugs for vulnerable populations. The SCHIP covers children who are uninsured and those in families with low-income. SCHIP pays for child’s physician visit, immunization, hospitalization and emergency room visits. Insured patients receive well-coordinated care under the Managed Care Organization (MCOs) and Accountable Care Organizations (ACOs). Health information is readily available to providers through an integrated technology system. Not only is there a great deal of choice when selecting physicians but there are other providers along the continuum of care chain. Uninsured people face challenges in accessing basic, well-directed, coordinated, continuous and routine health care. This may translate into typically a long wait to see a specialist. It may cause many people to encounter adverse effects because medical supplies are not readily available. Because of lack of insurance healthcare services can be prohibitively expensive for most people (Shi & Singh 2015). “In the U.S., public health can be affected by disruptions of physical, biological, and ecological systems. The health effects of these disruptions include increased respiratory and cardiovascular disease, injuries and premature deaths related to extreme weather events, changes in the prevalence and geographical distribution of food- and water-borne illnesses and other infectious diseases, and threats to mental health” (National Center for Environmental Health, 2015). Factoring in environmental health, safeguards the health of populations that are particularly vulnerable to certain environmental hazards e.g., children, the elderly, people with disabilities and persons new to places.
Characteristics of South African Health Care System:
The Republic of South Africa total expenditure on health as % of GDP (2013) is 8.9; life expectancy at birth m/f (2013) is 57/64; and total population (2013) is 52,776,000 ( WHO, 2013). The infant mortality rate per 1,000 live births (2013) is 32.8 (OECD). In the Republic Of South Africa, health care has the following characteristics: a) Pharmaceuticals, consumables and supplies; public health sector; private health sector; curative hospi-centric focus; human resources; fragmented funding pools; out-of-pocket payments and financing systems (South Africa Gazette, 2015). The National Health Insurance (NHI) of the Republic Of South Africa is a centralized health financing system that is designed to pool funds to provide access to quality, affordable personal health services for all South Africans based on their health needs, irrespective of their socioeconomic status. NHI is intended to ensure that the use of health services does not result in financial hardships for individuals and their families (South Africa Gazette, 2015). An individual can gain access to needed services, including specialized care. Healthcare services are paid for by government and out of pocket. Population coverage under NHI ensures that all South Africans have access to comprehensive quality health care services. This means that people will be able to access health care services closest to where they live. The health care services will be accessed at the appropriate level of care and will be delivered through certified and accredited public and private providers using the NHI Card. NHI creates a unified health system by improving equity in financing, reducing fragmentation in funding pools, and by making health care delivery more affordable and accessible for the population. NHI will eliminate out-of-pocket payments when the population needs to access health care services. In the long run, households will also benefit from increased disposable income as a result of a significantly lower mandatory prepayment ( Page 12). Primary Health Care (PHC) is being reengineered through four streams to improve timely access and to promote health and prevent disease. These streams are Municipal Ward-based Primary Health Care Outreach Teams (WBPHCOTs); Integrated School Health Programme (ISHP); District Clinical Specialist Teams (DCSTs); and Contracting of nonspecialist Health Professionals. This system has its benefits such as: Phakisa Ideal Clinic Realization Programme aimed at improving the performance and quality of health services in the PHC facilities. As well as quality public health infrastructure complete with bulk services such as provision of electricity, water supply, sanitation and waste management supported by effective transport and communication systems. South Africa has had a history of improvements that guaranteed access to healthcare services. Several proposals and attempts to implement health financing reforms namely: the 1928 Commission of Old Age Pension and NHI; 1941 Collie’s Committee of Inquiry into NHI; the 1943 African Claims that proposed equal treatment in the scheme of Social Security; the Dr Henry Gluckman National Health Services Commission of 1943 to 1944 that proposed NHI; The Freedom Charter as adopted by the Congress of the People, 1955; the 1994 Ministerial Committee on Health Care Financing; the 1995 Ministerial Committee of Inquiry into NHI (Broomberg and Shisana Report); the 1997 Social Health Insurance Working Group; Professor Taylor’s 2002 Committee of Inquiry into a Comprehensive Social Security System; Ministerial Task Team on Social Health Insurance and the 2009-2014 Ministerial Advisory Committee on NHI (Government Printing Works, 2015). Patients receive well-coordinated care through an established network of clinics e.g., from 2009 to 2013, the number of nurses trained on Nurse Initiated Management of Anti-Retroviral Therapy (NIMART) increased from 250 to 23,000. This increase contributed to the massive roll out of Anti-Retroviral Therapy (ART) “resulting in the largest ART programme in the world” (South Africa Gazette, Page 17). People make choices of which clinics to go to as well as selecting physicians. The challenges that people in this country encounter include: “high costs in the private health sector due largely to a fee- for-service model” ( South Africa Gazette Page 22 & 23); High HIV prevalence, e.g., for 15-49 year old is 18.9 (World Bank); controls in place to access HIV medication such as PrEP still serve as a hurdle to prevention (MCC, 2015); “the main cost drivers (other than human resources) in the public health sector are: pharmaceuticals; laboratory services; blood and blood products; equipment; and surgical consumables” (South African Gazette, Page 23); the lack of peer review or regulation of traditional healers who make claims for many cures including that for HIV; congestion at health facilities; and impact of weather changes that cause water shortages e.g., at Stanger Hospital in Ilembe, Kwazulu Natal, South Africa (Kaveel Singh, 2015).
Comparison of USA Health Care System to RSA:
The US health care system is not centralized, serves a population of 320,051,000; Life expectancy at birth m/f is 76/80; and total expenditure on health as % of GDP (2013) is 17.1. The infant mortality rate per 1,000 live births for 2011 is 6.05. Whereas for Republic of South Africa total expenditure on health as % of GDP is 8.9; life expectancy at birth m/f is 57/64; and total population 52,776,000. The infant mortality rate per 1,000 live births is 32.8.
Potential benefits for people in USA and RSA:
In USA, an individual can gain access to needed services, including specialized care through hospitals and organizations that supply health services, medical equipments, pharmaceuticals, supplies, health insurance and training work force. A national health system with tax-funded coverage and a health insurance system with multiple insurers exists. Access to different hospitals, health centers, government insurance programs such as Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP) provide vulnerable populations with affordability to health care services. These are benefits that people in this country experience because of the health system’s characteristics. People are guaranteed access to healthcare services.
In RSA, an individual can gain access to needed services, including specialized care. Healthcare services are paid for by government and out of pocket. Population coverage under NHI ensures that all South Africans have access to comprehensive quality health care services. People access health care services closest to where they live through certified and accredited public and private providers using the NHI Card or pay out-of-Pocket.
|Built areas contribute to good health. Photo courtesy of Tom Mukasa|
Potential challenges for people in USA and RSA:
In USA, uninsured people face challenges in accessing basic, well-directed, coordinated, continuous and routine health care. Because of lack of insurance healthcare services can be prohibitively expensive for most people. Public health can be affected by disruptions of physical, biological, and ecological systems. The health effects include exposure to elements, increased respiratory and cardiovascular disease, injuries and premature deaths related to extreme weather events, changes in the prevalence and geographical distribution of food- and water-borne illnesses and other infectious diseases, and threats to mental health.
In RSA, challenges that people encounter include:high costs in the private health sector due largely to a fee- for-service model; High HIV prevalence, e.g., for 15-49 year old it is 18.9; the controls in place to access HIV medication such as PrEP can be a hindrance for prevention; high costs for: pharmaceuticals; laboratory services; blood and blood products; equipment; and surgical consumables; the lack of peer review or regulation of traditional healers who make claims for many cures including that for HIV; congestion at health facilities; and impact of weather changes that cause, say, water shortages in hospitals.
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