Rachel Neill

Spending More, Getting Less: Public health expenditures aren’t paying off in South Africa, so private firms are stepping into the gap

From implementing a National Health Insurance scheme to battling the HIV epidemic, South African policymakers and health stakeholders face an enormous task in providing affordable and quality care to a diverse population of 52 million.

As compared to other countries with a Center for Health Market Innovations’ (CHMI) regional partner presence (Kenya, Nigeria, India and Pakistan) South Africa’s public health expenditure as a percent of total health expenditure is relatively high, 47.9 percent, compared to 38.1 percent in Kenya and 31.1 percent in Nigeria. Concurrently, out-of-pocket health expenditure as a percent of total health expenditure remains low at 13.8 percent, compared to 69 percent in Kenya, 86 percent in India and 90.2 percent in Pakistan.

But low out-of-pocket expenses and comparatively high government spending has not translated into quality services for South Africa’s poor. Since the 1994 democratic elections, access to health care has improved, but the quality of care delivered by the public sector has deteriorated. And while 80 percent of patients seek care in the public sector, approximately 70 percent of doctors and specialists work solely in the private sector.

CHMI has partnered with the Bertha Centre for Social Innovation and Entrepreneurship, an initiative of the University of Cape Town, to understand how private sector innovators are finding unique ways to serve the needs of low-income South Africans in the midst of this unique country context.

Fighting HIV with Innovative Approaches

CHMI profiles 63 programs in South Africa working on improving access and affordability to health care. Of those, 40 focus on HIV. This is reflective of South Africa’s distinctive disease burden – the country has the fourth highest HIV rate in the world (17.9 percent), after neighboring Swaziland, Lesotho and Botswana. In the CHMI database, South Africa represents only 4 percent of all program profiles, but 11.7 percent of all HIV programs.

HIV Home-based Care

Of South Africa’s 40 profiled HIV programs, six feature an element of home-based care. In response to the stigma associated with seeking care at health facilities, Cell Life has developed its own Aftercare program. Aftercare health care workers use mobile phones to record patients’ medical status and adherence to treatment in their homes, and data is transmitted via SMS to the Cell Life database, where care managers monitor patient information. Cell Life also reaches HIV-positive mothers through a 10-week-long SMS program which encourages mothers to return for post-natal care visits and receive prophylactics to prevent mother-to-child transmission. After testing the program in a randomized controlled trial, more than 90 percent of mothers in the experimental group came in for treatment, versus only 78 percent of mothers in the control group.

Similarly, the Sizophila Therapeutic Counseling Project trains community members living with HIV as therapeutic counselors. HIV patients with specialized ART needs, including pediatric patients, pregnant women, co-infected TB patients and mentally ill patients, are assigned a counselor who provides ongoing mentorship and support through home-based visitations. Of the first 1,000 patients in the program, 96 percent of patients were still on firstline drugs after 32 months, illustrating the potential utility of home-based care in stabilizing the health of patients.

Photo provided by New Start, a nonprofit HIV prevention program that offers counseling and testing, medical male circumcision and health communications services.

HIV Testing

Of South Africa’s 40 profiled HIV programs, nine include innovations around HIV testing. New Start South Africa aims to motivate healthy men and couples to get tested for HIV. The program has seven fixed sites and 16 mobile sites, set up at taxi stands, shopping malls, concerts and other events. All sites use rapid testing technology, include pre- and post-test counseling and provide referrals for HIV, sexually transmitted infections and TB care. After experiencing rapid growth, New Start added a franchise component to their services. Run by individual NGO “franchisees,” New Start-branded franchises are now active in Zimbabwe, Zambia, Lesotho and Swaziland.

Médecins Sans Frontières Khayelitsha leads an ART Adherence Club initiative in partnership with the Western Cape Department of Health. The ART clubs have been designed to act as a long-term retention model for stable ART patients. Thirty stable patients meet with a health care worker who provides quick clinical assessments, referrals when necessary, peer support and distribution of pre-packed ART every two months. Once per year, the patients meet with a physician for clinical management.

Emphasis on Integrated Care

South Africa’s high HIV positive rate has created an environment conducive to testing integrated care models. Integrated care models bring together a variety of different services related to diagnosis, treatment, care, rehabilitation and health promotion, often working across multiple disease specific interventions, in an aim to improve efficiency, quality, and access for the patient. South African health care organizations are integrating HIV testing and prevention into a wide variety of programs, particularly TB treatment and primary care.

Integrated TV/HIV Solutions

South Africa suffers from the highest TB burden in the world as a percentage of overall population, with 850 TB cases per 100,000 individuals. In absolute terms, South Africa has the third highest number of people infected with TB, after China and India. Further, out of the 83 percent of TB patients who know their HIV status, approximately 65 percent are positive.

A snapshot of CHMI programs reflects this high TB/HIV co-infection rate – out the 40 programs that have integrated TB and HIV care in the database, 27.5 percent of them are located in South Africa. Many of these programs focus on treatment compliance, a key priority of both HIV and TB care. On Cue Compliance equips pill bottles with a SIM card and transmitter; when the bottle is open, it alerts a health care worker. If the health care worker has not gotten an alert, they can follow up with a reminder to the patient, encouraging compliance.

Similarly, SIMmed requires patients to call a speed dial number after taking their medication. If they do not call the number within the allotted time frame, SIMmed sends an SMS reminder. If there is no response, SIMmed sends an SMS to a friend or family member tasked with reminding the patient via phone or a home visit. Early trials of both SIMmed and On Cue Compliance resulted in a 90 percent compliance rate, as compared to a 20-60 percent baseline average.

Integrated Primary Care and HIV Treatment

Six out of 17 South African primary care programs also provide HIV care (35.3 percent). This compares to only 44 out of 507 programs in the overall database (8.6 percent).

Unjani Clinics provide low-cost, high-quality primary health care and HIV treatment and counseling to underserved communities. The franchise clinics, constructed from converted shipping containers, are run by female nurse practitioners. Each of Ujani’s seven franchise clinics serves between 150 to 500 patients per month.

The Autonomous Treatment Center (ATC) is another integrated care model, providing primary care, pre-natal care, prevention of mother to child transmission expertise, on-site pharmacy, HIV testing and counseling services. Located in rural areas of Mpumalanga and Limpopo, ATC also provides TB treatment on behalf of the public sector through an agreement with the Department of Health.

Rachel Neill is a senior program associate for the Results for Development Institute, where she works on the Center for Health Market Innovations.

This blog originally appeared on the CHMI website and is reprinted here with permission.

Health Care
public health