South African Health Care

A System in Transition

 

Greg Connolly  12/2/02

Global Health Council

 

Since the overthrow of Apartheid in 1994, the health care system in South Africa has been under an ongoing revolution to erase inequities in service and access, and to fund a higher level of health care.  Their approach is to decentralize the health care system into a District Health System, and to assure that a standard Primary Health Care package is available to all.  This system in transition has made commendable achievements, but there are still plenty of improvements to be made before South Africa attains the system it has envisioned.  The most formidable adversary to their health care reform is the HIV/AIDS epidemic.  The successes and shortcomings of this middle-income developing country’s approach to improving health care provide valuable lessons to other countries that face similar challenges to improving their health care systems.

 

The South African Health Care System

 

South Africa, a middle income nation with a GDP per capita of USD$7,555, and a population of 43,791,000, is a nation in transition.[i]  After four decades of minority apartheid rule, a democratic government was established in 1994.[ii]  This radical change in identity has called for a great deal of policy adjustment.  This change, coupled with the emergence of the HIV/AIDS epidemic has cornered South Africa into a national crisis; a crisis that is centered on health care.  The keystone of any government is tending to the well being of its people.  The well being of South Africans is teetering on the edge, and the people are depending on the government to respond by putting the majority of its efforts into improving national health.

 

Currently, the total health expenditure per capita in South Africa is USD$530.00, and the total health expenditure as a percentage of the GDP is 8.8%.  These expenditures stand beside marginal quality health indicators such as the life expectancy at birth of 47.7 years for men, and 50.3 years for women.  Child mortality rates are 103 deaths per 1000 births for males, and 90 deaths per 1000 births for females.[iii]  Unfortunately, these figures are worsening in a landslide caused by HIV/AIDS.  But the government’s formidable approach to reforming health care, by starting anew with a vision of health care equity, is on the right track. 

 

South Africa’s vision for health care is a decentralized system that offers an equally accessible and free basic package of primary health care to all of its citizens.[iv]  These goals are presented in the National Health Bill of 2001, which establishes the structure for the implementation of a national health care system based on Primary Health Care (PHC), and operated by District Health Systems (DHS).  For a description of the government-funded services covered by the Primary Health Care package in South Africa, visit this website (http://www.doh.gov.za/docs/reports-f.html).  The national Department of Health, headed by Minister Mantombazana Edmie Tshabalala-Msimang, oversees the system of nine provincial health departments.  Municipal boundaries for local governments were demarcated in 2000.  Each provincial health department has its own ministers and leaders.  However, the youth of this decentralized system is resulting in predictable management issues. 

 

The impetus behind creating a decentralized health care delivery system was that provincial governments would have the ability to customize the health systems to their unique cultural groups, while the national department of health would balance out inequities to assure that all districts conform to the national health policy.  In such a culturally diverse nation, the state would be mistaken to mandate a one-size-fits-all national health care policy.  Meanwhile, the districts are presumably small enough, and carry enough social solidarity that the District Health Systems are centralized into one department.  Eric Buch of the School of Public Health of the University of Pretoria praises the model of decentralization:

 

“Establishment of a District Health System with provinces and local authorities starting to pool their resources and integrate care, [offers] a more comprehensive service under one roof.  This not only improves economies of scale and efficiency, but means that parents do not have to go to two or more venues and face duplicate queues and examinations to get care for themselves and their families.”[v]

 

He also explains that in order to meet the goals for elevating clinics to fully functional levels, all clinics must have infrastructural services, such as electricity, refrigeration, potable water, sanitation, and roads by 2004.[vi]  Not only are clinics to be improved, but more clinics are to be built.  The goal is to provide equal accessibility to health care for all South Africans.  This primary objective of the South African health care system is to ensure that all South Sfrican citizens are able to realize their fundamental rights to health care as enshrined in Section 27 of the Constitution. However, Dr. David McCoy, the Director of Research at the Health Systems Trust in South Africa, explains why the South African system is not yet a “universal” health care system:

 

“In order to define the nature of people’s rights to health care, the national DoH has defined ‘package of Primary Health Care’ that is expected to be available through the public sector. It lists the scope of services to be provided in clinics and district hospitals. In addition, we have a variety of clinical policies that define national policy on standards of treatment and care in the country. For example, we have official national HIV treatment guidelines.  However, while everyone essentially has unimpeded access to PHC, in practice, many people have physical and financial barriers to getting to health facilities, and when they do attend a health facility, there is a significant gap between what is set out in the policies with what is actually being delivered.”[vii]

 

The definition of “universal” health care that is generally subscribed to is a system in which the government covers the costs and administration of the entire health sector, such as in the Canadian Health Care system.  But this kind of system is highly unlikely to be instituted in South Africa.  The obstacles are that the health system is already saturated with issues demanding attention, there is an entrenched private health sector, HIV/AIDS is churning up any continuity in health system development, it is not an upper wealth nation, and there is not enough social solidarity. 

 

Dr. McCoy explains the funding mechanisms of the South African health system:

 

“We don’t have a dedicated health insurance system. The public sector is mainly funded from the general tax base and to a much lesser degree from user fees.  There are proposals for social health insurance for the poor but employed, [leaving the poor and unemployed unattended], which may segment the health care system between the unemployed and the employed, as happens in South America.  While this offers opportunities for more people to access the private sector, it could entrench a weak health care system for the poor who are excluded from social health insurance.  Outside of the public sector, is a large private health care sector which outstrips public health expenditure.”[viii]

 

In the private sector, prepaid health plans accounted for 76.6% of the private expenditure on health in 2000.[ix]  Medical Schemes are the dominant third-party intermediary with 73% of the private expenditure.[x]  And out-of-pocket expenditure on health as a percentage of the total expenditure on health in 2000 was 12.6%.[xi]  Antoinette Ntuli of the Health Systems Trust proclaims: “The greatest health sector inequity continues to be the imbalance of resources available to the public and private sectors.”[xii]  Such inequities are inherent in a young system that is developing rapidly on a macro scale.  Eric Buch explains the development pattern in South Africa:

 

“In other middle income countries the issues are more around constant improvement off the baseline.  In South Africa they are around providing services for all that were previously available to a few.”[xiii]

This approach has been necessary given South Africa’s impending health crisis, yet it has left much room for improvement.  The mission statement of the Department of Health’s “1999-2004 Health Sector Strategic Framework” is:

“While the first five years focussed on increasing access to health care, especially for those who did not have access, … the next five years will focus on accelerating quality health service delivery.”[xiv]

This optimistic outlook passes over the need to improve on areas missed in the initial surge of health sector reform.  It inappropriately implies that an end has been reached for achieving equal access to health care.  Let us now look at the issues that have challenged health sector reform, address suggested improvements, and present the direction in which South Africa is moving toward achieving its envisioned socialized health care system. 

 

Challenges to the South African Health Care System

 

If the vitality of the health care services were related to water supply, then the health care system would be the dam, and the reservoir would be the resources that power the system.  In South Africa, the reservoir is running dry.  There is inadequate funding, poor access to information, a outward migration of medical professionals, and insufficient leadership to sustain the system. 

The most basic resource that the health care system relies on is funding.  In light of the HIV/AIDS crisis, it is promising that the government spends 11.2% of its budget on public health.[xv]  However, this will need to increase.  In the medical sector, it appears that even if all efficiency measures are achieved, current public sector funding will not satisfy the costs of providing the care desired.[xvi]  Eric Buch suggests:

“There are two places that significant additional funds could come from.  The first is a budget that grows significantly in real terms, and the second through raising more funds from users.”[xvii] 

These are not dynamic solutions.  But perhaps what is most needed is more resources from the conduits built into the system.  However, the funding mechanisms built into the system are also problematic.  Antoinette Ntuli outlines the funding paradox:

“Current mechanisms for funding local government health services are problematic.  From the provincial perspective they do not allow for adequate monitoring, while local governments are concerned about the cash flow problems resulting from payments that are paid quarterly in arrears.”[xviii]     

In parallel, the private sector is also experiencing funding problems.  Eric Buch reports:

“The private sector model of guaranteed fee-for-service payment to providers through for-profit medical administration companies, together with other factors, kept private health inflation well above that prevailing in the economy.”[xix]

 

The above passage may imply that excessive expenditures are the results of overproviding by health care professionals, however Buch clarifies that this is not the primary cause of expense:

“Excessive expenditure on health care is not only driven by the lack of constraints on members due to third party payer insurance, but more importantly due to an asymmetry of information between provider and patient on what interventions are required and suitable.”[xx] 

Effective information dissemination is crucial to operating an efficient health care system.  In South Africa, information is in short supply.  Ninety-seven percent of provincial expenditures on health information goes to hospitals, with the districts getting only three percent.[xxi]  In order for inequities of access to be neutralized, this ratio must be reduced so that rural clinics are given, and return enough information to enable them to deliver care of acceptable quality.  When asked if South Africa is doing a good job of information dissemination, Dr. David McCoy responded:

 

“I guess it’s all relative. The Department of Health does take the need to disseminate information seriously. The Health Systems Trust is one of the main sources of information [in South Africa] to health care workers, and they are partially funded by the DoH.  [xxii]

 

 

 

 

 

The other side of information dissemination is information gathering.  Dr. McCoy elaborates on this theme:

 

“Research is very important, but it can also be very distracting.  What is important is relevant research and research that targets policy makers and managers as the consumers (not academic journal editors).  South Africa also needs to invest time in face-to-face communication of research findings, and not rely on passive paper-based dissemination.  The bureaucracy is reasonably receptive to constructive criticism, but this culture needs to be carefully nurtured and protected.”[xxiii]

 

One way any government bureaucracy can be culturally sensitive and open to civil input is to empower nongovernmental organizations (NGO’s) to perform some of the work on the ground.  Eric Buch makes a case for NGO support in this passage:

 

“It is generally agreed that NGO’s working in, and with, communities and those focussing on a health problem e.g. cancer, tuberculosis, or a disability, have the ability to achieve results and mobilize energy and volunteerism in a manner that is difficult for formal health services to match.  This energy seems to be dissipating in our society, with people waiting for government to do things for them.  The Health Department needs to intervene to create an enabling environment for NGO’s, facilitate the emergence of local NGO’s and provide seed funding in hitherto unserved areas.”[xxiv]

 

NGO’s tend to have an ability to feel the pulse of the people.  They also tend to access areas that would normally be overlooked by government.  One of the major challenges to the South African health care system is bringing health care to rural underserved populations.  These people often forego health services that would be deemed necessary by health professionals because they don’t have access to services, or because they lack the funds for services.  There are also many traditional healers throughout South Africa, who should not be dismissed in the new health care system, but should be allowed their niche alongside modern health care services.  NGO's are crucial to mediating sensitive issues like traditional healing, and helping to facilitate new measures in underserved areas. 

 

Extending service to underserved areas is one of the most significant challenges to the health care system.  Not only must new clinics be built, and basic utilities and resources provided, but also there need to be health professionals to work in underserved areas.  Doctors will need to commit to working regularly in clinics.  Moreover, supporting health services staff such as nurses and assistants will need to be enticed into working in underserved areas, and will require specific training for working in these new environments.  This will be a costly and demanding measure.  Eric Buch offers one suggestion for alleviating the financial burden and pressing demand for sending health professionals to work in underserved areas:

 

“Large numbers of rehabilitation, pharmacy, environmental and other assistant categories (mid-level health workers), with one to two years of tertiary education, need to be rapidly but effectively trained and deployed…One conclusion drawn by the Human Resources planning process is that the current staffing model, based on professionals alone, is unaffordable, and that extensive use should be made of mid-level health workers.”[xxv]    

 

This advice, while sensible, may sound grating to many South African health analysts who are pressing for a more professional work force.  Amid the rapid, but necessary changes to the health sector, the health work force is overburdened by changing values in the jobs, and unreasonable work loads.[xxvi]  Dr. Graham Bresick comments:

“Urgent attention needs to be paid to the low morale, disillusionment, and high levels of stress and burnout among health service staff.  We can’t hope to build a reformed and improved health sector on a spent work force.”[xxvii]

Difficult working conditions, few incentives, and low morale are causing health professionals to leave their jobs or seek work in other countries.  South Africa has an enormous problem with the colloquially termed phenomenon of “Brain-Drain.”  Many health care professionals, who have received their training in South Africa, emigrate to countries with more inviting health care systems.   South African Department of Health Minister Manto Tshabalala-Msimang states in her speech, “Health Department’s Multi-Pronged Health Staffing Strategy”:

“We believe that if there is a major – and insidious – threat to our overall health effort, it is the continued outward migration of key health professionals, particularly professional nurses, with a consequent de-skilling of the professional base in both the public and private sector.”[xxviii]

 

Antoinette Ntuli illustrates the magnitude of this threat with the following statistics:

 

“In 2001 there were 19.8 medical practitioners per 100,000 population as compared with 21.9 in 2000.  For professional nurses the ratio reduced from 120.3 in 2000 to 111.9 in 2001.”[xxix]

 

The Department of Health has taken a few measures to combat this readily apparent threat.  It developed a Code of Conduct for other Commonwealth Nations in their recruitment of South African professionals.  It created a new  “Community Service” program to encourage professionals to work in underserved areas.  And it sent 254 students to Cuba to train to become physicians.  These students have committed to return to South Africa to offer four years of service to underserved areas.[xxx]

 

Dr. David McCoy comments on these incentive programs:

 

“This is a major priority of the health system and we have been talking about incentive schemes for the last six years.  There has been a recent resurgence of interest in policy-making circles, but we await some positive outcomes.  The only program that has been put in place is a compulsory community service program for medical graduates of one year, and a program to place Cuban doctors in rural areas. Both initiatives have been partially successful, but are insufficient to address the “brain drain” and the inadequate levels of staffing in the rural areas.”[xxxi]

 

It is not only the doctors and nurses who are strained by the needs of the health care systems; it is also the administrators.  In the early stages of the new decentralized health care system, leadership was given to those who may not have had proper training, avenues of decision making were unclear, and the responsibilities of the leaders were too burdensome.  Antoinette Ntuli elaborates on these problems:

 

“Worryingly, many health services managers have a low sense of personal accomplishment.  Huge demands, difficulties in prioritizing, inadequate management skills, lack of rewards for competence or sanctions for incompetence, and hierarchies that are too rigid all impact upon their ability to deliver quality health care.  Other difficulties include inappropriate organograms, lack of financial delegation, unsatisfactory communication between provinces and districts and inconclusive appointments of staff, (especially to strategic positions) many of whom are in acting positions.”[xxxii]

 

Dr. David McCoy echoes her concerns:

 

“There are inadequate management skills amongst managers and policy makers who set the operational priorities for transforming the health care system in a rational sequence of steps.  One cannot put the roof on before building the walls.  This is technical work.”[xxxiii]

 

Building a national health system is not easy, and South Africa has only had eight years in which to do it.  The nation has certainly made a commendable effort at health care reform.  The problems that arose are all problems that can be solved, and were virtually inherent in developing a new health care system.  South Africa provides an example of a nation doing fairly well in transforming their health care system under pressure. 

 

However, that pressure is immense and must be confronted.  When asked if South Africa was doing a good job with its health care reform, David McCoy gave this response:

 

“Is the glass half empty or half full?  Relative to many developing countries we are doing okay.  Given the history of the country and the relative inexperience of the government, we are also doing okay. However, relative to our health needs and the emergency that is AIDS, we are doing poorly.  AIDS threatens to wipe out all gains made since 1994.  We have to run fast to keep still.”[xxxiv]

 

The HIV/AIDS Crisis

 

“South Africa has more HIV positive people than any other country in the world.”[xxxv]  Two years ago the South African government reported that 4.7 million, which is one in nine, South Africans was HIV positive.  Today that number is expected to be far higher.  The South African government is starting to acknowledge its massive HIV/AIDS crisis.  “This year the government almost tripled its anti-AIDS budget to USD$108 million, and plans to up to $194 million in the next financial year.”[xxxvi]  “Tony Leon, leader of the main opposition Democratic Alliance said, ‘South Africa’s fight against AIDS has been massively hampered and harmed by government’s dithering, denial and dissent from the orthodoxies associated with the disease.”  He also pointed out that women’s life expectancy will fall from 54 to 38 in the next decade, and more than 2 million children will be orphaned by AIDS in this time.[xxxvii]

 

Not only are children being orphaned, but also:

 

“Each year, more than 600,000 infants [worldwide] become infected with HIV, mainly through mother-to-child transmission.  WHO and the UNAIDS Secretariat recommend that the prevention of mother-to-child transmission of HIV, including antiretroviral regimens such as nevirapine, should be included in the minimum standard package of care for HIV-positive women and their children.”[xxxviii]

 

The article by WHO and UNAIDS also explains: “The simplest regimen [of PMTCT drug therapy] requires a single dose of nevirapine to the mother at delivery and a single dose to the newborn within 72 hours of birth.”[xxxix]

 

Yet despite the World Health Organization and UNAIDS endorsements of nevirapine therapy, the South African government was reluctant to distribute the drug to health providers.  Instead the Department of Health set up an eighteen-site test of the effectiveness and risks of Intrapartum Nevirapine treatment, because as Minister Manto Tshabalala-Msimang explained:

 

“The public sector cannot afford to provide the drugs, while nevirapine did not guarantee the virus could not be passed from mother to child.”[xl]

 

This is a clear example of the Department of Health’s reluctance to give HIV/AIDS the attention it has warranted.   It is this kind of negligence that prompted Dr. Peter Berman of the Harvard School of Public Health to say; “South Africa could be an example of what to avoid in AIDS policy.”[xli]

 

Dr. David McCoy issued the following statement on what other countries can learn from South Africa’s HIV/AIDS policy:

 

“Political leadership is critical [to an effective HIV/AIDS policy].  Openness is critical, as is making the problem a national priority at the early stages of the epidemic. 

 

Ensuring that the basic primary health care infrastructure is capable of providing correct treatment of sexually transmitted infections (STI’s), condoms, family planning, and TB control…in other words, getting the basics in place.  This then provides a foundation for the implementation of more complex treatment programs. 

 

Human resource training is critical – especially of community lay workers who can act as agents of community mobilization.  Prevention intervention is not just a health care system responsibility, but needs to be planned and implemented from a broad base of government and non-governmental institutions. 

 

Understanding local culture and beliefs is very important.  Social science research must be employed from the beginning to inform prevention interventions in particular.  The western model of individual-based counseling is inappropriate and has been a millstone around our neck.”[xlii]

 

These words of advice are poignant especially to countries that are now just starting to be infiltrated by HIV/AIDS.  India, China and other countries in Asia, where the virus is spreading most rapidly should learn from South Africa’s shortcomings in HIV/AIDS policy.

 

Implications

 

The South African health care system has many implications for developing countries.  The model of social equity in health care that South Africa envisions is appropriate to the needs of its people, and can be achieved given the nation’s wealth, infrastructure, and relative social solidarity.   Decentralization beneath a governing body seems to be the most effective design in a socialized health care system.  Public provision of primary health care services without interfering with privatized secondary and tertiary health care services achieves a balance of government control while allowing for the private market to drive progress.  South Africa’s approach to reform was on the macro scale.  This may not be possible for more diverse and impoverished nations, and as seen here, can leave holes, which require repairing.  Perhaps a more thorough approach to health care reform would be to start small in a pilot program format, and through the work of both government and non-governmental organizations, build up to a national system while attending to the complications that arrive along the way.  Most significantly, developing countries should learn from South Africa’s HIV/AIDS policy.  As South Africa is learning, while it is important to develop a strong national health care system, the effort may be futile if the country doesn’t also address the HIV/AIDS pandemic.   


Works Cited

 

Barron, Peter, and Asia, Bennett.  “The District Health System: South African Health Review 2001 – Chapter 2.” http://www.hst.org.za/sahr/2001/chapter2.htm.

 

Berman, Peter and Bossert, Tom.  “Interview with the Global Health Council.”  Harvard School of Public Health. 

 

Bresick, Graham. “Email to Greg Connolly – Dec. 13, 2002.”

 

Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

 

Cohen, Mike.  “World AIDS Day rallies focus on global awareness.”  Associated Press.  The Burlington Free Press.  December 2, 2002.

 

Goudge, Jane, et Al.  “Private Sector Funding: South African Health Review 2001.”  http://www.hst.org.za/sahr/2001/chapter4.htm

 

Mbatsha, Sandi, and McIntyre, Di.  “Financing Local Government Health Services: South African Health Review 2001 – Chapter 3.”  http://www.hst.org.za/sahr/2001/chapter3.htm.

 

McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 25, 2002.”

 

McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 29, 2002.”

 

McIntyre, D. and Gilson, L.  “Putting Equity in Health Back onto the Social Policy Agenda:  Experience from South Africa.”  Soc Sci Med 2002 Jun; 54(11): 1637-56.

 

Minister Manto Tshabalala-Msimang.  “Health Department’s Multi-Pronged Health Staffing Strategy.”  http://www.doh.gov.za/docs/pr/2002/pr1023.html

 

Ntuli, Antoinette.  “Listening to Voices: Preface to the South African Health Report 2001.”  http://www.hst.org.za/sahr/2001/preface.htm

 

Pillay, Yogan.  “Voices of Health Policy Makers and Public Health Managers: South African Health Review 2001 – Chapter 16.”  http://www.hst.org.za/sahr/2001/chapter16.htm.

 

Sait, Lynette.  “Health Legislation: South African Health Review 2001.”  http://www.hst.org.za/sahr/2001/chapter1.htm

 

“South African Health Reviews 1995-2001.  The Health Systems Trust. http://www.hst.org.

 

“South African Minister of Health Profile.”  http://www.doh.gov.za/ministry/minister.html

 

“WHO and UNAIDS continue to support use of nevirapine for prevention of mother-to-child HIV transmission.”  http://www.who.int/mediacentre/statements/unaids/en/print.html

 

“WHO Country Profile: South Africa.”  http://www.who.int/country/zaf/en

 

 



[i] “WHO Country Profile: South Africa.”  http://www.who.int/country/zaf/en

[ii] McIntyre, D. and Gilson, L.  “Putting Equity in Health Back onto the Social Policy Agenda:  Experience from South Africa.”  Soc Sci Med 2002 Jun; 54(11): 1637-56.

[iii] “WHO Country Profile: South Africa.”  http://www.who.int/country/zaf/en

[iv] Sait, Lynette.  “Health Legislation: South African Health Review 2001.”  http://www.hst.org.za/sahr/2001/chapter1.htm

[v] Buch, Eric.  “SAHR 2000: The Health Sector Strategic Framework: A Review.”  The Health Systems Trust.  http://www.healthlink.org.za/sahr/2000/chapter2.htm.

[vi] Buch, Eric.  “SAHR 2000: The Health Sector Strategic Framework: A Review.”  The Health Systems Trust.  http://www.healthlink.org.za/sahr/2000/chapter2.htm.

[vii] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 25, 2002.”

[viii] Dr. David McCoy.  Director of Research for the Health Systems Trust.  “Email to Greg Connolly – Nov. 29, 2002.”

[ix] “WHO Country Profile: South Africa.”  http://www.who.int/country/zaf/en

[x] Goudge, Jane, et Al.  “Private Sector Funding: South African Health Review 2001.”  http://www.hst.org.za/sahr/2001/chapter4.htm

[xi] “WHO Country Profile: South Africa.”  http://www.who.int/country/zaf/en

[xii] Ntuli, Antoinette.  “Listening to Voices: Preface to the South African Health Report 2001.”  http://www.hst.org.za/sahr/2001/preface.htm

[xiii] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xiv] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xv] “WHO Country Profile: South Africa.”  http://www.who.int/country/zaf/en

[xvi] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xvii] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xviii] Ntuli, Antoinette.  “Listening to Voices: Preface to the South African Health Report 2001.”  http://www.hst.org.za/sahr/2001/preface.htm

[xix] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xx] Buch, Eric.  “SAHR 2000: The Health Sector Strategic Framework: A Review.”  The Health Systems Trust.  http://www.healthlink.org.za/sahr/2000/chapter2.htm.

[xxi] Ntuli, Antoinette.  “Listening to Voices: Preface to the South African Health Report 2001.”  http://www.hst.org.za/sahr/2001/preface.htm

[xxii] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 29, 2002.”

[xxiii] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 29, 2002.”

[xxiv] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xxv] Buch, Eric.  “The Health Sector Strategic Framework: A Review: South African Health Review 2000 – Chapter 2.”  Http://www.healthlink.org.za/sahr/2000/chapter2.htm

[xxvi] Bresick, Graham. “Email to Greg Connolly – Dec. 13, 2002.”

[xxvii] Bresick, Graham. “Email to Greg Connolly – Dec. 13, 2002”

[xxviii] Minister Manto Tshabalala-Msimang.  “Health Department’s Multi-Pronged Health Staffing Strategy.”  http://www.doh.gov.za/docs/pr/2002/pr1023.html

[xxix] Ntuli, Antoinette.  “Listening to Voices: Preface to the South African Health Report 2001.”  http://www.hst.org.za/sahr/2001/preface.htm

[xxx] Minister Manto Tshabalala-Msimang.  “Health Department’s Multi-Pronged Health Staffing Strategy.”  http://www.doh.gov.za/docs/pr/2002/pr1023.html

[xxxi] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 25, 2002.”

 

[xxxii] Ntuli, Antoinette.  “Listening to Voices: Preface to the South African Health Report 2001.”  http://www.hst.org.za/sahr/2001/preface.htm

[xxxiii] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 29, 2002.”

[xxxiv] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 29, 2002.”

[xxxv] Cohen, Mike.  “World AIDS Day rallies focus on global awareness.”  Associated Press.  The Burlington Free Press.  December 2, 2002.

 

[xxxvi] Cohen, Mike.  “World AIDS Day rallies focus on global awareness.”  Associated Press.  The Burlington Free Press.  December 2, 2002.

[xxxvii] Cohen, Mike.  “World AIDS Day rallies focus on global awareness.”  Associated Press.  The Burlington Free Press.  December 2, 2002.

[xxxviii] “WHO and UNAIDS continue to support use of nevirapine for prevention of mother-to-child HIV transmission.”  http://www.who.int/mediacentre/statements/unaids/en/print.html

[xxxix] “WHO and UNAIDS continue to support use of nevirapine for prevention of mother-to-child HIV transmission.”  http://www.who.int/mediacentre/statements/unaids/en/print.html

[xl] Sait, Lynette.  “Health Legislation: South African Health Review 2001.”  http://www.hst.org.za/sahr/2001/chapter1.htm

[xli] Berman, Peter and Bossert, Tom.  “Interview with the Global Health Council.”  Harvard School of Public Health.

[xlii] McCoy, Dr. David.  Director of Research at the Health Systems Trust.  “Email to Greg Connolly – Nov. 25, 2002.”