tag:theconversation.com,2011:/us/topics/uhc-40037/articlesUHC – The Conversation2023-06-29T10:39:41Ztag:theconversation.com,2011:article/2086042023-06-29T10:39:41Z2023-06-29T10:39:41ZSouth Africa’s National Health Insurance bill has noble aims but leaves too much uncertain: it needs more work<figure><img src="https://images.theconversation.com/files/534572/original/file-20230628-17-36iu2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa’s National Health Insurance (NHI) bill has <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01294-1/fulltext">passed</a> the first hurdle towards becoming law, getting the country closer to its vision of achieving universal access to healthcare.</p>
<p>Section 27 of the country’s <a href="https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf#page=15">constitution</a> states that everyone has the right to access to healthcare. The <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">NHI bill</a>, which has been passed by the national assembly, is the manifestation of this provision.</p>
<p>Universal access to healthcare and the NHI are related. But they are not the same thing. </p>
<p>Universal access to healthcare is <a href="https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)">an ideal</a> which supposes that everyone should have the same access to healthcare. The NHI bill is a tool to achieve universal health coverage. It aims to ensure that all South Africans have access to quality healthcare services. The bill also aims to provide for the establishment of a fund which will be used to pay for almost all medical treatments from accredited providers. </p>
<p>But this bill has been contentious from inception. There have been multiple court challenges, with <a href="https://businesstech.co.za/news/government/696225/nhi-heading-to-court-with-many-more-legal-challenges-to-come/">more to come</a>, and numerous different voices have been raised <a href="https://www.gov.za/speeches/health-welcomes-pretoria-high-court-judgement-national-health-insurance-10-nov-2022-0000">against it</a>.</p>
<p>The aim of the NHI is a good and noble one. But the bill is bad law because it fails to provide reasonable certainty. Several court rulings have flagged this. The bill will have massive consequences, so it should be <a href="https://www.news24.com/news24/southafrica/news/sama-rejects-nhi-bill-in-its-current-form-20230530">rejected</a> and not enacted in its current form.</p>
<h2>The vision</h2>
<p>South Africa has a two-tier healthcare system. Those who have the financial resources, or medical insurance, use private healthcare practitioners and facilities. Those who do not have these resources use public practitioners and the facilities provided and paid for by the state.</p>
<p>The current healthcare system has not sufficiently catered for good quality healthcare for all. This system has precluded the poor or those without medical aid from using a large number of health professionals, services and facilities. The NHI will establish <a href="https://moneytoday.co.za/national-health-insurance-pros-cons/">a single pool</a> of healthcare funding for private and public providers. It will pay both these providers on exactly the same basis and expect the same standard of care from them. </p>
<p>For South Africans without medical aid (health insurance) or in lower income groups, the NHI will offer more equitable access to healthcare services. It will allow them to consult private practitioners and to attend private facilities. The NHI also purports to improve the resourcing of public hospitals and healthcare services as the burden of care will be more evenly distributed.</p>
<p>For South Africans who do have medical aid, the NHI may be a shock to the system. Those who are accustomed to private care may have to settle for lower standards while still paying a similar or higher fee. South Africans within a certain income bracket will have to make mandatory monthly payments towards healthcare in addition to carrying a higher tax burden.</p>
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Read more:
<a href="https://theconversation.com/south-african-taxpayers-will-bear-the-brunt-of-national-health-insurance-122409">South African taxpayers will bear the brunt of National Health Insurance</a>
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<p>Medical aid schemes will not be able to offer any services that are offered by the NHI. Private medical insurance will only be able to provide for “complementary or top-up cover” that doesn’t overlap with services covered by the NHI. </p>
<p>These issues are clear, but the NHI bill contains lots of grey areas. </p>
<h2>Grey areas</h2>
<p>The rule of law requires that everyone, citizens and corporates and governments, adhere to the law. They can only do so if the law is clear and unambiguous. Laws must provide reasonable certainty. </p>
<p><a href="http://www.saflii.org/za/cases/ZACC/2005/3.html">South African courts</a> have explained it like this: </p>
<blockquote>
<p>The law must indicate with reasonable certainty to those who are bound by it what is required of them so that they may regulate their conduct accordingly. </p>
</blockquote>
<p>The current version of the bill is uncertain in the following key areas: </p>
<ul>
<li><p>the migration of hospitals to semi-autonomous entities </p></li>
<li><p>the structure of the contracting unit for primary healthcare needs</p></li>
<li><p>establishment of the fund </p></li>
<li><p>the Health Patient Registration System </p></li>
<li><p>accreditation issues</p></li>
<li><p>purchasing of services </p></li>
<li><p>the amendment of other pieces of legislation to make room for the NHI and payment concerns.</p></li>
</ul>
<p>A significant concern relates to the uncertainty regarding what will be covered by NHI and what will not. As the bill expressly aims to cover the costs of certain healthcare services, it is reasonable to expect that these services be clearly set out. How can we follow the law when we do not know what it is? Without this certainty, the bill is vague and so it cannot be seen as good law.</p>
<p>The bill is also vague on how the NHI fund will be financed. Recent estimates have put its cost at more than <a href="https://www.iol.co.za/news/south-africa/kwazulu-natal/nhi-bill-do-we-need-it-who-will-pay-for-it-how-will-it-affect-my-medical-aid-all-your-questions-answered-6574c217-8f19-4dd3-9f6b-7a5230ac02de">R500 billion a year</a> (about US$27.6 billion). And what will happen to medical aid schemes? <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf#pag=19">Section 33</a> of the bill, which provides for the role of medical aid schemes, is open to the interpretation that these schemes will disappear. </p>
<p>Real doubt exists as to whether an NHI system will ever be workable in South Africa. The bill has been described as an <a href="https://www.dailymaverick.co.za/article/2023-06-25-national-health-insurance-is-a-big-fat-empty-promise-experts/">empty promise</a>. Again, this is bad.</p>
<h2>Ideal and practice</h2>
<p>Universal access to healthcare and the ideal of a national system of health insurance are important concepts which relate directly to core human rights, and as such are noble and necessary.</p>
<p>However, it’s often the case that an ideal falls short in practice. The NHI bill is no exception. Many concerns and critiques have been raised against the bill and its implementation. Satisfactory solutions have not yet been offered. </p>
<p>The NHI cannot be avoided. But to benefit all and live up to its potential, it should be fully thought through, planned in detail and not rushed.</p><img src="https://counter.theconversation.com/content/208604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Larisse Prinsen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The NHI bill aims to ensure that all South Africans have access to quality healthcare services.Larisse Prinsen, Senior lecturer in law, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952572023-02-22T15:31:47Z2023-02-22T15:31:47ZOver 90% of Rwandans have health insurance – the health minister tells an expert what went right<figure><img src="https://images.theconversation.com/files/498920/original/file-20221205-16-bcm2cc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Xinhua/Cyril Ndegeya via Getty Images</span></span></figcaption></figure><p><em>In 2015 the United Nations General Assembly <a href="https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)">adopted</a> universal health coverage as one of the sustainable development goals. The aim of universal health coverage is to ensure that every person and community, irrespective of their circumstances, has access to the health services they need, at the time and place they need it, without the risk of financial devastation. Many countries have committed to the concept, which has resulted in numerous health reforms. The World Health Organization <a href="https://apps.who.int/iris/bitstream/handle/10665/361229/9789290234760-eng.pdf?sequence=1&isAllowed=y">recognises</a> Rwanda as one of the countries that are performing well on the goal of universal health coverage. The <a href="https://southafrica.cochrane.org/">Cochrane Centre</a> summarises and disseminates information on what works and what doesn’t in health care. Professor Charles Shey Wiysonge, director of Cochrane South Africa and senior director at the South African Medical Research Council, spoke to Rwanda’s health minister, Dr Sabin Nsanzimana, about the road map for universal health coverage in the country.</em> </p>
<hr>
<p><strong>Charles Wiysonge:</strong> What does universal health coverage look like in Rwanda? </p>
<p><strong>Sabin Nsanzimana:</strong> In the last decade, calls for increased efforts to achieve universal health coverage have grown. Many countries have committed to universal health coverage – particularly in Africa. This has resulted in numerous health reforms. </p>
<p>Rwanda’s President Paul Kagame was <a href="https://au.int/en/pressreleases/20190209/africas-leaders-gather-launch-new-health-financing-initiative-aimed-closing">appointed</a> by other African heads of state as the leader on domestic health financing in the AU Assembly Declaration in February 2019. The aim of the declaration was to increase investment in health and have member states spend efficiently and effectively to achieve better health outcomes.</p>
<p>In the last couple of decades Rwanda has improved the health and well-being of all its people. This was done through a combination of evidence-based and people-centred strategies and interventions. The country has been able to make the following substantial progress:</p>
<ul>
<li><p>On the supply side, the country has built a healthcare delivery system on primary healthcare. Individuals and communities are at the centre of our actions. The increased number of health facilities <a href="https://www.statistics.gov.rw/publication/1767">(from 1,036 in 2013 to 1,457 in 2020)</a> has improved the geographical accessibility of care. It’s also contributed to the reduction of the average time used by a Rwandan citizen to reach a health facility. The average <a href="https://www.who.int/news-room/feature-stories/detail/rwanda-s-primary-health-care-strategy-improves-access-to-essential-and-life-saving-health-services">time used to reach</a> the nearest health facility has fallen from 95.1 minutes in 2010 to 49.9 minutes in the past 10 years.</p></li>
<li><p>On the demand side, the risk pooling has been greatly improved as a result of the extension of <a href="https://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-2020#:%7E:text=CBHI%20is%20a%20form%20of,setup%20and%20in%20its%20management.">Community-Based Health Insurance schemes</a>. These give the majority of the population access to healthcare services, and improve access to quality services. Insurance has also reduced out-of-pocket expenditures (which are 4% as a share of total health expenditure) in particular for the poor and most vulnerable people. Community-based health insurance covers <a href="https://www.rssb.rw/community-based-health-insurance-scheme-receives-financial-boost-from-ahf">over 85%</a> of the population. The percentage of the population with some kind of <a href="https://dhsprogram.com/pubs/pdf/FR370/FR370.pdf#page=74">health insurance</a> has increased from 43.3% in 2005 to 90.5% in 2020. This has helped to protect households against financial risks associated with sickness.</p></li>
<li><p>The government spending on health (15.6% as of the 2019/2020 financial year) has surpassed the <a href="https://au.int/sites/default/files/pages/32894-file-2001-abuja-declaration.pdf#page=6">15%</a> required under the 2001 Abuja Declaration. This shows the country’s high commitment to the development of health sector financing. </p></li>
</ul>
<p><strong>Charles Wiysonge:</strong> Where are the gaps and why do they exist?</p>
<p><strong>Sabin Nsanzimana:</strong> Progress towards universal health coverage is a continuous process. It responds to shifts in demographic, epidemiological and technological trends as well as people’s socio-economic status and expectations. If Rwanda is to meet the goal of achieving universal health coverage by 2030, we need to be far more ambitious to leave no one behind.</p>
<p>Additional health financing reforms and actions to maintain achieved gains and improve further health outcomes are needed. The fact that the country has achieved close to universal population coverage is in itself a great achievement. But there are still some people who are uninsured. We need to identify policy options to expand coverage to the hard-to-reach population in the informal sector. Health insurance has positively affected the use of services and equity. But further improvements are needed. We must extend the service coverage based on the need and reduce cost-sharing, especially for secondary and tertiary care.</p>
<p>Sustainability of health financing is also a critical issue. It requires finding innovative ways to mobilise domestic resources, adopting better resource pooling mechanisms and an effective strategic purchasing mechanism. These must ensure equity and efficient use of available resource and value for money.</p>
<p><strong>Charles Wiysonge:</strong> What else is needed?</p>
<p><strong>Sabin Nsanzimana:</strong> To move further and deeper towards universal health coverage calls for evidence-based policy reforms that would provide direction for a long-term model for service delivery (focusing on the primary healthcare level) and health financing in Rwanda. This will require adequate awareness among policy decision makers, and increased capacity in those areas and shared understanding of universal health coverage to support the necessary reforms.</p>
<p><strong>Charles Wiysonge:</strong> What can other countries on the continent learn from Rwanda’s experience?</p>
<p><strong>Sabin Nsanzimana:</strong> Strong leadership that sets a clear vision for the future is imperative. Countries need a development model that is inclusive. Such a model must consider gender equality, pro-poor policies, unity and solidarity.</p>
<p>Most important are robust institutions and legal frameworks driven by good governance, with:</p>
<ul>
<li><p>accountability, citizen participation, decentralisation </p></li>
<li><p>results orientation – performance contracts</p></li>
<li><p>investment in human capital – mainly capacity building.</p></li>
</ul><img src="https://counter.theconversation.com/content/195257/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rwanda has built a healthcare delivery system on primary healthcare with individuals and communities at the centre.Charles Shey Wiysonge, Director, Cochrane South Africa, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1954792022-12-13T13:27:56Z2022-12-13T13:27:56ZHypertension, diabetes, stroke: they kill more people than infectious diseases and should get a Global Fund<figure><img src="https://images.theconversation.com/files/499986/original/file-20221209-19531-9yfpxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Noncommunicable diseases such as diabetes, hypertension and cardiovascular conditions account for <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">41 million deaths</a> each year. That’s more than 70% of all deaths globally. Most of these deaths (77%) are in low-income and middle-income countries – including those in Africa. </p>
<p>These conditions are currently <a href="https://www.researchgate.net/publication/356360474_Tanzania_Non-communicable_Diseases_and_Injuries_Poverty_Commission_Findings_and_Recommendations">more prevalent</a> than infectious diseases. Sixty-seven percent occur before the age of 40. Besides being the leading causes of death worldwide, noncommunicable diseases carry a <a href="https://apps.who.int/iris/handle/10665/274512">huge cost</a> to individuals. These also undermine workforce productivity and threaten economic prosperity.</p>
<p>Healthcare provision in much of Africa still relies on <a href="https://www.brookings.edu/blog/future-development/2019/03/01/closing-africas-health-financing-gap/">external donors</a>. There’s insufficient funding to help low-income and middle-income countries control noncommunicable diseases. Most <a href="https://jamanetwork.com/journals/jama/fullarticle/2320320">development assistance for health funding</a> provided by international donors is allocated for infectious diseases and maternal and child health. In <a href="https://vizhub.healthdata.org/fgh/">2019</a>, funding for HIV amounted to US$9.5 billion. The amount allocated to noncommunicable diseases was US$0.7 billion. </p>
<p>Evidence suggests that addressing the noncommunicable disease pandemic can also mitigate other challenges like HIV, tuberculosis (TB), maternal and child health, and universal health coverage. </p>
<p>The <a href="https://www.theglobalfund.org/en/">Global Fund</a> to Fight AIDS, TB and Malaria is an international partnership. The fund invests US$4 billion a year to fight these three diseases. </p>
<p>I believe it’s now time to think of establishing a Global Fund for noncommunicable diseases, or expand the mandate of Global Fund beyond AIDS, TB and malaria. The epidemics of these conditions overlap. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8872228/#:%7E:text=The%20most%20prevalent%20HIV%20comorbidities,and%20hepatitis%20C%20%5B14%5D.">research</a> has shown that <a href="https://jamanetwork.com/journals/jama/article-abstract/2757599">comorbidities</a> such as diabetes and cancers are common in people living with HIV. </p>
<h2>Broadening healthcare provision</h2>
<p>Disease specific programmes have <a href="https://academic.oup.com/heapol/article/33/3/381/4812662">limitations</a>. As public health practitioners we should learn from our mistakes. We must build integrated programmes and health systems that address the interlinkages and co-morbidities. One example would be to include diabetes screening in TB treatment programmes. </p>
<p>In addition to integration, noncommunicable diseases require increasing investments. </p>
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<p>The Global Fund is seeking US$18 billion this year. At the same time <a href="https://www.thelancet.com/ncd-countdown-2030">The Lancet NCD Countdown 2030</a> projects that interventions for noncommunicable diseases need US$18 billion a year. That’s what it would take to meet the UN target of reducing noncommunicable diseases by a third by the year 2030. </p>
<p>I would argue that the case for <a href="https://pubmed.ncbi.nlm.nih.gov/35339227/">investment</a> in noncommunicable diseases has never been stronger. </p>
<h2>A roadmap</h2>
<p>The World Health Assembly recently <a href="https://www.who.int/news-room/feature-stories/detail/world-health-assembly-approves-a-global-implementation-roadmap-to-accelerate-action-on-noncommunicable-diseases-(ncds)">approved</a> the World Health Organization’s roadmap for the prevention and control of noncommunicable diseases covering the period 2023-2030. </p>
<p>The roadmap recommends actions to: </p>
<ul>
<li><p>promote “best-buys” interventions with a high return for every dollar spent, such as smoking cessation programmes </p></li>
<li><p>strengthen health systems </p></li>
<li><p>reduce noncommunicable disease risk factors such as tobacco use and unhealthy diets </p></li>
<li><p>embed noncommunicable diseases within primary healthcare and universal health coverage. </p></li>
</ul>
<p>This roadmap needs to be followed in line with the commitments to reduce air pollution and promote mental health and well-being.</p>
<p>The lessons learned from the COVID-19 pandemic offer opportunities for strengthening emergency preparedness and responses beyond pandemics. Emergency risk management and continuity of essential health services for all hazards – addressing the foundational health system gaps – can improve health security.</p>
<h2>What should be done</h2>
<p>How should Africa respond to the increasing burden of noncommunicable diseases? There needs to be a strong political will and buy-in from governments, with strong multi-stakeholder participation. </p>
<p>The <a href="https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025">UN General Assembly</a> decision on HIV and noncommunicable diseases commits governments to identify and address the comorbidities of HIV and other links to pressing global health challenges. These include links to noncommunicable diseases, learning from the perspectives of people living with these conditions and underscoring the importance of focusing on comorbidities. </p>
<p>The WHO’s <a href="https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030#:%7E:text=The%20Global%20NCD%20Compact%202020,of%20people%20living%20with%20NCDs.">noncommunicable disease compact</a> proposes concrete actions. These actions need to be data-driven and supported by noncommunicable disease-related indicators in health systems performance and access to healthcare metrics. </p>
<p>Monitoring systems need to be more diverse. The systems should capture and monitor progress made through sectors that affect health, such as housing and sanitation. Doing this would strengthen the monitoring of national systems and the capacity to address noncommunicable diseases comprehensively.</p>
<p>Health system strengthening and quality of care will improve significantly with additional resources for noncommunicable diseases through an entity like the Global Fund. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaushik Ramaiya is Honorary General Secretary of Tanzania Diabetes Association and we work with Ministry of Health (Tanzania) in implementing National NCD program which has been funded by World Diabetes Foundation (WDF) and Novo Nordisk Foundation. </span></em></p>Addressing the noncommunicable disease pandemic can also mitigate challenges facing people living with HIV and complement efforts against TB.Kaushik Ramaiya, Honorary Professor of Medicine & Global Health , Liverpool School of Tropical MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1720982021-11-30T14:36:32Z2021-11-30T14:36:32ZIn Burkina Faso healthcare is free only for some: why this is a problem<figure><img src="https://images.theconversation.com/files/432806/original/file-20211119-13-1x1p5ib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Healthcare in the country is free for children under five. </span> <span class="attribution"><span class="source">Nicolas Maeterlinck/BELGA MAG/AFP via Getty Images</span></span></figcaption></figure><p>Maternal and child mortality remains a major public health problem in low- and middle-income countries. The rates are <a href="https://www.unicef.org/media/60561/file/UN-IGME-child-mortality-report-2019.pdf">especially worrying</a> in poor countries like Burkina Faso. Financial barriers to access care still prevent many families from getting the services they need, when needed, limiting future progress in reducing high mortality rates. </p>
<p>In <a href="https://academic.oup.com/heapol/article/26/suppl_2/ii30/640606">2006</a>, Burkina Faso took various measures to improve financial accessibility to maternal and child healthcare. It introduced the policy of subsidising emergency obstetric and neonatal care. This reduced the price of reproductive healthcare services <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0875-2">by 80%</a>. </p>
<p>Ten years later, the country went further. It introduced a national free healthcare policy. This applies to all children younger than five – regardless of the reason for the consultation – and reproductive care such as deliveries, pre- and post-natal consultations and caesarean sections.</p>
<p><a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0141306">Studies</a> in <a href="https://pubmed.ncbi.nlm.nih.gov/23776054/">Burkina Faso</a> and other <a href="https://pubmed.ncbi.nlm.nih.gov/24992804/">sub-Saharan African</a> countries have <a href="https://academic.oup.com/heapol/article/29/2/137/637405">shown</a> the positive impacts of free healthcare. These policies improve access to healthcare, decrease catastrophic health spending and reduce health inequities. Free access to healthcare reduces self-treatment practices as well as the proportion of home deliveries.</p>
<p><a href="https://gh.bmj.com/content/3/Suppl_3/e001087">Evidence</a> suggests that the abolition of <a href="https://academic.oup.com/heapol/article/30/4/432/558465">direct payment</a> improves certain morbidity indicators and reduces neonatal mortality. </p>
<p>Despite these numerous studies, little knowledge has been gathered on the ethical issues surrounding free policies. Exploring these issues is important. There have been <a href="https://academic.oup.com/heapol/article/26/suppl_2/ii63/641019">reports</a> of <a href="http://ijme.in/articles/identifying-beneficiaries-for-user-fee-waivers-ethical-challenges-in-public-health/?galley=html">increased tensions</a> because the eligibility criteria can be difficult to meet. This is especially the case in contexts of high vulnerability. </p>
<p>We <a href="https://www.tandfonline.com/doi/full/10.1080/11287462.2021.1966974">conducted a study</a> in a rural health district (Boulsa) of Burkina Faso to explore what healthcare personnel and beneficiaries thought about compliance with the eligibility criteria. We also wanted to understand the resulting ethical issues, and how health workers and patients coped with these. </p>
<h2>Ethical issues</h2>
<p>All study participants were aware of the free healthcare policy. But some ambiguities remained about the eligibility criteria. For example, some mothers were unsure whether they were entitled to free postpartum care. The official limit (free postpartum care up to 42 days after delivery) was difficult to understand. </p>
<p>Similarly, some caregivers thought that free care included children aged 5 years, while it only concerns children aged 0–59 months. There was also a lack of knowledge that free healthcare was universal for children, in other words it covered all types of care, but not for the mothers, for whom only reproductive healthcare services were free. These ambiguities led to situations where patients were denied free care when they thought they were entitled to it.</p>
<p>Health personnel and mothers told us about deliberate practices to extend the benefits of free care to people who were not eligible. </p>
<p>One of the most commonly reported practices was to hide the exact age of children. This practice sometimes resulted in impersonation, when identification documents of another child under 5 were brought in as proof of age.</p>
<p>Another example was using an eligible person to receive a free consultation or medication for the benefit of someone else. Also, beneficiaries sometimes went to several different health centres to accumulate a larger supply of drugs, either to treat other family members or to build up a stockpile of drugs that could be used later.</p>
<p>These practices are risky because the treatment given to one person is not necessarily the same as the treatment that another family member should have. However, they are justified by the economic vulnerability of the households. Many women who are the primary caregivers have no control over the household’s finances. </p>
<p>Moreover, the ineligibility of older children raises ethical issues.</p>
<blockquote>
<p>For example, the malaria medicine they give here, if a child is over five years old, they do not treat him, and go take another one, younger. But all children are going to get sick from malaria; they should help us with all the children.</p>
</blockquote>
<p>Healthcare workers knew these issues. They saw the lack of agency of the beneficiaries and were sensitive to the households’ economic vulnerability. This situation placed them in an ethical dilemma: they had a duty to treat and relieve the suffering of patients, but also to ensure that the official guidelines issued by the Ministry of Health were respected.</p>
<p>Clinicians were confronted with these dilemmas in an even more blatant manner since they often resided in the community and shared the living conditions of its members.</p>
<blockquote>
<p>Sometimes you look at someone, if you see that it’s still not going well, you feel obliged to help, to include the patient in free healthcare so that they can benefit. Some patients, when they come, even five francs (US$0.01), they don’t have that.</p>
</blockquote>
<p>Healthcare workers found various ways to alleviate these ethical tensions and avoid conflicts with the community. They tried to make people aware of the dangers of giving medications to people other than those for whom they were prescribed, and they were flexible about cut-off points for eligibility. They adapted their procedures to limit circumventing practices, for example by directly observing the treatment administration and ensuring a closer follow-up of the patients.</p>
<h2>Remaining gaps</h2>
<p>Access to healthcare has improved for a significant proportion of the Burkinabe population. But financial barriers remain for those who are not eligible. This raises ethical concerns for caregivers in the most vulnerable households and for healthcare providers. </p>
<p>Practices and medical procedures were adapted to reconcile these tensions surrounding the eligibility criteria. These resulted in a local reinvention of the free healthcare policy. This made it more effective in real world conditions.</p>
<p>The partial removal of user fees is better than no removal at all, which raises even more important ethical issues. However, it is necessary to realise that the cost burden for healthcare has not evaporated for Burkinabe households. Rather, it has shifted to other categories of household members who are overlooked and continue to be ineligible for many public health interventions, such as children over five years old.</p><img src="https://counter.theconversation.com/content/172098/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Druetz receives research funding from a partnership of Global Affairs Canada (GAC), the Canadian Institutes of Health Research (CIHR) and Canada’s International Development Research Centre (IDRC). He also receives funding from the Fonds de recherche Santé du Québec. The funding agencies had no role in the study design, data collection, analysis, interpretation, writing, or decision to submit the manuscript for publication. </span></em></p><p class="fine-print"><em><span>Frank Bicaba does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Burkina Faso is one of the poorest countries in the world. Financial barriers still prevent many families from getting the health services they need.Thomas Druetz, Assistant Professor of Global Health, Université de MontréalFrank Bicaba, Researcher and PhD candidate, Aix-Marseille Université (AMU)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1473702020-10-22T15:25:27Z2020-10-22T15:25:27ZWhy Kenya’s pro-poor health financing reforms miss their mark<figure><img src="https://images.theconversation.com/files/363184/original/file-20201013-15-1eg398f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People wait for care at a Kenyan clinic.
</span> <span class="attribution"><span class="source">Photo by Wendy Stone/Corbis via Getty Images</span></span></figcaption></figure><p>Kenya has made several reforms in recent years intended to expand health service coverage to a wider population, and with a specific focus on the poor, and to reduce financial hardship due to healthcare costs.</p>
<p>The first of these reforms, in 2013, was the <a href="https://www.healthpolicyproject.com/index.cfm?ID=publications&get=pubID&pubID=400">abolition</a> of user fees at public primary healthcare facilities. The second, announced the same year, <a href="https://www.healthpolicyproject.com/index.cfm?ID=publications&get=pubID&pubID=400">made maternity services free</a> at all public facilities. This was upgraded in 2017 to a <a href="http://www.nhif.or.ke/healthinsurance/lindamamaServices">public funded health scheme</a> for pregnant women and infants managed by the National Hospital Insurance Fund (NHIF).</p>
<p>Third was the introduction of a <a href="https://ww1.issa.int/gp/162201">health insurance subsidy for the poor</a> in 2014. Under this programme, the government fully subsidises the National Hospital Insurance Fund premiums for selected poor households with orphans and vulnerable children, elderly people, and people with severe disabilities. This enables access to outpatient and inpatient care at participating public, private for profit, and faith-based health facilities. </p>
<p>The <a href="https://nyaspubs.onlinelibrary.wiley.com/doi/full/10.1196/annals.1425.011">evidence</a> from low- and middle-income countries shows that the rich rather than the poor tend to benefit more from public spending on health. Kenya is no exception in spite of health financing reforms that target the poor. For example, the <a href="https://pubmed.ncbi.nlm.nih.gov/28094465/">effective coverage</a> of maternal and child health interventions is estimated at 62% for the wealthiest quintile and 37% for the poorest. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599961/">health insurance coverage</a> is estimated at 39% for the richest quintile compared to 3% in the poorest. </p>
<p>Similarly, the incidence of <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-017-0526-x">catastrophic health expenditure</a> is five times higher (10%) in the poorest quintile compared to the richest quintile (2%). Despite the poor having the highest disease burden, they have limited access to care when they need it. Barriers to care may involve individual, household, or community factors, or factors in the health system itself. </p>
<p>To get a better understanding of these factors in Kenya, we conducted a <a href="https://pubmed.ncbi.nlm.nih.gov/31234940/">study</a> to assess the experiences and perceptions of the poor with health financing reforms that target them. This we did in two counties, one urban and one rural. We interviewed people in the poorest quintile drawn from the health and demographic surveillance systems, and those from households identified by the government as poor and registered for the health insurance subsidy programme.</p>
<p>What we found is that the removal of user fees or full subsidisation of insurance premiums doesn’t fully eliminate financial barriers. This is partly due to poor implementation of health financing policies. People still have to pay out of their pockets for some healthcare, and face numerous other access barriers.</p>
<h2>What we found</h2>
<p><strong>Geographical accessibility:</strong> The location and distance to health facilities have been shown to influence the utilisation of health services. For poor people living in rural areas, long distances to health facilities were a key access barrier. This was compounded by poor road conditions which worsened during the rainy seasons, limited means of transport especially at night, and high transport costs. </p>
<p>For example, some facilities contracted by the national hospital insurance fund were located far from registered users of the subsidy programme. The pro-urban distribution of health facilities, especially hospitals, has also been shown to limit access to care for the poor, elderly, and people living in rural areas.</p>
<p><strong>Availability of care:</strong> Overall, health financing reforms reduced financial barriers and improved access for the poor. But some health facilities suffered stock-outs of medicine and medical supplies. Sometimes medical equipment was lacking or not working. This limited the care received. </p>
<p>Shortage of drugs forced the poor to incur out of pocket payments. When this was not enough, they were forced into borrowing or purchasing incomplete doses or none at all. Public health facilities also suffered from healthcare worker shortages, absenteeism, and frequent strikes. During the <a href="https://gh.bmj.com/content/3/6/e001136">healthcare worker strike</a> in 2016/17, which lasted for 250 days, some people didn’t even seek care.</p>
<p><strong>Affordability:</strong> This was limited by the continued levying of a registration card fee at some primary health facilities. Laboratory services, injections and some other services also came at a fee. The poor also made informal payments to get treatment, skip long queues and obtain drugs that should have been provided for free. </p>
<p>Such informal payments disproportionately affect the poor. </p>
<p>Finally, delayed funding to health facilities serving subsidy beneficiaries forced them to incur direct costs to access services that were already covered.</p>
<p><strong>Acceptability of care:</strong> Some of the poor reported receiving less attention and feeling discriminated against by healthcare workers because of their low socio-economic status. Some private providers also gave preference to patients who paid in cash over health insurance subsidy beneficiaries. </p>
<p>The absence of effective grievance redress mechanisms made the poor feel voiceless. Poverty influences people’s ability to express themselves. This is evidenced by the fact that some poor people felt as if they didn’t have the right to complain. This is partly because health services were provided to them at no cost. Others felt that they were at the mercy of healthcare providers because if they complained then the health workers would stop attending to them.</p>
<h2>What needs to be done</h2>
<p>The overarching message is that policies that are intended to be pro-poor do not always benefit the poor. The design and implementation of such policies therefore requires a framework for monitoring that pays particular attention to who eventually benefits from these policies and identifies the barriers faced by vulnerable groups. Course correction measures during design and implementation should hence include addressing potential and actual barriers faced by vulnerable groups.</p><img src="https://counter.theconversation.com/content/147370/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edwine Barasa receives funding from the Wellcome Trust. </span></em></p><p class="fine-print"><em><span>Evelyn Kabia receives funding from Wellcome Trust. </span></em></p>Removal of user fees or full subsidisation of insurance premiums doesn’t fully eliminate financial access barriers.Edwine Barasa, Director, KEMRI-Wellcome Trust Nairobi Programme, KEMRI Wellcome Trust Research ProgrammeEvelyn Kabia, Health Economist, KEMRI Wellcome Trust Research ProgrammeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1472042020-10-08T14:41:57Z2020-10-08T14:41:57ZCombating lifestyle diseases can make a big difference in the lives of older people<figure><img src="https://images.theconversation.com/files/361630/original/file-20201005-20-xh55w0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Older people in urban informal settlements live in poor socioeconomic conditions.</span> <span class="attribution"><span class="source">Donwilson Odhiambo/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>Noncommunicable diseases account for about <a href="https://www.who.int/gho/ncd/mortality_morbidity/en/">71%</a> of the 57 million deaths reported around the world every year. Most of these deaths are caused by diabetes, cancers, heart disease and lung disease. Over <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">85%</a> of these “premature” deaths occur in low- and middle-income countries.</p>
<p>A big concern is the growing prevalence of these conditions in <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">older populations</a>. This is especially true in low- and middle-income countries where populations are currently <a href="https://www.who.int/ageing/events/world-report-2015-launch/en/">ageing rapidly</a>. </p>
<p>Noncommunicable diseases are, to some extent, preventable and manageable. But it is estimated that by 2030 they will cause <a href="https://www.who.int/ncds/management/palliative-care/introduction/en/">75% more</a> deaths than malnutrition and infectious diseases. They also create a burden of ill health and disability, particularly among older people. Mortality data don’t always reflect the true personal and family impacts and costs of noncommunicable diseases. </p>
<p>In sub-Saharan African countries, older people often play crucial roles in their families and communities. They care for younger relatives, for example, and contribute to <a href="https://www.helpage.org/silo/files/protecting-the-rights-of-older-people-in-africa.pdf">household income</a> through small-scale agriculture and petty trading. Addressing the health challenges of older people benefits the society as a whole.</p>
<p>The United Nations set sustainable development goals in 2015. One of these aims to <a href="https://www.who.int/global-coordination-mechanism/ncd-themes/sustainable-development-goals/en/">reduce premature deaths from noncommunicable diseases</a> by a third by 2030. It also aims to promote mental health and well-being through effective prevention and treatment.</p>
<p>In our <a href="https://academic.oup.com/gerontologist/article-abstract/60/5/806/5536118?redirectedFrom=fulltext">recent paper</a>, my colleague and I looked into the burden and impact of these diseases. We found that many countries in sub-Saharan Africa are falling short of meeting the noncommunicable disease global targets. Governments, civil society and individuals need to do a lot more to care for and to improve the health of <a href="https://commons.ln.edu.hk/otd/41/">older people</a>. </p>
<h2>Noncommunicable disease burden</h2>
<p>The growing burden of noncommunicable diseases in low- and middle-income countries is largely driven by <a href="https://academic.oup.com/gerontologist/article-abstract/60/5/806/5536118?redirectedFrom=fulltext">cardiovascular risk factors</a>. They include rapid population ageing, lifestyle and social behaviour changes. </p>
<p>Sedentary behaviour or physical inactivity, unhealthy diets, tobacco use, harmful drinking and air pollution all <a href="https://www.who.int/ncds/introduction/en/#:%7E:text=The%20rise%20of%20NCDs%20has,threatens%20to%20overwhelm%20health%20systems">contribute</a> to growth in noncommunicable diseases.</p>
<p>Many older people in sub-Saharan Africa’s urban informal settlements live in poor socioeconomic conditions and have unhealthy lifestyles. These settlements are common in major cities such as Nairobi in Kenya, and Accra in Ghana. </p>
<p>Older people living in these conditions are generally poor, and have little social protection and support. They are unlikely to receive regular <a href="https://academic.oup.com/gerontologist/article-abstract/60/5/806/5536118?redirectedFrom=fulltext">health checks</a> which would reveal early signs of noncommunicable diseases and risk factors. These communities may also lack <a href="https://www.cdc.gov/healthliteracy/developmaterials/audiences/olderadults/index.html#:%7E:text=The%20National%20Assessment%20of%20Adult,interpreting%20numbers%20and%20doing%20calculations">access to information</a> about lifestyle diseases. And they may not know what to do to keep healthy. </p>
<p>In addition, older people in these challenging settings suffer <a href="https://reliefweb.int/report/world/aging-population-challenges-africa">a great deal</a> from <a href="https://www.who.int/bulletin/volumes/91/10/13-118422/en/">less readily acknowledged</a> noncommunicable diseases. These include dementia and the long-term physical and psychological effects of injuries and violence. </p>
<p>The <a href="https://www.who.int/nmh/publications/ncd-status-report-2014/en/">economic burden of noncommunicable diseases</a> in poor sub-Saharan African settings is expected to double from about US$6 trillion in 2010 to over US$13 trillion by 2030. In addition, every 10% increase in noncommunicable disease prevalence will cause a 0.6% decline in the annual economic growth in low- and middle-income countries. </p>
<p>For individuals and families, the burden is more than economic. It’s about quality of life for older adults. Sub-Saharan Africa faces a higher pace of demographic ageing and attendant noncommunicable diseases. It’s essential to rethink how these conditions are dealt with. </p>
<h2>Recommendations</h2>
<p>Based on <a href="https://commons.ln.edu.hk/otd/41/">my research</a> on ageing and health in sub-Saharan Africa, I propose a number of interventions. </p>
<p>The conversation should start with up-to-date and reliable epidemiological data about noncommunicable diseases and their risk factors. This should inform prevention and control strategies.</p>
<p>Second, governments and civil society should increase awareness and recognise the role of healthcare professionals in managing these diseases. There should be a special focus on long-term care, palliative and end-of-life care for older people.</p>
<p>Third, a focus on universal health coverage would improve access to healthcare services for vulnerable older adults. This group is noted for <a href="https://www.cambridge.org/core/journals/ageing-and-society/article/they-dont-cure-old-age-older-ugandans-delays-to-healthcare-access/3EB31265B1EB5CA7C5C5B209FC71C6ED">delaying and avoiding</a> healthcare because of the higher cost of treating chronic conditions.</p>
<p>Fourth, there is the need to change behaviour through persistent public education about these conditions in rapidly ageing populations. Communication has to be linguistically and culturally appropriate if it’s to change behaviour.</p>
<p>Government policies should promote healthier diets and regular physical activity. Laws should ban, reduce, or monitor risk behaviours such as heavy alcohol consumption, tobacco smoking and exposure to indoor air pollution. The production and distribution of products such as alcohol, tobacco, and sugary foods should be taxed appropriately because of their <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-8364-y">relationship</a> with noncommunicable diseases.</p>
<p>Noncommunicable diseases are <a href="https://pubmed.ncbi.nlm.nih.gov/31322656/">expected</a> to have greater impacts in countries where poverty, malnutrition, poor sanitation, infections, and weak health and education systems persist. Unfortunately, many low- and middle-income countries including those in sub-Saharan Africa show such characteristics. Communities and families in these countries must make integrated efforts to address the challenges of noncommunicable diseases and improve the lives of older people.</p><img src="https://counter.theconversation.com/content/147204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Razak M Gyasi works for the African Population and Health Research Center. He receives funding from the Council for the Development of Social Science Research in Africa (CODESRIA) and Lingnan University. Hong Kong. </span></em></p>The higher pace of demographic ageing and the noncommunicable diseases that come with it call for new management approaches.Razak M. Gyasi, Postdoctoral Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1402042020-07-07T14:16:24Z2020-07-07T14:16:24ZSouth Africans must be healthier for universal healthcare to succeed<figure><img src="https://images.theconversation.com/files/344819/original/file-20200630-103649-19tkk9v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People exercising in Ellis Park in Johannesburg, South Africa. </span> <span class="attribution"><span class="source">Dino Lloyd/Gallo Images via Getty Images</span></span></figcaption></figure><p>Achieving a healthy population isn’t easy for any country – rich or poor. One of the approaches that’s gained traction over the past two decades is preventative care through <a href="https://www.ncbi.nlm.nih.gov/books/NBK235764/">health promotion</a>. Simply put, health promotion means keeping people healthy. This is seen as particularly useful in developing countries, where levels of preventable noncommunicable diseases are high, the resources to treat disease are scarce and the cost of treating sick people is often higher than programmes to keep people healthy.</p>
<p>The health promotion approach has two areas of focus. One is preventing disease through activities like health education messaging, screening and testing for conditions. The other is addressing the upstream drivers and causes of poor health. These include social and economic factors such as poverty and unemployment. They also include smoking, excessive drinking, low levels of exercise, poor diet, sub-standard living conditions, gender-based violence and mental illness. </p>
<p>The health promotion approach aims to change people’s behaviour and choices. But it is not enough just to tell an individual how to be healthy: people need support and social structures to promote, sustain and maintain healthy choices. </p>
<p>A number of countries have successfully adopted this approach using health promotion foundations. <a href="https://en.thaihealth.or.th/">Thai Health</a> is one example. Similar <a href="http://www.samj.org.za/index.php/samj/article/view/6281/4910">foundations</a> have been established in Switzerland, Austria, the Philippines and Malaysia. </p>
<p>In a <a href="http://www.samj.org.za/index.php/samj/article/view/12864/9145">recently published paper</a>, we argue that South Africa also needs a health promotion and development foundation if its proposed universal healthcare programme, the National Health Insurance (NHI), is to succeed. </p>
<p>Through the <a href="http://www.health.gov.za/index.php/nhi">NHI</a> South Africa (and legal long-term residents) are to be provided with essential healthcare, whether they can <a href="https://theconversation.com/coronavirus-pandemic-holds-lessons-for-south-africas-universal-health-care-plans-137443">contribute</a> to the NHI fund or not.</p>
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Read more:
<a href="https://theconversation.com/south-african-taxpayers-will-bear-the-brunt-of-national-health-insurance-122409">South African taxpayers will bear the brunt of National Health Insurance</a>
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<p>But South Africa faces high levels of disease, in particular <a href="http://www.samj.org.za/index.php/samj/article/view/12864">noncommunicable diseases</a> such as diabetes, hypertension, cancer and obesity. Many noncommunicable diseases can be prevented. The NHI is likely to battle to cope with treating large numbers of sick people, but much of this treatment could be avoided by promoting health and reducing disease. </p>
<p>In our <a href="http://www.samj.org.za/index.php/samj/article/view/12864">paper</a> we set out how this radical change of approach could be achieved and why health promotion could be an effective use of the limited funds.</p>
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Read more:
<a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">Why South Africa's plans for universal healthcare are pie in the sky</a>
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<h2>Getting healthier</h2>
<p>Noncommunicable diseases, many of which are avoidable, are having a significant impact on the health of South Africans and the South African healthcare system.</p>
<p>The increase in noncommunicable disease risk factors will likely lead to rising healthcare costs. </p>
<p>For example, in 2018, the public health sector spent an <a href="https://www.tandfonline.com/doi/full/10.1080/16549716.2019.1636611">estimated</a> R2.7 billion ($198 million) on patients diagnosed with diabetes. The estimates increased to R21.8 billion when undiagnosed diabetes patients were considered. The total costs associated with diabetes are likely to increase to R35.1 billion ($2.5 billion) in 2030.</p>
<p>Another common condition, <a href="https://pubmed.ncbi.nlm.nih.gov/17952226/">hypertension</a>, is an important risk factor for cardiovascular diseases and chronic kidney disease. It is often found in combination with diabetes. In <a href="https://www.statssa.gov.za/publications/Report%2003-00-09/Report%2003-00-092016.pdf">South Africa</a> 46% of women and 44% of men over 15 had hypertension in 2016. This is almost double the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31919-5/fulltext">world average</a> and has nearly doubled since 1998. </p>
<p>The <a href="https://dhsprogram.com/pubs/pdf/FR337/FR337.pdf">2016 South African Demographic and Health Survey</a> indicates high levels of obesity, which has health and cost implications. Forty-one percent of women are obese, a condition associated with an 11% increase in healthcare <a href="http://www.samj.org.za/index.php/samj/article/view/7260">costs</a>. </p>
<h2>What needs to be done</h2>
<p>Health behaviour in South Africa needs to shift from the norm of waiting to get sick and then accessing healthcare to preventing disease and keeping healthy.</p>
<p>To encourage this, we <a href="http://www.samj.org.za/index.php/samj/article/view/12864">propose</a> the establishment of a multi-sectoral National Health Commission or an independent Health Promotion Foundation linked directly to the NHI Fund. It should include several relevant government departments, civil society, academics and researchers. </p>
<p>Health promotion programmes need to be based on more than health knowledge. For example, individuals can’t practise good hand hygiene when water is not available, or eat healthy foods when these are not affordable. South Africa’s specific <a href="https://theconversation.com/pandemic-underscores-gross-inequalities-in-south-africa-and-the-need-to-fix-them-135070">realities and needs</a>, including poverty and its related behavioural impacts and health consequences, must be taken into account. This is why different government departments and stakeholders would need to work together.</p>
<p>We don’t know exactly how much of the noncommunicable disease burden could be eased by modifying risk factors. But the World Health Organisation
has <a href="https://www.paho.org/hq/dmdocuments/2011/paho-policy-brief-1-En-web1.pdf">estimated</a> that in the Americas 80% of all heart disease, stroke and type 2 diabetes mellitus and over 40% of cancer is preventable through multisectoral action. </p>
<p>Some of the changes that could make a difference to health are quite indirect.
For example, it is often not safe to exercise on the streets, so communities need to have more active and visible policing and accessible open spaces free from traffic and other competing activities to make increased exercise a realistic option. Healthy food needs to be subsidised and more easily available, and places that sell alcohol and tobacco need to be located at prescribed distances from schools. </p>
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Read more:
<a href="https://theconversation.com/south-africa-moves-one-step-closer-to-a-sugar-tax-and-a-healthier-lifestyle-88045">South Africa moves one step closer to a sugar tax -- and a healthier lifestyle</a>
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<p>Just how much funding is needed to promote health? Health promotion experts are calling for <a href="http://www.samj.org.za/index.php/samj/article/view/12864">2%</a> of the NHI Fund to be dedicated specifically to promoting health and preventing illness. This is certainly a reason to improve health promotion funding in South Africa. We cannot afford to wait any longer.</p>
<p>The WHO’s global <a href="https://www.who.int/ncds/prevention/launch-global-business-plan-for-ncds/en/">business case</a> for noncommunicable diseases shows that if low- and low-to-middle-income countries put in place the most cost-effective interventions, by 2030 they will see a return of US$7 per person for every dollar invested. This is certainly a reason to improve health promotion funding in South Africa. We cannot afford to wait any longer.</p><img src="https://counter.theconversation.com/content/140204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melvyn Freeman has contracts of work from the World Health Organization and Higher Health. He is a member of the Department of Health think tank on mental health.</span></em></p><p class="fine-print"><em><span>Charles Parry and Jane Simmonds do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa faces high levels of noncommunicable diseases such as diabetes and hypertension. The NHI is likely to battle to cope with treating large numbers of sick people.Jane Simmonds, Associate Staff, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research CouncilCharles Parry, Director, Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research CouncilMelvyn Freeman, Extraordinary Professor, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1374432020-05-17T08:50:35Z2020-05-17T08:50:35ZCoronavirus pandemic holds lessons for South Africa’s universal health care plans<figure><img src="https://images.theconversation.com/files/331354/original/file-20200429-51485-vvyfa1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A healthcare worker collecting a swab for a COVID-19 test from a community member. </span> <span class="attribution"><span class="source">AFP via Getty Images</span></span></figcaption></figure><p>The National Health Insurance (NHI) has become an idealistic concept known as “imaginary”. It’s become the idea onto which all South Africa’s aspirations for healthcare have been projected. The dream of a system that is fairer, less divided and more efficient. It’s even been called “<a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">pie in the sky</a>”. </p>
<p>It’s clear that some version of the NHI is going to happen regardless of anyone’s opinion. And its success or failure will be determined by the extent to which all South Africans contribute to it. </p>
<p>The <a href="http://www.health.gov.za/index.php/nhi">NHI</a> is a financing system that will make sure that all South Africans have access to essential healthcare, regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.</p>
<p>Other middle-income countries such as <a href="https://www.who.int/bulletin/volumes/86/4/08-030408/en/">Brazil</a> and <a href="https://www.who.int/bulletin/volumes/97/6/18-223693/en/">Thailand</a> have shown that it can be done.</p>
<p>This dream of a single national health system could be realised if South Africa is able to articulate a common vision for all its citizens. </p>
<p>But in a complex system such as the health sector, the ideal of universal health coverage as intended by the <a href="https://www.parliament.gov.za/project-event-details/54">NHI</a> is unlikely to be attained overnight with the passing of legislation. </p>
<p>The envisaged system can only be implemented through incremental and deliberate bottom-up design. It must incorporate the outcomes of experimentation and reflection with stakeholders at all levels of the system, over time. </p>
<p>The COVID-19 pandemic is shedding light on how best to go about building the NHI – and what to avoid.</p>
<p>On the positive end, it has highlighted the country’s interconnectedness and mutual dependence across sectors. The health minister has shown great leadership and <a href="https://mg.co.za/article/2020-04-13-covid-19-in-south-africa-trends-and-next-steps/">collaborated closely</a> with the scientific community.</p>
<p>On the negative side, the acute crisis has prompted government to work top-down through a centralised command structure. This is not how effective systems based on <a href="https://www.who.int/docs/default-source/primary-health/vision.pdf">primary healthcare</a> are built. In the absence of a design approach with clear cycles of learning and feedback of evidence from the ground up, the risk is that the whole NHI system will fail to be implemented. There are many examples of the “implementation gap” between well-intentioned policy and actual practice in South Africa.</p>
<p>So how do people think about healthcare? The most prevalent idea is that of fixing a machine, as if the body just needs a little help when it breaks down occasionally. The metaphor of war</p>
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<a href="https://theconversation.com/war-metaphors-used-for-covid-19-are-compelling-but-also-dangerous-135406">War metaphors used for COVID-19 are compelling but also dangerous</a>
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<p>may be helpful in responding to the acute crisis of the COVID-19 pandemic. But in the longer term it is not a constructive approach to building an equitable health system for all. The challenge needs to be thought of in different ways.</p>
<h2>A more appropriate metaphor</h2>
<p>A health system is more than a complicated organisation, it is an extremely complex one. The human body itself is an appropriate image of a complex, adaptive system. It’s a biological marvel in which each part simultaneously affects every other part. A further level of complexity arises when these changing systems are challenged by trauma or illness, and have to adapt to new environments or stressors. </p>
<p>It is remarkable how the body inexorably tends towards preserving or re-developing a functional norm after a catastrophic disturbance such as a stroke or major trauma.</p>
<p>COVID-19 is just such a trauma – an assault to all of our systems, out of the blue. Like the process of adapting to the challenges of a chronic disability, the South African health system must moreover cope with the inherent deficits in society resulting from the legacy of colonialism and apartheid, which created the enormous <a href="https://theconversation.com/pandemic-underscores-gross-inequalities-in-south-africa-and-the-need-to-fix-them-135070">inequities</a> that have been laid bare by the pandemic. </p>
<p>The fundamental divide between the for-profit value system of the private health sector on the one hand, and the human rights-based approach of the public sector on the other, needs to be <a href="https://www.dailymaverick.co.za/article/2020-04-06-outbreak-provides-valuable-insights-needed-to-implement-national-health-insurance/">bridged rather than deepened</a>, building on the intersectoral innovations that the pandemic has elicited. </p>
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Read more:
<a href="https://theconversation.com/covid-19-shows-that-where-there-is-political-will-there-is-a-way-to-work-across-sectors-134999">COVID-19 shows that where there is political will there is a way to work across sectors</a>
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<p>South Africa could learn a lot from the process of physical rehabilitation, and how a person can adapt to complex disruptions, with the pragmatic help of a team of skilled health professionals, through relationships and hope. Whatever the nature and extent of the precipitating historical event, the unrelenting task is to restore order out of chaos, and to work in solidarity with the patient to optimise their function over time. ‘Resilience’ is defined as the positive adaptation to significant adversity, that builds capacity for future challenges, in contrast to negative adaptations that ultimately make things worse.</p>
<p>The country’s health system will need such ongoing rehab post-COVID-19 to overcome divisions and build a national health system from the bottom up. The ideal of universal health coverage as intended by the NHI will require a deliberate process of experimentation, reflection and incremental adaptation over a number of years. Fundamental principles of primary healthcare, such as equity, health promotion and community participation, will be critical.</p>
<p>This COVID-19 pandemic highlights the fact that South Africa already has the technical expertise and capacity, in governance, in health economics, in health systems, in information systems, as well as in community participation in health. </p>
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Read more:
<a href="https://theconversation.com/investing-in-research-is-south-africas-best-insurance-policy-against-crises-135706">Investing in research is South Africa's best insurance policy against crises</a>
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<p>Inspiring initiatives in purpose-driven social entrepreneurship are motivated not by private profit but by public benefit. And there are population-based capitation <a href="https://gh.bmj.com/content/4/Suppl_8/e001551">models for primary care</a> in other middle-income countries that are already working well. </p>
<p>COVID-19 has brought many of these initiatives to the fore, to bridge the divide between those who have and those who don’t. Solidarity and commitment to the common good are the pivotal values that are needed at this time and into the future. </p>
<p>There is hard and persistent work that needs to be planned for, like a kind of ongoing rehabilitation process, to realise the dream of one health system for all South Africans.</p><img src="https://counter.theconversation.com/content/137443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steve Reid receives funding from South African Medical Research Council. He is a non-executive board member of two NPCs: Jembi Health Systems and Tekano Health Equity South Africa.</span></em></p>There is hard and persistent work that needs to be planned for, like a kind of ongoing rehabilitation process, to realise the dream of one health system for all South Africans.Steve Reid, Medical academic and Chair of Primary Health Care, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1358492020-04-19T08:10:08Z2020-04-19T08:10:08ZCoronavirus: never been a more compelling time for African scientists to work together<figure><img src="https://images.theconversation.com/files/328195/original/file-20200415-153318-8ekcrf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Collaboration is crucial for scientists to tackle the COVID-19 epidemic.</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Amid the rising number of deaths from COVID-19, political leadership, health systems and scientific prowess is being tested locally and internationally. The pandemic provides an opportunity for innovation and new scientific discoveries. For example, the emergence of cases in Africa inspire African-based studies to tap into the diverse genetic background of Africans for important clues in the identification of biomarkers of coronavirus infection. </p>
<p>However, for global scientific solutions to come from Africa a number of prerequisites will need to be met.</p>
<p>The past two decades have been characterised by efforts to reduce the global burden of disease by providing <a href="https://www.who.int/healthsystems/universal_health_coverage/en/">universal access to healthcare</a> for under-served and vulnerable populations. There have been parallel efforts to strengthen science, skills and infrastructure in Africa. The aim has been to support quality research and human capacity development working in <a href="https://www.uct.ac.za/main/research/groups/faculty-groups">research units</a> and <a href="https://www.nrf.ac.za/division/rcce/instruments/centre-of-excellence">centres of excellence</a> dotted across Africa. </p>
<p>But a response to a fast-emerging, highly infectious agent like COVID-19 demands a whole lot more. It requires strong collaboration, the use of new technologies and above all, fast-tracking of research.</p>
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<a href="https://theconversation.com/what-weve-learnt-from-building-africas-biggest-genome-library-126293">What we've learnt from building Africa's biggest genome library</a>
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<p>There has never been a more compelling time for African scientists to work together towards a common goal. An integrated approach is all the more imperative because any country that is left behind could be the next source of infection. </p>
<h2>Collaboration</h2>
<p>A crisis like COVID-19 demands that professional barriers be broken. This would facilitate a united approach by clinicians, scientists (both life and human sciences), biomedical engineers and public health specialists. Practically, this would entail assembling teams that work together, in the first instance, towards disaster management. In the second it would involve teams working on solutions that take into account the special circumstances of Africa – and each country. </p>
<p>These would be focused on quickly learning what has worked and not worked in the parts of the world that were affected first, and providing innovative ways forward for African countries. The size of Africa’s economy and the connectedness of its populations demands that Africa’s response be unified.</p>
<p>Collaboration is needed on another front too: technology. </p>
<p>The spread of the pandemic has resulted in an urgent need for a range of medical supplies. These range from personal protective equipment – face shields, surgical masks, diagnostic swabs, ventilator components and reusable N95 respirators. There is currently an <a href="https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide">international shortage</a> of N95 respirators as well as ventilators. African countries can’t procure these. They need to create their own. </p>
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Read more:
<a href="https://theconversation.com/coronavirus-inside-story-of-how-mercedes-f1-and-academics-fast-tracked-life-saving-breathing-aid-136028">Coronavirus: inside story of how Mercedes F1 and academics fast-tracked life saving breathing aid</a>
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<p>The pandemic presents a good opportunity to use new technologies. For example, with the advancement of 3D printing technologies, these critical supplies could be made on-site as required. These technologies could be used to replicate protective personal equipment. Several universities in South Africa have started using <a href="https://www.timeslive.co.za/news/south-africa/2020-04-07-sas-3d-printing-community-is-making-life-saving-protective-gear-from-home/">3D printing</a> to make masks. Delicate choices must be made between the most advanced technologies and an appropriate technology that can work on the ground and be accomplished with the limitations in the supply chains due to global lockdowns.</p>
<p>In addition, technologies such as <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/imaging-technique">imaging</a>, <a href="https://www.ebi.ac.uk/training/online/course/proteomics-introduction-ebi-resources/what-proteomics">proteomics</a>, <a href="https://www.ebi.ac.uk/training/online/course/introduction-metabolomics/what-metabolomics">metabolomics</a> and <a href="https://www.genome.gov/about-genomics/fact-sheets/A-Brief-Guide-to-Genomics">genomics</a> need to be applied to map the disease progression and its pathway and to conduct research on Africans in order to identify novel markers for vaccine or drug development. </p>
<p>There is therefore an urgent need for national regulatory bodies to develop and deploy dedicated fast-tracking mechanisms to support these kind of technologies.</p>
<p>Important questions for innovation and research include:</p>
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<li><p>understanding factors that facilitate infection with the coronavirus, </p></li>
<li><p>the life-cycle of the virus once in the human body (use of imaging), </p></li>
<li><p>the response of the host when invaded by the coronavirus in terms of genes expressed (transcriptomics), </p></li>
<li><p>the differences in proteins expressed when comparing infected patients and the uninfected (proteomics), and </p></li>
<li><p>the changes in the metabolites in the presence of the coronavirus (metabolomics). </p></li>
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<p>As a continent, and as governments, teams comprising experts from these different fields should be in a state of readiness so that they can be easily activated. And governments should be setting up laboratories that can spring into action when required.</p>
<h2>Fast-tracking research</h2>
<p>This crisis also presents an opportunity to access huge amounts of data from patients infected with COVID-19. These patients can participate in trials or their biological samples could be used in studies to advance science and medicine, and even to prepare for future pandemics. </p>
<p>Now more than ever, a strong motivation has been made for the need to increase research funding to strengthen responses by African scientists. </p>
<p>And research should be fast-tracked. Some changes should be made to facilitate this. One such change is that institutional and national ethics review boards should be allowed to waive some of the requirements for informed consent in very particular instances. Here we are thinking specifically about the use of samples with de-identified data, where there is no link to patient identity and when the research is of public health importance. </p>
<p>On top of this, strategic funds should be made available to support research that’s critical to countries and the continent.</p>
<p>Beyond COVID-19, collective efforts can also help the continent address other critical health challenges. New disciplines have emerged that have forced medical professionals to break barriers and to stop working in silos. Examples include global health, <a href="https://gh.bmj.com/content/bmjgh/4/5/e001808.full.pdf">global surgery</a> and <a href="https://www.researchgate.net/profile/Sudesh_Sivarasu/publication/335740793_Frugal_Biodesign_An_approach_for_Developing_Appropriate_Medical_Devices_in_Low-resource_Settings/links/5d78c9d1299bf1cb80986725/Frugal-Biodesign-An-approach-for-Developing-Appropriate-Medical-Devices-in-Low-resource-Settings.pdf">frugal science</a>. These disciplines are forcing us to improve health outcomes. </p>
<p>In the current time of this COVID-19 crisis, the opportunity to tackle the pandemic through science and innovation should not be missed.</p><img src="https://counter.theconversation.com/content/135849/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salome Maswime receives funding from the South African Medical Research Council, and is the President of the South African Clinician Scientist's Society and a Next Einstein Forum fellow.</span></em></p><p class="fine-print"><em><span>Collet Dandara receives funding from the Medical Research Council of South Africa (SAMRC), the National Research Foundation (NRF) South Africa and the University of Cape Town</span></em></p><p class="fine-print"><em><span>Sudesh Sivarasu receives funding from the Medical Research Council of South Africa (SAMRC), the National Research Foundation (NRF) South Africa, and the University of Cape Town</span></em></p>A crisis like COVID-19 demands that professional barriers be broken.Salome Maswime, Professor of Global Surgery, University of Cape TownCollet Dandara, Professor, Division of Human Genetics, Department of Pathology,, University of Cape TownSudesh Sivarasu, Associate Professor in Biomedical Engineering, Head of Medical Devices Lab, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1320422020-03-03T13:52:35Z2020-03-03T13:52:35ZGhana needs a better policy to guide care for cancer patients<figure><img src="https://images.theconversation.com/files/316273/original/file-20200219-10985-fq5y9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse in a hospital checks an IV</span> <span class="attribution"><span class="source">Wikimedia Commons</span></span></figcaption></figure><p>The <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf">World Health Assembly</a> urged countries in 2014 to include palliative care into their health systems. Its resolution called for equitable services, available to everyone who needs them. <a href="https://www.who.int/cancer/palliative/definition/en/">Palliative care</a> encompasses the support system for patients and their families when they face life-threatening illnesses. It aims to improve quality of life, relieve pain, and help people cope with death. </p>
<p>Palliative care is essential because it gives patients a choice in deciding how their pain and symptoms will be managed. Second, it ensures that patients enjoy the highest quality of life that is practically possible in the circumstances. Because of the increasing care required as a patient’s condition advances to the terminal stage, palliative care is a team approach. It includes nurses, doctors, social workers, volunteers, faith leaders and other health care professionals in supporting the care and well-being of patients and their families. </p>
<p>People are living <a href="https://journals.sagepub.com/doi/full/10.1007/s12290-008-0047-5">longer</a> than before because of advances in medical technology that makes the sick survive longer. The downside is that a longer life span increases the chance of a person experiencing illnesses such as cancer and heart disease, and this, in turn, increases the need for palliative care.</p>
<p>So palliative care is essential, especially when the illness is incurable or treatment is ineffective. And it is of great concern in contexts where healthcare resources for diagnosis and treatment are limited. </p>
<p>Cancers are among the leading <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">causes</a> of illness and death globally. Almost two-thirds of these deaths occur in developing countries, where palliative care is limited or nonexistent.</p>
<h2>Cancer and care in Ghana</h2>
<p>Ideally, <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-136">palliative care</a> should be accessible at all levels of health care and should place patients and families at its centre. The multi-disciplinary team approach ensures efficiency and is the best way to provide optimal palliative care.</p>
<p>In <a href="https://www.researchgate.net/publication/267814449_A_Structured_Approach_to_End-of-Life_Decision_Making_Improves_Quality_of_Care_for_Patients_With_Terminal_Illness_in_a_Teaching_Hospital_in_Ghana">Ghana</a>, patients with cancers and their families who seek services at oncology departments and palliative care units have to pay for treatment. In some cases, such services are inadequate or not within their means. Patients with national health insurance cards afflicted with most cancers and conditions like chronic kidney disease have to pay because the ailments are on the health insurance exclusion <a href="http://www.nhis.gov.gh/benefits.aspx">list</a>. </p>
<p>Currently, patients have to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3426378/">pay</a> for any care relating to cancer (other than breast or cervical cancer): diagnostics, chemotherapy and radiotherapy. </p>
<p>The <a href="https://www.graphic.com.gh/news/health/cost-of-cancer-treatment-worries-patients-dr-aryeetey.html">cost</a> of managing cancer, especially advanced cases, is usually beyond the financial means of patients and their families. Expecting them to pay for it does not conform to the equity principle advocated by the World Health Assembly. The scarcity of palliative care services and the financial barriers to using them amount to an ethical problem. It is unethical to deny cancer patients the same level of treatment given to, say, malaria patients.</p>
<p>Ghana does not have a clear <a href="https://www.businessghana.com/site/news/general/201259/Government-to-introduce-palliative-care-policy">national policy</a> on palliative care. It is reported that it took the <a href="https://www.modernghana.com/news/499268/breast-cancer-screening-to-go-under-nhis.html">advocacy</a> of a few women with breast cancer and the support of some health staff to lobby and petition Ghana’s parliament to get the treatment of cervical cancer under the national health insurance scheme. </p>
<p>The lack of access to palliative care in Ghana leads to considerable suffering for patients and their families. A recent <a href="https://www.nottingham.ac.uk/research/groups/ncare/news/congratulations-yakubu-salifu.aspx">qualitative study</a> conducted by my colleagues and I among men with advanced prostate cancer and their family caregivers in Ghana highlighted two main issues. These were challenges and burden of care as well as the support and coping strategies adopted. </p>
<p>Participants expressed the overburdening nature of the care responsibility. They spoke of feeling “alone in the middle of a deep sea”, disruption of their lives, and unhappiness. The only support available to them is their social network, their extended family and their faith.</p>
<p>It is also an issue for health professionals as they are expected to show the “<a href="https://journals.sagepub.com/doi/abs/10.1177/175045891702701001">6Cs</a>” – care, compassion, courage, communication, commitment, and competence. Healthcare professionals are unable to provide competent and collaborative palliative care without a policy and a budget provision. </p>
<p>Ghana needs a holistic palliative care policy and a clear, sustainable financial commitment to ensure its implementation. The Medical and Dental Council, as well as the Nursing and Midwifery Council of Ghana should ensure that the training of nurses and doctors in palliative care is prioritised. Government and relevant agencies must take the lead in ensuring that there is a practical palliative care policy that is tailored to the Ghanaian health system and the needs of patients.</p><img src="https://counter.theconversation.com/content/132042/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yakubu Salifu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ghana’s lack of a palliative care policy is posing a significant challenge to effective healthcare for cancer patients.Yakubu Salifu, Lecturer, Palliative Care, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253802019-10-31T14:45:11Z2019-10-31T14:45:11ZHow a lack of competition in South Africa’s private health sector hurts consumers<figure><img src="https://images.theconversation.com/files/297309/original/file-20191016-98678-1gqympv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Netcare is one of three hospital groups found to dominated the facilities market.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>An extensive inquiry <a href="http://www.compcom.co.za/healthcare-inquiry/">into South Africa’s health market</a> was recently concluded – the first ever process in the country that involved gathering evidence and then studying the private healthcare market from the perspective of competition and competition law. </p>
<p>The investigation ran over five years and included over 43 million individual patient records, 11 million admissions, specifically commissioned <a href="http://www.compcom.co.za/healthcare-inquiry/">studies</a>, written submissions, public hearings and seminars. The investigation focused on hospitals, doctors, and funders. Funders include the medical schemes who purchase healthcare on behalf of members, and the administrators and managed care organisations that medical schemes contract with.</p>
<p>South Africa’s Competition Commission set up the inquiry in response to prices in the private healthcare sector which, it said, only a minority of South Africans could afford. The country has a two-tiered health system. About <a href="http://www.statssa.gov.za/publications/P0318/P03182018.pdf#page=37">71%</a> of the population uses public sector, while the private sector serves around <a href="http://www.statssa.gov.za/publications/P0318/P03182018.pdf#page=37">27%</a>. </p>
<p>Ideally competition should translate into lower costs and prices, better quality, and generally more value for money for consumers. In its final report, which was <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/HMI-Executive-Summary.pdf">released recently</a>, the inquiry found that competition wasn’t working as it should in private healthcare. The sector was characterised by high and rising costs, significant overuse, and no discernible improvements in health outcome. </p>
<h2>Lack of competition</h2>
<p>There were a number of factors that – alone or in combination – led to a lack of competition in the sector. </p>
<p>One factor is that three hospital groups dominated the facilities market: Netcare, Mediclinic and Life. They accounted for more than 80% of the hospital beds and 90% of all the admissions. These three hospital groups, both individually and collectively, were able to secure steady and significant profits year-on-year. A few firms owning the majority of the market is an indication that competition may not be working effectively. </p>
<p>Hospitals don’t attract patients, they compete for doctors who admit patients. Most doctors had contracts with the big three. Successful entry by new hospital owners is very difficult as they cannot attract doctors as easily. </p>
<p>Hospital groups are also able to build additional hospitals where they aren’t needed, resulting in an oversupply of beds and ultimately overuse of services. </p>
<p>In South Africa more people are admitted to ICU compared to eight other countries with comparable <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/Health-Market-Inquiry-Report.pdf">published data</a>. The inquiry panel estimated that the country could save more than R2.7 billion – or 2% of its current private health care spend – if it halved the number of people admitted to ICUs and improved the care for patients in wards. Only the critically ill should be admitted to ICU. But the inquiry found that some of the patients who were in ICU could have been treated in wards.</p>
<p>There are no measures of quality of care in the public domain. This means that members of medical schemes and funders (who purchase healthcare on behalf of medical scheme members) weren’t able to judge if the care provided by doctors and specialists was effective.</p>
<p>The entire premise of effective competition is that purchasing healthcare services should be based on value – a combination of price and quality. This isn’t possible in South Africa. </p>
<p>There’s no way to assess if the care provided was improving health outcome. This is particularly problematic as the inquiry found significant over-servicing by doctors which cannot be explained by their patients’ level of illness. Doctors use a fee-for-service billing model. This means they bill patients for each service they perform during a consultation. In this system, the more you do the more you earn. This is called a perverse incentive and without knowing the impact of health outcomes neither doctors nor patients know if the extra tests or interventions are worth the cost. They also don’t know if it is improving health outcomes.</p>
<p>The inquiry also found doctors and specialists worked as individuals -– not as a team. There is growing <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5403641/">evidence</a> and acceptance internationally that team-based care is better and more cost effective. </p>
<p>Medical schemes compete for younger and healthier individuals. To do this, schemes have created numerous benefit packages. But these packages aren’t comparable. Medical schemes have done this in response to the absence of a mechanism for equalising risk between medical schemes. Medical scheme members do not know what they are paying for. Neither are they able to judge the quality of care. </p>
<h2>Recommendations</h2>
<p>The recommendations are aimed at creating greater competition, transparency, and accountability on how medical scheme member’s money is spent. They also aim to increase competition on the supply side (hospitals, doctors, and specialists) and on the demand side where funders represent the consumer. </p>
<p>Recommendations include a supply side regulator, whose job will be to:</p>
<ul>
<li><p>assist provinces in issuing licenses for hospitals;</p></li>
<li><p>assist with a process and a platform for price setting for doctors;</p></li>
<li><p>conduct or contract out research looking at cost-effective healthcare interventions, including technology; and</p></li>
<li><p>facilitate access to reliable information on quality of health and health outcomes measurement.</p></li>
</ul>
<p>To increase competition on the funder’s side, and to improve transparency for the consumer, the recommendations include that all medical schemes offer one comparable insurance package. In addition, government should introduce a mechanism to equalise risk between medical schemes so that they compete on the merits – not on risk or age selection.</p>
<h2>What next</h2>
<p>The recommendations have implications for the South African governments plan to introduce a National Health Insurance in a bid to level out the playing field between the public and private health care sectors. The plan is that the National Health Insurance will operate as a funding mechanism to move South Africa closer to universal health coverage. </p>
<p>Implementing the recommendations set out in the inquiry report is an essential step towards creating an environment where the purchaser – the National Health Insurance fund – will purchase from a private healthcare market that is competitive with lower costs and prices, and more value for money for consumers.</p>
<p>The National Health Insurance bill talks about strategic purchasing or value based purchasing which refers to using the capacity in the private sector to relieve the public sector. This aligns with the health market inquiry recommendations.</p>
<p>But it needs an independent supply side regulator to enable competitive price setting and coding mechanisms. Codes form the basis on which prices are determined – which is necessary for the National Health Insurance fund to reimburse providers. Value based purchasing also requires implementation of performance and outcomes reporting and monitoring. </p>
<p><em>Dr Lungiswa Nkonki was a panel member of the Health Market Inquiry.</em></p><img src="https://counter.theconversation.com/content/125380/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lungiswa Nkonki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The entire premise of effective competition is that purchasing of health services should be based on value - a combination of price and quality.Lungiswa Nkonki, Senior Lecturer, Department of Global Health, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1248142019-10-09T14:43:55Z2019-10-09T14:43:55ZWe did the sums on South Africa’s mental health spend. They’re not pretty<figure><img src="https://images.theconversation.com/files/295982/original/file-20191008-128644-1gtdayo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa has taken steps towards strengthening mental health care in the last 20 years. These include reforming the <a href="https://www.gov.za/sites/default/files/gcis_document/201409/a17-02.pdf">Mental Health Care Act 2002</a> and developing a <a href="https://health-e.org.za/wp-content/uploads/2014/10/National-Mental-Health-Policy-Framework-and-Strategic-Plan-2013-2020.pdf">National Mental Health Policy Framework and Strategic Plan 2013–2020</a>. </p>
<p>The strategic plan aims to integrate mental health into general health services to reduce the burden of untreated mental health conditions. It also aims to transform the system to provide quality mental health services that are accessible, equitable and comprehensive, particularly for community-based mental health care.</p>
<p>But significant information gaps have limited the country’s ability to initiate a sustained response to mental health care. For example, the most up to date population based prevalence estimates of the burden of mental disorders date as far back as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191537/">2003/4</a>. </p>
<p>The failure to implement the public policy on mental health was brought to light by the <a href="https://theconversation.com/patient-deaths-show-south-africas-care-for-the-mentally-ill-is-in-disarray-72472">Life Esidimeni tragedy in 2017</a>. Nearly 150 patients died after being moved from the Life Esidimeni Hospital to unlicensed facilities. </p>
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Read more:
<a href="https://theconversation.com/patient-deaths-show-south-africas-care-for-the-mentally-ill-is-in-disarray-72472">Patient deaths show South Africa's care for the mentally ill is in disarray</a>
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<p>New challenges are now arising with the planned introduction of the National Health Insurance (NHI) scheme, which is intended to move South Africa closer to universal health coverage. But <a href="https://ijmhs.biomedcentral.com/articles/10.1186/s13033-019-0260-4">early evidence</a> from NHI pilot districts show an inconsistency with the strategic plan and limited integration of mental health. If the relevant priorities aren’t explicitly reflected in the policies and activities supporting the NHI, mental health is likely to remain on the back burner. </p>
<p>The system must be clear about the care that mental health patients are entitled to and how providers will be identified and paid. Mental health care has to be recognised as an integral part of the health care system. </p>
<p>South Africa needs a good grasp of the problem and the resources required to address it. </p>
<h2>The gaps</h2>
<p>Until recently the country knew very little about a range of important factors related to mental health care. These included: the current state of investment in mental health; whether these investments were being used optimally; where the inequities in resourcing and access lay; and what priorities and plans should be in place to address these inequities. </p>
<p>In response to some of the biggest information gaps, we worked with national and provincial health departments and the South African Medical Research Council. We evaluated the health system costs of mental health services and programmes in South Africa for the 2016/17 financial year. We also documented and evaluated the available resources and constraints to inform a rational approach to planning effectively to improve mental health service delivery.</p>
<p><a href="https://academic.oup.com/heapol/advance-article/doi/10.1093/heapol/czz085/5572608">Our findings</a> offer – for the first time – a nationally representative reflection of the state of mental health spending. They draw attention to inefficiencies and constraints in existing mental health investments in the country. </p>
<h2>The current situation</h2>
<p>South Africa spends 5% of the total health budget on mental health services. This is in line with the lower end of <a href="https://www.who.int/mental_health/evidence/dollars_dalys_and_decisions.pdf">international benchmarks</a> of the recommended amount that countries should spend on mental health. </p>
<p>Yet, alarmingly, our study crudely estimated a treatment gap of 92%. This means that fewer than 1 in 10 people living with a mental health condition in South Africa receive the care they need. We also found huge disparities between provinces in the allocation of mental health resources. Provincial spending on mental health ranged widely across all levels of the health system. For example, in Mpumalanga, spending on mental health per uninsured South African was R58.50 while in the Western Cape it was R307.40. </p>
<p>Inpatient care took up 86% of the mental health care budget. Spending at specialised psychiatric hospitals made up 45% of the total. Services at the primary level of care made up only 7.9% of overall mental health spending. </p>
<p>This reflects a reactive mental health care system that is focused on treating the most severe conditions, rather than preventing or providing early interventions.</p>
<p>Mental health care users were admitted for longer periods than other patients – twice as long as other patients at district hospitals. At regional and tertiary hospitals, their admissions lasted around 6 to 8 times longer. At central hospitals, they spent almost 5 times longer. Mental health patients spent an average of 157 days in psychiatric hospitals per admission. Nearly 1 in 4 mental health patients were readmitted within three months of being discharged from any hospital. Readmissions alone consumed 18% of South Africa’s total mental health spend. </p>
<p>This indicates a highly inefficient system that fails to help patients transition to care in their communities. There is potential for cost savings in providing continuity of care and supporting people to live well in their communities after discharge from hospital.</p>
<p>Other findings included: </p>
<ul>
<li><p>Only three provinces had child psychiatrists in the public sector. </p></li>
<li><p>There was an extreme shortage of psychiatrists and auxiliary workers critical for rehabilitation and supportive services.</p></li>
<li><p>There wasn’t alignment between the national database of NGOs licensed by the department of health and those reported through primary data collection. </p></li>
<li><p>A number of drugs critical for the management of chronically disabling conditions such as bipolar disorder and depression, were not routinely available. </p></li>
<li><p>Most district hospitals weren’t compliant with the Mental Health Care Act, though they are expected to provide 72-hour assessments and subsequent referrals for further care, treatment and rehabilitation.</p></li>
</ul>
<h2>Way forward</h2>
<p>For the first time, South Africa has a <a href="https://zivahub.uct.ac.za/articles/An_Evaluation_of_the_Health_System_Costs_of_Mental_Health_Services_and_Programmes_in_South_Africa/9929141">nationally representative reflection</a> of the state of mental health spending and an appreciation of the inefficiencies and constraints emanating from existing mental health investments. This is one of the highest sample sizes of any costing study conducted for mental health in low- and middle-income countries.</p>
<p>Our study points to some obvious improvements that could be made. These include stronger service delivery at community and primary health care levels. And better referral pathways could reduce unnecessary readmissions. This would also shorten hospital stays. </p>
<p>The next phase must focus on accelerating the country’s progress towards meeting the goals set out in the strategic plan and taking forward the recommendations of the <a href="https://www.sahrc.org.za/index.php/sahrc-media/news-2/item/1811-media-statement-sahrc-to-release-the-report-on-the-national-investigative-hearing-into-the-status-of-mental-healthcare-in-south-africa">South African Human Rights Commission Report</a>. With these study findings in hand, the government now has a baseline from which to begin a rational planning process. </p>
<p>The government has asked us to help develop a mental health investment case for the country, which comes at a crucial time for the country’s mental health response, in light of the recent passing of the <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">NHI Bill</a>. This work will involve intensive and ongoing dialogue with a range of players involved in the provision of mental health services and research across the country.</p><img src="https://counter.theconversation.com/content/124814/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sumaiyah Docrat is a staff member of the University of Cape Town and her PhD is supported by the South African Medical Research Council through its Division of Research Capacity Development under the SAMRC National Health Scholars Programme from funding received from the South African National Treasury. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the University of Cape Town, the South African Medical Research Council or the PhD funders.</span></em></p><p class="fine-print"><em><span>Crick Lund is a staff member of the University of Cape Town and King's College London. He has received research funding from the UK Department for International Development, the Wellcome Trust, the UK National Institute for Health Research, the South African National Research Foundation, the US National Institute of Mental Health, the UK Economic and Social Research Council and Wellspring Philanthropic Fund. </span></em></p>Less than 1 in 10 people living with a mental health condition in South Africa receive the care that they need.Sumaiyah Docrat, Health Economist in the Alan J. Flisher Centre for Public Mental Health, University of Cape TownCrick Lund, Professor in the Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1226922019-09-17T21:29:41Z2019-09-17T21:29:41ZUniversal health coverage alone won’t radically improve global health<figure><img src="https://images.theconversation.com/files/292699/original/file-20190916-19072-u1gsi4.jpg?ixlib=rb-1.1.0&rect=0%2C58%2C1000%2C513&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If countries commit to universal health coverage alone, they will be emphasizing disease management over investing in wellness. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>This Sept. 23, the United Nations General Assembly invites world leaders and delegates to converge <a href="https://www.who.int/news-room/events/detail/2019/09/23/default-calendar/un-high-level-meeting-on-universal-health-coverage">for a meeting about universal health coverage (UHC) that’s expected to result in a political declaration</a>. </p>
<p>Since 2012 UHC has become a <a href="https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/67/81">policy framework through which the UN has pledged to improve global health</a>. Getting countries to implement UHC globally is also a now a sub-goal in the larger global aim of <a href="https://www.who.int/sdg/targets/en/">ensuring healthy lives and promoting well-being for all at all ages</a> (Sustainable Development Goal 3) <a href="https://sustainabledevelopment.un.org/?menu=1300">by 2030</a>. </p>
<p>The important place of UHC in the UN’s agenda means that countries such as Canada, for example, are assessing their <a href="https://www.idrc.ca/en/project/policy-research-institutions-and-health-sdgs-building-momentum-south-asia">international development partnerships partly by considering how much “progress” Global South nations are making with UHC</a>. Meanwhile, health researchers are <a href="https://www.ctvnews.ca/health/lancet-series-calls-on-canada-for-concrete-action-on-indigenous-global-health-1.3815761">holding Canadian leaders accountable for whether Canada’s oft-touted universal health care is truly sufficient to realize population-wide health</a>. </p>
<p>The <a href="https://www.who.int/news-room/detail/03-09-2019-who-director-general-calls-on-world-leaders-to-support-universal-health-coverage-high-level-meeting">World Health Organization</a> (WHO) first proposed UHC, defining it as a goal <a href="https://www.who.int/features/qa/universal_health_coverage/en/">“to ensure that all people obtain the health services they need without suffering financial hardship at the point of receiving them.</a>” The WHO also recognizes that primary health care — not just being able to access services when sick — must be in place to realize healthy societies. Last year, the UN <a href="https://sdg.iisd.org/news/global-conference-adopts-declaration-on-primary-health-care-and-uhc/">affirmed that primary health care</a> is the foundation for achieving UHC. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/_EXy9DTDJu8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">World Health Organization video on the importance of primary health care.</span></figcaption>
</figure>
<p>As a researcher in the area of <a href="https://idl-bnc-idrc.dspacedirect.org/bitstream/handle/10625/57091/IDL-57091.pdf">public health and health systems</a>, I hope that any global meaningful standard for universal health coverage will include benchmarks for primary health care including patient participation in health systems. These are necessary to enable countries to effectively evaluate the true impact of health investments. </p>
<p>The UN’s <a href="https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/67/81">current 2012 policy on global health</a> doesn’t address this concern. A new political statement supporting UHC should.</p>
<p>If countries only pay lip service to a <a href="https://www.youtube.com/watch?v=_EXy9DTDJu8&t=42s">commitment to primary health care (PHC) as a means of investing in people’s wellness</a>, the world will be working with global health goals focused on responding to illness and disease management. </p>
<h2>Much to be desired</h2>
<p>Right now, there isn’t a single country in the world with 100 per cent universal health coverage. All global health systems have room to improve. But UHC as it has been held up as a UN goal leaves much to be desired.</p>
<p>In 2012, the former director-general of the WHO, Dr. Margaret Chan, said that “<a href="https://doi.org/10.1016/S0140-6736(12)61493-7">universal health coverage is the most powerful unifying single concept that public health has to offer, because you can realise the dream and the aspiration of health for every person ….”</a></p>
<p>In ideal terms, UHC would cover as many people as possible with an essential package of health-care services without making them pay upfront.</p>
<p>But right now countries define this differently, making it easy to mask how effective health services are and how many people they’re actually reaching. </p>
<p>Many countries report having implemented universal health coverage — but each country offers quite different levels of services and financial protection, to different portions of the population. </p>
<h2>Dubious access, inadequate coverage</h2>
<p>For example, when governments design health services, they can assign a health clinic or a hospital to cover larger or smaller catchment areas, without much focus on who can actually access or use the services. </p>
<p>Afghanistan, for example, claims <a href="https://www.reuters.com/article/us-afghanistan-healthcare-funding-interv/worsening-security-in-afghanistan-threatens-health-gains-minister-says-idUSKCN1II2P4">60 per cent of its population is covered with basic health services within two hours of walking distance</a>. But people’s true access, and how they can actually use <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207102/">these services, not to mention their quality, is dubious.</a></p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292842/original/file-20190917-19083-zae2gu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Afghanistan’s claims that 60 per cent of its population is covered with basic health services is dubious. Here, an Afghan health worker gives a vaccination to a child during a polio campaign in the old part of Kabul, Afghanistan, Aug. 8, 2018.</span>
<span class="attribution"><span class="source">(AP Photo/Rahmat Gul)</span></span>
</figcaption>
</figure>
<p>The set of services can also be dramatically comprehensive or narrow or limited to a certain ceiling. </p>
<p>Canada, for example, globally known for its publicly funded health-care system, covers all people with “<a href="https://www.cfhi-fcass.ca/Libraries/Romonow_Commission_ENGLISH/Discussion_Paper_Medically_necessary_What_is_and_who_decides.sflb.ashx">medically necessary services</a>.” But many Canadians understand all too well what is not covered: <a href="https://doi.org/10.1016/S0140-6736(18)30181-8">out-patient medications, home and community care and institutional long-term care</a>.</p>
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Read more:
<a href="https://theconversation.com/leave-the-patchwork-to-the-quilts-the-case-for-pharmacare-122284">Leave the patchwork to the quilts: The case for pharmacare</a>
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<h2>Patient participation</h2>
<p>Three main goals of a health system are <a href="https://www.who.int/healthinfo/paper06.pdf">improving health, financial protection and responsiveness</a>. </p>
<p>A new vision for UHC must hold countries accountable for responsiveness towards patients’ medical and non-medical needs and preferences. Health systems are inherently <a href="https://www.ncbi.nlm.nih.gov/pubmed/12614697">social institutions in which the power dynamics between providers and recipients affect how they work</a>. Health systems must consider how patients are treated as persons, and <a href="https://gh.bmj.com/content/2/4/e000486">the environments where patients find treatment</a>.</p>
<p>Besides patients’ need for technically competent services, patients need to exercise their agency in making decisions about their care. And collectively, patients as citizens need to <a href="https://www.ncbi.nlm.nih.gov/pubmed/12614697">participate in health-care policy, planning and provision</a>. </p>
<h2>Primary health care</h2>
<p>A meaningful statement about UHC must address the fact that ensuring health is beyond the scope of ministries of health and the health-care sector alone, and that <a href="https://doi.org/10.1016/S0140-6736(19)31831-8">social factors impact health and community participation</a>.</p>
<p>Key principles <a href="https://parthealth.3cdn.net/ea9818ff461c9fbd2c_89m6bh39v.pdf">of primary health care have been evolving</a> since an international conference advocated Primary Health Care (PHC) as a <a href="https://www.who.int/social_determinants/tools/multimedia/alma_ata/en/">global health framework about 40 years ago</a>. </p>
<p>David Sanders of the School of Public Health, University of the Western Cape, South Africa, and an <a href="https://doi.org/10.1016/S0140-6736(19)31831-8">international team of health, epidemiology and public health researchers</a> summarize priorities of PHC to include: universal and equitable access to health coverage; individual and community participation in health policy and planning; collaboration across sectors to address determinants of health; using appropriate technology and resources in a cost-effective way.</p>
<p>For the sake of better global health, UN decision makers should realize a vision for people to lead healthy lives, not just create policy that responds to illness.</p>
<p>[ <em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/122692/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maisam Najafizada receives funding from Medical Research Foundation (MRF) at the Faculty of Medicine, Memorial University of Newfoundland.</span></em></p>The UN’s global health policy related to universal health coverage should be grounded in primary health care – with meaningful benchmarks to ensure patient participation.Maisam Najafizada, Assistant Professor of Population Health Policy, Memorial University of NewfoundlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1228062019-09-11T13:41:52Z2019-09-11T13:41:52ZRebuilding health systems from the bottom up: a South African case study<figure><img src="https://images.theconversation.com/files/291505/original/file-20190909-109962-1hazous.jpg?ixlib=rb-1.1.0&rect=15%2C26%2C2533%2C1594&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A community care worker providing treatment to a TB patient at her home. </span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:DOT_administering_treatment.jpg">Wikkicommons/Stherere23</a></span></figcaption></figure><p>The recent publication of the <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">National Health Insurance Bill</a> in South Africa has provoked <a href="https://theconversation.com/why-south-africas-plans-for-universal-healthcare-are-pie-in-the-sky-121992">vigorous debate</a>. Many question whether the proposed reforms contained in the Bill offer meaningful solutions to the <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-signing-presidential-health-compact-25-jul-2019-0000">well-documented</a> <a href="https://www.hqsscommission.org/">crisis</a> in South Africa’s health system. </p>
<p>This crisis is two-fold. On the one hand is the lack of access and poor quality in the public health system which serves around <a href="https://www.dailymaverick.co.za/article/2019-08-20-is-the-national-health-insurance-bill-open-to-a-constitutional-challenge/">85%</a> of the population. On the other hand is an expensive and inefficient private health sector for the remaining minority. There are massive inequities in the distribution of resources between the two sectors. </p>
<p>There is widespread recognition that health system legislation alone will not address the deep seated problems in both sectors. Top-down reforms like those proposed in the NHI Bill need to be complemented by a bottom-up process of strengthening health systems. This must be focused on the most decentralised level of the health system, the district health system. South Africa’s public health system is organised into 52 health districts. </p>
<p>My colleagues and I at the University of the Western Cape believe that this sort of strengthening is not only possible – it’s already happening in pockets. We have <a href="https://doi.org/10.1093/heapol/czz060">engaged</a> with district, provincial and national government players to document the potential of such bottom-up initiatives. </p>
<p>Our recently published <a href="https://doi.org/10.1093/heapol/czz060">research</a> showed how coordinated action by local, provincial and national government players, working with existing resources, can create a fairly rapid turn-around in the performance of health districts. The case study we focused on could provide valuable lessons as South Africa prepares to introduce the NHI. </p>
<h2>Gert Sibande District</h2>
<p>Gert Sibande is a health district in the largely rural province of Mpumalanga. In 2014, this district had the highest death rate from severe acute malnutrition in the country: <a href="https://doi.org/10.1093/heapol/czz060">28%</a> of children younger than five who were admitted to hospital with the condition died during their stay. </p>
<p>But there was a dramatic decline in deaths in Gert Sibande over the three years that followed. The number of children who died from severe acute malnutrition dropped to one-third of the previous levels <a href="https://doi.org/10.1093/heapol/czz060">9%</a>. This decline in deaths was associated with a <a href="https://doi.org/10.1093/heapol/czz060">59%</a> drop in admissions. </p>
<p>In other words, children with severe acute malnutrition weren’t only receiving more effective treatment, cases were being prevented from occurring in the first place. </p>
<p>Severe malnutrition has been a major contributor to child deaths in South Africa, along with causes such as pneumonia and <a href="http://www.samj.org.za/index.php/samj/article/view/12238">diarrhoea</a>. Despite South Africa’s wealth, child malnutrition remains unacceptably <a href="https://foodsecurity.ac.za/wp-content/uploads/2018/04/Final_Devereux-Waidler-2017-Social-grants-and-food-security-in-SA-25-Jan-17.pdf">high</a>. Addressing this is a national priority. </p>
<p>Our research team conducted in-depth interviews with healthcare providers and their managers, to identify how the rapid improvements in acute malnutrition outcomes in Gert Sibande District were made possible. </p>
<p>Interviewees reported widespread shifts in mindsets and practices over the three years. These included improved quality of hospital care for children with severe acute malnutrition and more rigorous identification of children at risk of malnutrition in primary health care facilities. Better referral systems and household follow-up of children by community health workers were also key. </p>
<p>We were particularly interested in understanding how these shifts were triggered in a public health system that is frequently regarded as being trapped in a culture of poor <a href="https://www.hqsscommission.org/">performance</a> and low accountability. </p>
<h2>Key health system interventions</h2>
<p>Changes were initially prompted by consensus in Gert Sibande District that there was a problem to be addressed. This was followed by a series of health system strengthening interventions. These included:</p>
<ul>
<li><p>the appointment of a recently retired, senior public sector manager from another province to visit the district once a month; </p></li>
<li><p>a system of reporting deaths to senior district clinicians and programme managers within 24-hours; </p></li>
<li><p>regular processes of problem analysis and response in district and sub-district structures involving managers, clinicians and information officers;</p></li>
<li><p>empowering dietitians, who were previously marginal actors, to play a central role in steering the response; </p></li>
<li><p>a system of reciprocal accountability where expectations of performance were matched by the provision of support and resources; </p></li>
<li><p>improved supply chains through the provincial office; and,</p></li>
<li><p>building capacity for connected systems thinking. </p></li>
</ul>
<p>Apart from the appointment of the part-time facilitator, no external donor resources were sourced or deployed to the district.</p>
<p>We characterised these interventions as producing three kinds of system-level change. One was “ways of thinking” (knowledge and the use of evidence). The second was “ways of governing” (leadership, participation and coordination). The third was “ways of resourcing” (inputs and capacity). </p>
<h2>Way forward</h2>
<p>The experience of Gert Sibande District is not unusual. There are several “pockets of effectiveness” in South Africa’s public health <a href="https://www.spotlightnsp.co.za/2018/09/21/building-public-health-system-capacity-for-nhi-learning-from-disease-specific-successes-for-system-development/">system</a>. This points to the latent capabilities available in this system. </p>
<p>We believe that unlocking this latent capability needs the kind of deliberate actions seen in Gert Sibande. The system-level changes and health outcomes achieved through such actions will, in turn, only be sustainable in the long run if they are enabled by higher levels of the system. </p>
<p>This entails, firstly, a recognition that change at the frontline won’t be engineered by a stroke of the legislative pen. Meaningful change requires systematic approaches to strengthening, working directly at base of the health system. Gert Sibande’s experience suggests that this does not necessarily have to cost more. </p>
<p>Secondly, national leaders are the best placed to steer a wider consensus on the need to separate political from administrative decision-making in the health system, especially at provincial level. Meritocratic appointment of district and provincial managers, accompanied by more decentralised decision-making on appointments of staff and use of funds, would be an important first step. </p>
<p>A third supportive action would be to invest heavily in developing distributed leadership and management capacity, oriented to public value, as part of a reinvigorated focus on human resources for health.</p>
<p>These approaches could lay the groundwork for a successful NHI that genuinely addresses systemic problems from the bottom up rather than imposing solutions from the top down. </p>
<p><em>Maria van der Merwe and Beauty Marutla from the Mpumalanga department of health, and Joey Cupido and Shuaib Kauchali from the National department of health contributed to this article.</em></p><img src="https://counter.theconversation.com/content/122806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Helen Schneider is a professor in the School of Public Health, at the University of the Western Cape. She holds a South African Research Chair in Health Systems Governance and receives funding from the South African Medical Research Council and the South African National Research Foundation. </span></em></p>Top-down reforms like those proposed in the NHI Bill need to be complemented by a bottom-up process of health system strengthening.Helen Schneider, Professor, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219922019-08-19T08:11:39Z2019-08-19T08:11:39ZWhy South Africa’s plans for universal healthcare are pie in the sky<figure><img src="https://images.theconversation.com/files/288366/original/file-20190816-192219-jswkjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa has a skewed healthcare system with an under-funded public sector and an expensive private sector.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Performance in South Africa’s two tier health system – the public and the private – has been worsening for some time. Politicians have attempted to attribute the decline in the public sector to a myriad of ills, none of their making. These include migrants; insufficient funds; insufficient staff; medical schemes; lawyers suing them for medical negligence; the existence of two tiers and even the middle class. </p>
<p>However, the real reasons place the blame firmly at their door. They are also largely responsible for the problems in the private sector. </p>
<p>In the face of these manifest failures, and to address the weaknesses in South Africa’s universal health coverage framework, the government has proposed an overtly political way forward – the <a href="http://www.health.gov.za/index.php/nhi">National Health Insurance Fund</a> (NHI). </p>
<p>Through this proposal the framers seek to collapse both the public and private systems into a single organisation. The proposers have done little more than outline enabling legislation for a new state-owned enterprise. It remains a mystery as to what this proposal has to do with the system-wide crises in the public sector, or the market failures in the private sector. </p>
<h2>Public health care failures</h2>
<p>Institutionalised patronage within provincial and national government has destroyed the capabilities of public health organisations – both national and provincial.</p>
<p>The country’s Health Ombudsman has also stated that the <a href="https://www.dailymaverick.co.za/article/2018-06-06-healthcare-rsa-is-still-afloat-maintains-minister-aaron-motsoaledi-while-it-sinks-around-him/">public health system is in a state of crisis</a>. And the Auditor General last year bluntly pointed out the country’s health services are in crisis.</p>
<p>This view is widely shared by civil society groups working in the health sector. </p>
<p>Evidence of the crisis can be seen in the mounting contingent liabilities for medico legal claims due to admitted medical negligence. These are now adding up to <a href="https://www.medicalbrief.co.za/archives/provincial-health-services-risk-r80-4bn-medical-negligence-claims/">more than a third</a> of the national health budget and growing.</p>
<p>A close look at the cases points to major failures in the system. For example, the bulk of claims are related to cerebral palsy cases. This is because sub-standard maternity services are being provided to mothers in the public health services. This has led to avoidable brain damage to children at birth.</p>
<p>These failures are matched by maternal mortality ratios at public facilities. The numbers are staggering, and place South Africa as an outlier for a country of its level of development. In 2017 the maternal mortality ratio in South Africa’s public sector was 135 deaths for every <a href="https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/">100,000 live births</a> in comparison to a benchmark for <a href="https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/">peer countries of around 42</a>. </p>
<p>The cerebral palsy cases as well as the maternal deaths are indicative of institutionalised mismanagement resulting from system-wide governance failures. </p>
<p>The picture isn’t universally bad. Public health services have been maintained in the Western Cape where irregular expenditure is much lower than in the country’s other eight provinces. The Western Cape’s lower maternal mortality ratio and almost non-existent medico legal cases are also testament to a much more efficiently run system which includes stronger governance regimes.</p>
<h2>Private sector failures</h2>
<p>South Africa has very high private health care costs, putting it out of reach for most people in the country.</p>
<p>The high costs have been a major point of contention for decades. In a bid to address the issue the country’s Competition Commission launched a health market inquiry five years ago. Its report, released earlier this year, highlighted a number of major market failures. These included a lack of transparency in the way health policies are sold, as well as a lack of competition between private health care providers.</p>
<p>The <a href="http://www.compcom.co.za/wp-content/uploads/2018/07/Health-Market-Inquiry-1.pdf">health market inquiry</a> has made a series of recommendations to fix the problems.</p>
<p>The former Minister of Health <a href="http://www.compcom.co.za/wp-content/uploads/2014/09/Speech-by-Dr-A-Motsoaledi-Minister-of-Health-to-the-Competition-Law-Conference-06-07-September-2012.pdf">sought to blame</a> the failures of the public health sector on the high costs of the private sector. But no evidence has been marshalled to demonstrate how this could rationally occur. </p>
<p>As the inquiry pointed out, market failures have resulted in higher costs for medical schemes members. And it blames the government for these market failures, pointing out that they can only be addressed by coherent and well governed government regulation. </p>
<p>The question is whether the government will listen to the health market inquiry. </p>
<h2>Universal healthcare</h2>
<p>The planned NHI in South Africa has no equivalent in any setting in the world. It’s deeply flawed on a number of fronts.</p>
<p>Firstly, in other countries systems of universal health coverage seek to cover people and groups who have inadequate healthcare coverage. But the public scheme South Africa is proposing goes much further than this. It’s designed to include people who already have cover through their own private contributions.</p>
<p>Secondly, it’s unaffordable. The proposal envisages raising tax revenue upward of 3% of Gross Domestic Product to cover medical scheme members through a public scheme. This would be equivalent to a 31% increase in personal income tax or a 63% increase in corporate taxes. </p>
<p>Thirdly, the legislation and supporting policy framework is short of any meaningful content. There have been no institutional or financial feasibility studies done. This is despite the fact that the NHI has been on the policy agenda for the past 10 years. </p>
<p>Fourthly, the department of health has shown that it’s incapable of coping with the current health system. It would therefore clearly not be able to take on something as complex as what’s envisaged.</p>
<p>Fifthly, the only analysis on the proposed NHI is from a failed set of <a href="https://www.businesslive.co.za/bd/national/2019-07-28-nhi-pilot-projects-reveal-deep-problems/">pilot projects</a>. The government’s own <a href="https://www.businesslive.co.za/bd/national/2019-07-28-nhi-pilot-projects-reveal-deep-problems/">evaluations</a> of these pilots provide no evidence for the proposed framework. </p>
<p>And lastly, a particularly fatal aspect of the proposed NHI is that it fails to address a model that’s allowed patronage to flourish and that has served South Africa so poorly. At the heart of the problem is the fact that the proposed new Fund would give the Minister of Health full discretion over all senior appointments. He would also be able to ensure political control over procurement of R450 billion in services and the accreditation of all public and private health establishments </p>
<p>The only conclusion that can be drawn from this state of affairs is that the NHI proposals are yet another symptom of the health crisis. Only a failing health department could generate a proposal like this and take it seriously – let alone expect everyone else to join them in their fantasy.</p>
<h2>So, what should happen?</h2>
<p>The reforms required to put South Africa’s health system on a better footing have been glaringly obvious for some time. </p>
<p>The public health system can only be turned around by a combination of governance reforms and decentralisation. This requires the implementation of supervisory structures, such as boards for hospitals, district authorities and statutory councils that are insulated from political appointments and interference. Politicians should be entirely separated from the operational aspects of health service delivery. </p>
<p>For its part, the private sector requires the implementation of the health market inquiry recommendations. Some of these include setting up a pricing regulator to manage annual price negotiations for hospitals and doctors and the establishment of an information regulator to bring quality of care information on private and public health services to the surface. </p>
<p>What South Africans don’t need is another five years of pretence that this team can create a brand new health system out of the ashes of the two existing systems. Unfortunately all we can be certain of are the ashes.</p><img src="https://counter.theconversation.com/content/121992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex van den Heever is affiliated with: the Helen Suzman Foundation as an unremunerated Fellow; and was a lead economist on the Health Market Inquiry until the end of 2017.</span></em></p>South Africa’s planned NHI has no equivalent in any setting in the world. It’s deeply flawed on a number of fronts.Alex van den Heever, Chair of Social Security Systems Administration and Management Studies, Adjunct Professor in the School of Governance, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1211442019-07-31T11:40:52Z2019-07-31T11:40:52ZMigration and health: what southern Africa needs to do to plug the gaps<figure><img src="https://images.theconversation.com/files/286437/original/file-20190731-186797-5rimkj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>A global commission <a href="https://www.migrationandhealth.org/">on health and migration</a> has released its report on how health care systems fail migrants. The aim is to provide the basis for evidence-based approaches to policy. The <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32114-7/fulltext">report</a> calls on civil society, academics, and policy makers to maximise the benefits and reduce the costs of migration on health. Ina Skosana asked three of the commissioners to explain what the report found on the challenges facing countries in southern Africa.</em></p>
<p><strong>What do we know about migration and health in South Africa and regionally? Why is there a concern?</strong></p>
<p>Both internal and cross-border migrants play a crucial role in sustaining household livelihoods and bolstering the South African economy. The concern is two-fold. The first is to strengthen health systems to serve both host populations and internal migrants most effectively. The second is to ensure a public health system that is capable – despite resource constraints – of responding humanely and effectively to cross-border migrants. </p>
<p>But, in reality, we know far less than we should to design effective health systems. This is surprising since the South African mining economy – and to a degree, regional economies – rested for decades on a web of coercive labour legislation designed to ensure the supply of low-wage migrant workers. Levels of temporary (often labour) migration remain as high as they were before South Africa become a democracy in 1994. </p>
<p>The profile of internal labour migrants is changing. The majority are men. But growing numbers of younger women are migrating to join the labour force, many leaving young children in the care of family members. </p>
<p><strong>Are health systems prepared to deal with the movement of people within and across borders?</strong></p>
<p>As the commission report explains, health systems are generally structured around nation-states. This means that migration, especially mobility across national borders, can lead to challenges. For one thing, access is critical. Aspects of access include:</p>
<ul>
<li><p>Patient engagement. This covers the social and cultural preparedness of public health systems to serve migrants and families, whether internal or cross-border. Practitioners’ sensitivity to the beliefs and practices of others shouldn’t be assumed. It can be learned. Patient engagement is thus closely tied to:</p></li>
<li><p>Clinical competence. Clinicians are trained to provide care to all patients, irrespective of background, who present to their clinic, ward or surgery. But
cross-cultural awareness is vital to effective history taking and clinical examination. This is true whether care is provided by a nurse, doctor or allied professional. Similarly, treatment prescription, adherence to medication and suggesting changes in behaviour to lower personal risk depend on quality communication between practitioner and patient.</p></li>
<li><p>System preparedness. A major challenge to health systems is continuity of care. This holds for both mobile and settled populations especially when – as increasingly happens – patients present with chronic or long-term conditions. Examples include those affecting the vascular system (like strokes), the metabolic system (notably diabetes), infections (TB) or mental ill-health (such as depression). </p></li>
</ul>
<p>In South Africa, the lack of a common identity number to support care provision means that internal migrants – a substantial proportion of the adult population – tend to access episodic rather than continuous care. This has serious consequences for the clinical management of conditions like hypertension, diabetes or HIV/AIDS.</p>
<p>Key competencies are also needed for care of special groups like adolescents and older people. </p>
<p>Altogether, this is a major challenge for South Africa’s health and medical training institutions. The upside is that, if addressed effectively, both host and migrant populations will benefit. </p>
<p><strong>Are there countries that are worse or better off? And why?</strong></p>
<p>Good examples of migrant-inclusive health systems exist. But there’s no mechanism to systematically review practices and outcomes. This makes it difficult to compare country experiences and recommend models. The World Health Organisation and World Bank have <a href="https://apps.who.int/iris/bitstream/handle/10665/174536/9789241564977_eng.pdf;jsessionid=70D75BA9866B150F75A9C2CDF8270B90?sequence=1">implemented a global system</a> to track progress in universal health coverage. But coverage for migrants, refugees and other mobile populations is not part of that process. </p>
<p>Countries that have ensured migrant health is high on the public health agenda include:</p>
<ul>
<li><p><a href="https://www.asylumineurope.org/reports/country/italy/reception-conditions/health-care">Italy</a>. Despite the profoundly divisive political debate underway, the right to health for migrants is enshrined in Italy’s Constitution. Irregular migrants can access essential health services anonymously and free of charge. They are also entitled to preventive care, including maternity and chronic conditions. Health promotion campaigns, interpreters and cultural mediators are widely used to overcome barriers.</p></li>
<li><p>Sri Lanka. The country launched an inclusive <a href="http://srilanka.iom.int/iom/?q=pbn/national-migration-health-policy-launched-sri-lanka">National Migration Health Policy</a> in 2013. Restrictions that might limit access by non-citizens have been removed. Community health services that are provided free to Sri Lankans are also available to migrants and refugees, including immunisations, antenatal and emergency care. Sri Lanka has promoted the migration and health agenda regionally, globally and at the highest political level.</p></li>
<li><p><a href="https://thailand.iom.int/sites/default/files/document/publications/Thailand%20Report%202019_22012019_LowRes.pdf">Thailand</a>. Undocumented migrants can buy low-cost subsidised health insurance once they’re registered with government under the One Stop Service Policy. Using the Health Insurance Card Scheme, migrants can access free care in public hospitals; similarly, the uninsured can access services but at a cost.</p></li>
</ul>
<p><strong>How will the Commission’s findings contribute to the improvement of the situation faced by migrants?</strong></p>
<p>First, we expect the findings to focus attention – at national level, in the sustainable development community and among regional and international bodies such as the UN – on migration health as a public health priority, an issue as relevant to internal migrants as it is to cross-border migration.</p>
<p>Second, the Commission documents clearly that those who migrate tend to be healthier than their resident counterparts and, in general, contribute meaningfully to local economic development, a priority for South Africa where jobs and employment are critical concerns.</p>
<p>Third, where cross-border or international migrants have experienced great hardship, an effective response by health care systems is called for. This will also benefit host communities, and may traverse the range of conditions from infections to mental health.</p>
<p>Fourth, a migrant-prepared health care system is likely to be more effective for all patients and conditions. This will boost public sector care for all users in South Africa. Quality of care will benefit from extending rather than restricting engagement with migrant communities.</p>
<p>Fifth, there are complexities and trade-offs given human resource, health system and funding constraints. But it’s better to have these foster concerted efforts by public sector leadership and stakeholders to optimise care in the spirit of universal health coverage, than to exclude communities with palpable needs.</p>
<p><em>Nyovani Madise, director of research and development policy at the African Institute for Development Policy, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/121144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Tollman receives funding from the SAMRC, Dept of Science and Technology SA, National Institutes of Health USA, UK Medical Research Council, and (previously) Wellcome Trust UK. He is affiliated with the SA Population Research Infrastructure Network (SAPRIN) and INDEPTH Network of population-based health and socio-demographic information systems.</span></em></p><p class="fine-print"><em><span>Miriam Orcutt is the coordinator of the UCL-LANCET commission on health and migration. She also sits on the steering committee of the Syria public health network
</span></em></p><p class="fine-print"><em><span>Davide Mosca does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health systems are generally structured around nation-states. Migration, especially across national borders, therefore leads to challenges.Stephen Tollman, Director: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the WitwatersrandDavide Mosca, Honorary Associate Professor, UCLMiriam Orcutt, Migration and Health Research Associate, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1209252019-07-29T12:43:20Z2019-07-29T12:43:20ZMigrants must be part of South Africa’s universal health plan. Here’s why<figure><img src="https://images.theconversation.com/files/285841/original/file-20190726-43114-1290yoa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">International migrants often struggle to access healthcare. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Seven years ago the United Nations (UN) endorsed <a href="https://www.uhc2030.org/un-hlm-2019/a-history-of-universal-health-coverage-in-the-un/">universal health coverage</a> as key to sustainable development and global security. </p>
<p>The South African government has taken up the challenge. President Cyril Ramaphosa has <a href="https://www.businessinsider.co.za/cyril-ramaphosa-state-of-the-nation-adddress-sona-national-assembly-job-eskom-violent-crime-2019-6">underscored</a> the government’s commitment to introducing South Africa’s verion of universal health coverage. He said that the revision of a new law to implement National Health Insurance (NHI) was at an “advanced” stage. The aim is to ensure that all in the country have access quality healthcare, without prejudice or financial detriment. </p>
<p>The country still has a long way to go. A <a href="https://www.businesslive.co.za/bd/national/2019-07-28-nhi-pilot-projects-reveal-deep-problems/">recent report</a> on the 11 districts where the NHI was piloted found that the projects were plagued with problems. Medicine stock levels in clinics and hospitals couldn’t be monitored because there was no internet connectivity and vacant posts couldn’t be filled because posts had been frozen. Teams of medical specialists were expensive, overworked and failed to achieve targets of improving infant health. </p>
<p>According to the <a href="https://www.who.int/whr/2010/10_summary_en.pdf?ua=1">World Health Organisation</a> (WHO) three features must be present for universal health coverage to be achieved. </p>
<p>The first is that the services provided must be extensive and include health promotion, prevention, treatment, rehabilitation as well as palliative care. The second is coverage, which includes some form of financial risk protection. </p>
<p>The third feature is universality. This means that everyone within the borders of a <a href="https://www.who.int/whr/2010/en/">country</a> must be included. The WHO has emphasised that this means international migrants – irrespective of legal or migration status – <a href="https://www.who.int/migrants/about/mh-qhc/en/">must be included</a> too. And that they must be afforded access to a minimum of <a href="https://gh.bmj.com/content/bmjgh/3/5/e001031.full.pdf">essential and affordable healthcare services</a>.</p>
<p>A glaring weakness in South Africa’s proposed NHI is care for migrants. Rather than addressing its aims of ensuring equitable access to quality healthcare for all, the NHI – in its current form – legitimises the persistent exclusion of international migrants from South Africa’s public health system.</p>
<h2>Migrants in South Africa</h2>
<p>South Africa is home to approximately <a href="https://www.sahrc.org.za/index.php/sahrc-media/opinion-pieces/item/1422-ensuring-health-and-access-to-health-care-for-migrants-a-right-and-good-public-health-practice">2 million international migrants</a>, around <a href="http://www.statssa.gov.za/census/census_2011/census_products/Census_2011_Census_in_brief.pdf">4% of the total population in 2011</a>. Most are from elsewhere in the Southern African Development Community region and have moved to South Africa in search of more work opportunities. </p>
<p>But migrants living in South Africa struggle to access public services – <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/">including healthcare</a>. This is the case even though they are <a href="https://www.sahrc.org.za/index.php/sahrc-media/opinion-pieces/item/1422-ensuring-health-and-access-to-health-care-for-migrants-a-right-and-good-public-health-practice">legally entitled to</a> these services. <a href="https://www.dailymaverick.co.za/article/2018-03-29-medical-xenophobia-public-hospitals-deny-migrants-health-care-services-sahrc/">Reports</a> of people being turned away from government health facilities due to immigration status, nationality or language spoken are widespread.</p>
<p>Migrant women in particular have experienced multiple challenges when attempting to access antenatal care, including at the time of <a href="https://www.dailymaverick.co.za/article/2015-09-06-health-e-news-mothers-and-children-are-collateral-damage-in-immigration-clampdown/">delivery</a>. Some facilities have even refused to allow women to take their newborns home if they couldn’t pay for <a href="https://www.health-e.org.za/2015/07/15/hospitals-hold-babies-for-randsom-say-mothers">services</a>. </p>
<p><a href="http://www.samj.org.za/index.php/samj/article/view/8569/6230">Looking after the health of migrants</a> is good for economic and social development. Excluding international migrants from the public health care system can result in a population wide risk. Denying a part of the population access to preventative and curative health services, undermines efforts to control infectious diseases – including HIV and tuberculosis. This has particularly worrisome implications for <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1002/jia2.25137">current HIV treatment as prevention interventions</a>.</p>
<p>The country’s existing law on migrant access to healthcare services is quite clear. It’s <a href="https://genderjustice.org.za/card/refugees-migrants-and-health-care-in-south-africa-explained/what-does-the-law-say-about-migrants-and-refugees-accessing-healthcare-in-south-africa/">unlawful</a> under the country’s Constitution to deny anyone, including migrants, access to healthcare services. </p>
<p>The question, then, is will the NHI build on these provisions and make the situation better for international migrants? Or will the NHI be in contravention of South Africa’s constitutional commitment to the rights and protection of all who live in it? </p>
<h2>The gaps</h2>
<p>How can the South African government make sure that international migrants don’t get left behind in efforts towards universal health coverage? </p>
<p>The answer is two-fold. First, South Africa needs to adopt a <a href="https://www.hst.org.za/publications/South%20African%20Health%20Reviews/9_Towards%20a%20migration%20aware%20health%20system%20in%20South%20Africa_a%20strategic%20opportunity%20to%20address%20health%20inequity.pdf">“migration-aware” approach to the health system</a> and ensure that this is included in the NHI bill. </p>
<p>Second, the country needs to learn from <a href="https://gh.bmj.com/content/bmjgh/3/5/e001031.full.pdf">Thailand</a>. As another low- and middle-income country, Thailand’s successful approach to universal health coverage that includes cover for undocumented migrants, provides important lessons. In Thailand, health insurance for documented and undocumented migrants has been introduced, and the provision of <a href="https://www.who.int/bulletin/volumes/95/2/16-179606/en/">migrant-friendly services</a> has been strengthened.</p>
<p>To achieve universal health coverage, there needs to be concerted effort across all of society. Political will and effective policies are paramount but it’s equally important to provide correct information and society wide education. </p>
<p>This will be difficult to implement in South Africa given the hostility international migrants face from community members and healthcare providers. Migrants are regularly <a href="https://africacheck.org/2019/01/29/analysis-are-south-africas-public-hospitals-overburdened-by-foreign-patients/">blamed for a range of ills</a> in the country, including unemployment, disease and poverty.</p>
<p>South Africa’s newly appointed Minister of Health, Zweli Mkhize, recently promised a <a href="https://www.dailymaverick.co.za/article/2019-07-15-could-a-national-health-insurance-fund-be-just-months-away/">social compact on health</a>. But it remains to be seen if this will reflect the importance of engaging with international migration as the government grapples with finalising its’ plans for universal health coverage.</p><img src="https://counter.theconversation.com/content/120925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jo Vearey receives funding from the Wellcome Trust.</span></em></p><p class="fine-print"><em><span>Sasha Frade does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Excluding international migrants from the public health care system can result in a population wide risk.Sasha Frade, Sasha Frade is a PhD student, as well as an Associate Lecturer, in the Demography and Population Studies, University of the WitwatersrandJo Vearey, Associate Professor, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/994042018-07-05T15:38:51Z2018-07-05T15:38:51ZNew healthcare plan promises to overhaul South Africa’s massively skewed system<figure><img src="https://images.theconversation.com/files/226237/original/file-20180705-122253-srcx81.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The proposed National Health Insurance aims to provide health care for all South Africans.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/rafiqs/14869270980/in/photostream/">Flickr/Rafiq Sarlie</a></span></figcaption></figure><p>Since 1994 South Africa has invested substantial resources in health care services. As a result, it’s has made significant health gains. For example, nearly 4 million people get HIV treatment and mother-to-child transmission has nearly been eliminated. </p>
<p>Service delivery has also been significantly expanded to more than 4000 health facilities. And there’s been a large increase in the number of health care professionals. </p>
<p>But health care needs aren’t static. For example, non-communicable diseases like diabetes and hypertension are now <a href="http://www.who.int/nmh/publications/ncd_report_full_en.pdf">responsible for more deaths</a> than HIV and TB combined. And in some instances successes have created challenges. For example, the expansion of HIV treatment has meant that there’s now a large cohort of chronic patients requiring ongoing care. In addition, the reality of a largely youthful population requires interventions so that health gains aren’t lost. </p>
<p>Health services in South Africa are delivered by a large public health system as well as very sophisticated (and profitable) private health providers. Funding in the public sector has declined progressively for the past six years. The result is that public health services are under increasing strain and unable to deliver adequate care to poor people, particularly those living in rural areas.</p>
<p>The private sector has also been under pressure. This has led to price hikes, making many medical aid schemes unaffordable. Membership numbers aren’t growing, partly due to the country’s very high unemployment levels – medical aid membership is linked to formal employment. The result has been even more pressure on the public sector.</p>
<p>Reform is clearly needed. All that’s in dispute is what it should look like. </p>
<p>The release of the <a href="https://www.gov.za/sites/default/files/41725_gon635s.pdf">National Health Insurance bill</a> is the government’s answer to the problem. The central plank of the plan is a National Health Insurance Fund that will buy health care services from health professionals and deliver through both public and private facilities. </p>
<p>The bill has been met with a raft of criticism, included funding concerns and the fact that it won’t fix the collapsing public system. But I believe that more fundamental questions need to be asked: does it address the goal of delivering universal access to health care for all South Africans? And can it do it in a way that doesn’t incur catastrophic expenditure?</p>
<p>The answer to these two questions I believe is yes.</p>
<h2>Breaking with the past</h2>
<p>Despite the bill’s flaws, it has two great merits. </p>
<p>The first is that it addresses the country’s current approach to health care where the quality and type of services people receive is informed more by their socio-economic status rather than their need for care. Instead, it adopts a population-based approach. This means that budgets would be allocated based on how many people live in an area and what their disease profiles and health care needs were. </p>
<p>If properly implemented, this approach would result in lower health costs over time because diseases like diabetes and hypertension could be detected earlier and health conditions would be managed more efficiently. </p>
<p>It’s second major merit is that it looks at health services through three vantage points: </p>
<ul>
<li><p>what services are needed, </p></li>
<li><p>who needs them, and</p></li>
<li><p>who will deliver them. </p></li>
</ul>
<p>This means that it separates who procures the health services from those who will deliver them. </p>
<h2>A change of focus</h2>
<p>The bill also promises to transform the way money is spent on health care because it’s premised on separating the procurement and the provision of health care services. This has two benefits. </p>
<p>Firstly, it will mean that health budgets are allocated more efficiently based on health needs rather than purely on use. Secondly it can potentially unlock significant savings through strategic procurement.</p>
<p>The country spends just under a half a trillion rand on public and private health care combined. But the funds aren’t allocated and spent efficiently.</p>
<p>For example, nearly half of the money that goes to primary care services is being spent on managing chronic HIV patients. While spending to maintain access to HIV care is important, funds need to allocated to dealing non-communicable diseases which are becoming an increasingly significant public health threat. </p>
<p>The private sector services has its own set of problems. Chief among them is that it’s approach is curative – that is treating people in hospitals – rather than preventative. </p>
<p>The bill envisages that primary health care facilities will become the main point of entry for all patients. </p>
<h2>Greater equity</h2>
<p>There’s another benefit to the proposed scheme: a more equitable spread of services. </p>
<p>There are currently over 4000 public health facilities that service over 80% of the population’s primary health care needs. In the private sector there are close to 5000 general practitioners who service the health care needs of only 16% of the population. And most are concentrated in urban areas.</p>
<p>People in rural areas are therefore largely dependent on an ailing under resourced public sector. </p>
<p>At the centre of the proposed universal health care system is the promise that everyone will have access to health care where they need it without incurring vast expenses. </p>
<p>By consolidating the health market, the bill opens the door to more equitably allocate resources. </p>
<p>If it’s successfully implemented, this approach offers a real opportunity to address the country’s grossly unequal access to health services.</p>
<h2>A marathon, not a sprint</h2>
<p>The national health insurance should be seen as an opportunity to bring about much needed health care reform in South Africa. But South Africans need to wake up to the fact that implementing this highly complex new system will be more like running a marathon rather than a sprint.</p>
<p>The final implementation of the national health insurance is still a long way off – another two phases are planned. And the release of the bill is also only the first legislative step. Over the next four years 12 additional pieces of legislation are expected to be introduced. </p>
<p>South Africans should be prepared to be patient.</p><img src="https://counter.theconversation.com/content/99404/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Russell Rensburg does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>South Africa’s health care needs to be reformed so that everyone has access regardless of affordability or location.Russell Rensburg, Programme Manager Health Systems and Policy, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/990282018-06-28T14:04:52Z2018-06-28T14:04:52ZSouth Africa’s universal health care plan falls short of fixing an ailing system<figure><img src="https://images.theconversation.com/files/225142/original/file-20180627-112604-12nm7oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A patient collects her medication at a clinic in Khayelitsha, South Africa.</span> <span class="attribution"><span class="source">MSF/Sydelle WIllow Smith</span></span></figcaption></figure><p>South Africa’s Health Minister Aaron Motsoaledi has finally gazetted the bill detailing an ambitious plan to roll out universal health care in the country through a <a href="https://www.gov.za/sites/default/files/41725_gon635s.pdf">National Health Insurance</a>. </p>
<p>The bill responds to a global campaign spearheaded by the <a href="http://www.who.int/universal_health_coverage/en/">World Health Organisation</a> and linked to the <a href="http://indicators.report/targets/3-8/">UN’s sustainable development goals</a> to make sure that no-one is left behind in accessing quality health care. </p>
<p>There’s no dispute that South Africa’s health care system needs major reforms. There are considerable inequities in health care between <a href="https://theconversation.com/a-human-step-to-equal-health-care-in-south-africas-rural-hospitals-41648">urban and rural areas</a>; between public and private <a href="https://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=3752&context=honors_theses">health sectors</a> and between primary health care and hospital care. And the country has a complex disease burden with heavy caseloads of <a href="https://theconversation.com/scientists-are-combining-forces-to-tackle-the-deadly-duo-of-tb-and-hiv-62378">HIV, TB</a> and <a href="https://theconversation.com/south-africas-sugar-tax-a-bold-move-and-the-right-thing-to-do-72010">non-communicable diseases</a>. </p>
<p>South Africa has poor health outcomes compared to other middle-income countries such as Brazil with similar health spending as a percentage of GDP. It spends more than R300 billion – or around 8.5% of its gross domestic product – on health care. But half is spent in the private sector catering for people who are well off while the remaining 84% of the population, which carries a far greater burden of disease, depends on the under-resourced public sector. </p>
<p>The health system performs poorly due to a combination of factors including the poor management of public sector hospitals, health professional shortages (particularly in rural areas), low productivity levels among staff, escalating private health care costs and poor quality of care. </p>
<p>But in its current form the proposed legislation won’t be a silver bullet. There are still too many inconsistencies and unanswered questions for it to be the final roadmap to universal health care in the country. </p>
<p>For example, the bill focuses on curative services, missing an opportunity to take a public health approach that focuses on disease prevention, health promotion and health protection. In addition, it doesn’t address the relationship between the public and private health sectors which is seen as a major impediment to fundamental change. </p>
<h2>How it will work</h2>
<p>The bill is informed by a vision of ensuring equitable access to quality health services, regardless of a person’s ability to pay or whether they live in an urban or rural area. The proposed insurance fund envisages the consolidation of public and private revenue into one funding pool. </p>
<p>The idea is to enable a more equitable system through, for example, cross-subsidisation and ensuring that essential services are made available. </p>
<p>All people will have to register as users of the fund at an accredited health care establishment or facility (whether public or private). And the fund will decide on the health benefits that the facilities will have to provide. This will depend on what resources the facility has. People will be able to pay for complementary health service benefits not covered by the fund. </p>
<p>To be paid, health care providers, such as general practitioners and hospitals, will have to register with the fund. They will have to claim for each patient that they treat and will have to keep a record of diagnosis, treatment and length of stay.</p>
<h2>Governance</h2>
<p>The structure that’s been proposed for the fund is raising concerns on two fronts: it appears unnecessarily cumbersome and there’s a lack of clarity on lines of command.</p>
<p>The bill makes provision for the fund to establish an independent board that will report to South Africa’s Parliament. But it makes no mention of how the board will engage with the health minister (political custodian) and public servants in the health department. Nor does it explain how the performance of the fund will be evaluated. </p>
<p>The bill also introduces two additional management layers: district health management offices and contracting units for primary health care. These units will provide primary health care services in specific areas. It includes a district hospital, clinics and community health centres as well as ward-based outreach teams and private primary care service providers. They will be contracted by the fund. </p>
<p>National, provincial, and municipal health departments will still exist. </p>
<p>But the bill fails to explain the relationship between the district health management offices and the contracting units and how they will engage with the national, provincial and municipal health departments. </p>
<p>Given that there are ten health departments operating in South Africa – a national department and one in each of the country’s nine provinces – these additional offices and units could result in a more cumbersome bureaucracy. This could lead to more inefficiency and greater opportunity for corruption. </p>
<p>The new structure will also change the responsibilities of provincial health departments. Some of the proposals don’t make sense such as the idea that municipalities should take control of managing communicable diseases. Ideally this should be a national function, given the serious threat that is posed by some infectious diseases. </p>
<h2>Many questions</h2>
<p>Other parts of the bill are also unclear. These range from financing to how complaints will be managed.</p>
<p><strong>Health financing and management:</strong> The bill doesn’t explain what the tax implications of the national health insurance will be for citizens. It also doesn’t set out the mechanisms that will be put in place to strengthen financial planning and monitoring systems, particularly in the public health sector. These are very important given current <a href="https://www.news24.com/Archives/City-Press/R12bn-unaccounted-for-in-Gauteng-health-department-20150429">chronic overspending</a>, inadequate financial management and corruption and lack of accountability in many <a href="https://www.thesouthafrican.com/public-health-fail-report-reveals-that-sas-health-facilities-are-in-crisis/">provincial health departments</a>.</p>
<p><strong>Service provision:</strong> The bill says everyone is entitled to a comprehensive package of services at all levels of health care. But it doesn’t spell out what these packages will include. Given budgetary constraints, it’s obvious that there will inevitably have to be trade-offs and difficult choices. </p>
<p><strong>The health workforce:</strong> South Africa doesn’t have a comprehensive health workforce strategy with detailed norms and standards. This remains the Achilles heel of health sector reform in the country. The lack of detail remains a serious omission in the bill. </p>
<p><strong>Complaints mechanisms:</strong> The bill introduces a new separate complaints directorate – the investigating unit. But it’s unclear whether this will be the first level of complaints or whether it’s a duplication of the complaints directorate in the existing Office of Health Standards Compliance. There also isn’t clarity about where the Health Ombud fits in. </p>
<p>Ensuring that South Africa has a quality affordable health care system is critical. And the bill presents an important opportunity to think systematically about what needs to be done to fix the current health system. But there is still a long way to go.</p><img src="https://counter.theconversation.com/content/99028/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laetitia Rispel receives funding from the National Research Foundation. </span></em></p>The bill to provide universal health care in South Africa is not the silver bullet for the challenges in the health sector.Laetitia Rispel, Professor of Public Health and DST/NRF Research Chair., University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/886822017-12-11T11:51:15Z2017-12-11T11:51:15ZThere’s more to evidence-based policies than data: why it matters for healthcare<figure><img src="https://images.theconversation.com/files/197968/original/file-20171206-926-sjv2uv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse weighs a baby at a clinic in Accra, Ghana. </span> <span class="attribution"><span class="source">Kate Holt/MCSP</span></span></figcaption></figure><p>A critical part of reaching the <a href="https://sustainabledevelopment.un.org/sdg3">United Nation’s Sustainable Development Goals</a> in 13 years’ time is to ensure that everyone can access equitable and affordable healthcare – more commonly known as universal health coverage.</p>
<p>The idea of “Health for All” was first put on the global agenda in 1978 at the <a href="http://www.who.int/publications/almaata_declaration_en.pdf">International Conference on Primary Health Care at Alma Ata</a>. It called for primary health care to be introduced as the first step to making sure that everyone has access to health care.</p>
<p>Since then, primary healthcare has been a feature of health systems across the world. But 40 years later, universal health coverage remains a challenge. About 400 million people <a href="http://www.who.int/mediacentre/factsheets/fs395/en/">do not have access to one or more essential health services</a>. This is because they are too far, too expensive, of low quality or non-responsive to patient needs. </p>
<p>The big question is: how can countries strengthen their health systems to deliver accessible, affordable and equitable care when they are often under-financed and governed in complex ways? </p>
<p>One answer lies in governments developing policies and programmes that are informed by evidence of what works or doesn’t. This should include what we would call “traditional data”, but should also include a broader definition of evidence. This would mean including, for example, information from citizens and stakeholders as well as programme evaluations. In this way, policies can be made more relevant for the people they affect. </p>
<p>Globally there is an increasing appreciation for this sort of policymaking that relies of a broader definition of evidence. Countries such as South Africa, Ghana and Thailand provide good examples.</p>
<h2>What is evidence?</h2>
<p>Using evidence to inform the development of health care has grown out of the use of science to choose the best decisions. It is based on data being collected in a methodical way. This approach is useful but it can’t always be neatly applied to policymaking. There are several reasons for this.</p>
<p>The first is that there are many different types of evidence. Evidence is more than data, even though the terms are often used to mean the same thing. For example, there is statistical and administrative data, research evidence, citizen and stakeholder information as well as programme evaluations. </p>
<p>The challenge is that some of these are valued more than others. More often than not, statistical data is more valued in policymaking. But both researchers and policymakers must acknowledge that for policies to be sound and comprehensive, different phases of policymaking process would require different types of evidence. </p>
<p>Secondly, data-as-evidence is only one input into policymaking. Policymakers face a long list of pressures they must respond to, including time, resources, political obligations and unplanned events.</p>
<p>Researchers may push technically excellent solutions designed in research environments. But policymakers may have other priorities in mind: are the solutions being put to them <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12475/pdf">practical and affordable?</a> Policymakers also face the limitations of having to balance various constituents while <a href="https://www.nature.com/articles/s41599-017-0046-8">straddling the constraints of the bureaucracies they work in</a>. </p>
<p>Researchers must recognise that policymakers themselves are a source of evidence of what works or doesn’t. They are able to draw on their own experiences, those of their constituents, history and their contextual knowledge of the terrain. </p>
<p>What this boils down to is that for policies that are based on evidence to be effective, fewer ‘push/pull’ models of evidence need to be used. Instead the models where evidence is jointly fashioned should be employed.</p>
<p>This means that policymakers, researchers and other key actors (like health managers or communities) must come together as soon as a problem is identified. They must first understand each other’s ideas of evidence and come to a joint conclusion of what evidence would be appropriate for the solution. </p>
<p>In South Africa, for example, <a href="https://www.odi.org/publications/10603-evidence-and-policy-south-africa-s-department-environmental-affairs">the Department of Environmental Affairs</a> has developed a four-phase process to policymaking. In the first phase, researchers and policymakers come together to set the agenda and agree on the needed solution. Their joint decision is then reviewed before research is undertaken and interpreted together. </p>
<h2>Joint efforts</h2>
<p>Integrating research into government policies and programmes can result in meaningful engagement between policymakers, researchers and other actors. </p>
<p>Increasingly, governments and researchers are partnering in various ways to ensure that research can feed into the policymaking process as results emerge. In this way, policymakers are part of the research design as well as the actual research and its interpretation, – known as embedded research. </p>
<p>Ghana’s <a href="http://www.ghanahealthservice.org/chps/category.php?chpscid=98">community-based Health Planning and Services</a> is a good example. By embedding the research in the Ghana Health Service, what started as a pilot in one part of Northern Ghana became national policy in 2005 to improve primary health care. </p>
<p>As part of scale-up efforts, policymakers, health managers and academic researchers worked hand-in-hand to design studies and analyse routine data to improve the programme. </p>
<p>Today the service is a key part of Ghana’s universal health coverage strategy. And importantly the primarily rural model is being adapted for urban areas. </p>
<h2>The journey to accessible health care</h2>
<p>As the Ghana example shows, when there is collaboration between governments and researchers, good results are achievable. This means focusing on long-term engagement and building a comprehensive view of evidence. </p>
<p>When evidence is better sourced and better understood, it can be deployed more effectively. This means that there should be investment in people who are at the front line of finding solutions and implementing change.</p>
<p>Policymakers, researchers, practitioners and communities need to come together to share their understanding of what evidence means, and how it can be used to strengthen health systems. This will help us chart a course to achieving universal health coverage.</p><img src="https://counter.theconversation.com/content/88682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aku Kwamie does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For healthcare to be accessible, affordable and equal, policies and programmes that promote universal health coverage need to be based on evidence.Aku Kwamie, Health systems researcher, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/791262017-06-29T15:01:33Z2017-06-29T15:01:33ZHow access to knowledge can help universal health coverage become a reality<figure><img src="https://images.theconversation.com/files/175369/original/file-20170623-27888-n157q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Shutterstock</span> </figcaption></figure><p>The World Health Organisation’s Director-General Dr. Tedros Ghebreyesus has set universal health coverage as one of the main priorities for his term. </p>
<p>Universal health coverage is defined by the WHO as free access to promotive, preventive, curative and rehabilitative health services. These have to be of a sufficient quality to be effective but without causing unnecessary financial hardship when paying for the services. </p>
<p>But Ghebreyesus’s goal is a challenging one, especially for low and middle income countries which make up around 84% of the world’s <a href="http://data.worldbank.org/income-level/low-income">population</a>. Yet they only have access to half the <a href="http://data.worldbank.org/indicator/SH.MED.PHYS.ZS">physicians</a> and a quarter of the nurses that high income countries have access to. </p>
<p>Similarly low and middle income countries only <a href="http://data.worldbank.org/indicator/SH.XPD.PCAP">spend</a> around US $266 per capita on health care. In contrast, high income countries spend a whopping US $5 251 per capita.</p>
<p>This means that attaining universal health coverage in poorer settings is challenging to say the least. Large cuts to foreign aid investment from a number of <a href="https://blog.oup.com/2017/05/pandemics-disease-control-science-trump/">high income economies</a> only compound this challenge. </p>
<p>To address this, affected countries need to start thinking smarter, and not simply work harder. Optimising available resources requires local researchers to apply themselves. In other words, these countries need to grow their knowledge economies.</p>
<p>High income countries already have access to significant resources. This is mainly due to their own knowledge economies flourishing. To match this low and middle income countries need to increase the investment in their research activity. This includes increasing the number of institutions and supervisors that support research.</p>
<p>Although low and middle income countries have seen an increase and improvement in all these areas, access to existing knowledge remains poor. Particularly when compared to access in higher income countries.</p>
<h2>The ideal knowledge economy</h2>
<p>A healthy knowledge economy needs:</p>
<ul>
<li><p>investment (funding set aside for generating knowledge), </p></li>
<li><p>people who create research and consume information, </p></li>
<li><p>higher education institutions, and </p></li>
<li><p>reasonable access to knowledge (existing, published research). </p></li>
</ul>
<p>Low and middle income countries <a href="http://uis.unesco.org/apps/visualisations/research-and-development-spending/">invest</a> around a third of what high income countries invest in research. They also have access to around a fifth of the <a href="http://uis.unesco.org/indicator/sti-rd-hr-res">researchers</a> high income countries have access to. To top it off, less than a quarter of the <a href="https://www.timeshighereducation.com/world-university-rankings">Times Higher Education</a> ranked universities are located in low and middle income countries.</p>
<p>Yet of all the cogs that make up the knowledge economy, access to knowledge is likely the easiest to achieve. Although accessible knowledge remains a problem, strides have been made with increased support of open access publication on a global scale. </p>
<h2>How accessible knowledge helps</h2>
<p>Given the growing penetration of the internet into low and middle income countries, information has never been more <a href="http://www.pewglobal.org/2016/02/22/internet-access-growing-worldwide-but-remains-higher-in-advanced-economies/">accessible</a> at any point in history than today. Yet
access to a sizeable and ever growing bulk of health care research remains poor.</p>
<p>Open access publishing has become a strong global movement. Roughly 20% to 50% of all published research is currently freely available online - depending on its year of <a href="https://www.theguardian.com/science/occams-corner/2012/oct/22/inexorable-rise-open-access-scientific-publishing">publication</a>. </p>
<p>Some have remained sceptical of open access publishing. Despite that many funding agencies and higher education institutions now insist on accessible research reporting from their beneficiaries, staff and students.</p>
<p>It’s hard to argue the possibilities if the 2.7 million plus health care publications published within the last three years were freely accessible in low and middle income countries. It would likely confer a tremendous benefit to both health care professionals and patients (or even universal health coverage).</p>
<p>It is important to understand that the purpose of access to knowledge generated in high income countries is not simply to copy it verbatim into lower income settings. The comparative resource restrictions that apply renders direct implementation largely unfeasible. However, accessible knowledge, wherever generated, provides the references needed to generate locally appropriate applications thereof.</p>
<h2>Navigating the challenges</h2>
<p>For many low and middle income countries, open access comes with barriers as a result of infrastructural challenges.</p>
<p>The <a href="http://www.who.int/hinari/about/en/">Hinari</a> programme is an example of this. It has been around since 2002. It’s supported by the World Health Organisation along with a large number of publishers and provides access to a substantial amount of published material for researchers from low and middle income countries. </p>
<p>But during its 15 year existence it has remained <a href="http://www.research4life.org/wp-content/uploads/2014/07/IPL-HINARI-Research4Life-Survey-Analysis-final.pdf">poorly supported</a>. Ironically, for a programme that has existed so long, the main reason for this appears to be poor access.</p>
<p>To solve this problem publishers could easily provide equitable access for low and middle income countries using <a href="https://docs.nexcess.net/article/what-is-geoip.html">geolocation internet protocols</a> in the same way Netflix does. As a video streaming service, Netflix controls the content its users can access based on where they are accessing the service from. If geolocation is now an industry standard for various similar information sharing, internet based services, why not also for publication?</p>
<p>For publishers contributing to Hinari, such a step should be fairly straight forward. Use of <a href="https://docs.nexcess.net/article/what-is-geoip.html">geolocation internet protocols</a> will allow researchers in eligible countries to access to research from participating publishers on any device, anywhere where they have an internet connection. This would include the patient’s bedside - not just the academic library. </p>
<p>Much of the knowledge required to establish the universal health coverage Ghebreyesus wants, already exists. Poor access to this knowledge presents a major barrier to achieving universal health coverage. </p>
<p>To unlock this knowledge for everyone’s benefit, policymakers and publishers need to seriously consider more innovative ways to provide access. Ironically, these solutions probably already exist as well.</p><img src="https://counter.theconversation.com/content/79126/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stevan Bruijns is a senior lecturer with the Division of Emergency Medicine at the University of Cape Town, South Africa, and the editor-in-chief of the African Journal of Emergency Medicine, a fully open access journal.</span></em></p>A critical part of attaining universal health coverage is access to published research.Stevan Bruijns, Senior lecturer in the Division of Emergency Medicine, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.