/ 30 August 2013

‘NHI will benefit the entire region’

Trevor Mundel at the Nwamatibjana health centre in Mozambique.
Trevor Mundel at the Nwamatibjana health centre in Mozambique. (Benoit Marquet /Bill & Melinda Gates Foundation)

South Africa's National Health Insurance (NHI) scheme will play a crucial role in freeing up donor funding for countries that need it more, said Trevor Mundel, the president of the Bill and Melinda Gates Foundation's Global Health Programme. 

"It's essential that South Africa comes up with alternative solutions [to fund healthcare] and thereby potentially free up donor money … with the economic crisis in developed countries that puts a premium on maintaining overseas aid," he said. "Mechanisms like the NHI, which will take on more of the [financial] burden, will help to do that." 

Mundel, a South African who studied medicine at the University of the Witwatersrand, said that South Africa has far fewer health burdens than its regional neighbours yet has significantly more resources. 

"In Mozambique, with a per capita GDP [gross domestic product per person per year] of $1 300, the wealthiest province, Maputo, has communities with a 37% HIV prevalence. I thought it was bad enough when I visited areas in KwaZulu-Natal with 30% [HIV infection rate]." 

South Africa's GDP per person per year is about $11 600 per person, according to purchasing powers parity figures.

"Even in parts of Mozambique where there is relatively good health infrastructure, it is not comparable to any of the systems in South Africa," Mundel said. "In South Africa, you've got HIV and TB [tuberculosis] co-infection but Mozambique has HIV, TB and malaria." 

Mundel also has an MSc in mathematics from Oxford University and holds a PhD in the same field from the University of Chicago. He is a former head of clinical research of a subsidiary of the drug company Pfizer in the United States. 

Based at the Gates Foundation's headquarters in Seattle, he said South Africa could learn from its neighbours when it comes to managing the stock of drugs at clinics and hospitals. 

Stock-outs: SA can learn from neighbours
In South Africa, public health facilities frequently run out of essential medicines to treat infectious diseases such as TB and HIV, according to the civil society group, Stop Stock-Outs. It threatened to take the health department to court in June "to look for solutions". The group said the Eastern Cape, KwaZulu-Natal, Limpopo and Gauteng in particular run out of stocks.  

In Mozambique's Maputo province, the organisation Village Reach has an "interesting solution", Mundel said. He visited the project, that the Gates Foundation partly funds, earlier this year. 

"The organisation acknowledges that it's very difficult for nurses in clinics to do inventory checking and ask for supplies while they're focusing on seeing patients. They have, therefore, taken healthcare workers out of the equation and replaced a push system [when stocks are constantly replenished] with a pull system [when orders are placed as medicines are about to run out]."

Village Reach has appointed people who are not involved in delivering healthcare to check inventories. 

"They go out to the clinics, look in the boxes and they say, 'Okay, not enough BCG [a TB vaccine for babies]'. Then they refill and travel to the next clinic. That's all they do." 

The organisation covers 79 health facilities in Maputo province with two trucks and four staff members. They fill out order forms at clinics and check whether the refrigerators in which vaccinations are stored are working. 

"They're measured or graded according to 'do you keep your clinics in supply?' If there are stock-outs at a clinic, they get a negative [grade]. All their focus is on just doing that and it seems to work ?so much better," Mundel said. 

According to the organisation's website, vaccine coverage rates in another province in which the distribution system operates, Cabo Delgado in northern Mozambique, increased from 68.9% to 95.4% for children between two and three years of age and the monthly incidence of stock shortages in rural health centres decreased from 80% to 1% over five years.

Mundel believes the same results could be achieved in places such as the former Transkei in the Eastern Cape. "What could you not do in the Transkei?" he asked. "For the cost of five vehicles and five people, you could pretty much get rid of the stock-outs. We're not talking about tens of millions of dollars here. It's pretty simple and it's just about good organisation."

TB drugs too "old" to save lives  
Mundel also said better TB drugs should be developed. The available drugs are "old" and have to be taken for unreasonably long periods (six months in the case of  normal TB and 18 months for multidrug-resistant TB) which makes it almost "impossible to be compliant". 

Health department figures show that fewer than half of MDR TB patients in South Africa are cured, mainly because people don't complete their treatment. The country has the third-highest number of TB cases in the world after India and China and the fifth-highest number of drug-resistant TB patients, according to the World Health Organisation. Statistics SA has reported that TB is the leading cause of death in the country, accounting for about 12% of the total. 

Mundel said it was "enormously difficult" to develop TB drugs and the phamarceutical companies didn't see a market for TB medicine. 

"Somehow the TB bug is very adaptive and tricky so drug companies have largely given up on TB," he said. 

TB has become the "forgotten and least-understood epidemic". 

"One-third of the world's population is latent infected and the death rate from TB was 1.4-million in 2011. For the size of the disease and the problem, there isn't nearly the amount of resources applied to it as there is with HIV. Even malaria potentially has more focus." 

Although the Gates Foundation invests almost more than double the amount of money in HIV than TB, Mundel said: "I would like to change that but it's almost a matter of consumption: because TB has been so chronically underfunded, the researchers working in this area, whether they're clinical or more basic, are much fewer. So, even if we were to increase our budget for TB, we would not find enough places to spend it on."

Mundel said the TB epidemic in the Western Cape is of particular concern. HIV aggravates the TB epidemic because it weakens the immune system of HIV-infected people, making it easier for them to develop TB. But in the Western Cape, only 40% of TB cases are HIV-related, Mundel said. "The force of infection of TB in Cape Town is the worst in the world, yet most of it is not HIV-related." 

Solution may lie in vaccines 
One solution is a TB vaccine. Scientists are working on several candidate vaccines but they are far from being finalised. 

"Vaccines are magic. From a public health perspective, there is nothing that's better. But my speculation is that we would more likely have a vaccine-like solution for HIV before we have something that's better than BCG [a vaccine that only protects small children and often mitigates the severity of the disease rather than preventing it] in TB."

The future of affordable vaccines for diseases such as TB, polio and pneumonia lies in the developing world, as production costs are significantly lower and the technological capacity of developing countries such as China and India have improved tremendously, Mundel said. 

For instance, China is developing an inactivated polio vaccine, or IPV, that provides much more protection against polio than the oral polio vaccine that is used in many developing countries. But, Mundel said, at $2, the vaccine is more expensive than the oral vaccine, which costs 13 US cents. 

"If China, however, got into the game, if they were to introduce this broadly, that volume alone would get the price down. My goal is to get the price down to 50c," he  said.  

Mundel said South Africa's only large vaccine manufacturer, Biovac in Cape Town, should be helped to develop its capacity. 

"But it will require significant investment, also from the government, and I believe there is funding to do that," he said. "We [Gates and other role players] are currently working on a plan for Biovac to produce vaccines for South Africa and the region."