With a quarter of South Africans over 50 conservatively projected to be suffering from one or more non-communicable diseases (NCD) by 2040, the country is “flying blind”.
That’s according to Professor Shivani Ranchod, a senior lecturer in actuarial science at the University of Cape Town, who says the collision of NCD and healthcare staffing crises, especially the shortage of specialists, combined with population growth, is deeply worrying.
Chris Bateman, writing for MedicalBrief, reports that she was addressing SA’s human resources health crisis and its quadruple burden of disease at the annual Hospital Association of South Africa (HASA) conference at Century City in Cape Town this month.
She says currently over 18% of South Africans over 50 suffer either from NCD co-morbidities (8.2%), depression (11.7%), diabetes (8.9%), heart disease (2.3%) or hypertension (25.3%).
“We have colliding crises – it’s a call to action, especially given the impact of COVID and burnout among healthcare providers. It’s time to connect to our hearts and move out of the cerebral – this is personal, not abstract,” she told delegates.
With the maldistribution of doctors geographically and between the public and private sectors, plus a “disjoint” between training platforms and service delivery platforms, the data were alarming.
Dire shortage of specialists
Per 100,000 population, South Africa had just seven full-time specialists in the public healthcare sector versus 69 in the private sector. SA’s specialist tally stood at 16.5 specialists per 100,000 people (2019 figures) compared to Chile’s 110, (2015 figures), and 274 (2015 figures), in the Organisation for Economic Co-operation and Development, (OECD), (37 country members).
“So, you can see just how serious the situation is. The second crisis in terms of the NCD public health emergency is the epidemiological transition. NCDs are lifelong and there’s a disproportionately high and inter-related burden in SA,” she said.
Ranchod says diabetes is the largest killer of women in South Africa, outstripping all other African countries, an aggravation being the complex relationship between HIV and NCDs.
“It’s something to do with the impact on the metabolic system – also, a huge percentage of South Africans have no idea that they’re walking around with diabetes,” she explained.
Layered on top of this was the intergenerational burden of trauma inflicted by SA’s history of violence and repression, which according to research could carry for up to 14 generations.
“We have work to do to heal this because mental health impacts with other diseases, becoming a risk factor via underlying alcohol and drug abuse,” she added.
While there were “excellent” HIV and TB projections, there was “almost no data” on NCDs and she warned that her scenario work was “unrealistically positive” because it assumed the burden of disease peer age group would not worsen.
The human resources for health “vortex” began with ageing nursing and specialist cohorts due to insufficiently fast training output, while ProfMed figures showed that clinicians were not necessarily emigrating but moving out of their professions.
“I get CVs of clinicians wanting to move out of clinical work every day on my desk. Then you have the enormous amount of political uncertainty in the country. People respond by going somewhere else, even if that country has universal health coverage and regulations on practice. It’s not so much the detail, but that feeling of uncertainty and physical risk,” she added.
RWOPS needs addressing
Another contributing factor was that 36% of public sector specialists appeared to be making use of the RWOPS (Remunerative Work Outside Public Service), where the extent of time they spent in the private sector remained unknown.
“It’s a huge problem, but we continue to allow it to happen,” she said.
If South Africans all contributed “just a little,” things could shift, “but polarisation stops us from problem solving”.
“If we stay in polarised camps, it’s difficult to act and move forward. We have to start solving actual problems on the ground now,” she urged.
The NHI could be seen as a panacea or a crisis – but a “middle way” needed to be found.
Most people tended to see NCDs as individual behaviour patterns revolving around tobacco or alcohol use, unhealthy diets, physical activity, the living environment, or childhood adversity.
However, “the systemic” needed to be reconciled with “the individual”.
“There are major drivers at a system level. People live in food deserts with no healthy food options – women don’t exercise as much because of safety issues. You have environmental crossing with lifestyle, crossing with socio-economic conditions,” she said.
Some suggested solutions
Ranchod, a strong adherent of value-based solutions, explained that “value” was about optimising patient outcomes within a financial envelope.
“This implies a population health perspective – optimising patient outcomes, not for individual patients, but across the system as a whole – which in turn implies a focus on equity and access.”
Locating value “front and centre” provided an alternative sequencing of reforms by starting with measurement, then focusing on delivery, and only then considering mechanisms to pay for care. This “leapfrog to care” approach was designed with low-and-middle-income countries in mind.
Among her solutions were setting up a separate health workforce planning agency, and bringing in key stakeholders and experts while establishing a centralised database for all healthcare professionals.
She said such a database would have to detail cadre type, sector, level of effort and demography for planning.
A simple initial change that would boost human healthcare resource planning would be to capture more data on health workers in the state PERSAL (salary) system.
Other innovations would be to encourage patient self-management to decongest the system, translate successful private sector health improvement incentivisation programmes into the public sector, and home delivery of medication with community healthcare worker adherence support. Ranchod said COVID had highlighted the ability of telemedicine to improve outcomes and access to healthcare.
She warned that current medical malpractice litigation (more than R70bn in the public sector at last count) stood to bring the healthcare system to its knees, let alone disincentivise specialists (gynaecologists pay R1.2m per annum for risk cover). A value-based care approach with patient-based outcomes measurement would reduce risk.
“We have the opportunity to think differently, build inclusive solutions, to orient towards value and ignite innovation. What are we waiting for?” she asked.
Shivani Ranchod - HASA 2022 A call to action PDF
See more from MedicalBrief archives:
SA’s public hospital staffing disaster: 12,000 vacancies for nurses and doctors
More investment in health workforce critical for future of SA – World Bank
Why rural South Africans don’t get emergency medical care in time
An 'important contribution' to understanding global health interventions in Africa