A healthier future

Rarely in South Africa can a minister have come to power carrying such a weight of expectation as Barbara Hogan.

Her first major public speech at the Aids Vaccine Conference in Cape Town in October was greeted with enthusiasm, and even international delegates speculated about the bright future that seems to lie ahead at last for South African healthcare.

Her speech was reminiscent of one of those games where one has to bash crocodiles on the head as they pop up apparently randomly through holes in the floor. Politely, and without naming names, Hogan took a baseball bat and bashed all the major crocodiles on the head: Matthias Rath and his vitamins, for instance.
Most of all she asserted the fact that HIV causes Aids.

She has appointed well-known Aids activist Fatima Hassan as her legal adviser, and appears to be encouraging more movement in the department of health than that flaccid organ has displayed for a while. It is possible that she may propose that the SA National Aids Council take a more direct role in the state’s responses to Aids, and may also get more control over the anti-TB programme. Such a move would finally unite, in some form, government actions against the two most devastating epidemics facing South Africa.

But as her ministerial seat becomes more familiar Hogan may well envy Hercules who only had 12 labours to complete—the list of challenges she faces is far longer than that. It includes a decrepit public health system; two major infectious disease epidemics; developing epidemics of non-chronic diseases and particularly those related to obesity and hypertension; lack of healthcare workers; lack of management; budget issues; increasing maternal and child mortality; a debate over the respective roles of the public and private healthcare systems; and the reality that South Africa is likely to miss health-related Millennium Development Goals (MDGs).

Traditionally health tends to be perceived as a less powerful government department, particularly because it is seen as a spending rather than investment department. Such an attitude appears to spring from short-term political thinking that doesn’t go past the next election, and also from the desire of both governments and donor organisations to fund projects that are tangible and can be monitored.

But public health is a “public good”, something that cannot be individually funded or used. It does not automatically translate into economic gain such as income levels or rates of economic growth—although some argue that it does, but in more subtle ways.

Professor David Bloom of Harvard University points out that there is an association between higher wealth and better health, but the effects don’t necessarily go just one way. Increased health could lead to an accumulation of physical and human capital—and thus be more likely to attract foreign investment. He said that increased chances of child survival can lead to a “demographic dividend” with people choosing to have fewer children, putting fewer demands on household resources and freeing women to work outside the home.

“A 10% gain in life expectancy translates into up to one additional percentage point of annual growth of income per year,” Bloom estimates. “That seems a lot of money to leave on the table because people can’t get their act together.”

He says that the most valuable asset for the poor is their labour: healthier bodies tend to be fitter, and more productive. Physically stronger people avoid long-term results of illness, whether neurological, cognitive or physical, as well as avoiding pain and suffering. Vaccination, for example, should be seen as an investment as well as a cost.

Bloom says: “If South Africa wants to achieve the MDG on schedule it needs to decrease child mortality at a pace without historical precedent, from 68 to 20 per 100 000. It’s hard to imagine South Africa can achieve that.”

His view that the best single thing the country could do towards achieving some of its MDGs is to extend its vaccine programme. Research in the Philippines found that immunised children were more likely to do well in language, maths and IQ assessments than those who didn’t. Analysing health interventions in that way attracts the attention of economic leaders and finance ministers, Bloom suggests.

But health improvements can take a decade to translate into an economic return, he observes, so the benefits tend not to accrue during the term in office of the implementers. This means that visionary leadership is needed to overcome the political reluctance.

Alex van den Heever, an economist at the Council for Medical Schemes, agrees that “healthcare is an investment. You need focused attention on human development. It’s the equivalent of Eskom: if you don’t invest all the time the lead time for achieving gains is rather long. But if you don’t do it you will have a human development black-out as catastrophic as Eskom’s but less noticeable, much in the way the impact of Aids hasn’t shown up in the GDP figures. South Africa is a victim of unbalanced development. It will face staggered growth and immense difficulties in further developing what it has built up.”

The inequity in South African society means that many people are vulnerable, and need public institutions to provide protection. Access to proper housing and nutritional support would alleviate many medical conditions, including infectious diseases, but this requires an administrative system that can detect and help those in need.

A striking feature of South Africa’s public healthcare system has been the disconnect between actions and accountability. While it is unfair for an individual or group of individuals to take the blame when fundamental structural causes lie behind problems, systems need to be developed which will ensure that people who have the power to make decisions are also held accountable for them in terms of both finances and service delivery.

Fixing the healthcare system means blocking out the routes of escaping responsibility so that people have an incentive to prevent the little problems that escalate into disasters.

There is a need for systematic institutional change. While policies need to be centralised, provincial level implementation has tended to be suboptimal. The provinces often don’t operate within a national policy framework and are too far away from the coalface of delivery to really know and respond to what is happening.

The information systems are in obvious need of rapid repair—or creation. Without accurate data it is impossible for policymakers to plan and for managers to implement responses and strategies. But such information systems may need to accept a trade-off between the amount of information that can be collected and its accuracy to avoid the “garbage in, garbage out” syndrome.

One of the most striking improvements in a government organisation occurred when the South African Revenue Service was given semi-autonomy. Such freedom should possibly be given for major hospitals. Considering that the CEO of a major hospital can be handling budgets into the hundreds of millions of rand, it’s remarkable how constrained they are with regard to operational financial decisions. Such a move would make sense, particularly given the triple function of such institutions—teaching, medical care, and research - but only if the devolution of power almost meant an devolution of responsibility and accountability.

The ongoing crisis in the ART programme has highlighted the problems with healthcare budgets. The provision of antiretroviral drugs can alleviate the huge strain put on the healthcare system as a result of the HIV/Aids epidemics by reducing the costs of treating opportunistic infections, and particularly hospitalisation.

But the burden of disease in South Africa is so high that any relief facing healthcare facilities as a result of the ART programme is swiftly followed up by the steady demand of new patients needing such treatment, and the needs of patients with other diseases that have been “crowded out” of healthcare services by patients with HIV/Aids. As the number of people on ARVs steadily climbs the costs of supporting such a chronic care problem will also impose an increasingly heavy burden, particularly if the current doctor-driven model is maintained.

The healthcare system needs an increase in budget - though this comes as the world continues to head into a financial crisis. Currently, health consumes approximately 3% of GDP. However, some analysis suggests that the problem may not simply one of budgets. Van den Heever says that international comparisons suggest that the most gains in healthcare occur when countries spend less than $500 per person.

It is the use and monitoring of such budgets that is crucial. Quality assurance—the preventive quality controls that should be one of the main supports of a functioning healthcare system—is not effective if those being monitored are involved in the acceptance or implementation of the assessment.

Regulatory controls should be implemented across both public and private sectors. The two should be held to the same standards - drug-resistant pathogens don’t need hefty deposits to gain admittance to private facilities, nor do they have to wait in the lengthy queues in order to enter state healthcare settings.

Similarly the district health system needs to be developed so that the people responsible for public health are given the freedom and responsibility to do their jobs effectively.

Mark Heywood, deputy chair of the South African National Aids Council, says the challenge is to work out first where to start. “For human resources there are lots of options. We are not using the ones we’ve got properly—we could design creative ways to get the private system involved. Significant investment in the lower rungs of the health system - the guards and the cleaners—would let the nurses get on with nursing.”

Johnny Broomberg from Discovery Health says that public healthcare in South Africa is probably worse than it was in the 1990s, due to a systematic degradation of skills, frozen posts, extensive periods of static budgets, and a habit of papering over the issues rather than addressing them.

Improving public healthcare means improving human resources, which means creating better working conditions. He also points out that as South Africa’s economic grows, health issues also undergo a transition as they move from the predominance of infectious diseases typical of developing countries, to the lifestyle diseases of growing affluence.

He says there needs to be a debate on financing policy, and that the public health sector needs to delegate authority to help find, attract and retain skilled staff. “We can help develop systems, there is the goodwill to get involved, but for so long it has been a complete stand-off,” he says.

A major problem for public-private partnerships however is the lack of contractual capacity within government. Development Bank of South Africa head Jay Naidoo said that it was time for business to take look at the resources it can use to help the public health sector.

“We know what we need to do. Why don’t we—is it because we don’t care?” he asks. Management issues are particularly important for the health sector, and overall leadership is one of the most profound challenges in this country, he says.

He adds that it is time to think differently and to use money more effectively to increase outcomes and change behaviour—such as giving incentives to mothers to attend antenatal clinics.

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