Cancer as a killer that has been increasingly claiming more lives across the world, compromising the effectiveness of governments to provide quality healthcare. One of the most prevalent myths, due to the obsolete mindset permeating most healthcare systems, is that treating cancer ought to be expensive.
A partnership started in March 2018 to address cancer crisis has quashed this myth. The Kwa-Zulu Natal Provincial Department of Health engaged the services of Health Systems Enablement & Innovation (HSEI) Unit to provide oncology services at both Inkosi Albert Luthuli Central and Addington Hospitals. HSEI is a division of the Wits Health Consortium, led by two young medical professionals, Dr Itumeleng Funani and Dr Wezile Chitha, and guided by our motto “Dignity Through Healthcare” took the challenge and put an alternative solution on the table.
“We were faced by a serious challenge, the health system at crossroads. The hospitals have invested in infrastructure, staffing, equipment and other support services. The hospitals were struggling to recruit oncologists through the traditional vehicles e.g. advertising. Patients frequent visits to the hospitals were becoming unbearable for nursing staff. The missing piece of the puzzle was the oncologist,” says Dr Chitha
According to Dr Chitha, “The hospitals continued spending on costs related to infrastructure, equipment, staffing and support services despite providing a limited cancer service. Patients continued to spend on transport, lost wages and caregivers whilst the hospitals could not guarantee them access to oncologists. This economic burden cannot be justified when the country boasts of such hospital infrastructure and an established private sector.”
“We are activists, we are motivated by social justice and the desire to enable South Africa’s public healthcare system to better utilise its infrastructure and human resources to serve the poor and marginalised rural populations”, says Dr Funani.
The initial Kwa-Zulu Natal engagement was for six months, but the success of the partnership seen this relationship continued by over 24 months.
HSEI is now using a similar model in Mpumalanga Province to build cancer care services from scratch, with a potential national roll-out if the political leadership can do what the then Head of Health in Kwa-Zulu Natal did in 2018. The model, according to Funani and Chitha, proves that cancer treatment should be made available to all who need it irrespective of their ability to pay and that an enabled public healthcare delivery system is the way to do it.
However, let us first establish how dire the prevalence of cancer is. World Health Organisation (WHO) figures are not flattering at all. Cancer is among the leading causes of morbidity and death worldwide, accounting for nearly one in six deaths. There were about 14 million new cases in 2012, and the number is expected to soar approximately 70 percent in the next two decades. Cancer claimed 8.8 million lives in 2015 worldwide.
Closer to home, WHO estimates show that almost 70 percent of cancer deaths occur in low and middle-income countries. Most of African countries fall in this bracket. They are defined by the World Bank as countries with a GNI per capita between $3,956 and $12,235 (upper middle income), between $1,006 and $3,955 (lower middle) and $1,005 or less (lower income). South Africa is among fewer than ten African upper-middle-income economies. Therefore, the whole Africa should lose some sleep over cancer; enough to do something drastic – and urgently so.
Although popular discussions in the media and in political circles tend to prioritise economic growth, job creation and democracy, the true measure of human civilisation is never complete without reference to a country’s human development index (HDI). This is a “summary measure of average achievement in key dimensions of human development: a long and healthy life, being knowledgeable and have a decent standard of living”, according to the United Nations’ Development Programme (UNDP). The undisputed inference at the outset is that without quality healthcare, in this case an effective strategy to fight cancer, no country can experience sustainable development for most of its population. Failure to do this spells doom for socio-political stability and economic prosperity; since an unhealthy population can neither thrive economically nor ensure peace security for even the rich. Solving the problem of access to quality healthcare, therefore, is not a health issue but a sovereign risk consideration.
COVID-19 recently exposed the inadequacies of the world’s healthcare systems as well as the lack of a regional and global cooperation strategy to deal with pandemic outbreaks. In the absence of global cohesion even those countries with world-class healthcare systems cannot thrive because the best they can do is to shut their borders to international travel – a recipe for economic disaster in the era of globalisation.
“With the right political leadership and vision combined with decisive administrative health leadership, progressive partners and resources”, according to Dr Chitha, “any country can beat cancer – the HSEI model is a good example of how to do it”.
HSEI offers a perfect collaboration between academia and the community by downloading invaluable insights from the hidden academic archives and journals to craft real solutions to the challenges facing society. Ordinary people do not read medical journals, where highly qualified and experienced health professionals share their knowledge – sadly far away from where they are desperately needed. It is not surprising that a unit of the Wits University is at the heart of this innovative partnership.
“South African universities have always been integral to the development of health services in this country. They have developed capacity, working with the State, to deliver advanced specialised health services, produce health professionals of global standing and produce globally recognised research for over a century, says Dr Chitha.
The other socio-economic divide in South Africa is the overconcentration of healthcare specialists, like oncologists, in private health sector where only those with medical aid receive treatment. The proportion of South Africans with medical aid, according to StatsSA’s General Household Survey, was 17.1 percent in 2016 and 16.4 percent in 2018. This means that huge resources concentrated in the private sector serve the minority of the population.
“The transformation of the health system in South Africa inherently includes transforming the private health sector, regulating private sector in the interest of the public sector dependent majority population and unlocking the private sector financial and human resources to serve the poor and underserved populations,” says Dr Funani
“With such advanced private sector infrastructure, we have to provide leadership and unleash the potential of the private sector to advance universal healthcare,” says Dr Chitha
Kwa-Zulu Natal certainly had to do something radical to address this inequality; the leadership were decisive enough to allow a collaborative effort involving academia and private sector oncologists to solve the cancer crisis and the entire country should follow suit.
On behalf of the provincial department of health, the HSEI project team devised means to attract and engage the specialists (who were largely in private practice) to lend their expertise to the enablement of the public health system.
“They have been willing to leave their private practices, provide their services for the patients in need on prearranged days and reasonable cost because we pay them without delay”, adds Dr Funani.
The uniqueness of this model, where the university acts as the bridge between the public and the private sector, highlights that the future of social services lies in collaboration, optimisation of existent public infrastructure and resources and in the change of mindset from maximum profit (low numbers of patients treated) to a service mentality (lower margins and high volumes of patients).
“It is a more sustainable business model and the 40 oncologists in our HSEI network have embraced it”, quips Dr Chitha.
The HSEI is not a commercial pipe dream. It is premised on what has come to be known as bottom of the pyramid (BOP) strategic thinking. BOP thinking was the result of extensive work by Indian scholar and Professor of Corporate Strategy at University of Michigan, CK Prahalad, in “The Fortune at the Bottom of the Pyramid – eradicating poverty through profits”, the book he famously published in 2004.
The gist of the book is that its advocation of new business thinking; a model that targets the poorest people in the world. Since these people, at the bottom of the financial pyramid, are poor the book argues that business must undergo a mind-shift from maximising profit, which healthcare service providers do in treating cancer, to pricing their offerings within reach of their lower income consumers.
This makes sense to low income to middle income countries like most African states. Even though South Africa is an upper middle income country, its income inequality is such that the World Bank labels it a “dual economy with one of the highest inequality rates in the world, with a consumption expenditure Gini coefficient of 0.63 in 2015 (worsened from 0.61 in 1996)”. This inequality, the World Bank explains, is “perpetuated by a legacy of exclusion and the nature of economic growth, which is not pro-poor and does not generate sufficient jobs”.
With the richest 10 percent of the South African population owning around 71 percent of the country’s net wealth (in 2015) and the bottom 60 percent sharing 7 percent of the net wealth, it is a no brainer that the only way to make healthcare accessible to the majority of South Africans is through a model such as the one employed by HSEI.
This is a model that could be the first step towards a fully integrated health system as envisioned in the National Health Insurance (NHI) policy documents.
“The current apprehension towards the NHI is that most people believe the country will need more money to implement it; while it is not money we need – but the enablement of the public health system through improved utilisation of both the public and private sector physical and human resources”, argues Dr Funani.
South Africa does not need to build new hospitals, he believes, to make NHI workable. Instead, existing resources must simply be managed better; underutilised academic and private health sector resources ought to be harnessed to provide services to those in need for less – provided they can be paid promptly.
If this sounds too simplistic, let us consider that in 2016, the public health sector in Kwa-Zulu Natal Province (KZN) was in the news for a reported “cancer crisis”. The shortage of human resources particularly in the oncology sector was acute in the public sector, aggravated by insufficient oncology equipment at these facilities and the waiting times for care. On 19 June 2017 the Times Live published a media statement confirming that the South African Human Rights Commission (SAHRC) had released a damning report stating that the KwaZulu-Natal Department of Health had failed its cancer patients.
In early 2018 a Joint Steering Committee (JSC) was established, comprised of representatives of the Provincial Department of Health, hospital management of the two hospitals, the HSEI at Wits. The outcome of this balanced mix of health project management insight, stakeholder engagements, simplification of contracting processes, recruitment of specialists and the application of research is improved access to oncology services in the province.
Today HSEI has successfully managed to place approximately 40 doctors on a rotational basis at both hospitals, treating a total of 18,838 oncology patients since April 2018. About 150 new patients and over 300 follow-up patients are assessed and treated every month. All specialist cancer clinics have been restored because of the stability in supply of oncologists. A third hospital, namely Grey’s Hospital, has been included in this initiative since the beginning of year 2020. The same can be expected in Mpumalanga soon.
Cancer is a global emergency; and South Africa cannot expect to be spared. Since its income inequality cannot be eradicated overnight, projects like HSEI are examples of what is possible when humanity and servant leadership meet. When medical professionals and specialists are led to answer the call from visionary political leadership they can once again prioritise one of the tenets of the Hippocratic Oath. This is the realisation that they “do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability”.
It is early days yet, but HSEI represents a definitive departure from the approach to healthcare that has led South Africa to its current state where a tiny minority is guaranteed quality care; where even those with medical aid commonly run out of funds in the middle of their treatment and have to simply hope for the best or wait to die.
HSEI has so far justified a closer inspection by all involved in the provision of healthcare in South Africa and the continent, not only for cancer but all ailments and even the treatment of other curable conditions that lead to needless deaths of millions of the poor majority. At last, South Africa stands at the door that could open a vista of possibilities – especially that elusive promise of a society in which everyone is free from the triple burden of poverty, ignorance and disease – not through bigger health budgets, but through enablement and improved efficiencies.
Dr Itumeleng Funani & Dr Wezile Chitha
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