Fixing healthcare needs a multidisciplinary approach, not just a medical focus.
It’s been just over 18 months since 11 pilot sites were chosen and financed to support limited health intervention in preparation for, and to try out, National Health Insurance (NHI) before it’s launched on a national scale.
But what is actually going on in these districts? Have changes been made? Are they affecting the communities that live there? Most importantly, what can we learn from the intervention so far, and what do they tell us about South Africa’s health system as a whole?
Bhekisisa visited two NHI sites –one in the Western Cape and one in Kwazulu-Natal – to find out.
Eden district, Western Cape
It’s surprising how few complaints about the quality of healthcare service there are among public sector patients in and around Knysna.
Maria Mathembu, a grandmother waiting for a taxi with her two-year-old grandson outside Knysna District Hospital, beams when she speaks about her experience.
"He’s very fine, he’s very happy," she says of her grandson, who came in because of a respiratory infection. Mathembu was given breakfast while waiting for him to be discharged.
"There are many, many laughs here," she says.
"There aren’t this many laughs at home. Healthcare is fine, it’s 100%. It keeps getting better."
But there is no shortage of complaints about life in general and service delivery in and around Knysna: everyone seems to have a bone to pick about shoddy infrastructure, lack of transport, unemployment and the long distances to health centres.
"I think things must change because the clinic is very far … The settlements must change, there’s water in the buildings, it’s damp inside. We need electricity in the area. Small kids run into the street and get knocked by cars," says Sibonga Ngonyama, a pupil who lives in an informal settlement just a few kilometres outside Knysna.
He says service at the clinic is fine; it’s the conditions that make getting there difficult, and getting sick easy, that are a problem.
Outside major cities, the quality of healthcare service is more of a problem. Maggie Jacobs and Charmaine Aweries hail from Buffelsnek in the Karoo, but are in Knysna to shop for food.
"We have no transport and there’s only a mobile clinic [in Buffelsnek] once a month," says Jacobs.
"Sometimes [the clinic] can’t help you. They give you a letter to go to the hospital [in Knysna], even though you have no transport."
Mathembu, Ngonyama, Jacobs and Aweries reside in Eden District, Western Cape, an NHI pilot district. Eden is both rural and urban, hosting towns such as George, Knysna and Plettenberg Bay, and much smaller, more historically deprived areas such as the Little Karoo.
The district NHI pilot programme, now in its second year, has focused on health systems analyses and intervention, such as staff contract management, reducing queue times and improving referral systems.
The pilot district has also rolled out district health specialist teams, which include a paediatrician, a gynaecologist, an anaesthetist, a family physician and a midwife.
These are based at George Hospital but travel throughout the area.
Finally, the pilot site has acquired three mobile clinics from the national health department to give dental and health check-ups to pupils in remote areas.
But the intervention may not be making much of a difference in the daily lives of those living in the district.
Health Minister Aaron Motsoaledi has repeatedly said that fixing healthcare will require a multifaceted approach. But, in part because of the way the NHI grants have been structured, most intervention in pilot sites is almost exclusively health-centred, and focuses on things such as referral systems and data management.
Most patients may not see or feel the benefits for years to come, and only feel them very marginally as bigger structural issues, such as better roads and better transport, don’t come into play at all.
Questions such as "have you heard of National Health Insurance?" or "do you know what NHI is?" are met with blank stares.
Limited community involvement or outreach may also be to blame, says Vuyisani Dala of the Plettenberg Bay branch of HIV lobby group the Treatment Action Campaign (TAC).
"There’s no communication between the community and the MEC for health … There was a business plan drafted without the consultation of community … We are so disappointed with the way it started. We thought that this initiative would start with the community knowing how it would happen," says Dala.
Patients and advocacy organisations also say the three mobile clinics are scarcely seen in the community.
The regional organiser of the National Education, Health and Allied Workers’ Union (Nehawu), Patrick Brown, notes that the vehicles often stand in the parking lot of the Harry Comay TB Hospital in George for days at a time.
The reason? Drivers have yet to be hired, and so nurses drive the clinics.
Nehawu is incensed. The union believes that promised jobs have been taken from the community because drivers and cleaners were meant to be hired, that nurses are being abused by having to take on extra responsibility without extra pay and without heavy vehicle licences or public driving permits, and that the community is not getting the services that have been promised.
Health MEC Theuns Botha acknowledges there’s a problem with the mobile clinics, but denies that nurses are driving the clinics illegally. He says the national department is responsible for making a budget available for the drivers.
But national health department spokesperson Joe Maila disagrees.
"The upkeep of the mobile clinics is the responsibility of the provincial health department," he says.
"It is expected of the province to make local arrangements to ensure that all mobile clinics are fully operational."
Botha’s office failed to respond to Maila’s comments.
Debates over how the programme is being rolled out in the Western Cape are also political.
Although the Western Cape health department’s vision 2030 document champions much of the same primary healthcare-focused intervention that the national department does, the Democratic Alliance is critical of the NHI in its current form.
The party does not agree with the notion that any health facility – public or private – should be accessible to all South Africans. It also does not advocate for increased taxes, an option that is reportedly strongly considered by the government, in order to expand healthcare access.
The Western Cape government is also worried about loss of provincial autonomy if and when a more streamlined national system goes forward.
Botha is also critical of the R11.5-million that has been allocated to each pilot site this financial year by the national health department.
He says it’s too small to make a dent and is equal to just a few days of the province’s daily health budget.
"We consider [NHI pilot site intervention] as only a small part of a health service and it can certainly not be seen as a testing field for a national health insurance. It … is certainly not addressing comprehensive health services," says Helene Rossouw, Botha’s spokesperson.
Yogan Pillay – the deputy director general for HIV, tuberculosis and mother, child and women’s health in the national health department – asked for patience during the NHI roll-out, saying, "this is a 14-year process".
But in the midst of growing pains, organisations and communities are confused about what they should expect from the NHI as a whole, and pilot sites specifically.
Poorer, more marginalised communities are perturbed that George Hospital was the site of recent upgrades, because it is in a wealthy metropolitan area.
But the hospital’s upgrades were not paid with NHI funds, but from a different pot of money called the hospital revitalisation grant, which the national health department uses to help provinces to renovate hospitals.
Dala says community members would benefit from directly accessing private services in the district, even though this isn’t part of the Eden pilot site programme. How the public-private model will work is still being discussed in high-level national and international meetings.
uMgungundlovu district, KwaZulu-Natal
The war room. That’s what monthly ward meetings between representatives of different departments – such as health, social development, human settlements – are called in the uMgungundlovu district, a NHI pilot site in KwaZulu-Natal.
They meet to discuss what’s going well, and what’s going badly, and rely in part on information offered by community caregivers – KwaZulu-Natal’s version of community healthcare workers, as well as family and school health teams.
Information is fed through the wards to the district, and from the district to the premier. Whereas in other districts the intervention at NHI pilot sites seems largely fragmented – that is, health specific only, without much interaction with other departments – in uMgungu-ndlovu, there seems to be a concerted effort to tackle the issues in a multifaceted way.
And there are many issues to deal with. According to the NHI district profile, uMgungundlovu has a population of more than one million people, nearly 30% of whom live in informal settlements. Less than a fifth of people have access to electricity, and about one out of 10 people has no piped water. About 13% of households live on less than R400 a month.
Abdul Amod is a nurse working as part of a school health team. He spends a week at a school, and speaks to pupils about health risks and healthy behaviour, touching on topics such as HIV prevention, rape and eating well.
He also conducts physical examinations, including blood pressure, eyesight and blood sugar level tests, checking pupils’ height and weight, and treating minor ailments.
Amod often refers pupils for other care, such as HIV and TB testing, or to meet with a social worker or psychologist.
"[When we] pick up problems early, we can catch them and turn things around. We need to do health education from an early age," he says.
School health teams are considered to be a main component of primary healthcare, as outlined in the NHI Green Paper.
Amod says that HIV and teenage pregnancies are by far the biggest problems for youth.
"A 15-year-old pupil once said to me: ‘If you don’t have HIV, you haven’t lived yet.’"
He blames "sugar daddies" – older men who provide material support to their younger female sexual partners – and multiple concurrent sexual partnerships, for the high rates of infection.
"Girls make passes at me," he says. "If a guy has a nice car, he’s a king in the area."
From August 2012 until March this year, school health teams had visited 100 schools across the district. They are prioritising rural and poor schools first, before reaching the better-resourced urban schools.
These teams referred 2 765 pupils for additional care.
That’s on top of the work of family health teams, who make community visits to individual households.
These teams conducted 4 588 visits from February last year until March this year, and made 3 058 referrals.
At the time of Bhekisisa’s visit in May, the district had employed 896 community caregivers, who are each expected to do 60 household visits a month – that’s about three a day – during which they share health information, collect data on each household, and refer people to healthcare centres as needed.
It’s hoped that they can soon dispense chronic medicine – such as antiretrovirals – to patients. This will reduce the number of patients who need to go to clinics, and make life easier for both healthcare workers and patients.
The district uses what is called the Benguela referral system, through which it’s envisioned that community caregivers can refer patients to a nurse, who can then refer them to a doctor or a specialist. The patient can be tracked through each level of the health system and followed up as need be.
"The focus that we have in our NHI pilots is to ensure that there are health promotion activities and there are disease activities," explains Sibongile Zungu, head of the provincial department of health.
"People are already sick, so we have to do the curative side, but for those who are not sick, we have to do a health promotion or disease prevention package. We are also trying to create an interest in health, to make people want to come to a health facility, either to get information or to get a screening."
Zungu notes that the district is also focusing on strengthening infrastructure and maintenance of facilities. It is auditing facilities to ensure that they meet core standards as set out by the national department of health, working on better transport for patients and moving from a paper-based to a computer-based data system for patient information and monitoring stock levels of medicines.
But that’s not to say there aren’t problems. KwaZulu-Natal is the site of the infamous TaraKLamp, a circumcision device that a 2009 World Health Organisation (WHO) report said had "low acceptability and high complication rates".
The device has been used at circumcision camps organised by the provincial health department. The clamp is meant to cut off the blood supply to the foreskin, causing it to dry out and fall off after seven to 10 days. But, according to the TAC, this often does not happen, resulting in the foreskin having to be removed surgically.
The TAC has described the TaraKLamp as an "unethical medical intervention" and accused the provincial government of "using an unsafe circumcision device that will injure thousands of men".
Patrick Mdletshe, the TAC’s provincial co-ordinator, says that there have been "many" events advertising the TaraKLamp in the district.
Studies have shown that medical male circumcision can reduce a man’s chances of acquiring HIV through heterosexual sex by up to 60% – a necessary intervention in a health district where almost 40% of pregnant women are HIV positive, according to health department figures.
Doctors can remove the foreskin of the penis either surgically or non-surgically through special circumcision devices such as PrePex, which has been approved by the WHO. The national health department is testing out PrePex at several pilot sites.
KwaZulu-Natal Health MEC S’bongiseni Dhlomo has asked for more evidence about the negative effects of the TaraKLamp before taking further action.
The TaraKLamp has been used across the province without the department, or manufacturers, first conducting clinical trials or pilot projects, as is required by the WHO. Media reports have linked the distributors of the TaraKLamp to KwaZulu-Natal king Goodwill Zwelithini kaBhekuzulu, claiming that he is benefiting financially from the distribution of the device.
Despite impressive numbers given by the provincial health department about their NHI pilot project, Mdletshe says that, on the ground, things remain the same for most patients.
"We don’t see that much difference because the problems that were there, they’re still there, even today," he says.
"I cannot pinpoint successes today because of the NHI. Maybe there are a few things that we do see, like the improvement of a few hospitals … but I don’t know if that was just ordinary upgrade of hospitals or if it’s because of the NHI pilot. Services generally are still the same: we still find people waking up at 4am to join the queues for hospitals or clinics, there’s still poor nurse attitude and there’s still a shortage of staff."
Last week, Stop Stock-outs, an umbrella group comprising organisations such as Section27, Médicines sans Frontières and the TAC, released a report considering stock levels across the country based on a telephonic survey conducted in September and October.
The survey found that 14.3% of facilities in uMgungundlovu ran out of antiretroviral drugs or tuberculosis medicine during this period.
The TAC has called for more community consultation on the NHI pilot site.
"Even health workers don’t know what it is or how it’s going to work," says Richard Shandu, a district organiser for the TAC in the province.
"People must be informed as to what will be happening. They must do consultation in rural and urban areas – each and every ward and district must be called. They need to use churches and traditional healers to get the word out. They must use all structures to inform the community ... We’ve seen the business plan but it’s not enough."NHI still has a way to go before the training wheels come off.
Eden district profile
• Population: 574 265 people (most of whom live in and around George);
• Living conditions: 8.1% of the population lives in informal housing;
• Percent of population insured: about 14%;
• Health facilities: 82, 35 of which are clinics;
• Immunisation rates (for babies under one year): 88.6%;
• Facility infant mortality rate (in 1 000 live births, the number of babies under the age of one who die in health facilities): 4.2, compared with 8.1 nationally; and
• Percent of new mothers testing HIV positive: 16.1%. –Information sourced from the Regional Development Profile: Eden District 2012, released by the provincial treasury; interviews with the provincial health department; and the 2011 National Antenatal Sentinel HIV and Syphilis Prevalence Survey in South Africa
• Population: 1 066 152 people in urban, peri-urban and rural areas;
• Living conditions: nearly 30% of the population lives in informal settlements;
• Percent of population insured: 14.9%;
• Health facilities: 87 health facilities, 54 of which are clinics;
• Immunisation rates (for babies under a year old): 92.9%;
• Facility infant mortality rate (in 1 000 live births, the number of babies under the age of one who die in health facilities): 14.7, compared with 8.1 nationally; and
• Percent of new mothers testing HIV positive: 39.8%. – Information sourced from the uMgungundlovu district profile compiled for the National Health Insurance pilot site, the uMgu
-ngundlovu District Aids Council’s HIV and Aids strategic plan for 2012 to 2016, and the 2011 National Antenatal Sentinel HIV and Syphilis Prevalence Survey in South Africa