SAHR_17.10.22_Chapter 12 INFRASTRUCTURE

Chapter 12 INFRASTRUCTURE

Boitumelo Mashilo, Laura Angeletti-du Toit, Nwabisa Daniels

Introduction The National Core Standards (NCS) for Health Establishments are the set benchmark for quality care in South Africa and delivery of health services is measured against this standard. This chapter provides an overview of available health infrastructure in the country, its condition and adequacy. It also highlights the broader infrastructure and non-infrastructure challenges that hamper the delivery of quality health care in the country. Thereafter, it reviews progress by various national initiatives aimed at responding to current challenges including the Ideal Clinic Realisation and Maintenance (ICRM), compliance with the NCS, Infrastructure Unit Support Systems (IUSS), Draft 10-Year Health Infrastructure Plan (10YHIP), and the Draft Maintenance Strategy. For each initiative, we review the achievements and remaining challenges, before looking at trends that will affect the provision of health infrastructure in the foreseeable future such as lessons from the COVID-19 pandemic and climate change.

Health care systems are concerned with the pooling of various inputs including human capital, medicine and medical supplies, laboratory and radiology services, and support services needed to deliver a quality service. These inputs are required in a holistic, integrated and complementary manner. Infrastructure in the form of facilities, health technology1 and equipment plays a critical role as an input that enables the provision of a quality health care service. Its provision enables access to the capacity to prevent, diagnose and treat diseases, and an environment that promotes healing. Without it, access to and quality of health care are compromised.

1

The chapter does not cover Health Technology, but it has many similarities with facilities whereby lessons on the latter may also be applied to the former.

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

However, the health care system in South Africa is plagued by vast disparities in the quality of care and infrastructure across the private and public health sectors. Thus, plans are underway to implement Universal Health Coverage (UHC) that will transcend socio-economic lines and equitable access to quality health care services will be a key outcome. The experience from COVID-19 already demonstrated the need for cooperation between the private and public sectors and this lays a strong foundation for UHC. It can therefore be argued that unless the health sector as a collective finds a way to leverage all available resources (both public and private) in a complementary and integrated manner, UHC will not be realised. However, there is a long path towards this end and many trade-offs must be balanced.

Description of the status quo Infrastructure is important in the provision of quality health care because it is the visible interface between health care professionals and the public (Erasmus et al., 2012).

Key to this is the availability of infrastructure (access), its location (proximity) and state (acceptable standards). Table 12.1 depicts that the public health care system had about 3 702 Primary Health Care2 (PHC) facilities and 403 hospitals in 2020. Compared to 2015, the number of PHC facilities declined by 63 while the number of hospitals increased by one. Important to note though is that visiting points and health points were not counted as PHC facilities in the 2020 statistics. A breakdown of the available capacity in PHC facilities shows that most of these were in the Eastern Cape, KwaZulu-Natal and Limpopo. For hospitals, most of these were in the Eastern Cape, KwaZulu-Natal and the Western Cape, however, the most bed capacity was in the Eastern Cape, KwaZulu-Natal and Gauteng due to the size of the facilities.

Table 12.1 Provincial spread of public health care facilities 2015

2020

Number of Hospitals

Number of Beds

Number of PHC Facilities

Number of Hospitals

Number of Beds

Number of PHC Facilities

Eastern Cape

92

14 039

812

92

13 231

809

Free State

35

4 765

250

34

4 908

248

Gauteng

42

18 026

413

42

17 358

406

KwaZulu-Natal

72

22 701

671

73

20 628

647

Limpopo

43

7 687

497

43

7 857

493

Mpumalanga

29

4 764

343

31

4 948

317

Northern Cape

17

1 890

170

17

1 597

169

North West

19

4 661

328

19

4 668

326

Western Cape

53

9 773

281

52

10 039

287

Province

Source: Various including the District Health Information System, provincial data and the SA Health Review 2

In this chapter, PHC facilities are clinics and community health care centres.

224

Infrastructure

Figure 12.1 Provincial spread of private health care facilities in 2020 Source: Medpages statistics In addition to availability of infrastructure, a common measure of access to hospital services is the inpatient bed capacity ratio, which is the number of hospital beds per 1 000 dependent population. The National Tertiary Health Service Plan (NTHSP) set an overall benchmark of 0.37 beds per 1 000 dependent population, made up of different benchmarks per level of care (0.66 beds for district beds; 0.33 beds for regional beds; and 0.13 beds for tertiary beds). Using the NTHSP benchmark ratio, the inpatient bed capacity ratio for South Africa’s uninsured population was 1.7 beds per 1 000 population in 2020, down from 1.9 beds per 1 000 population in 2015. For both these periods, the ratios were above the prescribed benchmark, suggesting that access is generally not a challenge. However, the decline in bed capacity ratio when the population continues to grow is a source of concern. This is because most people in South Africa are dependent on the public health care system and the number of dependents increases with population growth due to poor socio-economic conditions (high inequality, poverty and unemployment) which limit people’s choices based on affordability constraints.

Bed capacity rate per 1 000 dependent population 2015

2020

Number of Beds

Dependent Population ‘000

Public beds per 1 000 dependent population

Number of Beds

Dependent Population ‘000

Public beds per 1 000 dependent population

Eastern Cape

14 039

6 313

2.22

13 231

6 055

2.19

Free State

4 765

2 515

1.89

4 908

2 508

1.96

Gauteng

18 026

10 266

1.76

17 358

11 789

1.47

KwaZulu-Natal

22 701

9 729

2.33

20 628

10 160

2.03

Limpopo

7 687

5 290

1.45

7 857

5 604

1.40

Mpumalanga

4 764

3 819

1.25

4 948

4 095

1.21

Northern Cape

1 890

1 035

1.83

1 597

1 089

1.47

North West

4 661

3 402

1.37

4668

3 618

1.29

Western Cape

9 773

4 948

1.98

10 039

5 590

1.80

TOTAL

88 306

47 317

1.87

85 234

50 508

1.69

Province

Source: SA Health Review, 2020, and 2015 Draft 10YHIP

225

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

For PHC facilities, an appropriate measure of access is the number of consulting rooms available per 1 000 dependent population. However, there is no set benchmark for PHC facilities in the country and public information on the number of consulting rooms in South Africa is limited. The National Department of Health (NDoH) estimated the national average ratio to be 0.29 consulting rooms per 1 000 dependent population in 2015. It is not possible to compare this with 2020 due to data constraints. The World Health Organization (WHO) uses the number of health centres3 per 100 000 population as a benchmark and set this at 10 health centres per 100 000 population in 2018. Using the WHO benchmark, South Africa had an estimated 7.3 PHC facilities per 100 000 dependent population in 2020, a decline compared to 7.5 PHC facilities per 100 000 dependent population in 2015. For both 2015 and 2020, the number of facilities was below the recommended WHO threshold, suggesting that access to PHC is a challenge in South Africa. It must be noted though that the WHO indicator does not specify the size of the health centres and therefore the benchmark is skewed if facilities are not rightsized for the catchment population.

An additional measure of access is the proximity to health care facilities (distance and time) and the costs associated with the access. This is key in a country whose spatial form is known to be exclusionary. The WHO recommends that health care facilities should be available within a five-kilometre radius. According to McLaren et al. (2014), two-thirds of South Africans were found to reside less than two kilometres from public clinics and about 90% reside within a seven-kilometre radius. In terms of time, the 2019 GHS estimates that 41.6% of households can access health care facilities in less than 15 minutes and 43.2% of households can access health care facilities within 15 to 29 minutes. It is important to note that there are notable differences in urban versus rural areas, and across races. Further, the costs associated with accessing health care are prohibitive for the poor particularly in non-urban areas. Lastly, there are long waiting times associated with accessing free public health care, which results in people seeking private health care at costs that are unaffordable to them or opting to not seek medical care. These waiting times do not reflect people who due to inaccessibility challenges do not even attempt to seek medical care.

Table 12.3 shows the average waiting times associated with each level of care in 2015.

Overall, specialised hospitals had the shortest total time spent by a patient at two hours per visit, while regional and tertiary hospitals had the longest total time spent by a patient at four hours per visit. This does not include the long waiting lists associated with access to some medical treatments in the public health care system. An example of this would be the Chris Hani Baragwanath Hospital, which in March 2015 had a waiting list of 4 846 patients waiting for a variety of procedures. Most of these patients were awaiting ophthalmic (1 919), orthopaedic (1 326), urology (1 200), general surgery (357) and plastic surgery (44) procedures. This phenomenon is widely prevalent and points to factors that deter patients and disincentivise them from seeking any medical care.

3

These are facilities that provide health care services but have no beds other than those needed for emergencies and maternity care.

226

Infrastructure

Table12.3 Waiting times per level of care Level of hospital

Patient waiting time (in hours) for Total time (in hours) spent by a patient service/s per visit per visit

Specialized Hospitals

1

2

PHC facilities

2

3

District Hospitals

2

3

Regional Hospitals

3

4

Tertiary Hospitals

3

4

Source: National Department of Health Notwithstanding the challenges in the public health care system, 62.7% of households first consulted a public clinic for illnesses or injuries and 23.5% of households first consulted a private doctor in 2015. The remaining proportion of households first consulted either a public or private hospital, traditional healer or pharmacy, etc. By 2020, the proportion of households that first consulted a public clinic improved to 65.4% while those who first consulted a private doctor declined to 21%. The dependence on public clinics is consistent for all provinces except for the Western Cape, where the proportion of households that first consult a private doctor (37.2%) was almost as high as those who first consulted a public clinic (42.3%). The trend demonstrates an increasing reliance on public clinics as the first port of call when family members are ill or injured for those who were part of the sampled population.

This could indicate that government efforts to strengthen the PHC system are bearing results or that due to changes in the socio-economic status, private health care is no longer affordable or accessible for those who previously relied on it.

Figure 12.2 Type of health care facilities consulted first by households in 2015 and 2020 Source: GHS, 2016 and 2020

227

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

Users of the public health care system recorded lower levels of satisfaction compared to those who use private health care according to the 2018 General Household Survey. The survey reported that 80.3% of users of public health care facilities were somewhat satisfied or very satisfied compared to 97.6% of users of private health care. This highlights the shortfall in expectations in the overall health care system, albeit more so in the public than the private health care system.

In as far as the state of infrastructure is concerned, public hospitals were rated D+ and clinics D according to the 2017 South African Institution of Civil Engineering (SAICE) Infrastructure Report Card. The ratings indicate that these facilities are at a risk of failure – the infrastructure is not coping with demand and is poorly maintained. The Infrastructure Report Card states that any condition of ‘C’ and below in the context of health care facilities adversely affects patient care and safety, and places the facility and the staff at increased risk.

Further, the 2019/20 Annual Inspection Report of the Office of Health Standards Compliance (OHSC) indicated that only one in seven inspected health facilities complied with the NCS. These condition outcomes point to the need to prioritise maintenance, preventative or backlog, in order to avoid further deterioration in the condition of the current facilities, barring the need to expand access.

Compared to other countries in the continent, the state of South Africa’s public health infrastructure is among the poorest. As illustrated in Figure 12.3, South Africa has an index score of 0.13, which is significantly below the regional average score of 0.40.

The poor outcome is despite the country’s high total health spending, which is ranked second on the continent at US$1 148.37 per capita according to the World Bank (2018).

Figure 12.3 State of health infrastructure4 Source: The State of Health in the WHO African Region, 2018 Overall, the analysis in this section points out that notwithstanding the availability of infrastructure, access is a challenge from waiting times and cost perspectives. There are also quality of service issues, and these are reflected in the expectations shortfalls. The National Treasury (2021) reported that medico-legal claims increased from R265 million in 2012/13 to R1.7 billion in 2019/20. Further, contingent liabilities5 increased from R28.6 billion in 2014/15 to R111.5 billion in 2019/20. Dhai (2015) indicated that the rapid increase in medico-legal claims is

228

Infrastructure

indicative of deteriorated levels of care in the public health care system. Expectation shortfalls are also experienced in the private sector, however, the extent is not the same as the public sector and in some cases, there is limited publicly available information to conduct comparative analysis. In regard to medico-legal claims, these are also rising in the private sector but are predominantly driven by medical malpractice. The quality of the infrastructure is a major contributor to the shortfall in expectations for patients.

As such, inadequacies highlighted in this section undermine the quality of health care provided. A quality health care system must have the capacity and capability to respond adequately and timeously to evolving demographic and epidemiological needs of the total population.

Broad Overview of Infrastructure Challenges in the Health Sector The health sector faces several challenges and infrastructure is a contributor.

Unless the challenges are adequately resolved, the health sector will continue to deliver sub-optimal outcomes. As such, to the extent that infrastructure contributes to sub-optimal outcomes, this must be pointed out and resolved, in addition to addressing the need for new infrastructure where it is needed. Below are the key infrastructure challenges that contribute to inadequacies in the health care system of the country.

1. Poor condition of health care facilities: As stated in the previous section, a large proportion of public health care facilities are non-compliant with the NCS. These facilities exhibit defects, deep wear and tear, and signs of deterioration such as breakdowns in building structures.

2. Facilities are not fit-for-purpose: Health care facilities are seldom retired, repurposed or refurbished at the end of their economic life, some have inefficient layouts and others were built with inappropriate materials (i.e. asbestos). These factors adversely affect their usability and desirability.

3. Facilities are unresponsive to evolving patterns: The demographic and epidemiological patterns evolve with time, yet health care facilities remain static. The sector seldom rationalises health care facilities to ensure that the size, location and service coverage is appropriate for the needs of the catchment population.

4. Facilities have insufficient, old and dysfunctional health technology: There are facilities that do not have the requisite equipment for their levels of care. This is mainly caused by failure to replace damaged or obsolete equipment, and the inability of staff to operate the health technology where this is available.

5. Maintenance neglect: This is a multi-pronged challenge wherein budgeting for maintenance is generally not done, and even in cases where there are budgets, these are either not used (fully or partially) or are reprioritised to other cost pressures. The deterioration of facilities over time requires major refurbishments at a much higher cost.

The health status scores measure the general readiness of facilities to provide essential services and considered the availability of basic amenities and equipment needed for service provision; the total number of beds; and total hospitals, health posts and health centres per 100 000 population.

5 Total medico-legal claims against the state.

4

229

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

To remedy the challenges in this section, we propose that the sector prioritises maintenance as a matter of urgency by ensuring that sufficient maintenance budgets are allocated and ring-fenced for recurrent maintenance. Even when budgets are inadequate, recurrent maintenance programmes must be done to the extent possible.

We focus on recurrent6 maintenance because we believe this should take precedence over capital7 maintenance, and certainly new build. Further, maintenance of PHC facilities and hospitals should be differentiated by the hub and spoke model8 managed by the District Office as opposed to a centralised model. The sector must also prioritise the appointment of maintenance personnel at facility level and provide for the required goods and services.

Further, it is common knowledge that there are capacity constraints in the Provincial Departments of Health, health districts and the Department of Public Works and these are major contributors to challenges in the health infrastructure delivery value chain.

However, capacity and capability varies across provinces. We propose therefore that the NDoH directs its efforts towards strengthening capacity and capability in a targeted and customised manner according to the needs of each province. Where pockets of excellence exist in the sector, these should be leveraged for the greater good. It is also critical that the sector aims to build capability internally and institutionalise this to reduce reliance on consultants regarding responsibilities that officials should retain and tap into with respect to institutional knowledge, memory and expertise.

It cannot be overemphasised that strategic planning should be done correctly and regularly to inform any new capital work that is to be embarked upon. This should inform the suitability, fit for purpose, and right sizing of facilities. The catchment population and recommended bed norms per level of care, patient audits, referral patterns and occupancy statistics should inform the planning of upgrades and additions, replacements, and new hospitals. The practice of planning public beds independent from private beds should also be changed.

The IUSS guidelines, norms and standards (GNS) that were developed about 10 years ago must be used to support infrastructure planning and delivery in the sector, as they directly influence the size and cost of the health facilities (more on the IUSS in later sections). Adherence to norms and standards must be enforced and deviations without acceptable motivation reported to competent authorities such as the Auditor-General.

Other Issues that affect Infrastructure Provision and Efficacy The inefficiencies highlighted in previous sections are largely due to systemic challenges that must be tackled to improve the sub-optimal outcomes including in infrastructure.

The challenges also contribute to the high cost of infrastructure. These include: 1. Poor planning and coordination: The health sector dedicates very little time to project development and fails to identify the interdependencies between this phase and the operations phase. This is exacerbated by insufficient capability, skills and

Recurrent maintenance includes day-to-day maintenance; term contracts for specialist installations and statutory maintenance which is prescribed by the OHS Act. 7 Capital maintenance includes rehabilitation, refurbishment and replacement of obsolete assets, and addressing the backlog maintenance.

8 This is a maintenance model where the maintenance team is employed by the hospital and attends to surrounding PHC facilities.

6

230

Infrastructure

experience amongst those responsible for planning, specifying, procuring and overseeing the implementation and maintenance of infrastructure in the sector (Human Science Research Council, 2019). The infrastructure directorates in health departments have been hollowed out, institutional knowledge is lost and as such, these directorates are no longer ‘informed clients’. This is partly the reason for appointment of implementing agents, who also do not have the capacity and have to outsource the work to consultants with varying degrees of experience.

There is also no criteria currently to guide the public sector on project prioritisation and selection, which has resulted in subjective and inconsistent selection of projects.

There is limited coordination between and within health departments and related public sector structures, and no coordination between the public and private health sector.

2. Inadequate capacity and capability of personnel in public health facilities: The facility managers and Chief Executive Officers appointed tend to not have infrastructure skills and experience to lead or manage infrastructure projects in their facilities. This is exacerbated when infrastructure personnel are either unavailable or incapable. This results in facilities neglecting maintenance and exposing staff and patients to an unconducive work/healing environment. There are also many cases where it is known that health facilities are underfunded and understaffed and the outcomes continue to be poor-quality service.

3. Inadequate funding and poor quantity of spending: The health sector is faced with a trichotomy of inadequate budgets, underspending and sub-optimal spending.

Infrastructure budgets have declined over the last 10 years, which has limited public health infrastructure investment and widened the gap between public health infrastructure needs and total investment. The sector has also over the years been underspending on the allocated budget (e.g. inconsistent trend of underspending in the sector at an average 5% per annum between 2015/16 and 2018/19). Lastly, the trend of cost overruns and escalations, significant variation orders, over-specified and expensive designs and other cost inefficiencies is prevalent in the public health sector. These factors undermine value for money, make infrastructure provision costly, and undermine the rationale for additional infrastructure allocations.

4. Non-adherence to industry norms, standards and procurement legislation and processes: In addition to lower levels of compliance to the NCS, there is also noncompliance with building norms and standards, procurement legislation and processes, and bed capacity ratios. In relation to procurement of goods, works and services, the Special Investigating Unit report (2020) under the National State of Disaster indicated that within provincial government departments, procurement was non-compliant with minimum prescripts that regulate public sector procurement.

This was effectively a contravention of the Constitution and the Public Finance Management Act principles of fairness, equity, transparency, competitiveness and cost-effectiveness. The Auditor-General (2020) conducted a special audit for COVID-19 and found irregular procurement and contract management to the tune of R3.3bn in the public health sector. The biggest contributors were deviations in awarding of contracts without approved reason (R1.1bn) and non-declaration of interest by successful bidders (R1.1bn).

231

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

5. The disjuncture between infrastructure planning and operations: The lack of consideration of full lifecycle costs in the provision of infrastructure combined with poor asset management practices undermine the sector’s ability to be effective, let alone efficient. This is evident in the maintenance neglect once the infrastructure is built, facilities that are unresponsive to the needs of the catchment population, and the limited and outdated information on existing facilities and their condition.

6. Inappropriate use of consultants: There is an overreliance on consultants in the public sector even for functions that should ideally fall on officials. This is largely due to inadequate internal capacity and weak capability by officials in some cases.

This results in professional services providers (PSPs) and other consultants being used for the planning, execution and oversight of infrastructure projects on behalf of government. The issue is not the use of consultants, but rather the excessive use, particularly on responsibilities that should fall on officials. Furthermore, there are cases where the segregation of duties between officials and consultants is unclear, resulting in PSPs not being managed or their work unchecked by officials. This evades accountability and good governance principles.

Given the myriad challenges in the sector, we recommended that changes be initiated starting with improving the quality of spend. Measures in this regard could include tighter cost benchmarks and control measures, adherence to infrastructure norms and standards, and introducing an objective criterion to prioritise interventions based on available budgets. In parallel, the request for additional funding in the public sector can be done in line with increases in capacity and capability within the health departments.

Reforms by the Government to Resolve Challenges and the Extent of Success I. Ideal Clinic Realisation and Maintenance The ICRM programme was conceptualised in 2013 to systematically improve and correct deficiencies in PHC facilities in the public sector. The programme was officially launched in 2015 to standardise the requirements for all clinics and provide a benchmark against which all clinics will be measured to enhance the PHC system towards universal health access.

An Ideal Clinic is defined as a clinic with good infrastructure (i.e. physical condition and spaces, essential equipment, and information and communication tools), adequate staff, adequate medicines and supplies, good administrative processes, and sufficient adequate bulk supplies (i.e. clinic uses applicable clinical policies, protocols and guidelines, and partner and stakeholder support) to ensure the provision of quality health services to the community. The sector has developed Ideal Clinic and Community Health Centre Frameworks. These frameworks introduced a weighted ranking criterion that determines whether facilities meet the minimum requirements for ideal status. The infrastructure component has four indicators assessing whether facilities have: (1) suitable and adequately maintained physical space, (2) sufficient and adequately maintained equipment and furniture, (3) availability of bulk supplies and (4) reliable ICT infrastructure and hardware.

232

Infrastructure

Figure 12.4 Cumulative number of facilities that achieved an Ideal Clinic status Source: National Department of Health Annual Reports 2015/16 – 2020/21 The cumulative number of facilities that achieved the Ideal Clinic status increased from 322 in 2015/16 to 2 100 in 2020/21. The improvement means that about 60% of PHC facilities in 2020 met the required percentage compliance with the criteria. The SAICE report (2017) acknowledges improvements in the condition of PHC facilities because of the ICRM programme. Waiting times and availability of medical stock have also improved due to the programme. Egbujie et al. (2018)9 indicated that waiting times in KwaZulu-Natal reduced by four minutes between patient arrival and taking of patient vitals, and by 17 minutes between the taking of vitals and patient consultation since the introduction of the programme.

Challenges The programme initially suffered from divergent perceptions on the roles and responsibilities across national, provincial and local government stakeholders. This was exacerbated by the weak intergovernmental relations that limited cooperation and authority. Lastly, the programme had insufficient resources from a human capital and funding perspectives. As a result, there was the unintended consequence of neglect of facilities that were not part of the programme. Muthathi and Rispel (2020) indicate that approximately 25% of all PHC facilities that were ICRM programme compliant had lost their Ideal Clinic status in a four-year period. The Health Systems Trust posits that infrastructure deficiencies; inadequate equipment, consumables and furniture; and emergency medical service response times were some of the contributing factors that resulted in the loss of Ideal Clinic status.

Bonaventure Egbujie, Goeffrey Fatti, Ashraf Grimwood and Sameera Allie, ‘Impact of ‘Ideal Clinic’ implementation on patient waiting time in primary healthcare clinics in KwaZulu-Natal Province, South Africa: A before-and-after evaluation’, 2018, https://www.researchgate.net/ publication/324355467 9

233

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

II. The Office of Health Standards Compliance The OHSC was established in 2013 through the National Health Amendment Act, with the key objective of protecting and promoting the health and safety of users of health care services. The OHSC executes its mandate by ensuring that health establishments comply with the NCS. In addition, it ensures that complaints about health care are investigated and, where necessary, that action is taken.

The role of the OHSC includes the monitoring and enforcing of compliance by health establishments, both public and private, to the standards and norms approved by the Minister of Health; and ensures consideration, investigation and disposal of complaints relating to non-compliance with the said standards and norms. Further, there are several mandatory norms and standards that guide the implementation of all infrastructure projects across the development cycle including the areas of clinical services, health care environment, support services and procurement and operation.

Approval is required should there be a need to deviate from these norms and standards.

Infrastructure in both the public and private health sectors must meet the requirements of the OHSC.

Achievements The OHSC provides the public with information on acceptable quality standards that should be provided by health establishments and ensures that non-compliance complaints are investigated (Health Standards, 2022). In addition, it is a regulator with the legislative authority to regulate norms and standards, investigate non-compliance and support the implementation of the NHI by certifying facilities as compliant or non-compliant with the NCS (National Health Act, 2013). It also introduced a quality assurance mechanism through the development of the NCS, which regulates the quality of health facilities. Part of the areas assessed by NCS include the operational management, public health, and facilities and infrastructure. Lastly, the OHSC evaluates the quality of services and can improve accountability in the PHC system.

The percentage of health establishments that complied with the NCS increased from 16% of the 730 sampled facilities in 2017/18 to 43% of the 647 sampled facilities in 2019/20. Similarly, the percentage of health establishments that were non-compliant with the NCS reduced from 84% to 48% over the same period.

Figure 12.5 below provides a summary of compliance levels of health establishments with the NCS in the 2016/17 and 2018/19 financial years. It is worth noting that there has been an improvement in the compliance levels in provinces for both PHC facilities and hospitals. In terms of PHC facilities, both KwaZulu-Natal and Gauteng met the compliance levels for PHC facilities compared to 2017/18, when only Gauteng’s PHC facilities were compliant. In terms of hospitals, four provinces met the compliance levels, namely the Western Cape, Mpumalanga, KwaZulu-Natal and Gauteng in 2018/19. This was also the case in 2017/18, with improvements noted for Mpumalanga in 2018/19. This demonstrates that since the establishment of the OHSC, there has been an overall improvement in compliance levels for both PHC facilities and hospitals during the period.

234

Infrastructure

Figure 12.5 Compliance of health facilities with NCS infrastructure requirements Source: OHSC 2018/19 Annual Inspection Report

Challenges The OHSC has been criticised by the Portfolio Committee on Health (2014) for failing to provide solutions to challenges identified in health establishments. The committee wanted the OHSC to provide remedial actions for each facility and make recommendations to provincial stakeholders, as this is where the majority of the challenges were. Further, there are no consequences for provincial and national departments of health on facilities that are non-compliant, and no follow-ups are done on previously non-compliant facilities in subsequent annual inspections or other reports provided by the OHSC (Parliamentary Monitoring Group, 2014).

The Parliamentary Monitoring Group has also criticised the OHSC of having ‘a poor relationship with the private sector’, which hindered its oversight of the sector. The Group also highlighted that there were challenges of limited knowledge and resources available to the OHSC to fully execute its mandate.

III. Infrastructure Unit Support Systems The IUSS project was initiated by the NDoH in 2010 to develop national GNS for health infrastructure. The duration of the project was four years and the GNS were gazetted on 17 February 2014 (no. R116); 30 June 2014 (no. 512) and 8 May 2015 (no. R414). The GNS documents covered various aspects of public health infrastructure including: • Building Engineering Services and Professional service provider instructions • Various facilities e.g. Paediatric and Neonatal, TB Services, Mental Health and Critical Care • Support facilities e.g. Catering, Linen and Laundry, Administration and related services • Information Technology and Infrastructure

235

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

• Primary Health Care • Maintenance and Decommissioning • Order of Magnitude Estimators for New Clinics; New Hospitals; Upgrade and additions to clinics; Upgrade and additions to hospitals • Sustainable and climate resilient building technologies • Project planning and briefing guide The IUSS further provided data sheets which enabled briefing of consultants to simplify their work. The detail estimator for hospitals was also provided in draft format, allowing for disaggregated costing of all the sub-components of a hospital.

Achievements The frameworks developed through the IUSS can be utilised in the project brief particularly where the design-and-build procurement option is selected. They also assist in the development of the design, the monitoring and evaluation of proposals, planning of health technology and the operation of facilities. The proposals based on client briefs can be evaluated in terms of targets enabling optimum solutions to be developed. In addition, performance targets can be set and tracked from an early conceptual design stage through to operation of the facility. The order of magnitude estimators were updated quarterly with the Bureau of Economic Research escalation indices, meaning that they were kept updated up to October 2021. Lastly, the IUSS was widely used by the public and private sector with 42 529 users and 109 951 page views between 2018 and 2020. These users were not only local but included other users from six other countries including India, the United States and France (see Figure 12.6 below for details).

Users

Country

Sessions

600 400 200 0

1

1.

2.

3.

4.

5.

6.

7.

12 Feb 2018 31 Aug 2018 19 Mar 2019 5 Oct 2019 22 Apr 2020 8 Nov 2020 23 May 2018 9 Dec 2018 27 Jun 2019 13 Jan 2020 31 Jul 2020 Users New Users Number of Sessions per User Sessions

38,001

Country South Africa India United States France Kenya Nepal Germany

42,529

Users .

38 001 314 537 268 264 139 180

New Users 38 046 614 536 268 264 193 179

Page Views

109,951

42,928

Pages/Session

2.3

Figure 12.6 IUSS users by country and sessions between 2018 and 2020 Source: IUSS website archives

236

1.12

47,747

Avg. Session Duration

Bounce Rate

00:01:26

67.64%

Infrastructure

Challenges The NDoH did not enforce compliance with the GNS developed through the IUSS project. This was even the case for projects implemented by the Department, where consultants were not compelled to comply with these. It was the same case for benchmarks for gross building areas and cost, which were meant to ensure value for money. The IUSS website was hosted by the Council for Scientific Research and Industry and was grant funded from various sources. The website was subsequently discontinued after two years when the grant funding came to an end and the information has thus not been updated since to reflect the latest technology and treatment protocols.

There was no gradual transition away from the IUSS and the available information does not provide detail on whether the sector has reverted to the South African Health Norms and Regulation 158 for private hospitals. Despite the IUSS project coming to an end, some of the challenges that the project was meant to resolve remain, such as the gap between PSPs and clinical staff, and the lack of cost benchmarks for health infrastructure.

IV. Draft 10-Year Health Infrastructure Plan The Draft 10YHIP is a national plan to overhaul the health care system between 2015 and 2025 and was completed in October 2016. The plan was developed to facilitate the planning, resourcing, delivery and maintenance of the physical environment conducive to quality health care services. It was developed with the objective of equitable access requirements based on catchment population and contains the estimates of the value of all existing infrastructure, annual maintenance estimates (adjusted for facility per average condition), refurbishment and replacement value (adjusted per facility based on average condition), and new capacity requirements (based on access and population to bed/ consulting room ratios).

Achievements The Draft 10YHIP assisted the sector to develop an objective system of prioritising facility projects based on their condition. It encompasses objective and sound principles for portfolio and priority planning. This is an effort by the NDoH to ensure uniformity in the application in the prioritisation of projects in the sector. In addition, the initiative assisted the sector in establishing a baseline in terms of the number of facilities in the public and private sectors, their location and the generic conditions of public facilities, quantifying the backlog and determining the financial costs associated with the infrastructure needs of the public sector.

Challenges The initiative did not gain much traction within the sector and the 2015 Draft 10YHIP remains an informal policy document, which was never approved and enforced.

However, there is a collaboration between the NDoH and the Development Bank of Southern Africa to update the plan and enhance it into an online platform. The goal is to enable a more accurate identification of infrastructure requirements based on real-time information on the condition of health facilities.

237

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

V. Draft Maintenance Strategy The NDoH in collaboration with the Development Bank of Southern Africa finalised a Draft Maintenance Strategy in 2015. The strategy focussed on the principles of life-cycle costing, proactive maintenance, and maintenance excellence hierarchy.

As part of the life-cycle costing, a strong emphasis was put on utility consumption, collecting data, and planning interventions to reduce consumption costs. Among proposed interventions were developing annual provincial maintenance plans and making maintenance statutory to address some maintenance backlogs; to ensure maintenance of new assets – ring-fencing funds for personnel and goods and services; and move responsibility for maintenance to the provincial health departments (from the relevant implementing agents). Order of magnitude estimators were developed for the maintenance of clinics and hospitals and shared on the IUSS website.

Achievements The document was drafted and consulted with all provincial health departments, thereby providing for a pragmatic approach to maintenance. Most concepts were further developed in the One IDMS Operations and Maintenance Module (currently still in draft version).

Challenges Limited financial and human capital resources adversely affected the aspiration to reduce the maintenance backlog. The principles proposed in the document were sound and pragmatic, however, the document has remained in a final draft version since 2015.

Factors that may affect infrastructure in the future Lessons from the COVID-19 Response The COVID-19 pandemic demonstrated the strategic relevance of occupational health and safety in terms of infrastructure and facility management (see Chapter on Occupational Health). The need to protect health staff from contracting COVID-19 highlighted the direct link with the general status of maintenance, ventilation, and general flow in health facilities. The established aerosol transmission requires reviewing the norms and standards for natural and mechanical ventilation. Occupational health and safety capacity building is also needed mainly at the PHC level.

Medical service is not only provided at health facilities. With Artificial Intelligence, information technologies and remote-monitoring technology, some clients will not need to attend physically at a service point. Soon, health care facilities will not need extensive waiting areas, medical records, and outpatient consulting and counselling rooms. Preventative health services can be provided at a community level, reducing the pressure currently experienced at the facility level. Lastly, COVID-19 has also brought the need for an agile and flexible response. Overall, COVID-19 has shown the extent of the inadequacies in the health sector and the response by the sector was also revealing.

238

Infrastructure

Climate Change Africa is the continent most vulnerable to the impacts of climate change. Already experiencing temperature increases of approximately 0.7°C over much of the continent, predictions are that temperatures will rise further. Africa faces a wide range of impacts, including increased drought and floods. Soon, climate change will contribute to decreases in food production, changes in natural ecosystems and loss of biodiversity, floods and inundation of its coastal zones and deltas, the spread of waterborne diseases and the risk of malaria.

South Africa, the highest producer of greenhouse gasses in the African continent, is also one of the geographical areas most affected by climate change. Desertification along the western area, and extreme weather and flooding along the central and eastern part of the country require resilient health infrastructure. As an adaptation strategy, facilities will have to be carefully located and constructed with technologies capable of resisting extreme weather events.

Reducing the carbon footprint of the health infrastructure portfolio is one way to mitigate the increasing temperature in the atmosphere. It is recommended to design, build, upgrade and convert engineering systems to reach the Net Zero target – the state in which the greenhouse gasses going into the atmosphere are balanced by removing them out of the atmosphere. The Net Zero achievement requires concerted government efforts, as described in the signed Paris Agreement in 2015.

The Hospital of the Future There is no doubt that health care facilities in the future will be very different from the current ones: the use of robots, telehealth, 3D printers and Artificial Intelligence will likely require less space, as most of the care is provided away from them. Facilities in planning now must be designed to allow flexibility, adaptability and expandability.

South Africa requires a health service redesign to address inequality. This should provide the foundations for effective implementation of the Universal Care Coverage, requiring people-centred PHC, which focuses on treatments, prevention, community well-being, and quality of life.

239

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

BOX 1: Beaufort West Clinic, Green Building The Western Cape government required a new clinic in Beaufort West, in the Karoo district, of approximately 1 000 m2. The brief for the project was for the design and construction of a green building that would make use of alternative building systems and technologies. In addition, this facility would serve as a pilot in the province for climate resilient and sustainable facilities. The provincial Department of Public Works implemented the project at a total project cost of R26 million and construction commenced in June 2015, and practical completion was reached in May 2017.

The building was designed to try and encourage a feeling of wellness. It took into consideration natural light, space, colour, transparency, ease of route finding, and views to the outside. Some of the features that were included in the facility include: • Energy efficiency: The building harvests natural lighting and enhances this with colour.

In addition, the facility uses rock store technology to temper hot summer air and cold winter air to achieve the clinical environment standards without air-conditioning. The system works cyclically, with hot air being drawn in over the rocks during the day, where the rocks cool the air. In the evening, the warmed-up rocks have the cold night air drawn over them, and they cool down. In addition, the dropped eave blocks of the building are done such that they block the hot summer sun but allow the low-angled winter sun to penetrate the building.

• Indoor environmental quality enhancement: The wings are accessed along glazed ‘veranda’-like walkways, which helps to merge the facility with the natural landscape of the location. Furthermore, the facility uses appropriate orientation, calculated overhangs and integrates outward views, which offer spaciousness. Moreover, the roofs reflect the vernacular origin of the adjacent houses, which is done such that they provide internal

Source: Western Cape Department of Health

This project was done with set community participation targets for the contractor that would ensure secondary objectives of the project were met. This was done through continuous engagements with the local community, incorporating the Expanded Public Works Programme in the building process, sourcing materials locally where possible and subcontracting some of the work to small, medium and micro enterprises in the area.

Furthermore, the construction of the facility deliberately made use of labour-intensive technologies, in particular for the construction of the rammed earth external walls.

Post-construction, it is clear that the facility is an improvement of previous facilities and is a positive contribution to the community.

240

Infrastructure

The South African health care system faces a plethora of issues and infrastructure is but one of these. Inadequacies associated with the existing infrastructure combined with the need for more highlights how infrastructure contributes to sub-optimal health outcomes. This partially explains the expectations shortfall that patients and others experience when accessing or seeking to access the health care system. For those who can afford to pay for medical services, they can change service providers, however, those who cannot afford to, which constitutes the majority of the population due to unfavourable socio-economic conditions, have no choice but to access health services closest to them irrespective of the quality of service. This is the primary reason why UHC is proposed to transcend socio-economic lines and ensure equitable access to quality health care services. However, UHC will not be achieved in the short term and, although the NCS prescribes the benchmark for quality services, the number of facilities that comply with the benchmark is low and there are no consequences for those that do not.

The demographic and epidemiological patterns are evolving, and the health care system must respond with capacity and capability that is adequate and timely. To do this means that both symptomatic and systemic challenges must be addressed effectively and efficiently. The reforms already initiated in the sector have achieved varying degrees of success, but challenges remain. The case for more interventions is thus self-evident, over and above a need for follow-through on current reforms, including a review and improvement on these.

Catering for future health care needs requires that lessons be drawn from current developments and trends, as these will affect the way health infrastructure is provided.

Already with COVID-19, we learnt that medical services may not be provided only at health facilities, but rather remotely enabled by Artificial Intelligence, information technologies, and remote-monitoring technology, amongst others. As such, the need for extensive waiting areas, medical records, and outpatient consulting and counselling rooms will abate over time. The use of robots, telehealth, and 3D printers, etc., will become prevalent, implying less space needed at health facilities as care is provided away from them. Designs must thus allow for flexibility, adaptability and expandability. With respect to climate change, the sector must reduce its carbon footprint by designing, building, upgrading and converting engineering systems to reach the Net Zero state.

Given the critical role that infrastructure plays as an enabler of quality health care service, its improvement bodes well for health care outcomes. This chapter proposes infrastructure-specific improvements, which when combined with enhancements proposed in other chapters around other inputs and the combination of these inputs in a holistic, integrated, complementary and optimal manner, mean that the health sector will be more responsive and advance towards UHC aspirations.

241

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

Recommendations The government needs to maintain and strengthen its efforts to provide and maintain health care infrastructure as an enabler of quality health care. For this to happen, the following actions are recommended: • Ensure that infrastructure plans are aligned with service improvement plans. This will ensure that the PHC platform is prioritised, given that 90% of client only need to access these facilities.

• Apply quality management and continuous improvement to provincial 10-year infrastructure plans and streamline the infrastructure delivery process by not overburdening implementation through too many reporting requirements (i.e. ‘red tape reduction’). Moreover, differentiate between managing systems and reporting systems (Pharmaceutical Management Information System and Infrastructure Reporting Model). As health care facilities are complicated buildings, use Building Information Management in the design and construction phases, as this will alleviate coordination issues among designers and extensive variations on site.

• Standardise the Service Delivery Agreements between provincial health departments and implementing agents and keep monitoring the implementation thereof.

• Update the IUSS guidelines and keep the portal as originally intended: a platform for all the stakeholders involved in health care infrastructure – i.e. standardised layouts and functional units, as is currently done by the private sector.

• Update the South African Cost Norms for providing effective management of cost versus budget. Consider the entire life-cycle cost per project and prioritise maintenance.

• Capacitate training of the state human resource capacity to deliver health care infrastructure (i.e. to have educated clients). Engage Higher Education Institutes in reviewing their curricula for ensuring alignment between the new professional and technical workforce and the health care service demand.

• Use a dual mode for delivery of infrastructure (centralised approach) where provincial health departments are supported by NDoH, National Treasury, other pockets of excellence in the sector and the private sector when planning and delivering a new hospital. However, leave to provinces the implementation of projects related to PHC, based on standard layouts (decentralised approach).

• Use NEC term service contracts for maintenance and emergency work.

• Use the procurement method described in the Construction Industry Development Board (CIDB) Standard for Uniformity (design and construct, develop and construct, and management contractor), and disincentivise the professional fees linked to the work cost.

242

Infrastructure

References Council for Scientific and Industrial Research. Introduction to IUSS guidelines norms and standards. Available: https://slide player.com/slide/17463340/ Council for medical schemes. 2015. Council for medical schemes annual report 2015/16. Available: https://www.medicalschemes.co.za/publications/#20092014-wpfd-2015-16-annual-report Dhai A. Medico-legal litigation: Balancing spiralling costs with fair compensation.

2015. [Online]. Available: https://www.ajol.info/index.php/sajbl/article/ view/120167/109651 Egbujie B, Fatti G, Grimwood A, Allie S. Impact of ‘Ideal Clinic’ implementation on patient waiting time in primary healthcare clinics in KwaZulu-Natal Province, South Africa: A before-and-after evaluation. 2018. [Online]. Available: https:// www.researchgate.net/publication/324355467 Erasmus L, Poluta M, Weeks R. Integrated assessment and management of healthcare infrastructure and technology. 2012. [Online]. Available: https://www.up.ac.za/ media/shared/Legacy/sitefiles/file/44/1026/2163/8121/innovate7/ integratedassessmentandmanagementofhealthcareinfrastructureandtechnology.pdf Health Standards. Why standards matter. 2022. [Online]. Available: https:// healthstandards.org/ standards/why-standards-matter/ Health Systems Trust. South African Health Review 2017. 2017. [Online].

Available: https://www.hst.org.za/publications/South%20African%20Health%20 Reviews/HST%20SAHR%202017%20Web%20Version.pdf Health Systems Trust. South African Health Review 2020. 2020. [Online].

Available: https://www.hst.org.za/publications/South%20African%20Health%20 Reviews/SAHR_NO_BlankPages_3_8_Artifacts_07052021.pdf Hunter JR, Asmail S, Ravhengani NM, Chandran TM, Tucker J, Mokgalagadi Y. The Ideal Clinic in South Africa: progress and challenges in implementation. 2017.

Available: https://www.hst.org.za/publications/South%20African%20Health%20 Reviews/11_The%20Ideal%20Clinic%20in%20South%20Africa_progress%20 and%20challenges%20in%20implementation.pdf KPMG. 2016. Universal healthcare: One place, many paths. [Online]. Available: https://assets.kpmg/ content/dam/kpmg/pdf/2016/07/za-universalhealthcare-one-place-many-paths.pdf McIntyre D, Ataguba J. Access to quality health care in South Africa: Is the health sector contributing to addressing the inequality challenge? 2017. [Online]. Available: https://www.parliament.gov.za/storage/app/media/Pages/2017/october/ High_Level_Panel/Commissioned_reports_for_triple_challenges_of_poverty_ unemployment_and_inequality/Diagnostic_Report_on_Access_to_Quality_ Healthcare.pdf McLaren ZM, Ardington C, Leibbrandt M. Distance decay and persistent health care disparities in South Africa. BMC Health Serv Res. 2014 Nov 4;14:541. doi: 10.1186/s12913-014-0541-1. PMID: 25367330; PMCID: PMC4236491.

Medpages. Medpages Database. 2021. [Online]. Available: https://www.medpages. info/sf/index. php?page=stats

243

THE SOUTH AFRICA HEALTH REFORMS 2015-2020

Muthathi IS, Rispel LC. Policy context, coherence and disjuncture in the implementation of the Ideal Clinic Realisation and Maintenance programme in the Gauteng and Mpumalanga provinces of South Africa. 2020. [Online].

Available: https://health-policy-systems.biomedcentral.com /articles/10.1186/ s12961-020-00567-z Office of Health Standards Compliance. Annual inspection report 2018/19. 2019.

[Online]. Available: https://ohsc.org.za/wp-content/uploads/AnnualInspection-Report-_2018-19_Report_02-Mar-20-1.pdf Office of Health Care Standards Compliance. Mandate. Available: https://ohsc.org. za/who-we-are/#mandate Rensburg R. Healthcare in South Africa: how inequity is contributing to inefficiency.

University of the Witwatersrand. 2011. [Online]. Available: https://www.wits. ac.za/news/latest-news/opinion/2021/2021-07/healthcare-in-south-africahow-inequity-is-contributing-to-inefficiency.html Sanogo N, Fantaye A, Yaya S. Universal Health Coverage and facilitation of equitable access to care in Africa. 2019. [Online]. Available: https://www.frontiersin.org/ articles/10.3389/fpubh. 2019.00102/full Shohan M, Rubayet Ul, Alam ASM, Rakhi N, Kabir M. Onset, transmission, impact, and management of COVID-19 epidemic at early stage in SAARC countries. 2020.

[Online]. Available: https:// www.researchgate.net/publication/343734542 South Africa. Auditor-General. Second special report on the financial management of government’s COVID-19 initiatives. 2020. Available: https://www.agsa.co.za/ Portals/0/Reports/Special%20Reports/Covid-19%20Special%20report/ Second%20special%20report%20on%20financial%20management%20of%20 government’s%20Covid19%20inititatives%20-%20FINAL%20PDF%20 (interactive).pdf South Africa. Department of Health. Towards quality care for patients. National Core Standards for health establishments in South Africa. 2011. Available: https://static. pmg.org.za/docs/120215 health0.pdf South Africa. Department of Health. National policy on management of patient waiting time in outpatient departments. 2015. [Online]. Available: https:// www.knowledgehub.org.za/system/files/elibdownloads/2019-07/Patient%2520 Waiting%2520time%2520Policy%252014%2520November %25202016%2520PDF.pdf South Africa. Department of Health. 2015 Draft 10-Year Health Infrastructure Plan.

2015.

South Africa. National Treasury. Provincial budgets and expenditure review 2015/16 – 2022/23. 2021. [Online]. Available: http://www.treasury.gov.za/publications/ igfr/2021/prov/Chapter%204%20-% 20Health.pdf South Africa. Special Investigating Unit. 2021. Investigation into the procurement of, or contracting for goods, works and services, including the construction, refurbishment, leasing, occupation and use of immovable property, during or in respect of the National State of Disaster. Available: https://www.siu.org.za/wp-content/ uploads/2021/02/R23_of_2020_Final_report_on_matters_finalised_for_public_ release_05022021.pdf

244

Infrastructure

South Africa. Statistics South Africa. 2016 General Household Survey (P0318). 2017.

Available: http://www.statssa.gov.za/ publications/P0318/P03182020.pdf South Africa. Statistics South Africa. 2018 General Household Survey (P0318). 2019.

Available: https: //www.statssa.gov.za/publications/P0318/P03182018.pdf South Africa. Statistics South Africa. Annual quarterly and regional fourth quarter report 2018 (P0441). 2019. Available: http://www.statssa.gov.za/publications/ P0441/P04414thQuarter2018.pdf South Africa. Statistics South Africa. Quarterly labour force survey quarter 4: 2019. 2020.

Available: https://www.statssa. gov.za/publications/P0211/P02114th Quarter2019.pdf South Africa. Statistics South Africa. Mid-year population estimates 2020. 2021.

Available: http:// www.statssa.gov.za/publications/P0302/ P03022020.pdf South Africa. Parliament of the Republic of South Africa. National Health Amended Act of 2013. 2013. Available: https://ohsc.org.za/wp-content/uploads/2017/09/ NationalHealthAmendmentAct12of 2013.pdf.

South Africa. Parliament of the Republic of South Africa. National Health Act of 2003: Norms and standards regulations applicable to different categories of health establishments. 2018. Available: https://www.gov.za/sites/default/files/gcis_ document/201802/41419gon67.pdf.

South Africa. Portfolio Committee on Health. Committee calls on Office of Health Standards Compliance to suggest remedial action. 2014. Available: https://www. parliament.gov.za/news/ committee-calls-office-health-standards-compliancesuggest-remedial-action South African Institute of Civil Engineering. SAICE 2017 infrastructure report card for South Africa. 2017. [Online]. Available https://saice.org.za/wp-content/ uploads/2017/09/SAICE-IRC-2017.pdf United Nations. World Population Prospects. 2019. Available: https://population. un.org/wpp/Down load/Standard/CSV/ Van Dyk J. Is trust earned or given? Five COVID lessons for the NHI. Bhekisisa Centre for Health Journalism. 2020. Available: https://bhekisisa.org/health-newssouth-africa/2020-10-07-is-trust-earned-or-given-five-covid-lessons-for-the-nhi/ World Bank. The state of health in the WHO African Region: An analysis of the status of health, health services and health systems in the context of the Sustainable Development Goals. 2018. [Online]. Available: https://apps.who.int/iris/ handle/10665/275292 World Health Organization. Hospital beds (per 1,000 people). 2010. [Online]. Available: https://data. worldbank.org/indicator/SH.MED.BEDS.ZS World Health Organization. A vision for primary health care in the 21st century towards universal health coverage and sustainable development goals. 2018. [Online].

Available: https://www.who.int/ docs/default-source/primary-health/vision.pdf Young M. Private versus public healthcare in South Africa. Western Michigan University. 2016. [Online]. Available: https://scholarworks.wmich.edu/cgi/ viewcontent.cgi?article=3752&context= honors_theses

245