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How ‘NHI on Wheels’ is Bringing Life-changing Healthcare to Young People in Rural Eastern Cape

On July 16, 2024July 16, 2024 By ModernMedia

Children lining up to see the dentist at the Ekuphumleni Community Hall, near Whittlesea. (Photo: Sue Segar/Spotlight)

By Sue Segar

The Keready project uses mobile clinics to take healthcare services to rural areas. Sue Segar spent time with the project as they took eye, dental, and other healthcare services to communities in the Eastern Cape.

In the small Eastern Cape town of Bizana, hundreds of children stream into a large hall at the Oliver and Adelaide Tambo Regional Hospital on a brisk Tuesday morning in May. There’s a festive but orderly vibrancy in the air – the scene made all the more colourful by different school uniforms and young voices from tiny six-year-olds to learners in their late teens.

They’ll be assessed, and helped by doctors from Keready – an organisation offering mobile health services in many far-flung communities lacking healthcare services.

For weeks leading up to today, outreach teams from Keready’s mobile clinic operation have gone from school to school, asking teachers to identify children with eye problems. Today they arrived on various forms of transport – some on the back of a bakkie – from deeply rural communities as far as 100 kms away. Most of the children have little access to health services, particularly eye care, so the response is substantial.

I have travelled here with three doctors and an admin assistant from Keready’s East London office. They join other healthcare staff, including from the health department, for this two-day mega outreach in partnership with the Umbono Eye Project.

“Over the past three months, school educators identified 492 learners from 26 schools who have impaired vision,” says Ewan Harris, a pharmacist and consultant by training and a former deputy director-general of education in the Eastern Cape, who heads up Keready’s Eastern Cape team. “We will attend to these learners and if necessary, provide them with prescription spectacles and meds.”

Ntombizedumo Bhekizulu, a teacher at the Mhlabuvelile Senior Primary School at Ludeke Mission, has come with 16 children, “the ones who struggle to see what we write on the chalkboard”.

Bulelwa Mqhayi from Nomathebe Primary School in Isithukutezi adds: “It’s great that they can help these kids. Most of the parents are unemployed and on social grants and don’t have the money to take the kids to specialists. The clinics don’t help us with eye problems.”

The youngsters will also have a range of other health checks and will be sent to see one of the doctors on site if found to be in need of further health assistance. The health department has deployed a mobile dental unit, an audiologist, as well as a medic to provide advice on family planning and reproductive health.

A child being signed in for a health check at Bizana. (Photo: Sue Segar/Spotlight)

Before arriving at the registration desk, the children have already been given deworming tablets and a Vitamin A supplement, provided by the health department, while each group is given a health talk on age-dependent topics ranging from hand hygiene, to TB and HIV.

After handing in their registration and consent forms, the children go through basic vision screening tests by a team of “eye care ambassadors” – young people supported with employment opportunities through the Social Employment Fund, which is managed by the Industrial Development Corporation.

If the school children fail the eye screening test, they are sent to see optometrist Johan van der Merwe.

In between patients, he tells Spotlight he’s already found a number of “low vision candidates” and one who might need to be placed in a special school. “I’ve just done a full refraction on one child … It’s clear that he has a lens defect,” says Van der Merwe. Placing his hand on the head of another small boy, he continues: “This little one has been very quiet … he’s struggling to communicate. He needs thick lenses, or an operation by a specialist.”

Van der Merwe, who has been an optometrist for 22 years, joined the Umbono Eye Project permanently almost two years ago after volunteering his services once a week. “Before I joined, I was working in a mall in East London. I never saw sunlight.” He adds: “It has been very rewarding to make a difference to these children.”

Optometrist Johan van der Merwe assesses a child at Bizana. (Photo: Sue Segar/Spotlight)

At another mobile site, health department dentist, Dr Unathi Mponco, has been busy with youngsters suffering from a range of dental ailments. “There were sore teeth, rotten teeth, mobile teeth, and some children had very swollen gums…. Whatever I can treat on the mobile truck, I deal with here – otherwise if they need X-rays or the cases are more serious, I refer them to the hospital’s dental unit for a comprehensive exam,” she says.

In a mobile van outside the hall, health department medic Siyabonga Chonco has been consulting teenage girls all day offering family planning services. “The Alfred Nzo district has the highest rate of teen pregnancies in the Eastern Cape. We are trying hard to curb teenage pregnancy,” he says.

The teens are invited to ask any questions and to say whether they are sexually active and ready to take contraceptives. Chonco says in almost every case, he senses great relief from the learners to speak to an impartial young person. “They tell me that, at the clinics, the older nurses can be quite harsh…. They open up to me, especially with questions about contraceptives.”

He says broadly, young people are interested in long-term contraceptives. “They don’t want to have to go to clinics all the time.” Some will walk away with a contraceptive implant – a flexible plastic rod about the size of a matchstick that is placed under the skin of the upper arm to prevent pregnancy over three years – while others will choose injectables or pills.

At the end of two days in Bizana, the team has seen nearly 750 youngsters from about 40 schools, with 432 having had their eyes screened and 52 eligible for specs. For six of those children, the spectacles will be life-changing, says Van der Merwe.

Doctors Eileen Kaba and Anda Gxolo consulting with their little patients. (Photo: Sue Segar/Spotlight)

Apart from a few “high” prescriptions that might have to be ordered from overseas, a member of the team will deliver the specs personally to each learner, an occasion which is a highlight for the team. “When we first put the glasses on their faces, you just see smiles. The parents are so thankful. It makes this so worthwhile,” says Van der Merwe.

Keready is working closely with the provincial departments of health and education. The NGO recently received the Eastern Cape’s Batho Pele Award for enhancing healthcare in the province.

“We could never reach all these children as government,” says TD Mafumbatha, mayor of the Winnie Madikizela-Mandela municipality, adding “this is what collaboration looks like”.

But where did it all begin?

Keready, loosely translated as “We are ready”, was set up in February 2022 to encourage young people to vaccinate against COVID-19.

One of the people behind Keready is Harris, a pharmacist and consultant by training and a former deputy director-general of education in the Eastern Cape. Harris was working as a consultant for the Fort Hare Institute of Health, when he was asked to help design the Eastern Cape’s COVID vaccine rollout strategy.

“The COVID programme was a success because, through advanced digitisation, we were able to map the 84 000 communities in South Africa to their nearest schools, clinics and hospitals,” he says.

And it is out of that awareness of the spatial distribution of healthcare needs that Keready was born.

After the COVID programme ended, Harris, as national lead for the project, was tasked with setting up Keready’s offices in four provinces, including employing provincial leads, and staff as well as doctors and nurses. “Our vision was to give young doctors the opportunity to manage at the highest level, under our guidance.”

Implemented by DG Murray Trust (a South African philanthropic foundation) in partnership with the National Department of Health, Keready is funded by the German government through the KfW Development Bank.

The project reached full scale late last year with 46 mobile health clinics in four provinces: Eastern Cape (8), Gauteng (16), KwaZulu-Natal (13), and the Western Cape (9).

These mobile clinics move into different communities every day. At times they use a loud-hailer to attract people. Sometimes they are based at schools, other times at taxi ranks and other hubs of activity.

People of all ages who visit the clinics are provided with a range of health services, including screenings and tests for HIV, TB and diabetes, as well as given family planning advice and immunisations. Medication is prescribed, and, where possible, dispensed on the spot.

Keready also runs a WhatsApp line where youth can ask young doctors and nurses any health-related questions and get straightforward, non-judgemental answers.

When learning about Keready during a walkthrough of exhibition stands set up at the Birchwood Hotel in Boksburg during the 2023 Presidential Health Summit, President Cyril Ramaphosa described the movement as “NHI on Wheels” because of its efforts in addressing universal health coverage.

From Bizana to Whittlesea

Two weeks later, I am again travelling with the same Keready team – this time to Whittlesea, outside Queenstown. Over two days, we visit the Ekuphumleni Community Hall and Kopana School in Ntabethemba. A highlight of this outreach is that teenage girls will be supplied with sanitary pads, thanks to a collaboration with pharmaceutical and healthcare company Johnson & Johnson.

On day one, hundreds more pupils than anticipated arrive. School principals were over-enthusiastic in spreading the word of the outreach resulting in taxi-loads of pupils from unexpected schools arriving. Irate teachers try to negotiate a way for their pupils to be seen.

Teacher Nolitha Tuta tells me many of the children she’s brought are from child-headed households and some have had little to no access to healthcare services.

While waiting in the queue, a mother of a child from Bhongolethu Primary School describes how she walked for hours to bring her child for eye testing.

Children line up for their health checks at the Kopana School in Ntabethemba. (Photo: Sue Segar/Spotlight)

Despite having waited until the end of the day, students from Zweledinga High end up being driven back home at sunset without being assisted.

After two days in Whittlesea, nearly 1 200 pupils from 36 schools have arrived. Nine schools were turned away. Nearly 700 learners have been screened for eye conditions, with 88 eligible for specs and four referred to an ophthalmologist.

The doctors look exhausted. Dr Anda Gxolo says over the past two days numerous children presented with ear problems. There were also long lines for dental care this time.

Despite the long hours, Dr Phumelele Sambumbu, who manages five of the eight Keready mobile clinics in the Eastern Cape, says she loves her work. “I come from these parts – from a village between Cofimvaba and Tsomo. My old grandmother is bedridden. I know first-hand how difficult it is to have access to care when you’re from a village like that and when you suffer from ailments like that. The idea of bringing health services to people who would otherwise struggle to access them is what drives me,” she says.

Mapping the need

Based on its relationship with the department of health, Keready has ambitious plans to expand its grassroots outreach programmes to help narrow the gaps in healthcare nationally.

A map on the wall of Keready’s office shows the number of government clinics in the Eastern Cape relative to schools. There are around 700 clinics in the province, but over 5000 schools (which works out to more than seven schools per clinic). Nationally, the ratio is similar with around 3 400 clinics and 25 000 schools.

It’s no surprise then that, according to Harris, staff on Keready’s 46 mobile clinics in the four provinces where it operates cannot keep up with demand for their services.

“Based on our mapping of the national population, we know there are 2 500 communities that don’t have reasonable access to a clinic. Just to deal with the gaps, we need 2 500 mobile clinics. We can tell you exactly where in the country to put them,” says Harris.

To reach ill people who are ill but don’t know it, Keready aims for nurse-supervised ambassadors to do door to door visits in communities to check who has TB, HIV and hypertension. “We have digitised every street and every house by satellite. Each house would be marked off; if TB’s picked up, it is mapped,” says Harris.

Plans for the door to door programme are well under way, he says. “In the Eastern Cape, Keready has partnered with the Small Projects Foundation to train 80 young people [as nurse-supervised ambassadors] from the Industrial Development Corporation’s Social Employment Fund to do health testing house to house.”

Eventually, says Harris, there could be 80 people linked to each of the 46 mobile clinics, meaning that a total of 3 680 trained people could be going from door to door.

“Going forward we’d want to find the disease before the disease finds us – TB, HIV, hypertension, diabetes and general growth issues [in children] are the core areas we will address in this programme,” he says.

But the extent to which Keready can deliver on its ambitious expansion plans will depend on funding and to what extent government continues to implement services using mobile clinic outreach programmes. The German financial contribution to the Keready project comes to an end in September. “We are working day and night to get more funding,” says Harris. He says they will soon be meeting with potential donors.

Disclosure: Segar was hosted by the Keready team.

Republished from Spotlight under a Creative Commons licence.

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Categories : Substance UseTags : 9/7/24 codeine cough syrup opioid crisis Spotlight1 Comment

Codeine Addiction in SA: New Guideline Aims to Curb Abuse

On July 9, 2024July 10, 2024 By ModernMedia

By Jesse Copelyn

Rehab centres in South Africa have been admitting an increasing number of codeine users in recent years. Now, the country’s medicines regulator has published a draft guideline as part of a broader effort to track suspicious codeine sales.

South Africa’s medicines regulator – the South African Health Products Regulatory Authority (SAHPRA) – has released a new draft guideline which it says will help stem the misuse of codeine. The opioid, which is found in certain pain relief medicines and cough syrups, is used by some people in large doses to get high.

Under the new draft guideline, the regulator can request sales data (and other information) from manufacturers, suppliers or distributors of any scheduled medicines. This would allow them to track the flow of codeine all the way “from the manufacturer to the dispensary, be it a clinic, pharmacy, hospital, or doctor’s practice”, SAHPRA’s communications officer, Nthabi Moloi, told Spotlight.

Why is this important? Until now, health authorities have struggled to detect suspicious sales of codeine, which is found in both prescription and over-the-counter medicines. This problem manifests in two ways. For one, recreational users can often get a continuous supply of codeine directly from pharmacies. While people are only permitted to purchase a limited amount of the drug, many bypass this simply by buying from different pharmacies. It’s largely impossible to flag these individuals since there is no centralised data on what medicines people buy across vendors (though attempts have been made to address this).

The second issue relates to wholesale supply. Following a Carte Blanche investigation flighted last year, SAHPRA confirmed that a pharmacy group was making illicit bulk sales of codeine-based cough syrups. While patients are only allowed to get codeine from a licensed health worker or pharmacist, it’s thus no surprise that it can also be found on the black market.

The new draft guideline aims to tackle both of these problems by allowing SAHPRA to request information from companies and health workers about how much codeine they’re producing, selling or dispensing and who it is being provided to. This would “enable SAHPRA to detect anomalies in the distribution of medicines prone to abuse, such as abnormally large orders by dispensaries” Moloi explains.

It is the “first phase”, she says, of the codeine care initiative – which is an effort to centralise data on all codeine sales along the entire supply chain nationally. The plan is to ensure that the regulator can flag anything from an individual who is buying large amounts of codeine from multiple vendors to a wholesaler who is selling the drug to illicit dealers.

Codeine rehab admissions triple since 2019

The draft guideline, which is now available for public comment, comes at a time in which rates of codeine addiction are soaring throughout South Africa, according to admissions data from drug and alcohol treatment facilities. Most rehabilitation centres around the country are connected to a programme called the South African Community Epidemiology Network on Drug Use (SACENDU), which collects anonymised patient data from the different centres. Professor Nadine Harker, who oversees this project says “if you look at treatment admissions over time, there has been an increase [in codeine-related admissions] over the years – steadily but definitely”.

Indeed, SACENDU’s bi-annual reports show that in the first half of 2019, 277 people who went to SACENDU-linked rehab sites said they had been misusing codeine. This amounted to 3% of all admissions. But by the first half of 2023, this percentage had tripled to 9% – totalling 749 people. (In absolute terms the number slightly less than tripled).

Even before this uptick, health workers were concerned. In the mid-2010s, a survey of 238 (mostly private sector) doctors was conducted across South Africa. It found that 85% of these practitioners were worried about the easy availability of codeine in pharmacies.

Part of the concern is driven by the fact that people who use codeine-based medicines over a long time can develop a range of health complications, including stomach ulcers and liver damage (this is particularly when the medicines contain additional substances like paracetamol). And some people are more vulnerable than others, as genetic factors play a big role in how codeine affects a person.

Why is the problem getting worse?

Part of the spike in codeine use appears to be driven by a trend among young people, who sometimes mix codeine-based cough syrups with cooldrinks. The combination is often referred to as lean, and has become a popular party drug among high school students. Research shows that codeine’s low price and general accessibility is one reason for its popularity. Harker for instance notes that it’s often available at home, where kids “can pick it up out of their mom’s medicine cabinet”.

In other cases, people appear to be relying on the drug not for recreation but to cope with psychological distress. For instance, a 2022 study for which women were interviewed at rehab centres in the Western Cape and Eastern Cape found that many had turned to pharmaceutical products to deal with everything from trauma caused by physical abuse to grief over the loss of a child.

“I just wanted the pain to go away. I wanted my mind to switch off… [the tablets] actually made me dead inside if I can say that,” one woman explained.

A lack of awareness about the dangers of codeine also seems to play a role: 94% of doctors who were surveyed agreed that patients “do not fully understand the risk of dependence in taking over-the-counter medicines containing codeine”. The lack of regulatory control may contribute to this impression: one study at South African rehab centres found that “many participants were of the view that [over-the-counter] codeine-containing medicines were not drug[s] per se due to their free availability to purchase without any real regulations or protocols guiding their sale”.

Shouldn’t we just make codeine prescription-only?

Currently, the law states that codeine-based pills can be bought over the counter only under specific conditions. For one, they have to contain another active ingredient like paracetamol or ibuprofen, and each pill can contain a maximum of 10 milligrams of codeine. A person can only buy one pack and it must contain at most 5 days’ worth of medicine (with no more than 80 milligrams a day). Anything more and a script is needed.

Liquid codeine, like cough syrups, can be bought without a script if it contains no more than 10 milligrams of codeine per teaspoon (the maximum daily dose is 80 milligrams). The bottle itself may not contain more than 100 millilitres of syrup.

Products like Gen-payne, Myprodol, and Stopayne all contain small amounts of codeine – typically in combination with other painkillers such as paracetamol or ibuprofen. (Photo: Towfiqu Barbhuiya/Unsplash)

Some researchers that spoke to Spotlight argue these restrictions are too lenient, and that codeine should be ‘up-scheduled’, meaning that it would only be available if a patient has a script, regardless of the dose or combination. By doing this, children may find it harder to get a hold of cough syrups for lean, and people may generally become more aware of the addictiveness of the drug when used over the long-term.

Indeed, there are some studies which have found this approach to be effective in other countries. Research published in the journal Addiction found that when authorities in Australia made codeine prescription-only in 2018, a large poisoning information centre in the country began to receive significantly fewer calls about codeine-related incidents (both from health workers and members of the public).

But there are also potential downsides to this strategy. For one, as Spotlight has previously reported, increased regulation may make life harder for poorer patients seeking pain relief. This is given that they would have to spend more money for a consultation and prescription if they needed codeine-based painkillers.

Andy Gray, who chairs an advisory scheduling committee at SAHPRA, details a second issue: “I’m not convinced that up-scheduling would solve the issue if what we’re dealing with [in South Africa] is illegal behaviour… If [codeine] is being smuggled out of manufacturers or wholesalers, scheduling is not going to make a difference”.

Dr Andrew Scheibe, a harm reduction researcher at the University of Pretoria, notes a third related problem that may occur. “If people do have codeine-dependence and they’re unable to access the codeine, they might likely shift to accessing opioids… on the black market”.

Scheibe highlights the United States as an example, where prescription opioids like oxycodone and fentanyl have been at the centre of a major drug epidemic. “When they tried to increase restrictions on access to those opioids then people started using heroin,” he notes. A 2022 study found that this had taken place among opioid users interviewed in Connecticut, Kentucky and Wisconsin.

Whatever the answer, researchers agree that some basic steps need to be taken to educate the public. Harker says “a lot of awareness raising needs to happen at various levels, for instance at pharmacies”. She notes that “when someone purchases codeine over the counter, it’s important for a pharmacist to engage [with them and] make the consequences known to the individual if they use it outside of the dosages indicated… And we don’t do that enough from the medical or pharmacist’s side”.

Republished from Spotlight under a Creative Commons licence.

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Categories : Cardiovascular Disease HIVTags : 19/6/24 HIV pitavastatin Spotlight statins

Why a Major Finding on HIV and Statins may not be That Relevant in SA

On June 19, 2024June 19, 2024 By ModernMedia

By Elri Voigt

One of the biggest stories in HIV in the last year was that a class of medicines called statins could help reduce cardiovascular disease in people living with the virus. In response, treatment guidelines in the United States were quickly updated, but the picture is more complicated in South Africa. Spotlight’s Elri Voigt explores why the case for widespread use of statins by people living with HIV is less compelling in South Africa than in some other countries.

People living with HIV, provided they are stable on antiretroviral therapy, are affected by the same diseases as those who don’t have HIV, including cardiovascular disease, says Professor Mpiko Ntsekhe, head of Cardiology at Groote Schuur Hospital in Cape Town.

The key difference, he says, is that although both groups of people get the same spectrum of diseases, people living with HIV get those diseases more frequently and earlier. One way to think about this, he explains, is to imagine twins who are identical in every way except one is living with HIV. The twin living with HIV is more likely to get cardiovascular disease than the other twin.

And these differences can be substantial. Current evidence shows that people living with HIV have a twofold increased risk of developing cardiovascular disease compared to people not living with HIV, says Professor Hans Strijdom. He is the Head of the Division of Medical Physiology and Deputy Director of the Centre for Cardio-Metabolic Research in Africa (CARMA) at Stellenbosch University. The cardiovascular risk attributable to HIV, Strijdom adds, is now believed to be equivalent to that posed by traditional risk factors such as smoking. This prompted an editorial in 2018 in one of the top cardiovascular journals, Circulation, advocating for HIV to be recognised as a major cardiovascular risk factor.

He explains that people living with HIV who are stable on treatment are living longer, making them susceptible to the normal risk posed by older age. They also have “modifiable risk factors, in other words lifestyle risk factors”, like a higher smoking and alcohol use incidence, as well as increasing rates of being overweight and obesity. Strijdom says that living with HIV, even when someone is stable on treatment, causes low-grade inflammation, which over time increases a person’s risk for cardiovascular disease. “That all in combination are the current theories [of] why we think that they have a bigger risk of cardiovascular disease,” he says.

Important study findings

Arguably, the biggest news from last year’s International AIDS Society (IAS) Conference in Australia was findings from a study on heart disease in people living with HIV. The trial, called REPRIEVE, showed that a class of cholesterol-busting drugs called statins can prevent a lot of cardiovascular disease events in people living with HIV whose cardiovascular disease (CVD) risk score meets a certain threshold. Spotlight previously reported on these findings, which showed that compared to placebo, daily treatment with 4mg oral pitavastatin – a specific statin – led to a 35% reduction in major adverse cardiovascular events (MACE) in people living with HIV classified to be at risk of cardiovascular disease.

When the findings were presented at the IAS conference, the study’s principal investigator, Dr Steven Grinspoon, said that while the researchers still have to assess more of the data collected to get a clearer picture of things, like the mechanisms driving cardiovascular disease across regions and conduct additional sub-group analyses, the study has already shown that using pitavastatin can save lives.

These sub-group analyses were discussed in greater detail at the Conference on Retroviruses and Opportunistic Infections (CROI) held in Denver in March this year. For the most part, the use of pitavastatin in the manner prescribed by REPRIEVE was considered a huge success, and the United States has since changed its guidelines to include the use of statins in the primary prevention of atherosclerotic cardiovascular disease.

Why it is different in South Africa

However, for low-and-middle-income countries like South Africa, the case for pitavastatin might not be as clear-cut. In fact, a panel discussion at CROI was dedicated to exploring the implications of the REPRIEVE findings for such countries.

Ntsekhe, who was a speaker on the CROI panel, tells Spotlight that data from REPRIEVE’s sub-group analyses reveal there was a striking difference in event rates – which in the case of the study are MACE in those who were getting the placebo – by country income status. He explains that as predicted in high-income countries, the event rates were high, while in low-and-middle income countries – particularly in Sub-Saharan Africa – event rates were very low.

He says one of the reasons for the difference in event rates was that the screening tool used in REPRIEVE worked well to identify those people living with HIV who might benefit from pitavastatin in high-income countries like the United States, but it did not work well in Sub-Saharan Africa.

This means using pitavastatin as part of a primary prevention strategy is a much more effective intervention in high-income countries than in low-and-middle income countries like in Sub-Saharan Africa because the cardiovascular disease profile is so different.

Ntsekhe explains the term cardiovascular disease itself is broad and all-encompassing and there are many forms, including valve disease, heart muscle disease, and vascular disease. The dominant form of cardiovascular disease in the high-income countries (which he refers to as the Global North) is known as atherosclerotic cardiovascular disease, which is characterised by a build-up of fatty deposits and plaque in the arteries.

In Sub-Saharan Africa though, Ntsekhe says “atherosclerotic cardiovascular disease is but one of many forms of cardiovascular disease”, taking the fourth or fifth place in the ranking of types of major heart disease.

Research conducted in high-income countries don’t always take differences in disease burden into account, according to Ntsekhe. This means that interventions researched in high-income countries and shown to be effective in that context won’t necessarily work as well in low-and-middle income countries like South Africa.

Strijdom concurs that while results from REPRIEVE in the global context were a game-changer, the findings are not easily transferable to South Africa’s context because pitavastatin is mainly aimed at reducing “bad cholesterol” and coronary artery disease (also called atherosclerosis).

‘Taking money away’

During the panel discussion at CROI, Ntsekhe asked whether Sub-Saharan Africa could justify taking money away from other health programmes that work in order to invest in pitavastatin.

“I said basically what should be a priority for us is a) finding tools that can better identify those at risk and b) continuing to focus on what our local data suggests are the priority areas,” Ntsekhe says.

“If your entire prevention strategy is aimed at atherosclerotic cardiovascular disease, but it isn’t the dominant cause of disease [in your country], you’re going to be treating a whole host of people to try and tackle this thing that affects very few in a sense,” he says.

“It was not anything about REPRIEVE, it was a wonderful study, the hypothesis was tested, and it was shown to be correct, the intervention we know works,” Ntsekhe says. “It really then comes down to regional areas to think very carefully about how best they’re going to get their biggest bang for their buck,” he says. “We have to carefully consider the local context, local burden, we have set local health priorities, and weigh benefit and cost before we adopt new interventions or recommendations.”

SA’s cardiovascular disease burden

While Strijdom says we don’t have great data, he points to a large systematic review and meta-analysis published in 2018 in Circulation, which estimates that around 15% of the total cardiovascular disease burden in South Africa is attributable to HIV. “It’s probably higher than that. I would say that probably about one in five people with heart disease have heart disease because of HIV in South Africa,” he says, adding “that figure is probably only going to increase”.

Because of this, he says, there is a need for proper and clear primary healthcare guidelines specifically aimed at managing cardiovascular disease in people living with HIV, which we don’t currently have.

Strijdom says what we have at the moment since the rollout of the 2019 National ART Clinical Guidelines is very basic guidelines. This involves screening someone who has just been diagnosed with HIV by taking their blood pressure, and testing urine for glucose and proteins, and an assessment of their general cardiovascular disease risk by taking their medical and family history. These guidelines, according to Strijdom, only make provision for routine screening at baseline, but screening guidelines at follow-up visits are insufficient.

“I am, however, aware of the fact that there is progress especially from the integrated chronic disease management model which is currently being piloted in South Africa – and hopefully with that will come much more definitive and universal guidelines,” he says. “The bottom line is that South Africa, in its public health [sector] especially, really very quickly needs to come up with very clear and more comprehensive guidelines to actively manage cardiovascular disease risk in people with HIV.”

Need for annual screening

Strijdom suggest that to improve screening for cardiovascular disease risk in people living with HIV, there needs to be annual screening of people’s weight, their measure of body fat based on height and weight, waist circumference, blood pressure, cholesterol and triglyceride levels as well as testing urine samples for kidney function. There also needs to be a thorough family and medical history conducted for each patient.

“It’s not really a very expensive or very exhaustive list of stuff that you have to do. Unless of course they have specific symptoms and signs that leads you in a specific direction that you then have to perhaps do an ECG [a test used to evaluate the functioning of the heart] or cardiac imaging but that is usually determined by what you get from their history and clinical examination,” he says.

Ntsekhe says public health strategies to combat the growing burden of non-communicable diseases (NCDs), including cardiovascular disease, in South Africa must be strengthened. These include screening and prevention tools like checking a patient’s blood pressure and blood glucose, advising against smoking and alcohol as well as promoting health lifestyle choices like exercise and weight loss. These interventions should be offered to everyone, regardless of whether they are living with HIV or not, he says.

“The thing about NCDs and cardiovascular disease, for the most part, they are diseases of lifestyle and behaviour. So, when you talk prevention, it’s not always about drug prevention,” he says. “It’s more about intensification of those [interventions] that are already in the public domain, are very effective, and cost very little. Many of the public health and primary healthcare guidelines do advise local ministries, local health authorities on what should be happening.”

In terms of public education, Stritjdom says people need to be aware that there is something like high blood pressure. “If people are aware they will come to the clinic and will say please measure my blood pressure,” he says.

“Our health system is understandably focused on infectious diseases, but if we are not careful, we will then be totally unprepared to tackle the epidemic that will have replaced it. Namely, cancer, heart disease, stroke, obesity, diabetes, and it will totally overwhelm our public healthcare system,” he says.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags : 10/6/24 Minister of Health public health South Africa Spotlight

The Health Minister SA Needs: Astute Politician, Inspired Leader, Humble and Fair

On June 10, 2024June 11, 2024 By ModernMedia

By Ufrieda Ho

By month end, South Africa will have a new Minister of Health. Ufrieda Ho asked some academics and activists what qualities that person should have to tackle the key health issues the country faces.

The precise health minister South Africa needs right now may not exist. But the portfolio still demands that the person appointed to this critical position be up to the job.

The appointment, when it happens, will come against a radically shifted political backdrop. Firstly, the elections results of the May 29 point to a coalition government for the first time in 30 years of democracy. The final configurations of a likely government of national unity is still anyone’s guess. And secondly, the National Health Insurance (NHI) bill is now an Act. President Cyril Ramaphosa signed off on the bill just a fortnight before the elections. It means by law, the work on the advancement of NHI must begin even as the contentions and contestations remain as thorny as ever.

Another reason why getting the right person matters is the money that comes with the portfolio. Annual government spending on health is in the region of R270 billion. Most of this spend is currently directed via provincial health departments, but flows under NHI will be nationalised and the NHI Act gives the minister extensive powers over NHI, and indirectly, the NHI fund.

At the same time, problems like entrenched health sector corruption and high levels of medico-legal claims against the state remain acute. Health budgets have been shrinking in real terms over the last decade. Financial shortfalls and shortages of healthcare workers in our health facilities are dire, while health needs enlarge.

Bridging ideological divides

Fatima Hassan, a human rights lawyer and founder of the Health Justice Initiative, says: “Policymaking in a coalition government is going to be so difficult – a Herculean task. And the place where you’re going to feel it most acutely is in health, because we have a dual health system and because NHI is sitting on the table.”

She says the role of minister will call for an astute politician. She says: “It must be someone who can work with different parties as well as constituencies in different sectors to try to bridge a number of these ideological divides.

“Health is a lightning rod for the differences between the different political parties; we saw this in how the parties campaigned for or against NHI,” she says.

Hassan says the worst case scenario will be someone in the position who is a “placeholder minister” who stalls on reforms, is a person more concerned with “calming the markets” and someone who will simply play the political long game waiting it out until the next elections.

“It must be someone who is able to work on creating a fairer system for access to proper healthcare services across the country, not just in specific provinces. They must invest in health infrastructure, invest in human resources for health, and invest in some of the more positive aspects of preparing for national health insurance,” she says. She adds that the person must prioritise fixing the “glaring issues in the NHI Act” to avert looming law suits.

In addition, Hassan says the minister must be someone who can stand up to the bullying of private sector power, including the likes of big pharma, and must be able to show leadership on domestic health issues while also being a strong Global South voice on international platforms to champion global health equity.

‘Health is more than a biomedical response’

Professor Scott Drimie is a researcher at the University of Stellenbosch and director of the Southern African Food Lab. Drimie works on food systems and food security and how these intersect with the social determinants of health.

For Drimie, South Africa’s health minister must be a person with an expansive leadership style; a person who is able to work across government departments and also be awake to the grassroots realities people face. Around 85% of people in South Africa rely on public healthcare.

“The minister must be able to grapple with the lived reality of most poor people and put in place a health system that supports the most vulnerable.

At the same time, that person should be someone who understands that health is more than a biomedical response – health is also issues like food security, sanitation, stable livelihoods and safety,” he says.

Another quality Drimie highlights is that the minister should be open to collaboration and experimentation. He says there has to be a “whole-of-government” approach and a “whole-of-society” approach. The Department of Health cannot achieve its key performance indicators on its own; it needs to collaborate with departments including social development, education and basic education.

“It must also be able to be bold with programmes and work with communities directly as well as with civil society, health advocates and health activists,” he says.

Reform of bureaucracies in the health department must also be something the minister tackles, Drimie says. He says it means appointing effective managers who are not micro-managed or politically influenced. Effective implementers of policies and programme, he says, can be a counterweight to politics.

“Politicians can come with very short-term, very narrow party politics,” says Drimie. But, he adds, enduring and relevant health programmes survive beyond political tenure and are more likely to achieve positive health outcomes.

Put people first and ‘show humility’

For activist Anele Yawa, who is secretary general of the Treatment Action Campaign, we need someone who puts people first. He says the minister must serve the interests of people and show humility for the office.

“The minister must not be someone who pushes his or her agenda. A minister is appointed; he or she did not submit a CV to us. So a minister must understand that there will be times when we as citizens and civil society will disagree with them. It’s because we will continue to speak truth to power, we will continue to hold them accountable; whatever the new coalitions will look like,” he says.

“Our ministers must not be arrogant and think it’s because we hate them. We will disagree and we will fight because it is an effort to make sure that things are done the right way and we can bring health services to the majority – it’s that person who is working class, black and is a woman,” says Yawa.

He says it means a strong minister must be one who maintains an open-door policy; who arrives at community meetings in person; take calls personally and engages.

Yawa says it’s also critical that the seventh administration is one that works cohesively. “We voted on the 29 May for a contractual agreement with government; not a fashion show. It means that we don’t just need a good health minister, we need a good administration that delivers on water and sanitation, on education and on social development, and so on.”

Motivate and inspire

Professor Lucy Gilson is head of health policy and systems division in the School of Public Health at the University of Cape Town. Her top qualities for a good minister also centre on people skills. She says the health minister in South Africa must be an inspiring leader.

“The person must be able to motivate health workers and managers to be the best public servants they can be.

“The person must also inspire the public to trust in the public health sector,” Gilson says.

The new health minister must have strategic management skills, she says. These will be necessary to navigate the complexity of power and interests in a coalition government and to figure out how the NHI will take shape.

In the end, she says the person in the post should have patience and persistence. She adds: “Bringing change to the health system is a collective and sustained effort over time. The minister must be able to strengthen capacity, assemble coalitions and networks of learning, experience and mutual accountability.”

Republished from Spotlight under a Creative Commons licence.

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Categories : Respiratory DiseasesTags : 8/6/24 South Africa Spotlight tuberculosis

Slow Progress after Decision to Make TB Prevention Pills More Widely Available

On June 8, 2024June 8, 2024 By ModernMedia

By Tiyese Jeranji

Besides preventing illness and death, tuberculosis prevention therapy is estimated to be highly cost effective. Yet, uptake of the medication is not what it could be in South Africa. Tiyese Jeranji asks how much has changed since the Department of Health last year decided to make TB prevention therapy much more widely available.

Many people who have the TB bug in their lungs are not ill with TB disease. Having the bug in your body, does mean however that you are at risk of falling ill, should the TB bacteria get the overhand in its battle with your immune system.

Fortunately, we have medications that can kill TB bacteria before one falls ill. A recent World Health Organization (WHO) investment case, suggests such TB prevention therapy, commonly called TPT, reduces the risk of falling ill with TB in those exposed to the bug by 60% to 90% compared to people who do not get the treatment.

In South Africa, TPT has been available in the public sector for years, but until the publication of new government guidelines last year, only kids aged five or younger and people living with HIV could get the medication. Under the new guidelines, everyone who has had close contact with someone with TB should be offered a TB test and if they test negative be offered TPT – if they test positive they should be offered TB treatment. These changes dramatically expanded the number of people in South Africa who are eligible for TPT.

The antibiotics used for TPT has also changed in recent years. For many years, the only option was a medication called isoniazid taken for six or more months. We now also have two three-month options – isoniazid and rifapentine given once weekly and rifampicin and isoniazid given daily. These shorter duration treatment courses should help more people complete the treatment.

Down and up?

Dr Norbert Ndjeka, Chief Director of TB Control and Management at the National Department of Health, tells Spotlight that in recent years, South Africa has seen a steady decline in the number of people initiated on TPT.

The decline has been substantial. In people living with HIV, initiation on TPT dropped from 454 000 in 2018 to around 241 000 in 2023. In children aged five and younger who have had contact with someone with TB, it fell from 25 357 in 2018 to 15 775 in 2023.

TPT enrolments per province for 2023

Province	People living with HIV	Contacts < 5 Years	Contacts > 5 Years
Eastern Cape	34 623	2 551	4 771
Free State	14 535	562	1 027
Gauteng	67 333	1 368	4 241
KwaZulu-Natal	62 362	3 168	8 519
Limpopo	15 871	391	452
Mpumalanga	25 618	669	2 006
Northern Cape	3 178	855	1 595
North West	9 433	596	1 425
Western Cape	8 532	5 615	1 278
South Africa	241 485	15 775	25 314
*Typically, provinces with higher numbers of people diagnosed with TB or those with high numbers of people living with HIV will report higher TPT initiations.

There are two significant reasons for this decline, according to Ndjeka. Firstly, declining TB incidence, and secondly, declining HIV incidence.

“With fewer people diagnosed with TB disease, fewer contacts will need TPT, and with fewer people being diagnosed with HIV, fewer people will initiate TPT regardless of TB exposure,” he says.

WHO figures have shown a significant downward trend in the estimated TB cases per year in South Africa and according to Thembisa, the leading mathematical model of HIV in South Africa, the number of people newly starting HIV treatment has dropped from a peak of over 700 000 in 2011, to well under 300 000 in 2023.

But the recent downward trend in people taking TPT may be coming to an end. “We believe that the implementation of the new guidelines within the current strategic framework will lead to increases in TPT enrolment,” says Ndjeka.

In line with the new guidelines, there are also changes to what TPT data is being collected. “For example, we never used to report on TPT provision to contacts 5 years and older, but now we do and in 2023 at least 25 314 TB contacts 5 years and older were initiated on TPT,” he says.

20% increase expected in 2024

Based on the data reported for January and February of this year, Ndjeka expects that overall TPT initiations will increase by at least 20% in 2024 compared to 2023. Moreover, as documented in the National Strategic Plan for HIV, TB and STIs 2023-2028, there is a plan to have a steady annual increase in TPT enrolments leading up to 2028.

Ndjeka says based on the NSP TPT targets, South Africa is exceeding TPT targets for people living with HIV, but reaching less than 25% of targets for TB contacts. He points out that performance varies by province, but that all provinces have a long way to go in terms of reaching TB contacts.

‘Cost saving over time’

“The aim of offering TPT is to reduce the TB incidence,” Ndjeka says. “So, if everyone eligible is offered TPT there will obviously be increased costs initially but cost saving over time. This looks at cost of treating people with TB, lives saved/ deaths prevented as well as costs to patients.”

For South Africa, he says, it is estimated that we can reduce the number of people with TB by 138 000 by 2050 at an estimated cost of R23 226.90 per TB episode prevented.

Ndjeka says it costs the health department an estimated at R1 498.51 to treat one person with drug-susceptible TB for 6 months and R16 612.82 to treat one person with the standard drug-resistant TB treatment for 6 months. “These costs are for medications alone, which can also go beyond R70 000 depending on the patient and the type of resistant TB. Moreover, when factoring in clinical consultations, hospitalisations, and costs to patients the costs go up considerably,” he says.

The cost of providing TPT also depends on the regimen. One person on TPT can cost as little as R608.77 for a course of three months of isoniazid and rifapentine given once weekly, and up to R1 358.02 for 12 months of isoniazid. “TPT also has much lower associated costs for example there is no hospitalisation, fewer clinic visits and consultations,” Ndjeka says.

“By preventing TB, the cost of TB treatment is avoided along with the costs of treating some of the acute and chronic conditions that someone with TB may experience even after being cured of TB. These include chronic obstructive pulmonary disease, bronchiectasis and pneumonia,” says Alison Best, communication manager at Cape Town-based NGO TB HIV Care.

“For children under five in particular, who are at increased risk of disseminated TB like TB meningitis, the cost of not preventing TB could be death or severe lifelong disability,” she says, adding that preventing TB in a single individual also prevents the costs associated with any onwards transmission of TB from that individual to others.

Questions over implementation

Expanded TPT eligibility has been widely welcomed, but questions have been raised over how well the new guidelines are being implemented.

Best says government austerity measures have made implementing new initiatives in the healthcare setting challenging.

“There is not much political will to implement the guidelines (to expand eligibility for TPT) at provincial and district levels and this has translated into the slow release of circulars, delays in training health workers, poor knowledge of the policy and its low prioritisation,” she says.

Ingrid Schoeman, Director of Advocacy and Strategy at TB Proof (a local advocacy group), says often when a national policy is released, there are delays at provincial-level in releasing circulars to enable health worker training.

“This results in these services not being available at district-level. In the Western Cape, civil society organisations, the [provincial] Department of Health, City of Cape Town and implementing partners are now all working together to support health worker training, and implementing community-led awareness campaigns so that all close TB contacts know they are eligible for TPT,” she says.

Best adds that tracking the data to show how many people are starting and completing TPT tends to be difficult. She notes there are many gaps in capturing the information. This includes, at times, the limited recording of information in patient folders by clinicians and suboptimal inputting of data by data capturers.

Ndjeka says the national department of health has been conducting training on the new guidelines with provincial and district TB and HIV programme managers, district support partners and other trainers.

“They are then responsible for training health care workers. The antiretroviral therapy guideline training also includes TPT. Webinars on the knowledge hub (an online training platform) have also conducted,” he says.

However, Ndjeka conceded that there is a lack of awareness about the value of TPT. “Additionally,” he says, “there is reluctance from clinicians to provide TPT. This result in poor demand for TPT. Treatment adherence is another problem especially for people on the long regimen (12 months)”.

Plans to address these challenges, among other things, include marketing TPT as treatment for TB infection rather than prevention, targeted communication strategies, community mobilisation, and ongoing training and mentoring of healthcare workers, says Ndjeka.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags : 4/6/24 elections 2024 Minister of Health South Africa Spotlight

Who will be SA’s Minister of Health in the New Cabinet?

On June 4, 2024June 4, 2024 By ModernMedia

By Marcus Low

ANC President Cyril Ramaphosa, with Minister of Health, Dr Joe Phaahla and his deputy Dr Sibongiseni Dhlomo, during the signing into law of the National Health Insurance Bill. (Photo: @MYANC/Twitter)

After the ANC received less than 41% of the votes in last week’s national elections, negotiations are now underway that will determine how and by who South Africa is governed. Ministerial posts, including the country’s top health job, might be on the negotiating table. Spotlight considers the candidates for the post of South Africa’s Minister of Health.

For most of the last 30 years, it went almost without saying that the country’s Minister of Health would be drawn from the ranks of the ANC. But given the dramatic decline in the party’s electoral fortunes and the consequent pressure to enter into coalitions or other deals, the pool of realistic candidates for the post of health minister might this year be larger than before.

The President has the prerogative to appoint any members of the National Assembly as ministers, whether or not they are of the same party as the President. The President can also at his or her discretion appoint two ministers who are not members of parliament. It is also relatively trivial for a party to ask a Member of Parliament (MP) to stand down and to have another sworn in, as happened with Minister of Electricity Kgosientsho Ramokgopa. This means that candidates who were not high enough on party lists to get seats in parliament could still be substituted in.

Although technically the pool of possible health ministers is thus quite large, political realities narrow the choices down considerably.

Let’s start with candidates from the ANC, given that odds are still that our next health minister will be from the party.

First in line is South Africa’s current Minister of Health Dr Joe Phaahla. He is not on the ANC’s national candidates list, but he is high up on the party’s regional list for Limpopo and thus set to become a member of the National Assembly. Though some might describe his time as health minister over the last three years as uninspiring, he also hasn’t been implicated in any scandals or made any obvious blunders.

It might well be that President Cyril Ramaphosa, presuming he stays in the job, sees Phaahla as a safe pair of hands and considers him the right person to drive the ANC’s stated goal of preparing for and starting the implementation of National Health Insurance. Phaahla previously served for some years as Deputy Minister of Health.

Second in line is the current Deputy Minister of Health Dr Sibongiseni Dhlomo. He is also not on the ANC’s national list, but he is high up on the ANC’s KwaZulu-Natal regional list and thus also set to join the National Assembly. He is a former MEC of health for KwaZulu-Natal and former chair of parliament’s portfolio committee for health. If Phaahla is not to return, Dhlomo would be the most natural replacement.

After those first two candidates, things get much harder to predict.

Former health ministers Dr Aaron Motsoaledi and Mmamoloko Kubayi are on the ANC’s national list and Dr Zweli Mkhize is on the ANC’s KwaZulu-Natal regional list. Given that Motsoaledi’s time at Home Affairs has been something of a disaster, it is not impossible that Ramaphosa might feel he can get more out of him back in the health portfolio where his record was somewhat better.

A return of Mkhize to the health portfolio seems extremely unlikely given the grubby circumstances under which he left. Kubayi’s role for a few months as acting health minister was really just that of a care-taker, and a return is unlikely.

One interesting trend is that the ANC has largely chosen medical doctors as health ministers and deputy ministers – Phaahla, Dhlomo, Motsoaledi, and Mkhize are all medical doctors.

Current Eastern Cape MEC for Health Nomakhosazana Meth is high on the ANC’s national list, though the poor performance of the Eastern Cape Department of Health in recent years should mean her chances of getting the top health job are slim.

In previous years, current Limpopo MEC for Health Dr Phophi Ramathuba was considered a possibility by some, but her name is only on the ANC’s candidates list for the Limpopo legislature and a few ill-judged incidents, such as a video in which she berated a pregnant woman, would make her a controversial choice. She’s also often been at loggerheads with unions in Limpopo. A lack of standing with healthcare workers may also hold back the prospects of one or two others with health backgrounds who did make it onto the ANC’s national list.

Candidates from other parties

The DA remains South Africa’s official opposition. Should they become part of a ruling coalition or government of national unity, the current Western Cape MEC for Health would be the party’s most obvious candidate for the role of health minister. Mbombo is however only on the DA’s list for the Western Cape legislature and is thus likely to again be the province’s MEC for health.

Jack Bloom, the party’s leading health MPL in Gauteng over the last two decades would be a long shot for the post of health minister, as would Dr Karl le Roux, an award-winning rural doctor who has joined the party. Bloom is on the DA’s list for the provincial legislature and not on the lists for the national assembly. It is thus not entirely out of the question that he could become MEC for health in Gauteng.

The EFF received the fourth most votes nationally, having been third in the previous national elections. In the previous parliament they were represented on the portfolio committee for health by Dr Sophie Thembekwayo (not a medical doctor) and Naledi Chirwa. Chirwa is last on the EFF’s national candidates list and is thus very unlikely to return to the National Assembly. Thembekwayo is 36th on the EFF’s national candidates list.

It is also possible that other parties such as MK or the IFP could end up as part of a governing coalition or government of national unity and that candidates from these parties would thus also be in with an outside chance for the top health job. There will be many new, and to us unknown, faces in parliament – no doubt we’ve missed some people with solid health backgrounds in our analysis.

As mentioned earlier, the President can appoint two ministers to his or her Cabinet from outside the National Assembly. It is thus possible that someone with health management expertise could be roped in from outside the usual political circles.

Though very long shots, outsiders like Dr Fareed Abdullah – former CEO of the South African National AIDS Council and an important player in the early days of HIV treatment – or Professor Glenda Gray – outgoing President of the South African Medical Research Council – might well, and arguably should, be considered. Though we’d be surprised if strong outsider candidates like these two are interested in the job given how politically fraught the role is likely to be. That said, we suspect the right outsider candidate would be a hit in healthcare circles.

Ultimately, whichever way the current negotiations pan out, the ball remains in the ANC’s court when it comes to determining who will be our next Minister of Health. That means the decision is likely to remain subject to the ANC’s internal politics, with all the complexities that entails.

Despite all the intriguing possibilities, chances are thus that it will be Phaahla or Dhlomo who get the nod – and in terms of South Africa’s healthcare trajectory things will probably remain roughly as they are now.

Republished from Spotlight under a Creative Commons licence.

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Categories : Expert Opinion Healthcare Politics and RegulationsTags : 23/5/24 NHI Spotlight universal healthcare University of Cape Town

Let’s be Pragmatic – the NHI has Constructive and Contentious Aspects

On May 23, 2024May 23, 2024 By ModernMedia

By Susan Cleary for Spotlight

Professor Susan Cleary delivering her inaugural lecture as part of a lecture series by the University of Cape Town. (Photo: Supplied)

President Cyril Ramaphosa recently signed the NHI Bill into law. The question is whether this will bring South Africa closer towards Universal Health Coverage. Professor Susan Cleary argues that the NHI is a wide ranging reform with both positive and controversial aspects. The key will be to find a middle ground in order to continue on the journey to UHC.

President Cyril Ramaphosa signing the National Health Insurance (NHI) Act on the eve of the elections is a smart move from the perspective of a political party seeking to shore up its base. The concern though to those of us working to strengthen the health system is whether the NHI will enable the country to move closer towards Universal Health Coverage.

For the NHI naysayers, perhaps it would be important to alleviate some fears and concerns. The NHI is a long-term project. In the 2024 budget, National Treasury reduced the conditional grant allocations to the NHI in comparison to what was allocated in the 2023 budget. While signing the NHI Bill into law is a step forward, the reduction in resources towards NHI implementation reminds us that this is a long term project. In addition, it is likely that there will be legal challenges which will lead to considerable delays for the scheme to be fully implemented.

The NHI is a wide-ranging reform, with many positive aspects sitting alongside some key controversial aspects. Positive aspects include the opportunity to enable greater use of evidence and transparency in priority setting through the further institutionalisation of Health Technology Assessment processes (akin to ‘NICE’ in the UK), as well as the opportunity to use national-level purchasing power to drive down the prices of commodities such as medicines. The role of private multidisciplinary practices (GPs, nurses, health and rehabilitation professionals, etc) in the future NHI also holds some promise to improve access to healthcare particularly to parts of the country with limited access to public clinics.

On the other hand, there are two key controversial aspects. The first is related to what may or may not happen to medical schemes and medical scheme administrators once the NHI is fully implemented. My sense is that there is no short-term concern in this regard. A bigger concern is whether a single pot of money in the NHI fund will present a larger or a smaller corruption risk than the current situation of multiple pots spread across provincial treasuries and medical aid schemes.

Another concern is that the NHI reform might disrupt our ongoing progress towards Universal Health Coverage within our existing public sector. Our public sector is not perfect, but it is a system that has equity at its heart. The common definition of Universal Health Coverage is to provide all individuals and communities with access to needed promotive, preventive, resuscitative, curative, rehabilitative and palliative health services of sufficient quality to be effective, while ensuring that the utilisation of these services does not expose users to financial hardship.

The two main goals of Universal Health Coverage are: (1) the provision of quality health care services to those in need and (2) the avoidance of financial catastrophe in this process. Clearly healthcare is far from free – indeed it is very expensive – and so the goal of avoiding financial catastrophe is about implementing prepayment and risk pooling mechanisms, whether these are tax or insurance based.

Let’s first look at how we are doing on the provision of quality services. The below figure plots countries according to their achievements on the Universal Health Coverage Service Coverage Index. In this context, coverage of essential health services is measured based on indicators that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged populations.

On this index, South Africa’s achievement is at just over 70%, similar to many other middle-income countries. While there would be room for improvement, our performance is in line with our global peers.

Global comparison of countries in terms of service coverage and quality

Source: World Health Organization – Global Health Observatory (2024) processed by Our World in Data. Accessed May 2024.

The second indicator is financial risk protection. The below figure plots countries against the percent of total health expenditure that is paid out of pocket at the point of use. On this indicator, we score 5.7%, indicating extremely high levels of financial risk protection.

Global comparison of countries in terms of the percent of total health expenditure that is paid out of pocket

Source: World Health Organization (via World Bank) processed by Our World in Data. Accessed May 2024.

While this does not mean that there are no instances of financial catastrophe, undoubtedly there would be, particularly for those seeking treatment for certain types of cancers. That said, over the past two decades I have studied this issue extensively. Across a wide range of conditions in diverse settings, we have interviewed tens of thousands of people to understand the costs that they face in using health services, including everything from transport costs, to costs of food, shelter or accommodation, costs of child care, lost income, under the counter payments to public sector providers (which we never found), fees paid to private providers or money spent at pharmacies. This research consistently showed that the level of catastrophic spending was very low. Our performance on financial risk protection is outstanding. I celebrate the work of those colleagues that shepherded in the removal of user fees in our national health system during the dawning of our democracy. We should all be thanking them.

Despite these successes on Universal Health Coverage, there are areas of concern for the South African health system. We do not achieve health outcomes commensurate with our level of investment. My sense is that this is driven by our relatively high burden of disease; for example we continue to have the world’s largest HIV treatment programme. While our average life expectancy steadily increased with the introduction of antiretroviral therapy (although note the downturn from 2020 which coincides with the Covid-19 pandemic – see the below figure), the HIV epidemic has been a cruel setback that needs to be considered when we seek to make global comparisons on life expectancy and avertable mortality.

Global comparisons of life expectancy: 1970 – 2020

Source: United Nations World Population Prospects (2022) processed by Our World in Data. Accessed May 2024.

Now that the NHI Bill has become the NHI Act, it is time to move on from debates about whether we need NHI or not, and rather focus on how we can make the NHI work for us.

Our public sector will be the backbone of our future NHI and so we should seek to continue to strengthen this system. It would also be wise to put in place measures to strengthen our private system given that private providers are intended to play a key role in the NHI. We should be pragmatic.

The NHI includes many exciting opportunities for leveraging big data and artificial intelligence in health systems strengthening, but at this stage we hardly have any electronic health data. A clear step forward would be the further implementation of the National Digital Health Strategy (2019-2024) which includes the establishment of a patient electronic health record, amongst other needed developments.

In addition, the NHI places emphasis on the achievement of a purchaser provider split via establishing ‘Contracting Units for Primary Health Care’ (CUPS). These new entities will contract with both public and private providers within a defined geographic area, on behalf of a particular population. The establishment of CUP ‘proof of concept’ sites is therefore a priority, but must be done in a way that generates learning and enables adaptation to different contexts.

Let’s continue to push forward on many of these complex undertakings. It is going to take time, but it is needed, irrespective of the name that we choose to give to our health system.

*Cleary is professor of health economics and the head of the School of Public Health at the University of Cape Town.

Note: The views expressed in this opinion piece are not necessarily shared by the Spotlight editors. Spotlight is committed to publishing a variety of views and facilitating informed discussion that deepens public understanding of health issues.

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Categories : Healthcare Politics and RegulationsTags : 16/5/24 NHI public health Spotlight

FULL SPEECH | This is What will Happen Next Says Ramaphosa as He Signs NHI Bill into Law

On May 16, 2024May 16, 2024 By ModernMedia

President Cyril Ramaphosa at signing ceremony of the NHI Bill at the Union Buildings in Pretoria.

Speech by Cyril Ramaphosa, article from Spotlight

President Cyril Ramaphosa yesterday signed into law the National Health Insurance (NHI) Bill, which is the ANC-led government’s plan for universal health coverage, just 14 days before the country heads to the polls.

The NHI aims to unify the country’s fragmented health system, Ramaphosa said at the signing ceremony at the Union Buildings in Pretoria on Wednesday.

However, he also noted that processes are yet to be established and that the Act’s implementation will be incremental rather than a massive overnight overhaul.

Here are 8 noteworthy quotes from the President’s speech:

“[T]he NHI is a commitment to eradicating the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect”.

“[T]he NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention”.

“The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.”

“The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.”

“The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.”

“The NHI is an important instrument to tackle poverty. The rising cost of health care makes families poorer. By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.”

“Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.”

“The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.”

Here is Ramaphosa’s full prepared speech:

REMARKS BY PRESIDENT CYRIL RAMAPOSA ON THE SIGNING OF THE NATIONAL HEALTH INSURANCE (NHI) BILL, UNION BUILDINGS, TSHWANE, 15 MAY 2024

Minister of Health, Dr Joe Phaahla,
MECs of Health,
Senior Officials,
Representatives of the health fraternity,
Representatives of civil society,
Representatives of labour,
Members of Parliament’s Portfolio and Select Committees,
Public representatives,
Members of the media,
Distinguished Guests,
Ladies and Gentlemen,

We are gathered here today to witness the signing into law of the National Health Insurance Bill, a pivotal moment in the transformation of our country.

It is a milestone in South Africa’s ongoing quest for a more just society.

This transformational health care initiative gives further effect to our constitutional commitment to progressively realise access to health care services for all its citizens.

At its essence, the NHI is a commitment to eradicate the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect.

By putting in place a system that ensures equal access to health care regardless of a person’s social and economic circumstances, the NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention.

This vision is not just about social justice. It is also about efficiency and quality.

The provision of health care in this country is currently fragmented, unsustainable and unacceptable.

The public sector serves a large majority of the population, but faces budget constraints. The private sector serves a fraction of society at a far higher cost without a proportional improvement in health outcomes.

Addressing this imbalance requires a radical reimagining of resource allocation and a steadfast commitment to universal healthcare, a commitment we made to the United Nations.

The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.

The NHI Bill presents an innovative approach to funding universal healthcare based on social solidarity.

It proposes a comprehensive strategy that combines various financial resources, including both additional funding and reallocating funds already in the health system.

This approach ensures contributions from a broader spectrum of society, emphasising the shared responsibility and mutual benefits envisioned by the NHI.

The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.

The NHI carries the potential to transform the healthcare landscape, making the dream of quality, accessible care a reality for all its citizens.

The NHI Fund will procure services from public and private service providers to ensure all South Africans have access to quality health care.

The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.

Through more effective collaboration between the public and private sectors, we can ensure that the whole is greater than the sum of its parts.

The effective implementation of the NHI depends on the collective will of the South African people.

We all need to embrace a future where healthcare is a shared national treasure, reflective of the dignity and value we accord to every South African life.

Preparations for the implementation of NHI necessarily require a focused drive to improve the quality of health care.

We have already begun implementing a national quality improvement plan in public and private health care facilities, and are now seeing vast improvement.

In signing this Bill, we are signalling our determination to advance the constitutional right to access health care as articulated in Section 27 of the Constitution.

The passage of the Bill sets the foundation for ending a parallel inequitable health system where those without means are relegated to poor health care.

Under the NHI, access to quality care will be determined by need not by ability to pay. This will produce better health outcomes and prevent avoidable deaths.

The NHI is an important instrument to tackle poverty.

The rising cost of health care makes families poorer.

By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.

The NHI will make health care in the country as a whole more affordable.

The way health care services will be paid for is meant to contain comprehensive health care costs and to ensure the available resources are more efficiently used.

Through the NHI, we plan to improve the effectiveness of health care provision by requiring all health facilities to achieve minimum quality health standards and be accredited.

Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.

The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.

There has been much debate about this Bill. Some people have expressed concern. Many others have expressed support.

What we need to remember is that South Africa is a constitutional democracy.

The Parliament that adopted this legislation was democratically-elected and its Members carried an electoral mandate to establish a National Health Insurance.

South Africa is also a country governed by the rule of law in which no person may be unduly deprived of their rights.

We are a country that has been built on dialogue and partnership, on working together to overcome differences in pursuit of a better life for all its people.

The NHI is an opportunity to make a break with the inequality and inefficiency that has long characterised our approach to the health of the South African people.

Let us work together, in a spirit of cooperation and solidarity, to make the NHI work.

I thank you.

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Categories : Diseases, Syndromes and ConditionsTags : 17/4/24 Spotlight

Syphilis Rates are Spiking around the World

On April 17, 2024April 17, 2024 By ModernMedia

Colourised electron micrograph of *Treponema pallidum*, the bacteria that cause syphilis. Several spiral-shaped bacteria have been highlighted in gold. Credit: NIAID

By Biénne Huisman for Spotlight

Scientists worldwide are sounding the alarm at the return of syphilis, describing the comeback of the easily preventable infection as a huge public health failing – as an effective vaccine remains elusive.

Syphilis, one of the oldest known diseases, is making a resurgence worldwide. Top global scientists described this as a public health crisis and failure, given that the sexually transmitted infection (STI) – which can have dire and fatal consequences especially for newborn babies – is curable with early treatment.

The return of syphilis was under discussion at the 2024 Conference on Retroviruses and Opportunistic Infections (CROI) where scientists, clinicians, and public health advocates gathered in Denver in March.

Addressing delegates in the Colorado Convention Centre, Professor Khalil Ghanem of Johns Hopkins University School of Medicine in Baltimore, noted a paucity of data – while syphilis continues to increase with “clinicians caring for patients with complex clinical presentations”. Ghanem was pointing out that there is little systematic information on how to manage cases of advanced syphilis, like neurosyphilis (syphilis in the central nervous system) and ocular syphilis (syphilis in the eyes).

Among some medical practitioners, syphilis is known as “the great imitator” due to its variable clinical manifestations that can mimic other diseases. In its severe forms, it can cause chronic multiple organ damage in adults. The infection can also be passed on from a mother to her baby during pregnancy resulting in congenital syphilis, causing premature birth, miscarriage, stillbirth, and birth defects. In most cases, however, the bacterial infection is transmitted sexually. Transmission can be prevented through the correct use of condoms.

According to the World Health Organization (WHO’s) latest available figures for congenital syphilis – dated 2016 – globally there were an estimated 661 000 congenital syphilis cases that year; including 143 000 stillbirths, 61 000 neonatal deaths (a newborn baby dying within seven days) and 109 000 surviving infants with a clinical diagnosis. Spotlight recently reported on a rise in sexually transmitted infections in Gauteng and in 2021 published an in-depth article on congenital syphilis in South Africa.

‘A failure of the healthcare system’

Epidemiologist Alex de Voux, from the University of Cape Town, moderated a session on syphilis at CROI. Speaking to Spotlight between sessions, an impassioned De Voux said the return of syphilis is “a failure of healthcare systems (in South Africa and abroad) – because we have the tools, we know how to test for it, and we know how to treat it”.

She added: “The most extreme outcomes of congenital syphilis are stillbirths and neonatal deaths. We don’t even really understand the extent of longer term outcomes: neurological complications, skeletal deformations, impaired mental health development… And all these significant complications arise from an easily preventable infection. Remember, we use penicillin, which has been around for ages. The treatment hasn’t changed in all this time.”

Figures presented at CROI include from the Centers for Disease Control and Prevention in the United States, reporting a 76% increase in syphilis cases between 2013 and 2017. The WHO estimates that 7.1 million people between 15 and 49 years old were infected with syphilis in 2020. (See a WHO fact sheet on syphilis here.)

In 2018, at least 33 927 cases of syphilis were reported in 29 European Union member states, as recorded by the European Surveillance System (TESSy), at a rate of seven cases per 100 000 population. The reported syphilis rates were nine times higher in men than in women; showing a peak onset age of 25 to 45 years, in men.

Syphilis and HIV

One study presented at the conference surveyed 20 000 MSM (men who have sex with men) across ten cities in India, noting dramatic increases in syphilis in every city. It found syphilis was most prevalent in older MSM, pointing to a need for STI control efforts in this population. “Among people living with HIV, syphilis infection was associated with elevated (HIV) viral loads, raising concerns for transmission of HIV,” the study authors wrote.

Another study conducted in Cologne in Germany investigated 60 patients co-infected with syphilis and acute HIV. The study cites “rising co-infection rates and the unique interaction between these two sexually transmitted infections. Syphilis enhances HIV transmission and acquisition, while HIV accelerates the progression of syphilis…”

An ancient condition, the oldest artistic representation of syphilis is considered to be on a Peruvian jug dating back to the 16th century, depicting a mother suffering from syphilis holding a child. Famous people who had syphilis include Oscar Wild and Friedrich Nietzsche. [Read about the history of syphilis here]. Infections dropped sharply with the availability of penicillin in the 1940s.

However, over the past two decades scientists have reported an alarming spike in cases. This has been attributed by some to a drop in condom use. The reasons for a decrease in condom use is not clearly understood – one possible factor is a false sense of security given lower HIV transmission rates, effective HIV treatment, and the availability of HIV transmission prevention in the form of pre-exposure prophylaxis (PrEP). PrEP contains a combination of two antiretroviral medicines which are highly effective at preventing HIV infection when taken as prescribed by someone not living with HIV, while not offering protection against other STIs like syphilis. Access to condoms may also be a factor. As Spotlight recently reported, the number of condoms distributed by the South African government has decreased dramatically over the last five years.

Sex partners

One study presented at CROI found: “The risk factors associated with acquired syphilis are sexual behaviour, serosorting (a strategy that involves selecting sexual partners of the same HIV status) among people living with HIV, multiple sexual partners, the use of PrEP to compensate for HIV risk behaviour, and social networking sites or mobile device apps to find sex partners.”

At the syphilis session at CROI, Dr Angélica Espinosa Miranda, STI unit coordinator at the Brazilian Ministry of Health, presented a talk titled “The Burgeoning Epidemic of Congenital Syphilis”. She emphasised “the underdiagnosis of syphilis in pregnancy, especially in regions with limited healthcare access”.

Miranda’s statement resonates with De Voux’s research in South Africa, which found congenital syphilis cases to be gravely underreported in the country. Congenital syphilis is a notifiable condition in South Africa, meaning that if a doctor delivers a baby believed to be infected they are required by law to report it to the National Institute For Communicable Diseases. De Voux’s study relays how reported congenital syphilis cases in South Africa’s healthcare system between January 2020 and June 2022 – 36 cases for every 100 000 live births – were at least half the figure estimated by WHO scientists – thus bolstering the hypothesis that there is a high number of undiagnosed syphilis in South Africa.

Penicillin treatment

In her talk, Miranda added that ensuring that infected pregnant women receive timely and appropriate penicillin treatment is critical to preventing congenital syphilis. “Penicillin is the only effective treatment during pregnancy,” she said. “However challenges remain, such as limited healthcare access and penicillin shortages in some countries.”

When penicillin cannot be used (due to unavailability in a country or allergy in a patient) the WHO’s STI guidelines suggest using doxycycline 100mg twice daily orally for 30 days.

Penicillin shortages are a problem worldwide, and in South Africa too. “South Africa has also been affected by shortages of penicillin,” says De Voux. “In fact, often they will make sure that they keep stocks and prioritise pregnant women. So that means that sometimes other people who are infected with syphilis will get treated with something that’s much more burdensome. Instead of having penicillin injections, they will take oral tablets – doxycycline – which has these gastrointestinal side effects, so an upset stomach. You have to try minimise the side effects with f ood.”

Miranda stressed the need to invest in developing new strategies – antibiotics apart from penicillin – to treat syphilis. Meanwhile, epidemiologists agree that a vaccine for syphilis is important but that this scientific solution remains elusive.

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

Categories : Mental Health PaediatricsTags : 11/4/24 psychiatric disorders Spotlight

Focus on Children, Urges President of SA Society of Psychiatrists

On April 11, 2024April 11, 2024 By ModernMedia

Dr Anusha Lachman is the first child psychiatrist to hold the position as president of the SA Society of Psychiatrists. Photo supplied to Spotlight

By Sue Segar for Spotlight

There are serious gaps in psychiatry regarding treatment, prevention and care for children and adolescents in South Africa. Offering solutions, Dr Anusha Lachman tells Spotlight psychiatric services should be offered in ways that are Afro-centric and culturally sensitive.

“There’s a mental health crisis in South Africa and yet, today, there are fewer than 40 registered child psychiatrists in the country,” Dr Anusha Lachman tells Spotlight.

She is the first child psychiatrist to hold the position as president of the SA Society of Psychiatrists (SASOP) and she hopes to prioritise the “grossly under-represented and under-resourced” field of child and adolescent health in the country. While the field is certainly neglected, Lachman is not alone in trying to draw more attention to it – the 2020/2021 edition of the Children’s Institute’s excellent Child Gauge also concentrated on the mental health of children in South Africa.

Lack of data

One of the biggest issues in child and adolescent psychiatry, Lachman laments, is the lack of reliable data. She explains that most of the current research, literature and thinking about infant mental health is focused on Western, high-income settings but her focus is on the African context and in limited-resource settings. “We don’t have many figures on how many young people are suffering from the various mental health disorders,” she says.

While it is a struggle to get concrete, reliable statistics, Lachman adds there are some data to work with but South Africa lacks a collective data base that ties it all together.

Insight into the country’s mental health crisis, she says, is partly gauged from the number of referrals to primary health care centres for mental health support and evidenced by the long waiting lists for children to be assessed at specialist mental health clinics and at hospitals. “All we have, across our public hospitals, is the waiting list data which only tell us the duration that children with severe mental illness wait to get into secondary and tertiary level hospitals to access hospital-based care,” she says. The problem is that this type of data tells us little about the vast majority of adolescents with mental health issues who do not require hospitalisation.

Lachman is also head of the Clinical Unit Child Psychiatry at Tygerberg Hospital. The unit is the Western Cape’s only tertiary hospital based assessment unit for adolescents aged from 13 to 18 years with complex psychiatric presentations and severe mental illness. The young people they help often face not only mental health issues, but the full range of psychosocial challenges – from poverty to exposure to violence, substance abuse, and HIV.

“We know, for example,” she says, “what substance-use disorder looks like in children under twelve, and in young people under 21 because we get that from substance-use centres and rehabilitation centres. We know what proportion of children have HIV and TB and some infectious diseases, which by extension have psychosocial consequences and comorbidities, and we know about neurodevelopmental delays because we track things like school attendance and requests for access to support in special needs.

“We do have statistics on issues which affect children in South Africa disproportionately,” she says, “on food insecurity, intimate partner violence, instability in terms of accommodation etc. There are huge occurrences of abuse but there are inadequate services for children to be removed from those abusive homes, because we don’t have sufficient children’s homes or safety placements for example. So these are children who are disproportionally disadvantaged and that in itself is hard to quantify – and the psychosocial support structures are just not there.”

Lachman says the Western Cape department of Health and Wellness is making inroads into the lack of data by tracking and digitising child mental health statistics, through its Child and Adolescent Mental Health Strengthening Project. “This will give us some important data across emergency rooms throughout the Western Cape. Hopefully that can roll out to the rest of the country so that we can understand what children are presenting with.”

Hard to categorise

Asked which mental illnesses South African children and adolescents mainly suffer from, Lachman says child mental health is a function of multiple psycho-social stressors, structural problems, and fundamental relational challenges – and that’s hard to categorise.

“It’s a complex relationship between environmental stressors and vulnerabilities to mental illnesses.” She explains that environments that are high risk – with violence, poverty, untreated mental illness in caregivers, food insecurity and economic burdens – predispose children to mental illness expressed commonly in mood disorders, anxiety and trauma responses. “These take the form of poor functioning at school, learning challenges, suicide and self-harming attempts, drug-seeking behaviours and, in some instances, expressions of severe mental illnesses. ADHD is also commonly seen in this context.”

Lack of relevant research

Lachman bemoans what she calls the “distaste” for research that originates from the global South. “The biggest problem we face is the inability to publish and compete in international journals, not because our research is inadequate but because there’s a distrust of information originating from the lower-middle income countries or the global South.”

In terms of publication bias, she says the huge issue is that editorial boards and funders of journals consist largely of privileged white men.

“They don’t represent people of colour and ethnic majorities outside of the industrialised northern hemisphere countries. When we aren’t able to publish, we aren’t able to get the data out there, and when you don’t get the data out, there’s a vacuum of information and evidence-based treatment – and interventions are often coloured by information that doesn’t represent the lower-income communities and population groups.”

Lachman says research published a few years ago, by Stellenbosch University academic Mark Tomlinson, showed that less than three percent of all articles published in peer reviewed literature include data from low- and middle-income countries, where 90 percent of children live.

Low number of child psychiatrists

Turning to the shockingly low number of registered child psychiatrists in the country, Lachman notes that in the last three years, South Africa has lost five child psychiatrists to New Zealand. “This is about the brain drain, where there is targeted recruitment of qualified people [by] first-world or industrialised regions who can offer incentivised work opportunities which we, in South Africa, cannot compete with.”

She adds: “One child psychiatrist is trained only every two years. And only from a university that can train them. There are only four universities that can do that here – Stellenbosch, Wits, UCT and Pretoria. It depends after two years if the student passes the exam or not so that is why there are so few.” (Prior to training in child psychiatry candidates first have to complete the normal training to become a medical doctor.)

“So far there were two that qualified 2022 and one that qualified in 2023. And at the beginning of 2023, we had lost five child psychiatrists to New Zealand and Australia. It’s dire,” she emphasises. People remain registered with the Health Professions Council of South Africa (HPCSA) but that doesn’t mean they are physically in the country, Lachman adds. “Recent stats show that we have under 40 [child] psychiatrists in working environments, including those who have retired.

“We still sit with provinces that have zero representation for child psychiatry. We recently deployed one to the Eastern Cape, but, currently North West, Limpopo, Mpumalanga, don’t have any qualified [child] psychiatrists.”

‘Everybody’s business’

Yet, Lachman does not believe the only answer is to train more child psychiatrists. “The answer is more nuanced. It’s about upskilling and task shifting, and an openness to the idea that child and adolescent psychiatry is everybody’s business.”

“If you’re an adult psychiatrist, a physician a paediatrician, or a nurse, or even somebody treating adults, it’s your job to be aware of mental health problems in children,” Lachman adds. “I feel strongly about changing the narrative and moving away from the idea that it’s a specialist realm, because mental health is everybody’s business and child mental health should be pervasive in terms of focus, across various sectors.”

She also feels strongly that psychiatric services should be offered in ways that are Afro-centric and culturally sensitive. Such an “Afro-centric approach”, she says, “must include a diverse spectrum of input – so not just the mental health care providers who punt a specific model of medication and therapy – but partnerships with the educators, community workers, caregivers and allied health professionals to be able to effectively attempt to support and re-think models that can work in our setting.”

She suggests exploring opportunities for children to be screened early, recognised, and offered treatment. For instance, Lachman says, nurses at Well Baby clinics – where babies get immunised – can be trained in child mental health. “Whilst checking the child’s growth and immunisations, they could also look at whether the child is making eye contact, or engaging in reciprocal contact. If this is not happening, they need to know what further questions to ask and what to do next.”

Similarly, mental health awareness and screening should be in schools. Why do we offer sexual education, but not address mental health issues, she asks. “Just as we have so easily incorporated into school curriculums how people can get condoms, we need to ask them how they’re feeling, whether they feel isolated, want to harm themselves or want to die.”

Republished from Spotlight under a Creative Commons licence.

Source: Spotlight

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