Bada Pharasi, CEO of The Innovative Pharmaceutical Association of South Africa (IPASA)
Lessons from the COVID-19 pandemic have underlined the importance of continued investment into pharmaceutical innovation and R&D to not only bring life-saving medications to those in need, but to improve public health outcomes, writes Bada Pharasi, CEO of The Innovative Pharmaceutical Association of South Africa (IPASA).
From treatments for cancer, cardiovascular diseases and more recently, the COVID-19 vaccine, the pharmaceutical industry has made significant progress in the development of over 470 medications in the last 10 years alone.1
While the innovative pharmaceutical process typically takes between 10 and 15 years from discovery to regulatory approval2 – owing to factors including immense R&D costs, regulatory compliance, and the protection of patents3 – the fast-tracked development and approval of COVID-19 vaccines laid bare the need for pharmaceutical companies to be prepared to mitigate the risk of future outbreaks – and this means continued investment in innovation and R&D.
The pandemic underlined the need for countries to be prepared for outbreaks on the horizon. To ensure we can meet the next challenge, pharmaceutical innovations must match the pace at which diseases mutate. This kind of innovation is non-negotiable and requires continued investment as a safeguard against losing lives and endangering South Africa’s fragile healthcare system.
As we are in the midst of a cholera epidemic, as well as the recent measles outbreak,4 it’s important to continue driving innovation to treat diseases, with medicines developed by innovative pharmaceutical companies benefiting millions across the country every day.
This is evidenced by mortality rates for HIV/AIDS and TB in the country falling by 59.2% and 55.7% between 2007 and 2017, with at least 60 new medicines currently in the R&D pipeline to treat TB.5
While patents in pharmaceutical innovation protect the originators’ intellectual property, it is important that innovative medications be developed to ensure a continuous pipeline of access to generics once the patent has lost its exclusivity. This will drive consumer accessibility and affordability of life-saving treatments and medications that may otherwise be unattainable for many.
As we continue racing against the proverbial clock in protecting against current and future diseases, pharmaceutical companies should continue to invest in innovation and R&D to outsmart existing dreaded diseases, and provide agility and preparedness should the next unknown pandemic threaten. Our health, and lives, depend on it.
Dr Mark Blaylock, medical manager at Manguzi Hospital. PHOTO: Supplied.
By Sue Segar for Spotlight
There was a time, about 20 years ago, when, at the Manguzi district hospital in Northern KwaZulu-Natal, (and, of course, at hospitals throughout South Africa too) mothers and their babies were dying of AIDS at shockingly high rates.
“We used to get these patients who were slow progressors,” Mark Blaylock, medical manager at Manguzi, tells Spotlight. “Then there were the rapid progressors – babies who were HIV-positive who would get sick very quickly. There wasn’t much we could do for them. We’d give them vitamins and Bactrim, but ultimately they died. Then we had the ones who got sick a bit later, and those were even worse because now mum has had this baby for five years and they’ve bonded, and are a little family and now they are coming in with AIDS. Obviously, a huge number of mums died too. It was heartbreaking.
“It was the pregnancies that knocked their vulnerable immune systems. We’d watch it over and over again. The mums would come in looking ok and then they’d get pregnant and just go downhill. This was in the pre-ARV era. Pregnancy was a death sentence. I think people have forgotten what it was like in those days.”
Blaylock is talking to Spotlight from Northern KwaZulu-Natal, relaying how things have changed for the better since that terrible era. “It’s quite astounding,” he says. Blaylock returned to the hospital ten years ago after having been away for four.
“I was going through the stats recently, and in those days, 40 percent of all mothers who delivered were HIV positive, and about 40 percent of those babies born to HIV- positive mothers ended up with HIV either from birth or breastfeeding. About 20 percent would pick up HIV at birth and another 20 percent would pick it up subsequently through breastfeeding.
“These days, if we have one baby who is delivered HIV-positive or who picks up HIV, we get really upset. Our six-month HIV-positive rate now for babies is less than 0.6 percent and that is a dramatic change. It makes me so happy. Unfortunately, the young girls are still positive, but at least their babies are not becoming positive.”
Blaylock puts the changes down, “purely”, to prevention of mother-to-child transmission (PMCT) using antiretroviral therapy (ART). “Remember how, at one stage, we only gave HIV treatment if a patient was below a certain CD4 count? That was changed to test-and-treat, so regardless of their CD4 count, patients will get HIV treatment which brings the viral load down dramatically,” he says. “And now we have dolutegravir (an ARV), which is the backbone of our current HIV treatment. The success is due to prevention of mother-to-child transmission (PMTC) as well as the test-and-treat policy.”
‘A mixed bag’
It’s Sunday, a day off for Blaylock, and he’s speaking from a place with the best reception near his house on the edge of the Shengeza Lake. He lives here with his wife, Liz and their 13-year-old home-schooled daughter, Una. The sound of birds in the background makes it hard to hear him on the call. “It’s peaceful. There are hippos all around and lots of birds. It’s Eskom-free, which is even better. I love it. We live with three dogs, three cats, a genet, and I can’t tell you how many snakes. It’s paradise.”
It’s taken a long time to clinch this interview, but Blaylock has finally relented and forwarded us the provincial health department’s media protocol he has to adhere to. On problems in KwaZulu-Natal’s health system, he is reticent, saying only that it’s a “mixed bag”. “There’s a lot of dead wood, but there are real areas of excellence,” he says.
His reticence is understandable.
There was a time, also about 15 years ago, amidst the noise and turmoil of the last few years of state-backed AIDS denialism, when Blaylock was going through his own personal trauma. In April 2008, whilst working as chief medical officer at Manguzi, he was suspended for throwing an official photograph of then-Health MEC Peggy Nkonyeni into a dustbin in the hospital’s foyer. He did this out of anger and frustration, after his colleague at the hospital, Colin Pfaff was charged with misconduct for sourcing funding for antiretroviral drugs for pregnant women, and for implementing dual antiretroviral therapy to save babies from HIV – because politicians were not doing so.
He was also furious about comments made by Nkonyeni, questioning the integrity of rural doctors and suggesting they were racist. The South African National AIDS Council soon after asked the Human Rights Commission to probe the ‘racial tone’ of Nkonyeni’s remarks and to curb her ‘harassment’ of Manguzi doctors.
At the time, Blaylock (and Pfaff) were hailed by many working in the health sector as heroes with a deep commitment to their patients. In a letter to the provincial health department at the time, Blaylock said he had given his “heart and soul” to the under-resourced hospital, going beyond the call of duty.
Needing a change
Blaylock was reinstated but, in December 2008, he decided to leave, saying he needed a change and because the KwaZulu-Natal Department of Health was in “absolute disarray”. He says his old colleague Pfaff went to work as a missionary doctor in Malawi.
There was more to Blaylock’s decision to leave Manguzi than just the public disagreement with Nkonyeni. In our interview, he describes those days as “a really tough decade”. “Working in paediatrics, as I did for my first couple of years at Manguzi, I couldn’t take it anymore, emotionally. I just couldn’t do it, so I taught myself surgery. That was easier, as you could fix people. We were also so broken from losing so many friends, colleagues, and patients from HIV at the time. It was definitely traumatising and emotionally exhausting, not just for me but for Liz.
“There’s no doubt most of us were burnt out,” he says. “We kind of knew it, but we pushed on anyway. We were also quite a bit wilder and younger. We’d blow off steam by recklessly taking tiny boats across the lake, in the big waves, with lots of hippos – or we’d go for runs along the beach or naked midnight swims.”
The years outside SA
After leaving Manguzi, Blaylock moved to Ghana, where he took up a position as a general doctor at ABA Hospital in Tarkwa, north-east of Accra. “The hospital was part of the national health system but contracted to a mine, so we would treat people and then try and charge the government, fairly unsuccessfully, for the treatment,” he says. “I’d always fancied the idea of Ghana. I had this fantasy about Kwame Nkrumah and it being the first country to throw off Britain in Africa – but I didn’t enjoy it as much as I’d hoped. Everywhere you went, the police were pulling you over and asking for bribes.”
A defining moment was when Blaylock says he noticed the anti-malaria medication the hospital was giving patients was “just not working”. “Our malaria patients kept coming back full of parasites. I knew there were similar drugs in South Africa which were fantastic, so there was definitely something wrong.” He says he sent a sample to South Africa for testing and realised that “they weren’t as full of the good stuff as they were meant to be”. “I handed in the report and said ‘deal with it.”
From Ghana, where he married Liz and where his daughter Una was born, the family moved to the Kansanshi Mine Hospital in Zambia where they lived on a “beautiful golf estate, surrounded by poverty”.
“It didn’t feel right at all and was quite unfulfilling work,” he recalls. “I did GP work and there was lots of babbalaria – that’s when mostly the expat wives have a hangover on a Monday morning and they think they have malaria.”
Being “medically bored” in Zambia, Blaylock returned to Newcastle in KZN with the aim of specialising in anaesthetics. He worked in Madadeni Hospital’s anaesthetics department, before getting into a registrar’s programme on the anaesthetics circuit at various hospitals in Durban.
‘Like walking back home’
Then, in 2012, his friend and colleague Etienne Immelman, then working as medical manager of Manguzi, suggested that Blaylock should “come home”. “Etienne had been at Manguzi for more than 20 years when he retired six years ago. We’d always had a friendship and a mutual loyalty. He wanted someone to take over.”
Blaylock decided that indeed, it was time. It meant losing the opportunity to specialise, but he says it “felt right”. He went back as medical officer, before becoming manager.
“When I first arrived back, we were a small team, working hard. We all had the same commitment. It gave me a sense of purpose and belonging which hasn’t left.”
Blaylock said the hospital went through a “wonderful period” with a core team of great doctors. “But I burnt them all out during COVID – we had 164 deaths, but we pulled a lot of people through and many of the doctors have moved on. We have a young team now and they are getting there, but we don’t have the broad skill range we used to have. That is common across most district hospitals nowadays.”
So, is he happy to have come full circle, back to the place that was once a source of deep distress to him? “Yes,” he says. “For me, it’s about the community. This place gives me that, as well as a sense of stability and purpose. If you go into a little shop in Manguzi, everyone knows who you are. You say hallo to each other. You shout at a taxi driver and he says, ‘Hey Mark, don’t be so naughty’. When I came back ten years ago, it was like walking back home. It’s just a nice feeling.”
He says a lot has changed in the area. “People say there’s been no development, but when I first arrived at Manguzi in 2002, we knew every car on the road. Today, the town is overwhelmed with vehicles. There’s more money around. We almost never see malnutrition anymore. A lot of government programmes are working, as much as we like to diss them.”
Taking a stand
Given the toll that taking a stand has taken on doctors like Blaylock and Pfaff, one might be forgiven for wondering whether it was all worth it.
Did it make a difference to how things turned out? “Absolutely,” says Blaylock. “There were people scattered people around South Africa at the time who were doing great things. In our part of the world, it was Victor Friedland at Mseleni Hospital and Colin Pfaff (at Manguzi) who were the big drivers, pushing for the right actions to provide the services that the HIV Clinicians Society at the time thought was the correct one and was affordable. The Western Cape had already started, so we weren’t doing anything that groundbreaking except that it hadn’t been official policy yet,” he says.
“Can you believe that when HIV treatment first came to South Africa, it was going to be done at tertiary hospitals only? Imagine the repercussions for us sending a patient to Durban – in those days the Hluhluwe road was 160 kilometres of dirt road – to go and get their HIV treatment once a month. It was not sustainable.
“The HIV (Clinicians) Society pushed hard to get it decentralised to all hospitals. Then it was just going to be done by doctors and they said we absolutely cannot do it just with doctors. It has to be a nurse-run programme. Their vision became our current system. They weren’t the only people, but they were at the forefront of it at the time.”
‘Keeping it going’
Apart from the many advances in HIV treatment, much else has changed at Manguzi over the last 15 years. Blaylock says these days the hospital’s gastro wards are empty “thanks to the rotavirus vaccine”. “We’ve also seen a turnaround in acute respiratory tract infection,” he says. “The pneumococcal conjugate vaccine has changed that dramatically. We have also seen the pushing out of Continuous Positive Pressure Airway Ventilation (CPAP) for neonatal respiratory distressed newborns to district hospitals. This is a non-invasive way of ventilating babies with immature lungs,” he says.
“Our next great hope is the HPV vaccine, which will be a groundbreaker. It’s been rolled out in the past couple of years, but we’ll only see the effects in ten years or so because cervical cancer takes a few decades to come about. The other thing I really want to get in,” he insists, “is that our therapy department (offers occupational therapy, speech and hearing, and physiotherapy) at Manguzi is astonishingly fantastic. There are a lot of good things happening,” he says. “It is so easy to sit on the things that irritate you, but it is worth trying to remember the wins.”
As with several other rural doctors Spotlight has interviewed over the years, Blaylock seems deeply committed to building on what works at Manguzi and simply getting things done. As he says, “When you’ve invested so much into a hospital, you want to keep going as much as you can.”
The Select Committee on Health and Social Services has extended the deadline for public comments on the contentious National Health Insurance (NHI) Bill by two weeks, according to a report from Business Insider. In its announcement, the Committee said that it had received numerous requests from stakeholders to extend the date on written submissions for the act.
The committee has therefore extended the deadline from Friday, 1 September 2023 to Friday, 15 September 2023. The Bill is already before the National Council of Provinces (NCOP) after being passed by Parliament in June, in spite of vehement opposition. Once past the NCOP, which seems all but assured given its stubborn progress, it will then be sent to President Cyril Ramaphosa to be signed into law.
Contact details to submit enquiries or written submissions are at the end of the article.
Controversy continues unabated
An unrelenting barrage of criticism has been directed at the Bill, which so far has shown little change in response and according to many its constitutionality is questionable. While stakeholders are generally for universal healthcare and the idea of an NHI, the current public healthcare system is already under dire pressure, being underfunded, under-resourced in terms of skilled professionals and equipment, and riddled with corruption.
Indeed, South Africa would be the first country in the world to completely bring all healthcare. The fact that other countries with better governance track records and more resources have not done so has been brought up as a red flag.
Another is the vague notion that the government will pay for the scheme somehow – which inevitably means reaching into taxpayers’ wallets. The estimated cost of R300 billion and R660 billion a year will be by far the largest single government expense in a time of shrinking funds.
“Looking at 2026 – the year in which the NHI is supposed to be implemented – an enormous extra R296 billion will be required in order to balance the books,” the Solidarity Research Institute (SRI) said.
“This is unheard of for a middle-income country, where spending on education usually enjoys the highest priority. While more affluent countries spend more on healthcare, social grants usually receive the highest priority, never health,” said the SRI.
Options to foot the bill range from a staggering 40% surcharge on income tax to a payroll tax of 13.4%, which Professor Alex van den Heever criticised as being “incredibly naïve set of fiscal proposals that you cannot even consider implementing.” Discovery Health CEO Ryan Noach warned of a tax revolt if the government attempts to pay for this.
Practical allternatives on offer include a public-private partnership as envisaged by Business Leadership South Africa CEO Busi Mavuso.
Enquiries, as well as written submissions, can be directed to Ms M Williams, Select Committee on Health and Social Services, e-mail mawilliams@parliament.gov.za.
Various stakeholders within the medical schemes value chain have sharply raised concerns over the unending court challenges brought by the Board of Healthcare Funders (BHF) against CMS. As an agile regulator, the CMS endeavours to clarify any misconception and confusion over BHF’s court challenges.
Chronology of Events
Initially, the main issue brought by BHF in this case was to request the court to grant them a general exemption for medical schemes to offer low-cost benefit options and to declare an alleged moratorium unlawful by the CMS and Ministry of Health in order to prevent medical schemes from offering low-cost benefit options.
In response, the CMS vehemently opposed the application on the basis that there was no moratorium as alleged by BHF and it would be thus unlawful to grant BHF a general exemption for medical schemes to offer low costs benefit options.
“It must be noted that while the main case/dispute was still ongoing (even after CMS submitted an extensive record of documents that were compliant with relevant information and documents having been exchanged between CMS and BHF), surprisingly BHF brought an interlocutory application alleging that CMS and the Minister were hiding certain information.”
Accordingly, the interlocutory application requested CMS and the NDOH to release an exhaustive list of documents which the CMS believed were irrelevant and had no bearing on the main application.
Despite CMS’s vehement contestation to the court on the additional requested documents by BHF, Judge Botha granted the BHF the order they sought, and the CMS, as well as the Minister of Health were ordered to produce the documents listed in Notice in terms of Rule 30A within 10 (ten) days of the Court Order, being 24 July 2023.
Before the expiration of rule 18 of the superior court, CMS filed leave to appeal the court order of Judge Botha as CMS believed that the order was flawed in law and that the judge had no reasons for ordering CMS and the Minister to produce those documents.
While the CMS legal team was studying the order, BHF concurrently lodged a contempt of court on an urgent basis.
CMS, through its attorneys, moved swiftly and wrote to BHF urging them to withdraw the contempt application as the CMS had already lodged its leave to appeal the court order of Judge Botha and this meant that the court order by Judge Botha would been suspended.
BHF refused to withdraw the contempt application and the application was heard on 8th August 2023 and the court dismissed BHF’s application on 10 August 2023 with costs in favour of CMS and Minister.
Citing Judge E van der Schyff who emphasised that “in the Practice Manual of the Gauteng High Court Division that while an application maybe urgent, it may not be sufficiently urgent to be heard at the time selected by an applicant” and also strongly highlighted that it does “not mean that applicants can indiscriminately approach the urgent court on the basis of extreme urgency without having regard to the context and facts of each individual application.”
Based on this order, the contempt application is now in our view moot or rather has been overtaken by the leave to appeal lodged by CMS and the Minister and CMS/NDOH. The leave to appeal will be heard somewhere September 2023.
The main application brought by BHF is likely to be heard in later parts of 2024.
In South Africa, the use of pit latrines remains a prevalent human rights issue, infringing on every person’s right to life, dignity, and health, as well as their right to access water and adequate basic sanitation. Despite their unavoidable application in certain contexts, pit latrines pose numerous risks to life, health, and safety, particularly in schools and areas lacking proper sanitation infrastructure such as informal settlements, prompting efforts to eliminate their presence in the country.
As far back as 2019, the Department of Water and Sanitation (DWS) launched a campaign called Khusela, which means “to eradicate” in isiZulu, to abolish pit latrines by 2030. Given the extensive challenges related to sanitation infrastructure, eradicating pit latrines is going to take time, particularly in rural areas. Nonetheless, this human rights issue must be squarely addressed and that functional, sustainable alternatives to open pit latrines are given the proper prioritisation.
Pit latrines: the shocking numbers
From a sanitation perspective, there are 380 schools in South Africa with no running water. 3392 schools still use pit latrines, which affects 34 489 teachers and 1 042 698 learners. While it is difficult to ascertain exact population figures, it is estimated that there are still four million pit latrines in use by communities throughout the country, of which only two million are Ventilated Improved Pit (VIP) latrines, while the remainder are ordinary pits with, or without covers. VIP latrines are a type of pit latrine that has a ventilation pipe that allows air to circulate through the pit, which helps to reduce odours and the breeding of flies. These latrines are also typically constructed with a more substantial exterior structure than ordinary pit latrines.
Endangering communities
The use of pit latrines can be perilous, posing a safety risk, particularly for young children, females, and vulnerable individuals. Without proper maintenance or safety precautions, accidents such as falls, injuries, and even drownings occur. Pit latrines contribute to the spread of disease, posing a major health hazard to users and nearby residents, as inadequate waste management and poor sanitation practices contaminate the groundwater and soil, as well as nearby water sources which lead to the transmission of waterborne diseases like cholera, diarrhoea, and dysentery. Pit latrines often lack essential sanitation facilities, such as handwashing stations or proper waste disposal systems, which results in unhygienic environments, poor personal hygiene practices, and an elevated risk of infections and diseases.
For affected communities, the lack of access to clean water and proper sanitation has a significant impact on health and well-being. The lack of access to safe and hygienic sanitation facilities can lead to health problems, which can make it difficult for people to work and earn a living. The correlation between adequate sanitation and poverty is a complex issue, with several contributing factors. As such, it is important to address these factors to improve sanitation and ultimately reduce poverty.
Challenging to service
Pit latrines are used primarily in areas that do not have access to water. These gradually fill up over time, primarily with solid waste as most liquid waste evaporates or is absorbed into the soil. Originally estimated to last seven to ten years, these latrines often require maintenance in just two to three years due to the significant amount of additional waste they receive. Decisions must then be made to either close the latrine and dig a new hole or seek servicing, a challenging task that involves treating the solid waste to create a more liquid environment before using a honey sucker or vacuum tanker to extract and dispose of the waste in a treatment plant. The remote locations of many facilities add to the complexity of the process.
Seeking practical solutions and facing reality
This highlights the urgent need for practical solutions when addressing the challenges posed by pit latrines. To illustrate the practicalities, consider the sheer number of pit latrines – four million, with two million being VIPs and two million standards. Replacing all of these with waterborne sanitation is simply unfeasible in the short term, as this would require an additional one billion litres of water daily for flushing alone. This is currently an insurmountable obstacle in terms of water supply and treatment, considering the condition of existing waste treatment plants. The South African private sector has sought to find the most practical and effective way to address the critical issues of safety, environmental impact, and serviceability of these facilities. To make a tangible difference, it is necessary first to acknowledge that an immediate conversion to waterborne solutions is not practical, in the short and medium term.
Attainable, cost-effective alternatives
A safer alternative to pit latrines has been developed and tested extensively and is ready for implementation in communities. It is a cost-effective, dry sanitation unit that addresses health and safety shortfalls, installation difficulties and servicing problems with pit latrines while ensuring that environmental and underground water contamination cannot occur. The main structure consists of concrete and the door is made of injection moulding plastic, with a ventilation pipe to limit odours. The waste containment unit has a 1500-litre bladder with a 3–5-year guaranteed life cycle, which can be removed without disabling the unit. The units are mobile, and no pit must be dug, which reduces installation costs and limits the abandonment of land. The unit itself is shaped in an ellipse to maximise space utilisation and waste containment, using a rotating bowl to dispose of waste, which prevents contact with faecal matter. The unit is sealed to prevent insects from entering or exiting the system and uses environmentally friendly products to treat waste, all of which address environmental concerns.
A cleaner, safer future
The need to eliminate pit latrines in South Africa is clear, given the multitude of risks they pose to the health, safety, and environment of communities. While an immediate conversion to waterborne sanitation may not be practical due to water supply and treatment limitations, the development of safer alternatives, such as the dry sanitation unit, offers promising possibilities. By prioritising the implementation of such practical and effective solutions, South Africa can significantly enhance the well-being and quality of life of its communities, making strides towards a future where pit latrines are replaced with safe, sustainable, and healthier sanitation options for all citizens.
Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/
The South African Pharmacy Council (SAPC) has been given judicial go-ahead to introduce its Pharmacy-Initiated Management of Antiretroviral Treatment (PIMART) initiative, which will allow specially trained pharmacists to manage and prescribe medicine to patients with HIV and tuberculosis.
Pretoria High Court Judge Elmarie van der Schyff has dismissed an application brought by a doctors’ organisation – the IPA Foundation – for the setting aside of the programme.
She said the pilot project had emphasised the value of the initiative, which was in line with the World Health Organisation’s vision to promote widely accessible primary health care.
“The untapped value of pharmacists in fighting HIV was also emphasised by the efficient role pharmacies played in meeting health care needs and providing health care services during the Covid-19 pandemic,” she said.
“The need to widen access to first line ART and TPT therapy on a community level is not a figment of SAPC’s imagination but a dire need that is also evinced in other countries.”
The IPA Foundation approached the court, under the Promotion of Administrative Justice Act (PAJA), seeking to review and set aside the SAPC’s decision to implement PIMART.
IPA claimed that the SAPC had failed to give interested parties an adequate opportunity to comment before the initiative was implemented. It further contended that PIMART unjustifiably encroached on the domain of medical practitioners and was in conflict with legislation.
IPA also accused SAPC of misleading the Director-General of Health, claiming there had been extensive consultation with stakeholders, which led to the approval and issuing of permits for the initiative.
The SAPC said the application should be dismissed. It said pharmacy-provided primary healthcare was a well known and functional concept in South Africa and PIMART was simply a “widening of this”.
Referring to the background and context, Judge van der Schyff said, in line with WHO recommendations that all people living with HIV must be provided with ART, the department of health had requested the SAPC to consider and implement interventions that would ensure that patients had increased access to medicines.
This led to the SAPC requesting the Director-General in August 2018 to consider issuing permits to pharmacists who had completed supplementary training, to manage patients and to dispense medication under PIMART.
In March 2021, the SAPC published a notice for public comment regarding the adoption of PIMART. The first permits were issued in August that year.
However, IPA submitted objections outside of the timeline for comments. It said this was because its members were struggling with another wave of the Covid-19 pandemic.
“Pharmacists and doctors operate in distinct and separate professional domains, the boundaries of which are closely guarded and some tension exists … IPA’s objection to PIMART seems to be rooted, partially at least, in this professional tension.
“This is evidenced by its fear that the decision to implement PIMART might ‘open the floodgates’ and ‘pave the way for pharmacists to ultimately treat and prescribe other schedule 4 drugs in respect of acute illnesses’,” the Judge said.
She noted, however, that the National Drugs Policy, in line with WHO guidelines, promoted “task shifting” to advance access to medicine and that at primary level, prescribing should be competency based, not occupation based.
Any alleged adverse effect that PIMART held for a medical practitioner had to be considered against the need to expand primary health care services aimed at preventing and treating HIV and providing first-line ART therapy.
Judge van der Schyff said the initiative gave members of the public a choice as to whether they wanted to approach a pharmacist, who had been issued with a permit, or a general practitioner.
In considering procedural fairness, the judge said there was nothing sinister in the timing of the notice calling for comment, that the project was not something hidden in secrecy and “I find it improbable, as alleged, that none of IPA’s members had timeous knowledge of the board notice”.
The decision to implement PIMART also fell within the ambit of the SAPC’s powers.
Evidence also showed that the PIMART training course was developed to ensure that pharmacists who successfully completed the training would be suitably qualified to safely and effectively assist in providing ART.
Judge van der Schyff dismissed the review application and ordered IPA to pay the costs.
Professor Francois Venter, former President of the Southern African HIV Clinicians Society and Director of Ezintsha, an HIV research organisation at Wits University, commented, “I hope this is the end of it. The pharmacies are an essential part of the health system, and pharmacists internationally play a big role in expanding HIV services.”
Doing ‘the right thing’ for one’s health, be it eating well, exercising, or going for an annual HIV test or blood pressure check, is easier said than done. One way to nudge people to make these ‘right’ decisions is to offer rewards or incentives. Discovery Health Medical Scheme’s Vitality programme is probably the best local example of such an incentive programme.
While incentive programmes have made a splash in private healthcare, they’ve hardly caused a ripple in South Africa’s public sector. In fact, the only public sector incentive of any notable scale of which we are aware was the vouchers that were offered to people who got vaccinated against SARS-CoV-2. There have been several scientific studies of cash transfers and other incentives, but the data is relatively limited and the differences between studies were substantial, as indicated in this review of cash transfers for HIV prevention, among others.
Evidence from other countries has shown that a targeted public sector incentive programme could yield significant positive results. The Indian Government launched a programme called Janani Suraksha Yojana (JSY) in 2005, “with the goal of reducing the numbers of maternal and neonatal deaths” using a conditional cash transfer scheme to encourage giving birth in a health facility. In those who benefited from the scheme, there was a reduction of 4.1 perinatal deaths per 1000 pregnancies and a reduction of 2.4 neonatal deaths per 1000 live births.
As Spotlight has recently reported, South Africa is doing relatively poorly against its diabetes and hypertension targets and substantially better against its HIV targets. Yet, we can find no evidence that the Department of Health has given serious thought to incentive programmes in these various areas.
Some might argue that the impact of such programmes is unproven and that they are too expensive. No doubt, a carbon copy public sector version of Vitality is wishful thinking. But are there any elements of it worth copying or adapting for the public sector?
“It has always amazed me that incentives are always so OK for rich people like me, on Discovery, but somehow unacceptable for poor people ‘who should do it for their own good’ in the public system,” says Professor Francois Venter, who heads up Ezintsha at the University of the Witwatersrand. He describes it as patronising.
Venter says that while hugely complex issues like controlling non-communicable diseases (NCDs) and obesity can’t be solved with incentives, they could certainly be added to the very limited toolbox of the existing arsenal being used to prevent disease or death through early detection, testing, and screening. He says incentives “definitely should not be dismissed right off the bat when it comes to the 84% of people who rely on the public system”.
The power of ‘points’
An estimated 60% of diseases across the board are caused by unhealthy lifestyles, according to a 2022 study published in the International Journal of Environmental Research and Public Health. In line with such evidence, Discovery’s Vitality programme is primarily focused on encouraging its members to make healthier lifestyle choices.
“Vitality aims to leverage behaviour change techniques, most notably using incentives, to motivate or nudge members to adopt healthy behaviours,” says Dr Mosima Mabunda, who is the Head of Wellness at Vitality. She says that four core factors are implicated in most NCDs, namely an unhealthy diet, a lack of physical activity, smoking, and alcohol misuse.
The Vitality programme is complex and uses a wide range of incentives and rewards to motivate members, including giving members monetary rebates for healthy food purchases, subsidised gym membership, and a comprehensive points-based system that rewards a range of healthy lifestyle choices. These points can be converted to cash or used at a range of local retailers. There is an incredible variety of Vitality rewards that range from discounts on flights to discounts at movie theatres.
According to a Discovery report, the “overall impact of Vitality on mortality rates is significant”. By “making people healthier” they say they have achieved an average reduction in mortality of 13%.
Several experts interviewed by Spotlight point out that most of this data has not been published in reputable, peer-reviewed journals. Even so, it is certainly plausible that Vitality’s annual incentivised health check helps with earlier diagnosis of hypertension, diabetes, and even HIV. Similarly plausible is the idea that points may successfully incentivise some people to exercise more. Scepticism of the health benefits of other elements of the Vitality programme may well be warranted – it is hard to know without independent analysis.
Importance of early detection
The underlying logic of such incentive systems is typically that the savings due to behaviour change or early detection outweighs the cost of the incentives. Put another way, the private sector isn’t just doing this to help people stay healthy, they are also doing it to save money. The costs and benefits for state-run incentive programmes will obviously look very different, but there may well be cases where the benefits of incentives outweigh their costs.
It is also possible that in some instances incentives are actually needed more urgently by users of the public sector than the private. As Professor Harsha Thirumurthy, who is an expert on behavioural economics and health incentives based at the University of Pennsylvania points out, “the majority of Vitality members don’t face barriers like transport costs” or even being located many kilometres away from the nearest state facility.
Late diagnosis or poor disease control has high human and economic costs in both the public sector and private. According to a 2013 study published in the Global Health Action journal, uncontrolled diabetes caused 8000 new cases of blindness and 2000 new amputations in South Africa in 2009 alone. More recent statistics reveal the situation is getting worse. In 2018, then KwaZulu-Natal MEC for Health Dr Sibongiseni Dhlomo revealed that six amputations occur every single day – which equates to over 2100 a year – in that province.
And the financial implications are staggering. For example, a 2022 literature review that looked at the costs of treating common NCDs in South Africa, estimated the cost of treating one person for one year with medication for type 2 diabetes to be roughly between R1000 and R3500 in the public sector. In comparison, the study also looked at the costs of treating common complications of uncontrolled diabetes. For example, diabetes-related renal disease was estimated to cost roughly R67 000 per person per year.
Screening for diabetic retinopathy, an eye condition that causes vision loss, costs between R110 and R370 per person. In comparison, the cost of treating ophthalmic disease in people with diabetes is estimated to be R59 000 per person per year.
These are only the health system costs and don’t include the costs of serious complications and lifelong disability to individuals, families, and communities.
Barriers to healthy lifestyle choices
Most experts we spoke to agree that the Vitality programme in its entirety is too complex and expensive to be replicated at scale in the public sector. Additionally, helping the majority of the population make healthy lifestyle choices, particularly those around healthy diets and physical activity, is a mammoth task and exceeds the ambit and powers of the National Department of Health.
“It’s really important to appreciate that there are so many environmental, social, [and] structural factors that make it difficult for people to quote-unquote ‘do the right thing’ when it comes to health-related behaviours,” says Thirumurthy. “For example, people are constantly subjected to advertising of unhealthy food products. Many are living in environments that make it hard to eat a healthy diet even if they wanted to.
“To really make a difference, we have to take a step back and identify the overall system-level or structural changes that could be made to influence people’s diets and other health behaviours. We need to think about what types of government regulation and policy levers can be utilised to achieve better health outcomes,” says Thirumurthy, who is also the co-founder of South Africa’s first ‘nudge unit’, based at Wits University called Indlela: Behavioural Insights for Better Health, which is focused on identifying low-cost behavioural solutions to public health challenges.
As Spotlight previously reported, many of these issues are flagged in South Africa’s recently published Strategy for the Prevention and Management of Obesity in South Africa 2023 – 2028. But while most experts we interviewed felt the strategy flagged the right issues, there was also agreement that the strategy didn’t set out a realistic plan for dealing with those issues. And not finding ways to deal with these issues is costing a lot of money.
In 2018, the public sector cost of treating patients diagnosed with diabetes alone totalled R2.7 bn “and would be R21.8 bn if both diagnosed and undiagnosed patients are considered”, according to a 2020 report about the health promotion of NCDs published by the South African Medical Research Council (SAMRC). Moreover, in real terms, it is estimated that by 2030 the cost of all type 2 diabetes cases will soar to R35.1 bn.
According to Thirumurthy, incentive-based interventions represent one creative solution with the potential to help improve health outcomes and reduce the financial burden on the health system in the long term. “I’m not saying incentives or rewards-based programmes are going to save the day, so to speak. However, they do represent a small but important part of an overall policy package that is necessary to address NCDs. Global experience suggests this policy package should prioritise regulatory interventions, including taxes on sugary sweetened beverages and other unhealthy foods, but incentive-based interventions can certainly be a useful addition to a broader strategy or policy package,” he says.
A public sector annual health check?
Early detection is one area where the public sector could potentially benefit from copying a private sector incentive scheme.
Vitality’s annual health check is a free screening and testing consultation that includes HIV testing, mental health screening, body mass index evaluation, blood pressure check and a blood glucose test, among other things. Members are rewarded handsomely with points, simply for showing up. Critically, these checks are offered at many pharmacies and are thus relatively easy to access.
According to Belinda Kahler, Wellness Specialist for Vitality, there is data that suggests that the inclusion of a screening questionnaire for depression in their annual health check yields significant benefits for both the scheme and its members. She says that members who complete the screening and are flagged as high-risk are over three times more likely to seek professional help which “fosters early detection and management which reduces complications and ultimately reduces healthcare costs”.
One way a public sector version of this could work would be for the state to contract with nurses at private sector pharmacies and GPs to provide the checkups in addition to public sector clinics. This would make it much easier for people to access these checkups, and may well boost early diagnosis of diabetes, hypertension, and other diseases, especially if an incentive is included. For this to work, the public sector data systems to facilitate the capturing of measurements and test results will have to be in place, but presumably, work along these lines is already underway for the NHI data system that is being developed. Many public-sector clients already collect their medicines from private-sector pharmacies and some were vaccinated against SARS-CoV-2 at private-sector pharmacies – so it won’t be breaking entirely new ground to add checkups to the mix.
According to Thirumurthy, programmes that are ongoing, requiring daily or weekly action, are not feasible or sustainable for the public health system at this stage as they are too resource-intensive, requiring constant monitoring, and reward allocation. “But incentivising a once-off or annual behaviour, such as going for a vaccination or health check, is not only more likely to succeed compared to daily behaviours like going to the gym or taking a certain number of steps, it is also much more cost-effective and much easier for a government to implement,” he says.
He says addressing healthy lifestyles is incredibly difficult and preventive care interventions represent a more attainable goal for the National Department of Health. Screening, preventive care, and early detection save money and lives, but it is notoriously difficult to get patients to engage in the health system before they get really sick or experience noticeable symptoms. More often than not, patients seek care too late to prevent costly complications.
“Depending on the particular behaviour, test or screening combination that is incentivised, a programme like this could really move the needle on the intended health outcome and equate to money well spent in future averted healthcare costs,” says Thirumurthy.
Dr Brendan Maughan-Brown, who is the Chief Research Officer at the Southern Africa Labour and Development Research Unit, points out that “we really are going to have a collision of comorbidities in the next seven to eight years” fuelled by an ageing HIV population. “All these NCDs are going to become even more burdensome to the health system – already in some areas, over 25% of people over 50 are living with HIV. This is going to be a major challenge for the health system, insurers, and the NHI, so thinking about solutions now, including a proposed annual health check or screening, is a good place to start.”
What should incentives look like?
Once-off or annual programmes do not need to be expensive, according to Dr Sophie Pascoe, who is the Indlela Co-Director. “They would require a level of coordination, but there are many companies who I’m sure would be willing to come on board as sponsors. The big supermarket chains could subsidise grocery vouchers or incentives could be in the form of airtime backed by one of the big mobile networks, for example,” she says. These partnerships would “benefit everybody” by encouraging those targeted behaviours, while sponsors would profit from the exposure and an increase in their customer base.
“I think part of the problem is, when we mention the word ‘incentives’, everyone imagines a lot of money and big rewards. But the rewards don’t need to be big or costly,” she says.
Maughan-Brown, who is also an expert in behavioural economics and the behavioural determinants of HIV risk, says that for an incentivised preventive programme to be successful, there needs to be a comprehensive understanding of the various “hassle factors” faced by those who rely on the public health sector. What would be valuable to people? Transport, airtime, grocery vouchers, child care, paid leave from work or something else? He says a lot of work would need to be done to understand what rewards will work and there needs to be a level of flexibility because different people will need or value different incentives.
Pascoe, in turn, suggests that a lottery incentive could be added and would be inexpensive to augment an immediate but smaller reward that would be received directly after the health check or screening intervention, for example.
She adds that another difficulty when it comes to advocating for this kind of programme is that tangible benefits or outcomes will only be seen in the long term, while government is more receptive to programmes or policies with clear and quick results.
Venter has similar concerns. He says there is a perception that these programmes are expensive to implement and run. “But that is only part of the issue,” he says, “I find it bizarre that I get incentivised left, right, and centre by Discovery, yet every time we raise it for poor people, I get told ‘they should be doing it, anyway’. It makes no sense.” As it stands, Venter says that problematic and pervasive perceptions need to be addressed before any incentive-based programme will even likely be considered by policy-makers and government officials, and even international funders, civil society, and the media for that matter.
‘Already incentivised’
National Department of Health Spokesperson, Foster Mohale, told Spotlight that his department “is not against incentivisation but each preventive programme has its own issues and each community of health system user has different incentives for staying well”. He agrees that the “public health benefits of health checks and health screening” have the potential to “result in early detection and reduced costs to the health system”.
However, he says that these services are already incentivised and that considering interventions inspired by Vitality is “inappropriate”. Asked about the nature of the current public sector incentives, he said, “[It] depends on what one sees as an incentive! For me, a gym membership, Fitbit, express check-in queue or cheap flights are of no value and I regard them as an insult. For others, they rush to ‘benefit’. For the majority of South Africans, a visit from the [community health worker] is the incentive!”
Mohale argues that, by definition, incentive “means inducement, motivation, motive, reason, encouragement” and that, “in the true spirit of incentives”, “testing and screening services are incentivised through health promotion in ALL public health clinics, and in school health programmes”.
He says that “the massive programme for HIV testing [is] incentivised through free testing [and] specific clinics”. He adds that the department offers another incentivised programme in the form of adherence clubs, where groups of about 30 people who are on chronic medication meet regularly, share their experiences with each other and receive some screening and counselling from healthcare workers.
NOTE:Professor Francois Venter is quoted in this article. Venter is a member of Spotlight’s Editorial Advisory Panel. The panel provides the Spotlight editors with advice and feedback on the quality and relevance of Spotlight’s public interest health journalism. The Spotlight editors, however, remain editorially independent and solely responsible for all editorial decisions. Read more on the role and purpose of the panel here.
Allmed Healthcare Professionals, a leading healthcare agency, has launched its innovative Pay Slip App, designed to provide convenience and efficiency to its valued staff. The app, available for both Android and iPhone devices, revolutionises the pay slip distribution process, eliminating the need for staff to physically visit the office.
The development of the Pay Slip App began in January 2022 with the vision of addressing the challenges staff faced while collecting their pay slips. “We saw that our staff were spending time and money to come to our offices, which led to inefficiencies and unnecessary expenses,” explained Zukisani Sirwaxa, Operations Manager at Allmed. “Our goal was to save costs, improve accessibility, and streamline the entire process for our staff.”
The user-friendly app allows staff to access all their pay slips since they started working for Allmed, aiding them in financial planning and loan applications. Staff can easily check their pay details, including overtime, leaves, and earnings for specific shifts. This real-time access empowers staff to proactively manage their finances.
Karishma Dayaram, Business Unit Manager at Allmed, highlighted the app’s broader benefits, saying, “The Pay Slip App not only saves costs in printing and delivery but also frees up valuable staff time that was previously spent on manual processes. It enhances transparency and empowers our staff with immediate access to their essential pay information.”
Donald McMillan, Managing Director of Allmed, shared his excitement about the app’s unique features, stating, “As one of the first agencies to introduce such a dedicated Pay Slip App, we have been at the forefront of technology adoption in the industry. We are continuously exploring ways to improve the app’s functionality to meet our staff’s evolving needs.”
The Pay Slip App, developed in collaboration with a third-party developer, underwent a rigorous testing phase to ensure its efficiency and reliability. Since its launch, the app has received several thousand downloads, and Allmed has been proactive in addressing any technical challenges to ensure a seamless user experience.
Looking towards the future, Allmed envisions expanding the app’s functionalities to provide enhanced communication with our staff. “We are exploring the possibility of using the platform to share important updates, memos, and notices directly with our staff,” said Zukisani Sirwaxa. “This will further streamline our communication and foster a dynamic and connected community.”
As a forward-thinking company, Allmed recognises the importance of environmental responsibility. “We are also proud to align ourselves with the green initiative,” stated Donald McMillan. “By embracing digital solutions like the Pay Slip App, we are reducing paper usage and contributing to a sustainable future.”
In the recent judgement handed down by the Pretoria High Court in favour of Board of Health Funders (BHF), the Council for Medical Schemes (CMS), Registrar of Medical Schemes and the Minister of Health were ordered to deliver a complete record, which will shed light on the moratorium on granting exemptions to medical schemes to provide LCBO benefits. The order directed the CMS and the Minister of Health to deliver all documents or information requested under Rule 30A within 10 days of the order, but all the respondents failed to meet the deadline.
After the ten-day deadline had passed and noting that the documents were still not produced and there was no appeal to the court order, the BHF was forced to return to court to seek answers. The BHF filed a contempt of court order on an urgent basis. In this application, the BHF highlighted that no complete record had been submitted even though the deadline for the Minister of Health and CMS to do so was on 24 July 2023. In response, the CMS and the Minister of Health opposed the contempt of court action and appealed the rule 30A judgement delivered on 10 July 2023. The Minister of Health, acting through his attorneys, allowed his own team to submit certain documents in terms of rule 30A, and the attorneys have stated that the delivery of the documents demonstrates good faith. This is despite the appealing of the judgement and order delivered in the rule 30A application.
The legal battle against the CMS and Minister of Health not only highlights their failure to comply with the court’s order, but also raises concerns about transparency and accountability within the healthcare system. This delay not only hampers the progress towards implementing affordable healthcare solutions, but also undermines public trust in the decision-making process of these regulatory bodies. This lack of adherence to court orders highlights the urgent need for effective enforcement mechanisms to ensure that court decisions are respected and implemented by the relevant parties.
In a media briefing on Tuesday, 8th August, the Council for Medical Schemes (CMS) sought to clarify its process and recommendations over the approved 5% increase to medical aid scheme contributions, levels above which the medical schemes must motivate for. As for low-cost benefit options (LCBO), the CMS indicated that they would only provide a report to the Health Minister by the end of the month. This could prevent medical schemes from applying for new LCBOs in 2023.
Mr Mondi Govuzela, Senior Manager of Benefits Management, explained that the 5% approved increase is based on the Consumer Price Index (CPI) for 2022, which indicated a 4.9% increase. Schemes therefore may raise contributions by 5%, in line with the Reserve Bank’s inflation prediction for 2024. A prudent percentage markup should be incorporated to take into account cost increases and demographic changes, he advised. Before COVID, contribution increases have typically been 2.4–5% above CPI. The years 2020 to 2022 saw contribution increases dip below CPI.
One of the cost drivers that Mr Govuzela noted in the media briefing was supplier pressure stemming from fewer doctors and specialists, who were pushing for higher remunerations. Increased costs elsewhere in the healthcare industry. On the member side, growing rates of chronic diseases, membership ageing and coverage for medical services also added pressure.
LCBO would appear to be a solution for many individuals to access private healthcare for at least some urgent conditions, but the CMS has yet to comply with a Pretoria High Court ruling ordering that they provide a report on their moratorium on granting exemptions to medical schemes to provide LCBO benefits. The case was brought by the Board of Health Funders (BHF).
As to what the CMS’s response to the LCBO ruling was, CMS Registrar Dr Sipho Kabane said that the CMS was preparing a report that would be delivered to the Health Minister “by the end of the month”, but would not be drawn on what it might say. The deadline for registering new benefit options is September 1.
In their circular explaining the decision increase, the CMS acknowledged the persistent macroeconomic headwinds facing medical schemes and their members, with a meagre 1% increase predicted for SA’s GDP next year. “Against the backdrop of the current adverse macroeconomic conditions characterised by multi-year higher interest rates due to stubbornly higher inflation rate, volatile domestic currency and surging energy prices and overall lacklustre economic growth, it is evident that most household budgets will remain constrained for a foreseeable future, leaving most consumers under a precarious financial position. To cushion members of medical schemes against further financial distress and the probable risk of losing their health insurance cover due to affordability constraints, medical schemes are advised to limit their cost increase assumptions for contribution increases for the 2024 benefit year to 5.0%, in line with CPI.”
