By John Carruthers, assistant editor, April 02, 2013
As a country that has recently begun implementing controversial measures toward universal health care, South Africa and its more than 48 million citizens provide an illustration of a country going through the growing pains of system-wide change in the delivery of health care.
Addressing historical discrepancies
The inequalities in health care between the underfunded public system and the private system for those with greater means has led the South African government, led by the majority African National Congress party, to introduce the National Health Insurance initiative. This system will provide citizens essential health care regardless of employment status.
As the system currently stands, there is a sharp divide between those patients of means and those who cannot afford private medical care. A 2010 paper, “Health Care Financing in South Africa: moving toward universal coverage,” pegged the number of physicians seeing private-sector patients at 79 percent, which seems reflective of the vast number of underserved patients, according to dermatologist Percy Naidu, MD, of Durban, KwaZulu-Natal, South Africa’s third-largest city. University of KwaZulu-Natal dermatologist Anisa Mosam, MD, estimates the percentage of patients unable to afford private care at approximately 70 percent of the population, nearly all black Africans (who make up 79 percent of the population). This leaves 21 percent of physicians treating the vast majority of South Africa’s population. [pagebreak]
“Currently, the health system caters [differently] to the haves’ who can afford private medical aid and the have-nots,’ who cannot,” Dr. Naidu said. “We have approximately 95 registered medical aid societies that provide health care for the haves.’ These patients receive treatment from private practitioners and specialists and can utilize private hospitals.” They can afford to pay for care themselves or have employer-provided insurance. “The have-nots’ have to attend state facilities which, in some cases, are inadequately equipped,” Dr. Naidu said. “Patients have to wait in long queues and if referred to a specialist have to wait for months before they are seen.”
Even private-sector physicians, Dr. Naidu said, face economic challenges, including poor remuneration for consultations and a three-month waiting period for reimbursement. Pre-authorization for procedures is mandatory, and dermatologists in both the public and private sectors encounter difficulty when attempting to treat patients with biologic therapies.
South Africa’s Department of Health is phasing in the NHI plan over 14 years, a process that began in 2012 with 1 billion rand (equal to $11.23 million) budgeted for pilot projects. Included are efforts to upgrade nursing colleges and tertiary hospitals in the effort to extend care to all citizens. Allied health workers, given the undersupply of physicians treating this population segment, are slated to be a large part of the program. In addition to nurses and physician assistants, resources will be utilized to train midwives and select alternative health practitioners. Health policy experts in the country predicted in July 2012 that each primary care worker in the country would need to cover an estimated 250 households, or 1,000 patients, for the program to see success. The pilot programs will divide the country into health care districts and focus on assigning health care workers to each one to raise the overall level of care and measure success. [pagebreak]
Even this sweeping change, however, faces challenge from those who feel the government is over-reaching in trying to bring change to both the public and private sectors, according to Dermatology Society of South Africa president and Johannesburg dermatologist Rob Weiss, MD.
“There is a huge lack of resources, skills, and the capacity to put [the National Health Initiative] in place and certainly no money to fund it,” he said.
Patients who wish to see a dermatologist in South Africa have a similarly bifurcated experience. The majority of specialist care, including dermatology, is only available in the major hospitals. Those with private insurance can easily make an appointment with the dermatologist of their choice. Those in the public system, however, are most often seen by nurses in primary care facilities and referred to general practitioners at regional hospitals. From there, patients in need of a dermatologic diagnosis or biopsy are referred to a tertiary dermatology center.
There are currently 167 members in the Dermatology Society of South Africa, 110 of whom are exclusively in private practice. There are also 6,000 general practitioners in South Africa who offer aesthetic and cosmetic services, according to Dr. Weiss. Where patients are able to receive care, he said, the standard of care is “comparable to the best in the world,” but there are significant waiting times for most specialists. [pagebreak]
“The public sector has been sadly neglected by political incompetence in the past decade. Despite this, a reasonable standard of care is dispensed to the vast majority of the population,” Dr. Weiss said. “Overcrowding, lack of sufficient drugs, and staff shortages plague this sector.”
Public health concerns
The biggest challenge to health care in South Africa, according Dr. Mosam, is the staggering HIV/AIDS rate; 15.6 million South African adults are infected, more than in any other country. A total of 17.8 percent of the population has HIV/AIDS, and the disease accounted for 310,000 deaths in 2009. The disease and its associated conditions provide a great deal of work for dermatologists in the country.
“In my setting we have the burden of infectious disease, especially HIV, and all of the opportunistic infections and inflammatory conditions which accompany it,” Dr. Mosam said. “Patient denial, access to health care, and late presentations are always a challenge.”
Dr. Naidu agreed, calling the disease the greatest challenge facing South African practitioners.
“Skin disease is the first manifestation of HIV in at least a third of patients. Certain infectious, inflammatory, and neoplastic conditions are pathognomonic of HIV/AIDS. Papular pruritic eruption (eosinophilic folliculitis), seborrheic dermatitis, herpes zoster in young patients, Kaposi’s sarcoma, and widespread molluscum contagiosum,” Dr. Naidu said. “Pulmonary tuberculosis, especially drug resistant forms (MDR and XDR), is the most common cause of death.” [pagebreak]
The rate of HIV/AIDS, Dr. Weiss said, can pose a challenge to dermatologic diagnosis.
“South Africa has the dubious distinction of having the highest number of patients with HIV/AIDS in the world. A very high percentage of patients in the public sector will have diseases related to this disease,” he said. “In many cases, the common presentation of dermatological diseases is altered in the presence of HIV infection, making diagnosis challenging.”
Skin cancers and melanoma, he added, are also very common in South Africa, which ranks with Australia as having the highest incidence in the world. The rate of interpersonal violence, according to Dr. Mosam, remains unacceptably high, manifesting itself in the highest death rate per 1,000 in the world (see sidebar). The country also struggles, separately, with its markedly high infant mortality, maternal mortality, and tuberculosis rates. [pagebreak]
In addition to the challenge of disease and societal troubles, Dr. Naidu said that management difficulties in some hospitals and health systems leads to doctors not having properly equipped facilities, further handcuffing their ability to treat the underserved.
“Some hospitals, due to either poor supply chain management or corruption, lack even the basics like gloves, gauze, and sterilizing liquids,” he said. “Theatre facilities are inadequate and often cases are cancelled. Breakdown in diagnostic equipment such as MRI machines can take months to repair.”
Despite the challenges facing the South African system, there are concrete signs of turnaround, according to Dr. Mosam. The vast overhaul of a traditionally unequal system, she said, provides hope for the future, as do the results of previous efforts to curb public health problems.
“The change in leadership at the national level is a positive one. We now have specific programs in place for the four major public health concerns [HIV/AIDS/tuberculosis; maternal, newborn, and child health; non-communicable diseases; violence], and the largest antiretroviral treatment program in the world, which reaches 1.7 million people,” she said. “We have voluntary HIV/AIDS counseling and testing for 13 million people, and our program to reduce mother-to-child transmission of HIV reduced the rate of transmission from 32 percent to 3.5 percent between the late 1990s and 2009.” [pagebreak]
As the system evolves, Dr. Mosam and Dr. Naidu say that there will be an increased emphasis on multi-disciplinary medical teams and telemedicine. The Department of Health will undertake studies on the following areas of the health system through 2017:
- Management of health facilities and health districts;
- Quality improvement;
- Infrastructure development;
- Medical devices (including equipment);
- Human resources planning, development, and management;
- Information management and systems support; and
- Establishment of an NHI fund.
For dermatologists and patients in South Africa, the coming years will bring significant change and new challenges to a historically troubled care system. The plan for dermatology, according to Dr. Mosam, is to train nurses in dermatology and have them see patients at a district level before referring them on to dermatologists at regional centers. In addition, a new diploma program for general practitioners will equip them with more dermatology training that will allow them, along with the dermatology-trained nurses, to see more patients before referring on to dermatologists. Dermatologists, she said, will be positioned at regional, tertiary, and central hospitals.
“With the implementation of the NHI, the larger community will have better access to dermatology services and patients with simple problems will be dealt with at the district level,” Dr. Mosam said. “The more complex problems will be referred to regional hospitals which will be serviced by dermatologists. The tertiary and quaternary conditions will be referred on to the academic hospitals where teaching and research will be carried out.”
Learn more about the public health challenges in South Africa in our online-only sidebar.
South Africa at a glance
Population: 48,810,427 (worldwide rank: 26)
Gross domestic product (GDP): $578.6 billion (26)
Age demographics: 0-14 years old, 28.5 percent; 15-64 years, 65.7 percent; 65+, 5.9 percent
Median age: 25.3 years
Annual death rate: 17.23/1,000 (1)
Life expectancy: 49.41 (220)
Health expenditure: 8.5 percent of GDP (45)
Physician density: 0.77/1,000 patients
Source: CIA World Factbook, 2013
About the contributors
Percy Naidu, MD, is a private practice dermatologist at Netcare Umhlanga Hospital in Durban, South Africa, and the immediate past president of the South African Dermatology Society.
Anisa Mosam, MD, is a dermatologist and associate professor in the department of dermatology at the Nelson R. Mandela School of Medicine at the University of KwaZulu-Natal in Durban, South Africa. In providing her input, she consulted with Werner Sinclair, MD, and H.M. Coovadia, both of whom were involved in the development and implementation of National Health Insurance.
Robert Weiss, MD, is a private practice dermatologist in Johannesburg and the current president of the South African Dermatology Society.