THE IMPLICATIONS OF CHANGE IN SOUTH AFRICAN SOCIETY FOR THE HEALTH PROFESSIONS

To address this problem, one has to look at (i) societal changes and future developments, (ii) changes in health care as such and (iii) the linkage between these two. In this respect we must realize that we are living in an era where economic, technological, demographic, social and political changes are accelerating. The interface between these changes results in the age of discontinuities as far as individual trends are concerned. To work therefore with projected futures amounts to brain gymnastics. A more realistic approach is to define the key drivers or trends and structures shaping the future of society and health care, and from this deduct the possible implications for health professions.

To address this problem , one has to look at (i) societal changes and future developments, (ii) changes in health care as such and (iii) the linkage between these two.In this respect we m ust realize that we are living in an era where economic, technological, dem ographic, social and political changes are accelerating.The interface between these changes results in the age of discontinuities as far as individual trends are concerned.To work therefore with projected futures am ounts to brain gymnastics.
A more realistic approach is to define the key drivers or trends and structures shaping the future of society and health care, and from this deduct the possible implications for health professions.
Societal key drivers affecting change The process of societal change evolves around economic, technological, dem ographic, political and societal change.
ECO N O M IC CO RE D R IV ER S Our exports must shift from a raw material base tow ards high tech and mineral benificiation The industrial economies is becoming uncoupled from raw materials and labour due to better design, microchip, artificial metals and minerals, com puter assisted design and production and micronization.Unless we can effect this changeover before 1995, chronic balance of payments problems, lower economic growth, less employment opportunities and therefore less public and private funding for health care will result.Because it will be a capital intensive process, it will form the wealth creating part of our economy, and not the job creating part.
Growing inability to sustain a high economic growth rate The slowdown of further growth in im port substitution, the lower growth rate in industrial economies, our lower exports of raw materials due to lower dem and in industrial countries, the unfriendly external political environm ent, our low internal savings rate and shortage of skilled labour more and more results in a growth rate not exceeding 3% per year.
Employment and health funding will suffer likewise.
Dem and and production structure will shift tow ards basic/B lack demand Up till now Whites received the dom inant share of disposable income; they therefore dom inated the market.Due to a lower white birth rate, saturation of the white market for especially durables and a lower growth rate in income, the internal market will have to shift towards the Black market.They have the numbers, but not the income.The expected lower growth rate will not enhance the income redistribution process materially.Basic needs (especially of Blacks) instead of luxury needs will form the backbone of the market.This also implies for health care.

Inability of enough employment creation in form al/m odern sector
We need to create about I 000 new jobs per workday to absorb all potential work seekers.To succeed, we need an economic growth rate of 6% per year.This means we are heading tow ards a situation where 40-50% of our people will have to be employed outside the form al/ modern sector of our economy.The inform al sector and inward industrialization will form the jo b creation part of our economy.The health implications of this is that many people will not be formally employed, belong to medical benefit or have a sustainable income.Emphasis must shift from economic dem and or population ratio to health or biological needs health model We lack a medical care system in which government is relatively uninvolved while the private sector carries the bulk of health services as well as a small rich /p o o r imbalance to sustain an economic dem and model for health care for all people in this country.We also do not have the money to sustain a population ratio model; at least not one based on First W orld ratios.A health or biological needs model taking into account available technology and finance, w hat kind, am ount and quality levels of services are required to attain and m aintain a healthy population will more and more become the order of the day for the bulk of the population.Fulfilling health ethics by providing services according to needs and not according to social or economic conditions of consumers will mean that the emphasis must shift from rem edial/curative to A prim ary/preventive health care.To a l a r ^ extent the economic need model will apply to those who can pay for it.

TECH N O LO G IC A L KEY D R IV ER S Inform ation and biological revolution can surpass industrial revolution
We are witnessing two changes that can surpass the industrial revolution of the previous century in scope and magnitude.It started with the com puter, progressed tow ards micro electronics, and with the aid of optical fibres, is entering the inform ation era where national and international networks of info becomes interlinked.The development of com puter assisted medical technology such as M RI (magnetic resonance imaging scan in which tissue and no bones appear), CA T scan, a SONO scan (computerized reconstruction o f sound waves beamed through the body) as well as com puter assisted in fo rm atio n ^^ storage, retrieval and distribution of h e a n P care knowledge will become the order of the day to survive in health care professions.The second revolution that will grow in the next 10 years is biotechnology.It is aimed at redesigning of living organisms for use in (i) plant m anipulation, (ii) animal m anipulation, (iii) health m anipulation (a shift from chemical based medicine tow ards a body chemistry base) and (iv) materials manipulation to design synthetic fibres and materials.The resultant advances in medical and medicine technology will have an im portant effect on the structure of health care in th at preventive health care will grow.

New drug delivery systems
Advances in biotechnology will result in new drug delivery systems and more specific on targeted drugs.Drugs will be introduced into the body by implants, skin surface devices, controlled release mechanisms and m icrocapsulation that will allow more precisely targeted and consistent delivery of pharmaceuticals.C onstant m onitoring of results and side effects will become an im portant part of health care.

D E M O G R A P H IC KEY D R IV ER S Black fertility rate is unacceptably high
The W hite natural growth rate is heading tow ards below the replacement rate.The Coloured and Indian rate is also falling.The Black fertility rate is still very high.The difference between a replacement fertility rate at 2015 and 2050 in terms of numbers is shown in graph 5.The extra cost of this difference as far as medical care is concerned is estimated at R670m per year by 2020 in real term s, while that for education will be R2000m in 2020.We cannot afford it.Furtherm ore, the carrying capacity of the land in terms of w ater is estimated at 80 million people.A preventive health care programme, integrated with an economic development and education programme, will be vital for survival.
An ageing W hite and a young Black population This is the result of the differences in birth rates.The results are shown in graphs 1-4.White health care will shift tow ards the aged and chronic illnesses, skin care, eye im pairm ents, etc.To a lesser extent this will be the case am ong the Indians and Coloureds.The opposite will happen am ong Blacks, unless their fertility rate can be lowered.The mean age of Blacks are now entering the high reproductive age.Child care and allied diseases will dominate.

Political key drivers
We can determine three forces at this stage.The first is the revolutionary take over of power force; mainly at the far left ^^h e political spectrum.The second is the ^H irib u tio n of power force, mainly to the nght of the political spectrum.The third is the power sharing force as the only evolutionary force.These forces result in the see-saw scenario in the sense that if we do not have development, jo b creation, etc., the balance might shift to one of the extremes.

R EG IO N A L CH A N G E KEY D R IV ER S
The second "G reat T rek" Economy and population wise our society is moving in a northerly and north easterly direction.Transvaal and N atal is benefiting, while the southern part of the country is suffering.Unemployment, lower income and fewer facilities will result in stretching health facilities to the limit.

Mass urbanization of Blacks
The W hite, Coloured and Asian urbani zation process is more or less completed in the sense that these groups have a 90% urbanization rate.At present only 40% of Blacks are urbanized; the m ajority in the

Integrated First and Third World
Historically the towns and cities in the white areas were the First W orld, whilst the rural and Black areas were the Third World.Due mainly to urbanization this is becoming an artificial dem arcation.More and more both worlds will become interwoven in the cities and towns as far as the economy, population and services needed, are concerned.The full spectrum of health care facilities will have to be provided, especially in the cities.A quality distinction between the services of both worlds will also be artificial.

Cost o f health care escalates beyond control
The real per capita outlay of government and health services are rising too fast, as shown in Table 1.The big increase is not in the D epartm ent of Health itself, as their work is mainly preventive in nature, but rather at the provincial level whose focus is mainly remedial in nature.The latter increased by 39% from 1970-1984, whilst real G D P rose only by 11%.The real per capita outlay on government health services even exceeded the growth in the private Sector.The result of this will be twofold.The first is a movement away from the emphasis on remedial care and the labo ratory centered health care and training tow ards a preventive/prim ary or com m u nity health care and training approach.The second is privatization of medical services.F or this to succeed, the cost of medication and medicine must be lowered through new structures.The present private sector structures are too expensive to accom m odate government patients.CH C, group practices, etc. is unavoidable.

Self-medication
Medical apparatus is becoming smaller, portable, cheaper and easier to handle.C om puter diagnostic systems, the so called sm art card health record and hospital on your wrist is a growing phenom enon.The treatm ent of chronic diseases such as asthm a, ulcers, arthritis, diabetes, etc., move more and more tow ards the end user in the sense of self-diagnosis and medication.The growth in patient-ready packs medicine, coupled with national advertising, will enhance this trend.
Alternative health care O ut of hospital services is in the take-off stage.Surgicentres, emergency care centres designed to receive critically ill people, urgent care centres that provide care for routine or m inor surgery problems, occupational medicine clinics, pure form M prim ary care centres, technology based ™ home health care services, walk-in or urgy centres, will more and more form an alternative to hospital treatm ent.The reasons for this is threefold.The first is lower costs, as these centres are on average 40% cheaper than hospitals.The second is convenience coupled to technology.The third is a social response towards the clinical/ depersonalized big hospitals.High tech needs high touch to survive.

Holistic health care
In this approach the physical, mental, spiritual and em otional states are inter related with each other and the environ ment.The focus is on prevention, teaching of basic self care skills to all, extensive home care support programmes, focus on outpatient rather than in-patient care, deemphasize role of physicians, group practices and com m unity health centres.A part from the fact that health care p e o ^P will be more involved in giving advice, they will have to be a part of a group practice and have more knowledge of natural pro ducts such as hom eopathics, spices and vitamins.

Provinsies
Subsidie Tesourie 19*^71 This means th at the clinic or com munity health centre, industrial clinics (even mobile ones) on a HM O basis will have to form the backbone of health care.From there on they can move up the hospital ladder towards more remedial care, also on a HM O basis.
This also means that we must differentiate in our training between the prim ary/ preventive care and remedial care.The bulk of health workers will fall under the form er and would not need the specialized knowledge needed by the remedial health care personnel.
An integrated approach needed A survey done by the British "The Econo m ist" has found that the prim ary health care approach of the W HO has failed in many African countries.Prim ary health care is above all an integrated package: it's measures reinforce one another, and in isolation each may have little effect.If, for instance, clean water and sanitation are not introduced simultaneously, im m unization programmes may often result only in shifting the pattern of diseases.M any of the W HO programmes in Africa are fragmented because they are sponsored by different organizations and not co-ordinated.

Group practices needed
There are basically two reasons why par ticipation of health workers in group practices, either as paid employees in a CH C, or as an individual in a private practice, are needed and will grow.The first is that the holistic health concept cannot work w ithout a multi-disciplinary approach.The health industry of the future will not mean simply the treatm ent of disease.The emphasis will be on early diagnosis and the maintenance of health.Medical care will be integrated into a system concept, em bracing preventive and remedial medicine, food and diet, prim ary/preventive and remedial health care, physical activities such as biokinetics, preventive cosmetics such as skin care for the aged, etc.The second reason is that a preventive health care program m e cannot work successfully without a m ulti dimensional approach, as was shown by the African experience.
Rescheduling of medicine Schedule 3 and higher medicine that is essentially of a preventive nature will have to be rescheduled to schedule 1 and 2. In the same m anner some schedule 1 or 2 medicines can be deregulated to OTC grouping for use by nurses, etc. R estructuring medical benefit schemes At present they pay a percentage on prescription medicine.This enhances the remedial health care approach, often resulting in an unnecessary expensive treatm ent.It is com m on knowledge that 20% members of medical schemes is responsible for 80% of all claims.The basic problem is that they function as sick aid schemes instead of health aid schemes.It is necessary that their structures be changed to accom m odate the following principles.First, that preventive health care, especially in industrial clinics on HM O basis, can also be claimed.Secondly, that a use tariff for everyday/norm al claims and a risk tariff for abnorm al claims, be instituted.The latter must fall in the category of medical insurance on which a member can earn a no-claim bonus if he lives a preventive lifestyle.Thirdly, that a basic list of medicine (BLM ) must be instituted.Preventive health care and privatization can only be effective if we can lower the cost of medicine.
Holistic training needed There are two reasons for this.The first stems from the holistic health and group practice needs.For a nurse to function successfully in such an environm ent, she must have a running knowledge of the other discipline1 involved in the team.
The second reason is accelerated tech nological ch nge.The more change there is, the quick ;r knowledge becomes obsolete.The more technique and spe cialised your training is, the bigger the danger of obsolete knowledge and machines replacing people.Also, the more specialized trained people need to be retrained virtually from scratch if technological change occurs, while a holistic or generalist trained person can be retrained on an "add o n " basis.The high growth rate in specialized para-medical professions is a case in point.

H. Boshoff, D.Comm. Professor, Institute fo r Future Studies
Potchefstroom University