South Africa has a two-tiered health system. Public health services – which are largely provided free of charge – are run and funded by the state. Private healthcare is owned and run by the private sector. Patients have to pay themselves or via medical insurance to access private care.
The majority of South Africa’s population – 80% – relies on the public health sector. This includes patients receiving care for breast cancer.
All breast cancer patients experience challenges during their treatment journey. However, the specifics vary considerably depending on treatment, socioeconomic circumstances and where the individual lives.
In the private sector, breast cancer treatment is widely available – at a cost. In contrast, few public health facilities have the specialists and resources to treat breast cancer.
Services such as chemotherapy are only available in tertiary hospitals which are located in the country’s urban centres. Although there is minimal cost to the individual for the treatment, access to the central hospitals can be a barrier to care.
I’ve been working at the Breast Clinic at Tygerberg Hospital in Cape Town, South Africa for five years. A major problem patients have repeatedly highlighted is transport to and from the facility. It is a great expense (as a share of the monthly family income). And, depending on where they live, it can be difficult to get to the hospital; it may involve multiple journeys. Transport is the most common reason a patient doesn’t follow their treatment regimen.
The outcome from breast cancer should not depend on where a person resides, but it is an important factor in determining outcome.
Public transport in South Africa
Access to private vehicles is a problem among the patients at Tygerberg. Most of them rely on public transport.
In South Africa, three kinds of public transport are available: trains, buses, and minibus taxis. For some patients, there’s another option in the form of the HealthNet transport service. This is a limited service provided to the major hospitals in the Western Cape province. It does not run every day and has to be booked in advance. Many of our patients can’t use it as a result.
Although the service is free of charge, the HealthNet buses are not always available on the day of a medical consultation or treatment, and patients must therefore make alternative arrangements.
Minibus taxis are the most common and most expensive mode of public transport. About two thirds of households use them. Due to crumbling infrastructure, there has been a sharp decline in the use of cheaper modes of transport such as buses and trains between 2013 and 2020.
Unfortunately, there are no statistics on travel expenditure for the patient population. However it has previously been reported that low-income households spend one-third of their income on transport. This figure could be higher for patients as travel for hospital appointments for diagnosis and treatment involves multiple visits.
Usually, a patient diagnosed with cancer may require four hospital appointments for investigations. If they require systemic treatment, such as chemotherapy, this entails eight hospital appointments as patients are usually given eight cycles of treatment. The average patient would therefore need to make 12 visits to the hospital to receive the necessary care.
As one of the oncology nurses commented:
Most of the people who are sick (and) who need our help here (Tygerberg Hospital) live nearby. Even though they live nearby, it’s not within walking distance.
A possible solution
Given the increasing problem of transport identified, the Tygerberg breast unit transport fund (in its present form) was founded as a collaboration with Dr Justus Appfelstaedt in 2010, with funding from Pink Lady Apples. Pink Lady Apples is a local apple producer which runs an annual fund raising campaign, Crafts for Cancer.
Initially, the fund was a cash-based system which had the advantage of immediate reimbursement. But this resulted in problems with equity, management, and processing of the funds. It now utilises a “move money” bank account and reimburses patients for their travel costs to hospital appointments.
Remuneration is based on the standard taxi fare per individual from their postal code to Tygerberg Hospital.
In the first nine months of 2022, over 100 patients had their transport costs reimbursed. About 20% of payments were not collected, however, and further follow-up is needed to understand why.
This project has assisted many patients with their travel expenses.
We believe it could work for patients in other districts as well, if the necessary funds were available. Within the unit, the transport fund has been extended through the creation of the Breaking Barriers NPO, which assists other patients in the Breast and Endocrine Unit with their travel costs and access to social support.