/ 18 August 2009

Better management is key

UNAids executive director Michel Sidibé visited South Africa recently as part of an African tour. Susan Mathew asked him for his ideas on how to improve the country’s beleaguered health system

You’re a strong supporter of universal access to healthcare. Do you think the national health insurance (NHI) system the South African government wants to implement will work?
If it won’t work in South Africa, it won’t work anywhere else in Africa. I don’t think we can pretend that it will happen in Burkina Faso or in Mali, where resources are more limited. But South Africa first needs to reform its public health system to make sure it can support national health insurance in the long run.

Will the NHI eliminate the need for a private healthcare system?
There should be intensive and open dialogue between the public and private health sectors. The private sector should not get the impression that the public sector wants to kill it. That is an unhealthy approach. Public health systems have their limitations.

How should the private sector be involved?
The private health sector should provide some of the services to reduce the burden. I strongly believe in public-private partnerships. But it should be defined. The private sector should not cease to exist.

Private analysts complain that the NHI process is not transparent. What’s your impression?
I think it’s impossible to implement an NHI system successfully without this type of debate. The debate should focus on issues of equity, redistribution of opportunity and social justice. If it doesn’t, you’ll have a parallel system and a breakdown in your system. South Africa’s private health system is one of the most advanced in Africa, if not the world. People travel from all over to access your private health services.

In some parts of South Africa, access to essential medicines for the prevention of mother-to-child transmission of HIV has decreased. Why do you think this has happened?
Management issues are central. It’s important to better manage and have monitoring systems in place. Botswana is almost there. It has a 4% mother-to-child infection rate, which is virtual elimination.

So what can South Africa learn from Botswana?
In Botswana there was certainly earlier, stronger commitment to really making sure that it dealt with these issues. It was perceived by [political] leadership there as a survival issue, so they put an emergency plan in place and they put all their energy into combating HIV/Aids.

Many people believe Thabo Mbeki’s government refused to combat Aids. Are you hopeful that the Zuma government will change this?
The challenges are there, but the energy, the resources and the imagination also exist in this country. Nothing could be more worthy for any leader, for his or her legacy, to say: “During my tenure I managed to make sure that no baby was born with HIV in my country.”

South Africa has problems managing the distribution of the medicines in public hospitals. How do we tackle such problems?
I discussed this issue with Health Minister Aaron Motsoaledi and Deputy President Kgalema Motlanthe during a recent visit. They’re very concerned. It’s time to have an oversight system. You need to move from crisis management to strategic management, looking [at] deficits in management capacity. It’s often a lack of vision or policy.

You’re on record as saying the South African government needs to strengthen public accountability in the use of provincial budgets and that there needs to be a better understanding of how these budgets are allocated. Why?
Proper management of resources and funds is critical. If you don’t ensure the resources that are made available at the lower levels are accounted for, it becomes difficult to bring about social transformation. You must have — and I don’t like the phrase — “war rooms” to identify the gaps and where the breakdowns are in the system. If the central authority has no normative function or mechanism to hold local [and provincial] governments accountable and to report back, things become difficult.

Zulus in South Africa have significantly higher HIV infection rates than other ethnic groups. They don’t practice circumcision. Do you think Zuma, himself of Zulu descent, should encourage Zulu men to be circumcised to decrease the risk of HIV transmission?
If any public health measure reduces your chances of getting a life-threatening disease by 60%, as circumcision does for men, then any reasonable authority would implement it. I hope the South African government will conduct a serious review of all the findings and that Zuma will begin promoting that.

Do you think many people will listen to him?
Oh yes! I’m convinced of that. That is the beauty of leadership — particularly [with regard to] a [popular] president such as Zuma. But first he needs to have the facts; second he needs to be convinced; third he really needs to demonstrate that it can be done without harming society.