Colliding epidemics

Overcoming past injustices, backlogs and disparities in healthcare while dealing with the huge burden of disease is a significant challenge for South Africa’s health department. These and other issues were discussed at the Mail & Guardian Thought Leader dialogue on healthcare in Rivonia on January 28, 2016, with a powerful line-up of medical professionals presenting.

According to Dr Yogan Pillay, deputy director-general, department of health, the department is dealing with four colliding epidemics - maternal, newborn and child epidemics, HIV and tuberculosis, non-communicable disease and violence and injury. Citing a 2009 Lancet report, Pillay said that South Africa had twice the global average per capita burden of ill health and the highest health burden of any middle-income country.

Despite the mountain of issues that need to be overcome, Pillay said mortality rates are declining and more accurate issuing of death certificates is proving this.

“Statistics published in December 2015 demonstrate steadily declining rates, from 614 014 in 2006 to 453 360 in 2014. While we are still not meeting all our targets, with the exclusion of malaria, there has been a 10% reduction [in] infant mortality rates in infants under five and in the maternal mortality ratio,” he said.

“It is clear that if we know the causes of under-five mortality, we can have a good plan to address these.

“HIV remains a major contributor to mortality,” said Pillay. “If we look at prevalence and sex, this is different between male and female, with females infected at a very young age - probably by ‘sugar daddies’ - and this pool of young women is in turn infecting another age group of young men.”

The medical community needs to address how to break the chain of transmission and decrease the incidence of infection particularly in the 15- to 24-year-old age group, said Pillay, describing the age issue as a “big challenge. We presently have 3.4 million people on anti-retroviral treatment. The challenge is persistent and not going away soon.

“We won’t extinguish HIV by 2030, but should come close at 0.2%; however, we need to be spending a lot more than we are now.


“We need to leapfrog and come up with ideas on how developing countries can use technology. One such way is our HIV treatment application. This contains the 2015 HIV treatment guidelines for NIMART (Nurse Initiated Management of Antiretroviral Treatment) trained nurses - 293 pages of information available on cellphones via iStore and Google Play. The app also provides for reporting drug stockouts and has already had 9 719 downloads in five months.

“It has also been realised that we are not reaching the youth with traditional media and in August 2015, [the health department] launched, a mobisite targeting 10- to 24-year-olds. This provides information on issues relating to the health needs of young people, live chats with experts and peers and surveys. It now has 28 070 users and 57 454 pages have been viewed.”

Pillay described the NDP (National Development Plan) priorities, which are to increase life expectancy to 70 years, decrease infant and maternal mortality, decrease the burden of disease, decrease injuries and trauma, aim for a generation free of HIV by 2030 and apply what he described as the “elephant in the room” - the National Health Insurance (NHI) scheme, which, coupled to the Universal Health Care (UHC) progamme, is expected to shape the future of the healthcare system.

The UHC’s Goal 3 targets include ending the epidemics of malaria and neglected tropical diseases, and combat hepatitis, water-borne and other communicable diseases; reduce by one-third premature mortality from non-communicable diseases and promote mental health and wellbeing — strengthening the prevention and treatment of substance abuse, including narcotics and alcohol — by 2030. It is also the intention by 2020 to halve the number of deaths and injuries from road traffic accidents.

“Everything is based on health. There is one goal, but a large number of things to achieve,” he stressed. “The menu, unfortunately, is a long one and includes thinking about the service delivery platforms and not just the NHI,” said Pillay.

“Despite the window of opportunity, we need to consider a wasteful economy and this means we have to do more with less. There has been progress in mortality and morbidity rates, but we did not achieve the millenium development goals and need to collaborate with all sectors to achieve our social development goals.”

Burden of illness and affordability crisis

Unlike countries like Germany, South Africa lacks a healthcare plan that matches demand geographically, modified around demographics that change with the burden of illness.

“There is a crisis here,” said Dr Brian Ruff, chief executive PPO Serve. “Our bed days are amongst the highest in the world, plus [there is] the issue of variable quality, especially for high-needs patients with complex, long-term challenges. This is a system with excess, wasteful use of resources, and poor benefits and gaps.

“The system capacity in terms of supply of clinicians and hospital beds is poorly used and should serve many more South Africans, but instead it is hospi-centric. There are weak community clinical services and professionals work and compete in isolation, not in teams.”

Ruff said that the biggest crisis is lack of affordability, making quality healthcare inaccessible for most South Africans. He outlined structural and governance issues and a remuneration system that supports service provider sustainability and fair rewards.

“We need to match the local burden of illness with clinicians and beds available to avoid denying access or wasted capacity, and provide incentives for consistent, evidence-based clinical decisions. Local competition plus a busy system [would] mean fair payment negotiations, affordable premiums and healthy new entrants onto schemes.

“Schemes are competing on the wrong basis for consumers, offering spurious benefits, glitzy add-ons and marginal price differences; they are managed by administrators for whom member stewardship is less important than growing profits. They effect tariff prices, design-restricted benefits and imposed managed care — and managed care is ineffective, with individual clinical providers resisting scheme-managed networks.”

Ruff said providers are fragmented and the absence of local teams and systems means no provider competition for consumers, with clinical fragmentation causing patients to slip through the cracks daily.

“The national coverage requirement suppresses local innovation. Hospital oligopoly networks are prospering, while clinical data and interoperability standards remain inadequate. Health IT investment lacks the ambition needed to promote reform.

“To fix the system, one must understand the situation. The country and health sector is in transition, looking towards broader insurer risk pooling through current consolidation and the future NHI fund. New payment and efficient delivery models are needed,” said Ruff.

“The emerging gap market is the phase we are in at the moment and in time, as the middle class grows and the supply side reflects its growth, we should achieve a unified market and a unified supply system.”