Despite all the criticism, Nkosazana Zuma’s department is revolutionising health care, reports Jim Day
DESPITE scandals, unauthorised spending and a history of putting her foot in it, Dr Nkosazana Zuma’s Health Department is systematically revolutionising South Africa’s health-care system.
Zuma is blamed by many for the R14,2- million Sarafina II disaster and the trumpeting of the poorly researched Aids ”wonderdrug” Virodene.
But many health workers, even some who believe Zuma has retained her Cabinet position only because of political clout, acknowledge the radical changes she has set in motion during the past three years.
Her ministry has developed a policy of free public health care for all, has built hundreds of new clinics and has begun reallocating funds from tertiary hospitals to primary health-care facilities.
These long-term programmes, based largely on World Health Organisation guidelines, enjoy huge support among those involved in health care.
In implementation, however, Zuma has managed to make enemies of pharmaceutical manufacturers, medical students, doctors who dispense medicines, pharmacists and many health professionals who see their funding being shifted elsewhere. Many HIV/Aids activists have called for her head. Opposition political parties have joined in, fuelled further by the auditor general’s reports on financial mismanagement in the Health Department.
Senior health officials interviewed by the Mail & Guardian believe the nation has the resources to provide basic health care for every South African. But they say it will mean cutting costs by treating most illnesses and injuries in primary-care clinics instead of in the far more expensive tertiary hospitals.
It requires reducing the cost of medication, and ploughing the savings back into health facilities. It requires redistribution of resources into under- served regions of the country. And it requires health-care workers to operate in the townships and rural areas where they are most needed.
If these requirements can be met, and if health officials can keep to their timetables, a bottom line emerges: eight years. By 2005, officials believe every South African will enjoy up-and-running health-care facilities.
This would be in stark contrast to the current inequities: infant mortality is nearly eight times higher among blacks than among whites; infant mortality among coloureds is more than five times greater than whites. Residents of Sandton visit a doctor an average of six times a year; the township average is about once a year.
Public health spending grew by 9% this year to about R20-billion, or about 11% of the government’s total budget.
The Health Department’s main thrust is in these areas:
New clinics: Between October 1995 and the end of this year, in a crash programme, nearly 300 new clinics will have been built and another 152 clinics expanded, according to official figures. In contrast, the (previous) government in 1993 built only 17 new clinics.
Each new clinic serves about 10 000 people. That works out to nearly three million people who are for the first time getting access to health care, largely in the previously most neglected regions of KwaZulu-Natal, Northern Province and the Eastern Cape.
Another 100 new clinics are in the planning stage. After these, the building programme will be scaled back and resources switched into other areas. An estimated shortfall of about 600 clinics will then exist, to be gradually overcome.
There have been problems, however, in staffing the clinics and maintaining adequate supplies of medicines. As a health consultant in KwaZulu-Natal put it: ”In some districts, instead of having 17 dysfunctional clinics, now we might have 19 or 20 dysfunctional clinics … Let’s see the same enthusiasm in running them as there was in building them.”
Health officials insist no new clinics are built unless the provincial governments can guarantee adequate funds to run them. Often, however, it is not a question of having the money: qualified staff might not be available and competent managers not in place to ensure medicines get to the clinics.
Nevertheless, having the new buildings on the ground is seen as the key first step to providing basic services. About 4 800 new health-care posts have been created to staff them, and the department is developing programmes to improve the training of nurses and other workers.
Tackling the drugs industry: The department tabled legislation last week meant to bring down the high cost of medicines, setting off a battle with the pharmaceutical industry.
The planned legislation goes after a wide range of players in the industry. It seeks to prevent most doctors from dispensing medicines because of claims that many doctors over-prescribe drugs to increase their profits: ”Doctors are very guilty of oversupplying,” said Bada Pharasi, the department’s chief director for registration, regulation and procurement.
The practice of pharmaceutical companies giving doctors free ”samples” of expensive brand-name drugs to encourage their use is to be banned. Some doctors sell these freebies at a profit, even though less expensive generic drugs might be available.
The legislation seeks to deregulate the ownership of pharmacies to increase competition.
It also encourages substitution of cheaper generics for brand-name medicines and allows for ”parallel importation” – importing medicines at lower prices than manufacturers set for the South African market.
The Pharmaceutical Manufacturers’ Association sees this both as an invitation to allow counterfeit drugs into the country and as a violation of the manufacturers’ right to set the price of their products.
”We will fight that to the end,” said Mirryena Deeb of the association. She warned several manufacturers were considering disinvesting from South Africa if the legislation is enacted.
Manufacturers blame inflated drug prices on high mark-ups through the distribution chain and at the retail level; in turn, retailers blame manufacturers’ high prices; everyone blames the high rate of theft from government drug inventories, which it is estimated costs taxpayers up to R1-billion a year.
The legislation addresses each of these areas. Officials see reducing drug costs as a key to extending care. The department has already established an essential drugs list – an attempt to reduce bloated inventories while ensuring every clinic has the basic drugs necessary to treat 90% of the illnesses doctors and nurses encounter.
”Vocational training”: About 1 000 medical students will start working for the Health Department as medical officers next year if legislation goes through requiring two years of ”vocational training” in order to be licensed as a doctor.
Health officials say this is necessary to provide experience and supervised training for the students, and will also benefit patients. Students say it is forced community service, and some are threatening legal action against the department.
Although officials stress the training side, the programme was originally an attempt to bring young doctors into the public sector.
South African doctors have been reluctant to practise in the townships and rural areas where medical needs are most pressing, driving officials to import more than 300 doctors, mostly from Cuba, to serve these areas. The vocational training programme could be a long-term solution to the deficit of doctors in some areas, but students predict the plan will backfire.
Most young doctors work overseas when they complete their training, ostensibly to settle the debt – as high as R90 000 – which many have incurred. Medical students insist most return to South Africa after a few years. The prospect of two more years’ training will keep more doctors from returning, further exacerbating the shortage of medical professionals, they say.
In a separate attempt to train more doctors for work in under-served areas, the department has chastised medical schools for not increasing the numbers of black and coloured medical students. Studies show these students are less likely to emigrate, and are more likely to practise in underserved areas.
Preventing disease: The department is quick to point to programmes it has begun to provide immediate health benefits. Its polio immunisation campaign has reached more than eight million children since 1995, and officials hope to eradicate the disease by next year.
Immunisation drives against measles, tuberculosis, diptheria, polio, whooping cough, tetanus and others have been stepped up.
By the end of last year, the department’s school nutrition programme was reaching nearly five million pupils. Although there are problems of poor management, studies indicate school attendance and performance have improved.
Health care faces enormous challenges in the next few years: caring for 2,4-million people already infected with HIV, rebuilding the 33% of hospital facilities which are dilapidated, and dealing with increasingly resistant strains of diseases like tuberculosis and malaria.
In the words of an evaluation of the department’s first 1 000 days: ”Its achievements must be viewed against the backdrop of its predecssors and the legacy which they presented. When this is done, its achievements can be clearly seen and appreciated.”
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