How can South Africa's healthcare system become more integrated?

May 05, 2017 - reading time 7 mins

By Mia Malan

Director, Mail & Guardian Health Journalism Centre

Mia Malan is the Mail & Guardian’s health editor and the director of the newspaper’s health journalism centre, Bhekisisa. She heads up a team of seven Johannesburg-based reporters and 10 correspondents in African countries other than South Africa. She loves drama, good wine and strong coffee, not necessarily in that order.

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The most common definition of integration is “the organisation and management of health services so that people get the care they need, when they need it, in ways that are user friendly, achieve the desired results and provide value for money."

That says the World Health Organisation in a 2008 technical brief.

What does integration look like?

Imagine walking into a primary healthcare clinic in the rural Eastern Cape where a nurse is able to diagnose complex forms of drug resistant tuberculosis. She uses a small, portable machine that resembles a SodaStream cold drink maker.

With this device the nurse can also measure the amount of virus in the blood of her HIV patients to establish within 90 minutes whether their antiretroviral medication is working. If there’s too much HIV in their blood it means the medicine is no longer effective and that their drug combination might need to be changed.

In addition to this the machine can test if some of the nurse’s patients have dangerous forms of HPV infection, which can lead to cervical cancer.

All the nurse needs to do to perform such life-saving diagnoses is to change the cartridge in the device to the appropriate one, each time she wants to do a new type of PCR (a type of DNA analysis) test. She would need to follow simple instructions on how to enter a patient’s sputum or blood sample in the cartridge.

Previously the nurse had to send samples to a government laboratory in a city four hours away. It would often take weeks for the results to arrive back at the clinic. Sometimes they would get lost in the system and not return at all.

World Health Organisation data show that only seven out of every ten of South Africa’s Tuberculosis (TB) patients are put on treatment and 10% of people with TB are never diagnosed, often because of fragmented services and bad coordination. Or, patients simply don’t return to clinics to collect their results.

But now, this nurse could technically even go to villagers’ homes with her device to test them for the diseases this machine can detect – if she had the time, of course.

Far-fetched? Actually not.

According to the national health department’s deputy director for HIV, TB and maternal health, Yogan Pillay, this scenario is likely to materialise as soon as July, when the American diagnostics company Cepheid launches its newversion of the Gene Xpert Omni machine. “We might not be able to implement the use of the device fully until the next financial year, because of cost, and the time it would take to do geographical mapping to establish which clinics will benefit the most from the machine. But we’re likely to try out a few demonstration sites this year if we can negotiate that with the company,” says Pillay.

“When you have one diagnostic tool for several conditions you essentially create an on-site mini lab, that allows for ‘point-of-care’ diagnosis and immediate treatment, because patients don’t have to return to the clinic on a different date to collect their results,” Pillay says. “It’s really where we’re heading in terms of integrated health services at a diagnostic level.”

Connected care for better integration

South Africa’s public health system desperately needs “connected care technology” such as the Gene Xpert Omni to improve healthcare service delivery. In some cases, technology has already paid off: in 2014, the health department implemented a mobile app which sends weekly SMS messages to pregnant women on how to manage their pregnancy at which stage. Mom Connect, which has 1.6 million registered users, also allows women to log complaints about bad services, and doesn’t require the user to have cell phone data or a smart phone. “It empowers both pregnant women and the system,” Pillay explains. “The good thing about the complaints, mainly about long waiting times and nurses with bad attitudes, is that they’re in real time and that we can do something about it as quickly as possible.”

But South Africans don’t view their health system as integrated, not even in the private sector, according to Philips’ 2016 Future Health Index research. Patients and healthcare professionals who participated in the study did however see “clear value of future integration”.

The health department is now considering introducing a campaign in which all patients visiting public health facilities are screened for the TB germ, and some even tested for TB disease (when the latent TB germ in someone’s body has developed into active TB) on the spot.

Such integration is however not a cure for inadequate resources; testing more people would increase the duties of health workers who are already working in an under resourced environment. The World Health Organisation warns that such efforts are not sustainable without “expanding the overall work force at some point”.

Public and private healthcare sectors can learn from each other

Only thirty percent of South Africa’s doctors work in the public health sector, serving more than 84% percent of the population – well over 40 million people, according to a 2014 special report in The New England Journal of Medicine. And that scenario is likely to worsen as many provincial health departments – the implementers of health policy – are employing austerity measures as they struggle with rising costs and mounting debt.

But in many respects South Africa’s well-resourced, yet fragmented private healthcare sector, can learn from the public health sector’s integration efforts. About 16% of South Africans have private health insurance which provides them with access to 70% of the country’s doctors, according to The New England Journal of Medicine.

“In a well-functioning academic or public hospital the medical team [the different specialists and therapists] of a patient will meet regularly to discuss a joint treatment plan for that patient. But in the private sector doctors rarely work in a multidisciplinary team,” says Jonathan Broomberg, CEO of Discovery Health, the administrator of the country’s largest medical aid scheme, Discovery Health Medical Scheme. “This often leads to lower quality care and higher cost of treatment – partly, because of waste, such as the same investigations being performed multiple times by different doctors who aren’t communicating, or medical errors, which are made because doctors don’t have access to each other’s information.”

For example, “Polypharmacy” – when different doctors have prescribed multiple medicines to a patient, drugs that may work against each other – is one the most frequent outcomes of uncoordinated efforts. “We for instance have many elderly members, who suffer from multiple conditions, who are on five to ten different medications of which the one maybe exaggerating the effects. Dizziness, which lead to falls, is a one of the most common complications,” says Broomberg.

Numerous studies have shown that the frequency of hip fractures among the elderly can be reduced significantly when drug prescriptions are coordinated to prevent dizziness.

For Discovery Health this has yielded results: there has been 60% improvement in the “physical functioning” of elderly people who are members of the senior care co-ordination programme, which was started in 2013. The “cognitive functioning” of members has improved by 55% and the burden on caregivers has been reduced by 65%. Moreover, there have been 57% fewer preventable hospital admissions.

Ideally, health integration in South Africa should bridge the gap between the under-resourced public and wealthy private sector. But the country’s National Health Insurance scheme, which aims to do this, is moving slowly and is riddled with infrastructure and coordination problems.

The private sector has theatres and expensive diagnostic equipment, which are rarely used at night. It has well established electronic billing and health record systems from which the public sector can benefit.

But sharing between these two sectors is rare. Why?

“Rather than it being a technology problem, it’s a problem of political will,” Broomberg argues. “Does the leadership in the government and public healthcare system, and the leadership in the private healthcare industry, see enough benefit in working much more closely together? That’s the main obstacle.”

The solutions are there. But are they wanted by the role players involved?