Salary inequality and primary care integration in South Africa

Separation of curative and preventive health programmes often impairs the coordination of primary care in developing countries. Salary differentials between organisations may aggravate non-cooperation. Implementation of a unitary national health service by South Africa's first democratically elected government has been hampered by salary differences, but no organisation possessed information on their magnitude. This paper reports on a study which estimated the distribution and conditions of service of all 224,000 public health sector personnel in South Africa, modelled options for equalising salaries between health authorities, and considered the financial and political feasibility of the options. The most important salary differential was between provincial and local authority nurses. The option to increase salaries selectively for personnel in rural and primary care would be most feasible and most in keeping with government plans. Health service unions face conflicts of interest, and professional organisations may oppose changes in nurses' roles. In a rapidly changing health system with fragmented managerial information, a combination of administrative survey, quantitative modelling and policy analysis helped clarify a key obstacle to reform. The South African case is a warning to other countries that decentralised pay bargaining may result in uncoordinated care which may be costly and difficult to overcome.