By Glenn Ashton · 4 May 2010
South Africa is located at ground zero for HIV and TB. Our health is further impacted by the ravages of poverty and poor diet. When a treatable illness becomes a chronic condition, people cannot work regularly or properly. An unhealthy nation is a dysfunctional nation.
Health is one of the fundamental human rights recognised by both the UN Declaration of Human Rights and by our Constitution. The manner in which this right is constitutionally framed is important, as it not only sets out the right to health care services, including reproductive health care, but also the right to clean water and adequate food, as well as adequate levels of social security.
This is all well and fine on paper but given the massive shortcomings and disparities in our health system we clearly still have some way to go towards the provision of comprehensive health care. While we have a degree of universal health care, it is patchy and all too often inadequately resourced and funded. The time and effort required to access care also present real obstacles to universal health care.
South Africa continues to have two parallel health systems. Firstly, it has a privately funded system servicing the wealthier 20% of the population – including a significant chunk of the civil service - at an annual cost of around R43 billion (2005). Then there is a public health system serving the poor and unemployed remainder at R33.2 billion. Therefore the well off are funded to the tune of more than R6,000 per person, while the poor make do with less than R900 per person.
This inequity has spurred the government to investigate a compulsory nationally funded health insurance initiative (NHI). It is hoped that this scheme will facilitate equitable access to health services across the board. This project was largely driven by the recently deceased Deputy Minister of Health, Dr Molefi Sefularo, who will be sorely missed for his work toward a more equitable health system.
The NHI is already meant to be in place, but public concerns around the cost and the implications for those who already have funded health plans have stalled its initiation. The private health care industry lobbied strongly for further reflection. The question they ask is whether we can afford such a scheme with costs estimated at up to R218 billion, according to some recent estimates.
A broadly representative Ministerial Advisory Committee, including civil society, government and business representatives was appointed as a sounding board on the NHI in September 2009, to provide objective inputs and to break the deadlock. Its proclamations are eagerly awaited.
Meanwhile the public health care crisis continues. Despite instituting a three tier national health system, with primary care provided at clinics and secondary and tertiary care provided in feeder hospitals and specialist hospitals respectively, the system remains under-resourced and largely dysfunctional.
Visiting a clinic can take up a full day, sometimes longer. Primary care is inconsistent, with staff working under heavy caseloads and pressure. Staff numbers and training remain inadequate and although this shortcoming has started to receive attention, intervention is long overdue. Every day a patient spends at a clinic is a day lost working or seeking work. When patients are referred to hospitals or have routine check-ups another day is lost, usually for a 10-minute examination and prescription. This is clearly inefficient.
Our national approach to health care has mainly followed the conventional allopathic, western medical approach. While there is a trend towards the use of alternative therapies such as traditional healers, alternative medicine and modalities such as traditional Chinese medicine (TCM), our primary interventions in both the public and private health care services remain symptomatically focused, with very little emphasis on preventative health care. This is incongruous in a nation as diverse as South Africa and is hopefully something that the NHI advisory board will closely appraise.
For instance we have significant numbers of trained doctors from Cuba, with more graduates studying there. Their curriculum has been critiqued by our medical universities as having inadequate clinical training. However the two systems emanate from different mindsets, with the Cuban practice heavily focussed on systemic, preventative medical interventions and ours toward a symptomatic, clinical approach.
We certainly have a significantly higher degree of chronic illness than Cuba but we are apparently missing an important opportunity with these Cuban trained doctors, as well as the many Cuban doctors who have come out here to assist our ropey national health system by serving a few years in South Africa.
The opportunity is this: Would our health spending not be more efficient utilised if we focused more closely on prevention than on treatment? Cuba has excellent health indicators in relation to per capita medical costs, far superior to ours. Its health indicators are in many cases better than the USA – its infant mortality rate is lower and life expectancy is almost identical. Yet Cuba spends a mere US$ 251 per capita (R1800, double the spend of our public health system) against the $5711 spent in the USA. Cuba spends still almost ten times less than the $2389 spent in the UK, which also relies on a National Health Insurance system.
It is true that Cuban health workers are paid far less than those in the North, but the real secret to their successful health programme is the almost obsessive focus on preventative medical interventions. Complimentary medicine is central to their training. Every family is visited and assessed annually at home. Patient : doctor ratios are far lower than ours, allowing more personalised attention.
This is similar to traditional Chinese medicine, where doctors tend to spurn clinical analyses and instead concentrate on holistic, systematic, preventative analysis. Cuba has also learned that prevention is not only better, but far cheaper than cure. While China has seen an increasing adoption of allopathic medical practices, these are generally resorted to only when traditional interventions have failed. This lends credence to the fact that traditional Chinese doctors are rather disdainful of western medicine, preferring rather to examine the system, not the symptom. It is also notable that both the Cuban and the Chinese approaches rely heavily on complementary, not allopathic treatments.
We need to ask whether the problem is that Cuban doctors are poorly trained, or is it rather that they are inefficiently deployed? While their clinical knowledge may not match that of peers trained at local universities, they could certainly assist to shift our focus toward adopting a broader preventative medical approach, especially in primary health.
Preventative health interventions in South Africa are fairly recent and have – quite correctly – focused on the HIV and AIDS pandemic, a hugely costly and resource-hungry sector when prevention fails. Surely it is logical to expand this approach?
Are we not wasting vast resources by treating increasing numbers of patients who have fallen victim to other lifestyle diseases such as obesity, circulatory disease and diabetes, not to mention preventable water borne and nutritional diseases? We need to teach people how to avoid contaminating water sources and not simply rely on top-down sanitation provision. By enabling communities to prevent environmental and industrial pollution, by creating opportunities for people to grow fresh fruit and vegetables to supplement limited diets, are just some of many examples of essential health interventions that can reduce strain on our existing health services.
We already have much in common with Cuba. We have a history of efficacious natural medicines, with substantial knowledge on how to use them well. Why do we not fully harness our natural pharmacopoeia? Cubans are taught the basics of complimentary natural health care at school. Empowering people to take control of their own health reduces burdens on medical services.
Surely we should use the cadre of Cuban-trained doctors as a vanguard of preventative health focussed professionals? Why must we focus solely on a system that economic statistics have demonstrated to be both overpriced and having limited efficacy?
We certainly have far more in common with China and Cuba than with the developed north. It is questionable whether we can afford to apply the western medical model to our situation at all.
Western doctors may tell us to improve our lifestyles, to eat well, to exercise, to get enough sleep. But that system supports an industry that has a vested interest in our ill health in order to create profit, while unacceptable levels of iatrogenic (caused by medical treatment) disease impact unacceptably high numbers of people. Western medicine often has the side effect of making many people ill, while curing some along the way.
Any threat to this industry brings howls of derision but change it must – we simply cannot afford to continue to feed the spiralling cost of medical interventions, either private or nationally funded. Should we place our health in the care of an industry or would it be preferable to rely on a systemic approach that examines the whole that does not just see people as diseased clients?
Sure, there is a place for allopathic medicine. But if you think about it, it really is counter-intuitive to access the medical system only when illness strikes. Supportive, systemic interventions in the pursuit of good health should gain wider acceptance, through tapping the broadest swathe of health interventions, not only conventional western medicine.
As traditional Chinese doctors say – and Cuban doctors reiterate - it is better for me to keep you healthy than to try to cure you when you are already ill. Surely this is the route our NHI and entire health system should follow?