Category: Expert Opinion

Op:Ed – How Collaboration can Help South Africa to Build a Better Healthcare System

Photo by Sora Shimazaki: https://www.pexels.com/photo/diverse-anonymous-colleagues-shaking-hands-at-table-with-coffee-and-folders-5673475/

As various players in South Africa’s health arena give input into the National Health Insurance, and the form it should take, they are agreed on one thing: its goal to achieve quality universal healthcare for all South Africans.

The recent COVID-19 vaccine rollout is a good foretaste of what is possible for South Africa’s healthcare system through the power of cross-sectoral collaboration – and a great case study for health systems strengthening in other countries too.

The rollout saw the public and private sectors, trade unions and community organisations pooling their resources and expertise to get the vaccines to South Africans as fast as possible, and the campaign showed that the country has the resources and expertise to provide a better, more equitable healthcare service.

The question is how we take these lessons and embed them in a healthcare system that serves all of a country’s citizens, and does so in a sustainable way, while adhering to best practice standards.

The clear answer is through the power of partnership – which has been demonstrated to work both here and in the rest of the developing world. Promoting public-private partnerships (PPPs), can accelerate access and distribution of innovative medications. By working together, government, originator companies, and funders can ensure that patients benefit from the latest advancements in healthcare.

Rwanda, for instance, has made significant progress in managing non-communicable diseases (NCDs) through community-based health insurance schemes. Brazil has successfully implemented a comprehensive primary healthcare approach. These countries have prioritised prevention, early detection, and treatment of NCDs, which can be adapted to the South African context.

Locally implemented initiatives under the global Making More Health (MMH) programme include training community health workers to provide primary care services, supporting local entrepreneurs in developing innovative healthcare solutions, and partnering with NGOs to improve access to healthcare in rural areas. These initiatives have helped address complex healthcare issues by empowering local communities and leveraging local resources.

MMH is a social initiative from Boehringer Ingelheim in collaboration with Ashoka, which combines business and social values to unleash innovation and achieve economic and social progress in healthcare. The objective of this long-term initiative is to source social innovation around the world, to explore unconventional partnerships and business models, and to encourage Boehringer Ingelheim employees.

We must also turn our attention to NCDs, which are a major health threat. The WHO estimates that globally, they are responsible for 74% of all deaths. Research into South Africa’s NCD states can play a crucial role in health systems strengthening by identifying the most prevalent diseases, understanding their risk factors, and informing evidence-based policies and interventions. This would help target resources more effectively and improve health outcomes.

This requires robust health data, hosted on a digital infrastructure, which would promote data-sharing among healthcare providers, and encourage the use of standardised data collection methods. This would help create a more accurate picture of the population’s health needs and enable better decision-making across the entire health ecosystem.

We also need to make sure we retain our world-class doctors, and address our critical nursing shortage – it’s estimated we need about 26 000 additional nurses to fill the gap. Without sufficient personnel to deliver healthcare, all the best intentions in the world will not deliver universal health coverage.

We must invest in improving the working conditions and incentives for healthcare professionals in the public sector, strengthen primary healthcare services, and promote collaboration between public and private providers. This would help to ensure that the expertise and experience of these professionals is effectively employed to benefit the broader population.

Moreover, increased collaboration with innovator companies in the private sector, many of whom are already involved in initiatives to strengthen the health system, would ensure patients receive the right treatment while expanding reach across the entire population. This would help tackle inefficiencies, streamline processes, and enable better resource allocation.

The fundamentals of health system strengthening in South Africa include adequate financing, a well-trained and motivated healthcare workforce, efficient supply chain management, and strong governance and leadership. Addressing these gaps – through partnership and collaboration – would help build a more resilient and responsive healthcare system and ensure that South African citizens have access to better healthcare.

Frank Dialogue on NHI: Medical Schemes are a Government Asset

As the National Health Insurance (NHI) Bill makes its way through the approval process in the National Council of Provinces (NCOP), many actors in various sectors have called on the South African government to carefully consider the concerns raised regarding the proposed bill.

Stressing this point as one of the panellists in the Kwa-Zulu Natal leg of the Frank Dialogue on NHI hosted by media anchor and Leadership magazine editor, Prof JJ Tabane, and his team, recently in Umhlanga, Dr Katlego Mothudi, Board of Healthcare Funders (BHF) MD, acknowledged that both the public and the private sectors were not perfect, but cited that destroying the private sector was not going to accelerate the attainment of the global agenda of Universal Health Coverage. Strengthening a health system requires reform of six pillars; and the National Health Insurance formed part of the finance pillar only. He further noted that the private sector was a national asset to contribute to the success of health reform.

Other participants in the dialogue were the Minister of Health, Dr Joe Phaahla, Dr Kgosi Letlape (former Health Professions Council of SA and SA Medical Association chair), Zwelinzima Vavi (SA Federation of Trade Unions chair), Dr Nicholas Crisp (Department of Health Deputy-Director: NHI), and Nozibele Tshobeni (Sizwe Hosmed Acting PO).

The primary aim of these events has been to facilitate a constructive and inclusive discourse among various professionals in the sector, with the Minister of Health, regarding the proposed NHI Bill. 

Emphasising the importance of overcoming several issues before the Bill could be successfully rolled out, Prof Tabane acknowledged that the health crisis in South Africa was of significant concern, rendering the implementation of universal health coverage (UHC) a necessity.

Asked about the future role of medical schemes under NHI, Crisp reiterated that NHI was not about scrapping medical aids, but about the right of all South Africans to access affordable healthcare: “The bill does not abolish or repeal the National Health Act. It merely goes about a different way of financing – a single fund to care for the majority of the health benefits that we need as a nation to strive.

However, Dr Mothudi disagreed with Crisp and highlighting that a multi-payer system was a better model given the south African context that has load of fraud and corruption.  “Why not a multi-payer system, as originally proposed in the first NHI Green Paper?” he asked.

“Between now and that point,” Crisp explained, “we need the medical schemes to continue what they are doing but to do it more effectively than they are doing at present. They criticised us in the Health Market Inquiry, saying we did not provide leadership. Now we are providing leadership – we want to have a multilateral negotiating forum, we want to set prices, want to introduce other related measures:

A moot point made by Sizwe Hosmed’s Ms Tshobeni in her concluding remarks was that while she agreed that NHI was “overall, a good idea”, pushing the Bill through was putting the cart before the horse: “How we are going about it is really the problem.

“We are not that far apart in our discussions on this, but where we are drifting apart can be answered by the question ‘why are we here?’” asked Dr Mothudi.

“Going on blaming apartheid etc is not good. The Medical Schemes Act, for example, was promulgated in 1998 – post-apartheid. So, we must take responsibility for these challenges. Secondly, Government must provide stewardship, being responsible for the lives and healthcare of every citizen. Right now, we only have one Department of Health, not one for the public and one for the private sector.”

Also noted was that the private sector “does not run itself”. The National Health Act is there to guide practitioners and establishments how they should behave, while the Medical Schemes Act is enforced by the Council for Medical Schemes under stewardship of Department of Health.

While many views were expressed about the pros and cons of NHI, among the most common once again were, as already mentioned, the wisdom of a single payer system. Contributing his views on this, the BHF’s Dr Mothudi revived the originally drafted concept of a multipayer system for the fund: “A multipayer system was proposed in the first NHI Green Paper but was thrown out! A multipayer system would work in the same way as it did during the COVID vaccination campaign. When standing in the vaccination queue you wouldn’t know who was paying for the service for the person in front of you – employer, medical aid, or government?

“The pricing and service for the vaccine and procedure,” he said, “was set the same for all and for everyone.”

To watch the Frank Dialogue Click Here

Opinion Piece: The Rise of Affordable Medical Insurance

Reaching the masses with quality healthcare services

Photo by Hush Naidoo Jade Photography on Unsplash

By Sandra Sampson, Director at Allmed Healthcare Professionals

With its two-tiered, highly unequal healthcare system, only 14.86% of South Africa’s population can currently afford private healthcare, and rising costs are making it difficult for many to keep paying their monthly medical aid premiums. There are plans to implement National Health Insurance (NHI) to fund healthcare in the public and private sectors, although this process which began in August 2011 has been slow, and the NHI Bill is still under consideration in the National Assembly.

Despite concerns about the state’s ability to implement the NHI effectively and competently, delivering quality medical care to the population must continue to be a priority for every healthcare provider. This is where a specialist Temporary Employment Services (TES) provider can assist – delivering a flexible, competent, quality workforce on demand for institutions in both the public and private sectors.

Increasing access to quality healthcare

The public healthcare sector is primarily intended to serve those who are unable to access private medical aid and is currently accessible to all, regardless of immigration status or nationality. Significant funding is a massive drawcard for specialists in the private sector, which has resulted in a widening gap between public and private healthcare facilities in much of the country. The impending NHI is intended to address this gap and enable greater access to specialist care and more free services for all, while improving the quality of public healthcare by establishing a national fund that will allow for the purchasing of healthcare services on behalf of users. Estimates for funding this national health initiative range from R165bn to R450bn, and the government has been given the go-ahead by the Gauteng High Court to continue its recruitment drive before the bill has even passed.

Access starts with affordability

In line with this move, affordable healthcare insurance is on the rise. This trend starts with partnerships between healthcare and financial services providers, and has already been seen in the likes of Dischem, Clicks and Tyme Bank’s TymeHealth, all offering medical insurance, enabling access to high-quality healthcare specialists to a market that was previously woefully under-serviced. As the demand for quality healthcare increases, there will be a proportionate increase in the need for healthcare professionals.

Practical resourcing alternatives

It is not economically or practically feasible for healthcare institutions (whether in the private or public sector) to hire more medical professionals permanently, which means they will have to explore other resourcing options. This is becoming increasingly difficult in South Africa, as many skilled medical staff are seeking work elsewhere as a result of poor working conditions created by loadshedding, corruption, and incompetent administration. Although the Department of Home Affairs has added new skills to our country’s critical skills list (many of which include medical practitioners and individual specialisations) the healthcare industry is still severely understaffed. Hospital groups are only growing more frustrated with the government’s inability to address the decreasing number of medical practitioners, particularly nurses. The Hospital Association of South Africa (HASA) has reported that nurses in the country are reaching retirement age without the necessary inflow of younger employees. In 2020, there were more than 21,000 nurses in training, but South Africa still needs as many as 26,000 additional nurses to meet the growing demand.

Meeting the demand flexibly

TES providers in the healthcare sector have the potential to meet the demand of healthcare institutions for nurses and specialists, without these institutions having to commit to the responsibilities and costs associated with full-time employment. TES providers are on hand to supply the vetted and highly-skilled workers so desperately needed. Every healthcare institution can be supplied with the resources necessary on a shift-by-shift basis. So, if, for example, there is a deficit of five ICU nurses at a certain hospital, a TES provider can meet this with very short notice. If, on the other hand, patients are discharged or rerouted, these additional nurses can be cancelled at short notice, and the TES provider picks up the hospital’s slack and answers it with flexible resources on demand. Additionally, when it comes to meeting the fluctuating demand for speciality staff, a TES partner will become indispensable.

Equitability and affordability depend on agility

Ultimately, regardless of when the NHI comes to fruition, healthcare institutions should begin partnering with a TES provider if they haven’t already. Along with providing medical professionals on demand, this comes with cost-saving benefits for the hospital or clinic. Not having to employ full-time staff to meet fluctuating needs is a cost-saving exercise. Not only from a wage standpoint but also from an HR perspective in terms of payroll, industrial relations and skills development. The TES partner is responsible for all aspects of the employment relationship, while the healthcare institution gains access to qualified healthcare professionals as needed, at a fixed rate on flexible terms. This means that as soon as hospitals decide to invest in making their wards and spaces bigger and more efficient, they will have access to the medical resources necessary to staff them in a manner that enables equitable access to quality healthcare.

Opinion: Exciting Health Reforms are Possible if We can Move Beyond All the Political Sclerosis

By Marcus Low, Spotlight Editor

It is often enlightening for us at Spotlight to ask how and why certain services differ in the ways they do between the private and public healthcare sectors.

Take something as simple as needing medical help when you have a flu that just won’t go away. As a private sector patient, I’d call my GP’s office and make an appointment. Providing I get there on time, chances are I would at most be asked to wait for 10 or 20 minutes in a comfortable waiting room. By contrast, at many public healthcare facilities, you are not able to make an appointment, and often have to wait for long hours in a poorly ventilated and overcrowded waiting area and will likely end up seeing a nurse rather than a GP.

Some aspects of such differences are understandable, albeit deeply problematic. The shortage of doctors is much more acute in the public sector than in the private sector. There is a moral imperative to address this imbalance, but as previously argued, the current NHI plans are just one way to address it.

Why some public healthcare facilities still do not use appointment systems is harder to explain. Even if some users prefer to queue rather than to have appointments, it is odd that all facilities do not at least have hybrid systems with some appointments and some queueing. Having appointment systems is not rocket science and doesn’t have to cost millions.

There are, of course, other examples. As a private healthcare user, it is relatively trivial for me to get a six-month chronic medication script from my GP and to arrange for the medicines to be delivered to my home. Though there has been significant progress in this direction in the public sector, many people still find it hard to get scripts and collect their medicines.

Of course, differences in available resources are a large part of what is going on here, but it is not the whole story. As a private healthcare user, my needs, my preferences, and my time are generally respected in a way that seems rare in the public sector. To be clear, there are many committed healthcare workers in the public sector who show exemplary respect for their patients, but at a systemic level, as in the decision not to have appointment systems or not to allow for extended medicine refills, people’s time and needs are being disregarded.

Apart from the risk of corruption and mismanagement, much of the middle-class resistance to NHI may well have to do with the fear that people who can now access private healthcare services will become subject to precisely this kind of systemic indifference to their needs. And indeed, while the rhetoric around NHI has often been about ideals like the need for greater social solidarity, we haven’t really seen a vision presented of NHI as offering better, more respectful, and more personalised healthcare.

But, with a bit of flexibility, this could change.

Consider annual checkups. Rather than asking public sector patients to go to overcrowded clinics with long queues for tests, why not give public sector users the option of getting their basic screening tests for HIV, TB, hypertension, and diabetes done at private sector pharmacies along the lines of Discovery Health’s Annual Health Checkup. Of course, data systems will have to be developed to support this and it will have to be budgeted for, but the extra convenience will no doubt make a big difference for many and could help with early detection of these diseases. (We previously wrote about the idea of such an expanded annual checkup programme here.)

Getting the state to pay for such checkups at private sector pharmacies is not exactly NHI as set out in the bill, but the idea certainly shares some DNA.

To be fair, there are at least some exceptions that show such innovation is possible. Maybe most notably, these days many public sector patients can collect their chronic medicines at private pharmacies or other pickup points. Though still a work in progress, the evolution of the public sector medicines distribution system shows that we need not wait for the NHI Bill before taking steps to make things easier and more convenient for users.

In addition, with the NHI pilot projects we have seen at least some awareness that there is a need to try new things and learn from them. Unfortunately, on the whole the NHI pilot projects didn’t meaningfully pilot the key aspects of NHI, and where they did, as with GP contracting, it didn’t go well. And here one gets to the rub. From the outside one gets the impression that those who wanted to run pilots we could actually learn from lost out to those who consider the pilots just another step toward building political support for NHI.

As for the NHI Bill itself, the fact that the ANC and much of the portfolio committee on health, has been intent on reducing almost all discussion on the Bill to a simple for or against shows a clear disdain for meaningful engagement. Indeed, whatever its merits, the ANC’s version of NHI has become fundamentally associated with an overdose of ideology and an absence of curiosity and critical thinking.

But we don’t have to buy into the ANC’s sclerotic thinking.

There are many possible ways to reform and improve our healthcare system. Some will be affordable, some won’t. Either way, it would be foolish to simply turn our backs and pretend they are not there.

*Low is the editor of Spotlight.

Republished from Spotlight under a Creative Commons Licence.

Source: Spotlight

National Health Insurance Bill: Will it Wipe out Medical Insurance?

The NHI Bill does not contain any clarity on how South Africa’s large and complex medical schemes and insurance industry will be affected.

Photo by Bill Oxford on Unsplash

By Lenee Green, Partner, Mateen Memon, Associate & Mariam Ismail, Trainee Attorney at Webber Wentzel

On 12 June 2023, the National Health Insurance Bill (the Bill) was passed by the National Assembly and is currently with the National Council of Provinces for consideration. Its laudable aim is to make primary healthcare widely accessible.

The Bill has been closely scrutinised by various stakeholders in the healthcare sector. Concerns have been raised by medical schemes and insurers about the effect the Bill will have on their current businesses.

The Bill, among other things, covers:

  • who will be able to access health care services;
  • how these services will be funded;
  • the establishment of a board and advisory committees to achieve the objectives of the Bill;
  • general provisions applicable to how the fund will operate;
  • complaints about and appeals of decisions made by the fund; and
  • the source of income of the Fund and transitional arrangements.

Clause 33 of the Bill states that once the National Health Insurance (NHI) is fully implemented, medical schemes can only offer complementary coverage for services not reimbursed by the NHI. Clause 6(o) of the Bill allows individuals to purchase services not covered by the NHI through voluntary medical insurance schemes. This means medical schemes cannot cover services already covered by the NHI, potentially jeopardising their existence. This approach may face constitutional challenges related to the right to access healthcare, property rights of medical schemes, and freedom of trade and profession.

It is contemplated that the Minister of Health will introduce regulations limiting benefits to services not reimbursable by the Fund.  We have not yet seen any indication when these regulations will be published.

Current regime

Broadly, four main categories of business will be impacted by the Bill:

  • business of a medical scheme as defined in the Medical Schemes Act 131 of 1998 (MSA);
  • insurers licensed to conduct insurance business pursuant to the Insurance Act 18 of 2017 (the Insurance Act);
  • insurers who offer products pursuant to section 8(h) of the MSA (the Exemption Framework); and
  • insurers who offer products pursuant to the regulations published under each of the Long-Term Insurance Act 52 of 1998 and the Short-Term Insurance Act 53 of 1998 (the Demarcation Regulations).

Medical schemes

Presently, only medical schemes may carry on the “business of a medical scheme” as defined in the MSA. The “business of a medical scheme” involves undertaking liability for the provision of obtaining “relevant health services”, defraying expenditure for “relevant health services” or rendering health services by the medical scheme itself or by any supplier of a “relevant health service” in return for a premium or contribution.

A “relevant health service” under the MSA is very wide. It includes “any health care treatment of any person by any person registered in terms of any law, which treatment has as its object…” The objects include a broad range of medical services, including the physical or mental examination of a person, the diagnosis, treatment or prevention of any physical or mental defect, illness, or deficiency, ambulance services and hospital or similar accommodation.

Insurers

Medical schemes must be distinguished from medical insurance provided by insurers. Insurers may provide medical insurance under, among other dispensations, the Insurance Act. Schedule 2 to the Insurance Act provides for various classes and sub-classes of insurance business for which life insurance companies and non-life insurance companies may be licensed. Schedule 2 allows insurers to provide health and disability benefits under the risk class of business for life insurance and accident and health and travel insurance under the classes for non-life insurance.

Health insurance is provided upon the happening of a health event. A health event is defined in the Insurance Act as one that relates to the health, mind or body of a person or an unborn, other than a disability event. The disability event is defined and includes circumstances where a person loses a limb or becomes physically or mentally impaired. It is apparent that there is an overlap of products provided for in the Insurance Act and offered under the MSA.

The Demarcation Regulations provide for the demarcation between insurance business and medical schemes business. The regulations provide that a benefit that would otherwise have been a medical scheme benefit, but meets the exact requirements (definitions) set out in the tables in the Demarcation Regulations, is classified as an insurance product.

In March 2017, the Counsel for Medical Schemes (CMS) issued an exemption framework for insurers as a transitional arrangement while the development of a low-cost benefit option (LCBO) for medical schemes was developed (Exemption Framework). To the extent that an exemption was granted to an insurer in terms of section 8(h) of the MSA, and subject to the conditions of the exemption, the insurer was permitted to continue to underwrite those products until the expiry of the exemption. On 25 January 2022, the CMS granted insurers that had previously been granted an exemption in terms of the Exemption Framework an extension of a further two years.

The background to the LCBO is that a ministerial task team on social health insurance launched the low-income medical scheme consultative process in 2005. In 2015, the CMS issued a circular that considered introducing a guideline to allow medical schemes to introduce LCBOs in response to the growing number of working South Africans who did not have medical scheme coverage because they could not afford it. Following various engagement processes, the LCBO Framework Advisory Committee issued a Report in May 2022 (the Report). The Report states that LCBOs still have the potential to “alleviate pressure in the public healthcare system and allow resources to be redirected to the poor”. This process has progressed quite slowly, and it remains to be seen what comes of it if anything.

While the Bill is a piece of framework legislation, it does not provide clarity on what will become of insurance under the current regime. The fate of medical schemes is dealt with in a very cursory manner, without considering the nuances of the current regime.

The LCBO could have been a path to make healthcare more accessible, but the process has become stifled, and it may never come to fruition. What is left in the wake of the Bill is a great deal of uncertainty. Industry participants and stakeholders will have to keep abreast of the process and ensure that their comments are taken into account as the system evolves.

Opinion Piece: Commemorating Carers Week: Putting the Spotlight on South Africa’s Unsung Heroes

By Donald McMillan, Managing Director at Allmed Healthcare Professionals

Donald McMillan

The caregiving workforce plays a crucial role in our society, but their efforts often go unnoticed. These individuals, known as carers, selflessly care for those in need due to factors such as illness, age, or frailty. Unfortunately, they face numerous challenges that can take a toll on their well-being. It’s important to raise awareness of their struggles and provide them with the necessary support. To bring these issues to the fore, communities are coming together between the 2nd – 6th of October 2023 to commemorate Carers Week.

Caregivers have an enormous responsibility that often goes unnoticed by society. The emotional strain that comes with caregiving can have a direct impact on their mental health and often leads to depression. They often devote their time and interests to the role of voluntary caregivers and face many challenges due to the lack of recognition and support from their professional peers and society in general.

Initiatives in place

In response to these issues, governmental efforts have been put forth to assist both caregivers and non-governmental organisations with the aim of alleviating some of the financial burdens associated with their work. A noteworthy instance of this support is exemplified in the community home-based care program run by The Association for the Aged (TAFTA), which secures government funding to informal caregivers. This initiative and others like it, combined with the Carer’s Grant are part of positive strides being made within this space. However, further support is still needed to ensure that caregivers receive adequate support as they strive to provide high-quality care to their patients.

The government alone cannot be the only one providing support to carers as society and the private sector each have to role to play in alleviating the burden that sits on the shoulders of carers, particularly within impoverished and rural communities. The logical progression is for the government and all stakeholders to channel their resources into a comprehensive framework that encompasses financial aid, training, and support services for carers. Additionally, the pursuit of affordable and inventive caregiving solutions cannot be neglected.

Rising to meet growing demands

As South Africa’s population ages and chronic illnesses surge, the demand for caregiving services has swelled to unprecedented levels. To adequately address these escalating requirements, several measures must be adopted. Establishing community-based networks of support can furnish practical assistance and emotional solace. Carers must also receive enhanced training and upskilling to hone their capabilities, all the while being granted the acknowledgement and admiration they rightfully deserve.

It is imperative for entities that offer caregiving employment to invest in training to equip carers with the tools required for high-quality care provision. The integration of emotional counselling facilitated by clinical experts constitutes another crucial component of the caregivers’ support structure.

Strengthening the system

The symbiotic relationship between government bodies, stakeholders, and relevant associations is pivotal in reshaping the caregiving landscape. The collaboration between the Department of Social Development (DSD) and the South African Association of Homes for the aged- (SAAHA), exemplified by their joint registration of care workers both formal and informal, signifies a significant step toward accountability and much-needed assistance. The synergy of corporate involvement and government funding has the potential to revolutionise the lives of caregivers in both formal and informal capacities.

Upskilling the informal carer workforce stands as a cornerstone for improving the quality of caregiving. Creating and running specialised courses tailored for caregivers is essential, as it not only enriches their knowledge and competencies but also bolsters their confidence, employability, and job satisfaction. These comprehensive courses should span various aspects, from personal care to dementia management, empowering caregivers to confront their daily challenges head-on.

Galvanising society

As mentioned, support for carers should transcend the boundaries of governmental programs and corporate ventures. The broader society has a pivotal role in elevating the status of carers. Displaying empathy, extending practical aid, advocating for improved resources, and propagating awareness about the struggles of caregivers all fall within our capability as members of the public. Initiatives rooted in communities, campaigns, and programs can collectively reshape perceptions and extend tangible support.

Carers are one of the important pillars on which our society relies, and more need for recognition of their contributions and tribulations must be given. By advocating for increased support, enhanced financial backing, and inventive solutions, we can uplift carers and ensure their endeavours do not remain obscured. With the collective resolve of government bodies, stakeholders, businesses, and the populace, we can pave the path to a brighter, more nurturing future for carers and their cherished ones.

Medical Gaslighting: When Conditions Turn out not to be ‘All in the Mind’

By Caitjan Gainty, Senior Lecturer in the History of Science, Technology and Medicine, King’s College London

Photo by cottonbro studio

Gaslight, a psychological thriller starring Ingrid Bergman, was a box-office hit when it was released in 1944, but its time in the limelight could have ended there. However, the ruse employed by its villain gave the work remarkable staying power.

Set in 1880s London, the story plays out in the upper-middle-class, gas-lit home of Gregory and Paula Anton. Gregory is intent on making Paula think she is going insane so that he can have her committed to a mental institution and claim her inheritance. He attempts to convince her that the gas lighting in their house, which the audience can see is flickering, is not really flickering. What her senses tell her is a lie – a sign of her steady descent into madness.

Today, the term “gaslighting” is widely used to describe psychological manipulation, where a person is made to doubt their perception of reality. Politicians are accused of it, as are celebrities. The term also used in discussions about health.

Medical gaslighting refers to cases in which a healthcare practitioner imposes a pattern of questions, testing or diagnosis that runs counter or tangential to the history or symptoms the patient is describing or experiencing.

There is usually a clear power imbalance at play. More often than not, gaslit patients are women, members of the LGBTQ community, people of colour and older adults.

It is a painful reminder that medicine does not occupy a rarefied space apart from society and history. Those who are socially, culturally, politically or economically marginalised don’t find that this experience suddenly changes when they walk through the clinic door.

In many ways, the term gaslighting is an apt fit for medical settings, especially when it comes to the common refrain: “It’s all in your head.”

One of the best-known examples relates to heart disease, where a woman’s symptoms are twice as likely as a man’s to be simply written off as mental illness. This missed diagnosis is often explained by the fact that women’s heart attack symptoms are “strange and unpredictable” (compared with a man’s “normal” symptoms). However, that excuse doesn’t hold water – there is a large overlap in heart attack symptoms between the sexes.

Elsewhere, social media and news reports are full of egregious examples of women being medically gaslit. There are those whose cancer reached an advanced stage before they could get a doctor to take them seriously. And those whose lives were imperilled by a doctor who dismissed their pain as anxiety, as postpartum depression, as not nearly as bad as they think it is.

Examples of medical gaslighting also accrue around chronic but poorly understood diseases. In recent years, there’s been the medical community’s slow and halting recognition of long COVID. Before that, it was long Lyme disease or chronic fatigue syndrome, as Jennifer Brea’s 2017 documentary Unrest movingly shows.

Algorithmically out of whack

Yet medical gaslighting is a far more complex creature than gaslighting in other contexts. While Gregory’s attempts to gaslight his wife were malicious and intentional, medical gaslighting quite often overlaps with a more basic problem in medicine: misdiagnosis.

In many cases, misdiagnosis occurs not because an individual doctor is being malicious or even intentionally – though perhaps unconsciously – prejudiced, but because the symptoms they observe in the patient before them are “algorithmically” out of whack with the standard set of symptoms and characteristics they have been taught to look for and associate with different diseases.

Since these algorithms were explicitly built around heterosexual white men, it makes sense that the vast majority of those who have experienced medical gaslighting or misdiagnosis hail from beyond this extremely narrow band of the population. But even at a more basic level, individuals are simply not standard. Human bodies don’t conform as closely to the algorithms as medicine would ideally like them to.

“The bottom line,” as one doctor put it, “is that diagnosis is hard.” It does not help that research into diagnosis is never as well-funded as research into treatment.

That’s not to say there aren’t any covert (or overt) Gregory Antons out there in medical practice, of course. But it does mean that if we want to address medical gaslighting, the answer is probably not as simple as training medical professionals to be more sensitive to their patient’s descriptions of their symptoms.

Indeed, the very foundation of modern medicine agitates against this kind of attention to individual symptoms, asking medical professionals instead to measure patients against a set of standards – to think statistically as they make their diagnostic decisions.

Until a much greater part of society is included in that statistical reckoning, we can expect medical gaslighting to remain a part of our medical experiences. And even if or when that happens, our system will still be one that grapples with the difficult task of matching the emphatically square holes of symptom and diagnostic categories with the differently shaped realities of individual symptoms and illness experiences.

The Conversation

Republished from The Conversation under a Creative Commons License. Read the original article.

Medical Sector Airs their Concerns about the NHI Bill and the Impact on the Health of Citizens

At a recent media briefing session hosted by the Board of Healthcare Funders (BHF), managing director, Dr Katlego Mothudi, together with a distinguished panel of healthcare leaders addressed critical concerns regarding the National Health Insurance (NHI) Bill proposed by the South African government. The panellists, including BHF’s Chairperson, Ms Neo Khauoe, Dr Stan Moloabi, Chairperson of the BHF’s Universal Health Coverage Committee (UHC), Dr Mvuyisi Mzukwa, Chairperson of the South African Medical Association (SAMA), Prof Alex van der Heever, an expert in Health Care Governance at University of Witwatersrand  (WITS), and BHF’s Head of Health System Strengthening, Dr Rajesh Patel, jointly emphasised the critical importance of addressing the current shortcomings in the NHI Bill. The panel highlighted the urgent need for systematic amendments before the Bill’s implementation. 

While the BHF supports the concept of universal health coverage, Neo Khauoe strongly disagrees with the approach of the NHI Bill that public healthcare funding must increase at the expense of medical schemes.  “The private health funding sector in South Africa should not be sacrificed in favour of NHI. It is too valuable in terms of jobs, scarce skills, infrastructure, financial investment, the quality of the health care services its beneficiaries receive, the value it adds to the economy, and the support it has lent to the public health sector,’’ she said.  

Rajesh Patel, highlighting concerns within Section 33 of the Bill, pointing out the need for clarity in the Minister’s decision-making processes regarding the inclusion of rules for thorough implementation and addressed ambiguity in NHI contracting with health service providers. He said, one of the bigger complications is that maternity care has been excluded from the medical scheme’s benefits.  

“There are absolutely no indicators in Section 33 to guide the Minister as to when NHI is fully implemented. Section 33 is thus contrary to the constitutional principle of administrative justice and allows the Minister to act arbitrarily. The determination by the Minister is an administrative decision that is subject to Section 33 of the Constitution and the Promotion of Administrative Justice Act No. 3 of 2000. As such, it must be lawful, reasonable, and procedurally fair. How is the Minister to know what will make his decision lawful if Parliament gives him no guidance in the NHI Act? The minister is not the lawmaker. That is Parliament’s role,” said Patel. 

He emphasised the complexity of the NHI fund contracting health service providers and proposed the simplification of the process to encourage the participation of private sector firms in this undertaking. The private health service providers are estimated to be between 65 000 and 70 000 individuals and entities. The issues raised include the capacity for the responsible party for certifying and accrediting these health service providers and facilities, which will thereafter determine their eligibility for contractual engagement. The slow pace of certification and accreditation may limit access to care for healthcare users, as the user must register with NHI via accredited health service providers. Should contractual arrangements fail the health citizens risk not being funded from the NHI.

Stan Moloabi, Chair of the UHC Committee at BHFs, emphasised that medical schemes are important in healthcare provision and this importance is beyond just financial aspects. Serving as an integral stakeholder in the ecosystem that allows the health citizen’ to access the necessary health services in a timely, effective, and efficient manner, ultimately ensuring the provision of high-quality care.  Moloabi concluded by saying, “We are currently facing uncertainties regarding the specific details that will arise from the ongoing policy changes outlined in the NHI Bill.  As private healthcare funders, our primary goal is to actively collaborate with policymakers, which is crucial to achieving our shared objective of achieving UHC.“

According to Alex van der Heever, the NHI Bill is designed in a manner that will further undermine the already precarious situation of the South African healthcare sector. The discourse surrounding the move towards the achievement of universal health coverage in the country necessitates a comprehensive examination of the underlying goals associated with the concept of universal health care. Medical schemes are currently an integral component of the health system providing cover to 9 million lives. The hybrid universal coverage model is widely employed across the globe. He expressed his concerns pertaining to the single funder in the NHI Bill and the pressure on the health care system should all citizens rely on a single scheme. Furthermore a single fund is an impractical approach for both rich and developing countries Given South Africa’s limited GDP strength, such a proposition appears particularly unreasonable. 

Neo Khaoue provided an in-depth analysis of the prospective financial consequences that enterprises may encounter because of the implementation of the NHI programme. Khaoue specifically emphasised the expected discrepancy in healthcare accessibility rates among employees under the NHI Bill in comparison to the existing system. The discrepancy is anticipated to extend the duration of employees’ recuperation, resulting in supplementary expenses for employers because of the postponed resumption of employees’ work duties. Considering the democratic nature of South Africa, it is crucial to prioritise the provision of opportunities for South African citizens to exercise their autonomy in shaping the course of their own future.  Khauoe questioned the means through which discrepancies between private and public healthcare systems can be mitigated, particularly considering the existing difficulty of lengthy waiting times for various medical treatments.  She said, “What strategies could be used to help the NHI Bill to simplify some of its processes, for example, if one is prepared for a certain operation but there is no anaesthesia available and the procedure is not performed on the specified day, what then? Furthermore, it is imperative to establish a reliable mechanism to guarantee that those who have been scheduled for operations or procedures will indeed undergo them on the designated days without any rescheduling. This demonstrates the necessity of both public and private sector involvement in addressing and resolving existing imbalances as a primary concern.” 

 According to Mvuyisi Mzukwa, the Chairman of SAMA, the NHI Bill has the potential to impose financial consequences on healthcare practitioners. Although healthcare providers may qualify for payment for services provided to beneficiaries of the NHI, it is important to note that the rates for these services may be standardised. This standardisation could potentially lead to a decrease in their revenue compared to the fees charged in private practice. Therefore, it may be necessary for practitioners to adjust their financial expectations and business strategies. He affirmed that the potential consequences of NHI could vary significantly depending on the legislative and regulatory framework in place. He went on to say, “Nevertheless, it is crucial to consider the financial implications for healthcare professionals when finalising the NHI Bill. The most important thing is that as the private health care practitioners we want to participate via collaboration with the policy makers in ensuring that we achieve those ideas they have.” 

“As BHF, we are resolute that we provide the health citizen with a comprehensive understanding of the potential implications, challenges, and shortcomings of the NHI Bill before the upcoming provincial briefing sessions to be convened by the government. This is essential for fostering transparency, informed public discourse, and evidence-based policymaking in healthcare reforms and for giving South Africans a clear understanding of how the Bill will affect the lives of every citizen. I urge all South Africans to participate as it will impact all of us,” Katlego Mothudi said. 

Mothudi highlighted that BHF firmly supports the freedom of the people of South Africa to spend their disposable income as they see fit, including insuring any of their health needs through medical schemes. This right is derived from the constitutional value of personal freedom in a democratic society and the rights to human dignity, privacy, freedom of association, freedom of thought, belief, and opinion, and the right to have access to health care services and emergency medical treatment. 

“The NHI Bill is anticipated to have a cascading impact on the already declining state of the public health system in South Africa,” concluded Mothudi.    

Opinion: Safer Sanitation Solutions – The Quest to Eradicate Pit Latrines in South Africa 

Robert Erasmus

By Robert Erasmus, Managing Director at Sanitech 

In South Africa, the use of pit latrines remains a prevalent human rights issue, infringing on every person’s right to life, dignity, and health, as well as their right to access water and adequate basic sanitation. Despite their unavoidable application in certain contexts, pit latrines pose numerous risks to life, health, and safety, particularly in schools and areas lacking proper sanitation infrastructure such as informal settlements, prompting efforts to eliminate their presence in the country.

As far back as 2019, the Department of Water and Sanitation (DWS) launched a campaign called Khusela, which means “to eradicate” in isiZulu, to abolish pit latrines by 2030. Given the extensive challenges related to sanitation infrastructure, eradicating pit latrines is going to take time, particularly in rural areas. Nonetheless, this human rights issue must be squarely addressed and that functional, sustainable alternatives to open pit latrines are given the proper prioritisation.  

Pit latrines: the shocking numbers  

From a sanitation perspective, there are 380 schools in South Africa with no running water. 3392 schools still use pit latrines, which affects 34 489 teachers and 1 042 698 learners. While it is difficult to ascertain exact population figures, it is estimated that there are still four million pit latrines in use by communities throughout the country, of which only two million are Ventilated Improved Pit (VIP) latrines, while the remainder are ordinary pits with, or without covers. VIP latrines are a type of pit latrine that has a ventilation pipe that allows air to circulate through the pit, which helps to reduce odours and the breeding of flies. These latrines are also typically constructed with a more substantial exterior structure than ordinary pit latrines.  

Endangering communities 

The use of pit latrines can be perilous, posing a safety risk, particularly for young children, females, and vulnerable individuals. Without proper maintenance or safety precautions, accidents such as falls, injuries, and even drownings occur. Pit latrines contribute to the spread of disease, posing a major health hazard to users and nearby residents, as inadequate waste management and poor sanitation practices contaminate the groundwater and soil, as well as nearby water sources which lead to the transmission of waterborne diseases like cholera, diarrhoea, and dysentery. Pit latrines often lack essential sanitation facilities, such as handwashing stations or proper waste disposal systems, which results in unhygienic environments, poor personal hygiene practices, and an elevated risk of infections and diseases.  

For affected communities, the lack of access to clean water and proper sanitation has a significant impact on health and well-being. The lack of access to safe and hygienic sanitation facilities can lead to health problems, which can make it difficult for people to work and earn a living. The correlation between adequate sanitation and poverty is a complex issue, with several contributing factors. As such, it is important to address these factors to improve sanitation and ultimately reduce poverty. 

Challenging to service 

Pit latrines are used primarily in areas that do not have access to water. These gradually fill up over time, primarily with solid waste as most liquid waste evaporates or is absorbed into the soil. Originally estimated to last seven to ten years, these latrines often require maintenance in just two to three years due to the significant amount of additional waste they receive. Decisions must then be made to either close the latrine and dig a new hole or seek servicing, a challenging task that involves treating the solid waste to create a more liquid environment before using a honey sucker or vacuum tanker to extract and dispose of the waste in a treatment plant. The remote locations of many facilities add to the complexity of the process. 

Seeking practical solutions and facing reality  

This highlights the urgent need for practical solutions when addressing the challenges posed by pit latrines. To illustrate the practicalities, consider the sheer number of pit latrines – four million, with two million being VIPs and two million standards. Replacing all of these with waterborne sanitation is simply unfeasible in the short term, as this would require an additional one billion litres of water daily for flushing alone. This is currently an insurmountable obstacle in terms of water supply and treatment, considering the condition of existing waste treatment plants. The South African private sector has sought to find the most practical and effective way to address the critical issues of safety, environmental impact, and serviceability of these facilities. To make a tangible difference, it is necessary first to acknowledge that an immediate conversion to waterborne solutions is not practical, in the short and medium term.  

Attainable, cost-effective alternatives 

A safer alternative to pit latrines has been developed and tested extensively and is ready for implementation in communities. It is a cost-effective, dry sanitation unit that addresses health and safety shortfalls, installation difficulties and servicing problems with pit latrines while ensuring that environmental and underground water contamination cannot occur. The main structure consists of concrete and the door is made of injection moulding plastic, with a ventilation pipe to limit odours. The waste containment unit has a 1500-litre bladder with a 3–5-year guaranteed life cycle, which can be removed without disabling the unit. The units are mobile, and no pit must be dug, which reduces installation costs and limits the abandonment of land. The unit itself is shaped in an ellipse to maximise space utilisation and waste containment, using a rotating bowl to dispose of waste, which prevents contact with faecal matter. The unit is sealed to prevent insects from entering or exiting the system and uses environmentally friendly products to treat waste, all of which address environmental concerns.  

A cleaner, safer future 

The need to eliminate pit latrines in South Africa is clear, given the multitude of risks they pose to the health, safety, and environment of communities. While an immediate conversion to waterborne sanitation may not be practical due to water supply and treatment limitations, the development of safer alternatives, such as the dry sanitation unit, offers promising possibilities. By prioritising the implementation of such practical and effective solutions, South Africa can significantly enhance the well-being and quality of life of its communities, making strides towards a future where pit latrines are replaced with safe, sustainable, and healthier sanitation options for all citizens. 

Can the Health System Help Answer South Africa’s Youth Unemployment Issue?

Photo by Ivan Samkov on Pexels

Amid skyrocketing youth unemployment, healthcare, a vast sector which touches all of our lives at some point, seems a sensible space for young people to set their sights on for opportunities. From clinical sciences to pharmacy, there is a myriad of careers in the healthcare ecosystem, but there are also factors preventing this potential from being unleashed, writes Bada Pharasi, CEO of The Innovative Pharmaceutical Association South Africa (IPASA).

A career in health has long been seen as a symbol of success in South Africa. The no-nonsense nurses in our communities, the hard-working doctors and the knowledgeable pharmacists have long represented those who had “made it”.

For many of us, these were the lucky ones who had found a career path that was both rewarding and respected. This has also been the way that South Africans view the myriad of the less visible jobs in healthcare (lab technicians, pharmacist assistants, dieticians, the list is endless).

Bada Pharasi, Chief Executive Officer of IPASA

As South Africa grapples with the highest unemployment rate1 in the world, with youth unemployment being the biggest concern (currently at more than 60%2), it’s not difficult to see why the healthcare system with its vast range of careers would present a solution. Careers in health not only benefit young people looking for a start in life, but they also build South Africa’s capacity to provide care for millions who desperately need it.

As young people search for the stepping stones to long, rewarding careers, many will be advised by well-intentioned family and friends to seek a future in healthcare. And it’s not bad advice.

As a sector that can generate employment opportunities at both ends of the value chain – from highly skilled specialists in technology and research to those who operate in palliative or frail care environments2 – the recent effects of the Covid-19 pandemic underscored the essential value and role that healthcare workers play in bolstering South Africa’s socio-economic and overall health resilience.

Human resource gaps in healthcare are clear

In 2020, the Hospital Association of South Africa suggested that there was a shortage of between 26 000 and 62 000 professional nurses and this shortage is expected to increase to between 305 000 and 340 000 by 2030 as the country’s population continues to grow. Alarmingly, estimates suggest that only 26 ,000 will be trained by then3.

South Africa also has less than one doctor per 1000 patients4. In a country with serious disease burdens, the situation is far from ideal.

The need for long-term planning

A challenge often cited when posts are frozen in healthcare is funding. While there are undoubtedly funding constraints in the healthcare system, it seems unlikely that the addition of funds will solve the challenge. It’s worth rethinking the way the human resources pipeline in South Africa is structured and where the bottlenecks lie.

South Africa’s history of inequality, which is deeply entrenched in the country’s healthcare system, has created the twin challenge of a shortage of skills and inadequate capacity to manage and distribute those skills to where they’re most needed. There are also policy bottlenecks that can hinder progress.

For instance, while complementing the qualification with some kind of work experience and community service spent in the public sector is an applaudable initiative, it becomes counterproductive when there aren’t enough posts in the public sector to place people coming out of training institutions. This, in turn, limits the number of professionals who can qualify, adding incrementally to the shortage of personnel every year. 

Similarly, the cap on the number of personnel that the Nursing Council can accredit per year may limit the number of posts needed, but it doesn’t help address the shortage of nurses in South Africa.

The burden of disease in South Africa, coupled with the uneven spread of healthcare facilities means that it’s also a singularly challenging environment to work in. This means that retention policies, and initiatives that prioritise the well-being of healthcare workers are also important considerations.

It’s worth noting that over the past few decades, there have been a number of well-considered human resources strategies for the healthcare system in South Africa5. Unfortunately, these have suffered from inadequate implementation. This long-term planning and implementation is critical.  

Ultimately, it means ensuring that we’re able to encourage young people to take up these worthy careers with the guarantee that once they qualify, their skills will be put to good use. 

As the National Department of Health prepares to move South Africa toward the National Health Insurance scheme, the question of staffing becomes even more critical. It’s going to call for long-term strategies that will need to be implemented over generations.

References:

  1. Leshoro D. 179 000 job losses means South Africa now leads the world in unemployment [Internet]. Citypress. 2023 [cited 2023 June 5]. Available from: https://www.news24.com/citypress/business/sas-deepening-unemployment-headache-20230516
  2. [No title] [Internet]. [cited 2023 June 15]. Available from: https://www.statssa.gov.za/?p=15407
  3. Health sector can create thousands of jobs in SA [Internet]. SABC News. 2019 [cited 2023 June 5]. Available from: https://www.sabcnews.com/sabcnews/health-sector-can-create-thousands-of-jobs-in-sa/
  4. Francke RL. Nursing shortage puts rural South Africans at risk – report [Internet]. DFA. 2023 [cited 2023 Jun 6]. Available from: https://www.dfa.co.za/opinion-and-features/nursing-shortage-puts-rural-south-africans-at-risk-report-2355a0bd-ea21-4483-9429-cb9351ac0a1d/
  5. Critical shortage of doctors in SA – less than 1 doctor for every 1 000 patients [Internet]. Democratic Alliance. [cited 2023 June 7]. Available from: https://www.da.org.za/2022/05/critical-shortage-of-doctors-in-sa-less-than-1-doctor-for-every-1-000-patients#:~:text=09%20May%202022%20in%20News,doctors%20per%201%20000%20patients.
  6. Ryneveld Mv, Schneider H, Lehmann, U – Looking back to look forward: a review of human resources for health governance in South Africa from 1994 to 2018 [internet]: https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-020-00536-1