Despite noteworthy improvements in its public health system, South Africa is still facing huge problems in fighting diseases such as TB  and HIV/AIDS. Among several reasons, the poor patient adherence to medical prescription stands out.  Though the Government is trying to address the issue, the desirable results still lag behind. Future years look brighter than today’s, but additional efforts are required to pull the final goal off

By Pietro Dionisio

EU health project manager at Medea SRL, Florence, Italy

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

Taking a Pill: Not So Counted On in South Africa

 

South Africa is improving people access to its health system. Unfortunately, though the country has the largest antiretroviral therapy (ART) program in the world, with 2.5 million patients on treatment in 2014, it also carries the third largest drug resistant (DR) and multi-drug resistant (MDR) tuberculosis (TB) burden in the world. And now that TB incidence is slightly decreasing, it remains, however, as high as 454.000 cases in 2015. According to WHO, the rate of DR TB is about 3,5% among the newly infected people and almost 7% among already treated cases.

As a main cause of TB drug resistance, the poor  patient adherence to medical prescription is fueled by a number of factors that may be summed up in a couple of words: ignorance and mistrust.  Especially in the poorest areas, such as Kwazulu-Natal, among others, there is a lack of knowledge about the disease, its treatment and the importance of care, as well as about the close connection between adherence and disease progression.  Moreover, many patients are disillusioned by the health system. They do not trust the services the Government is providing, while preferably relying  on alternative or traditional medicines.

Social stigma is something scaring TB people. Mainly in rural zones, affected people are often stigmatized and marginalized. Relevantly, the HIV  stigma index found that TB ranks as the second leading cause of stigma experienced by people living with HIV, after HIV itself. More than one-third of the people who disclosed their TB infection reported being teased or insulted because of their status while about 40% reported being the subject of gossip.

From bad to worse, communities are not involved in treatment programs, thus traditional beliefs remain rooted in the villages ‘culture fostering marginalization and stigmatization.

Additionally, there are structural and institutional barriers endangering adherence to prescription. As would be the case for a poor patient-care provider communication. Clinics are often too far (as a rule in rural areas), and communication tools are not available to all. This hurdle limits doctors in promptly detecting patients at non-adherence risk. Under these circumstances, there is no psychological support from clinicians to patients.

Since 1998, South Africa has been trying to address the issue through the implementation of telemedicine services. The use of telemedicine ensures that waiting times for patients are reduced in an efficient and cost effective manner. But, whereas these strategies are promising, there are few sustained telemedicine programs due to a lack of proper management and technical capacity. Hence,  a cycle of “pilot, implement, fail” is common.

As such, patients  still have to face long waiting time, while services are not well integrated and medicines are scarce. The lack of medicines in rural areas is, indeed, a real threat. People seeking medical attention are often told that there is no medication and directed to a big, much more expensive hospital.

Not to mention that in South Africa  there are only 0.8 doctors (in total) and 0.2 doctors (in public system) for every thousand people, compared with an average of 3.5 in developed countries. This occurs at a time when the percentage of doctors leaving the country is on the rise, with only a 30% of all doctors working in the public sector and a barely 3% of graduating doctors deciding to work in rural areas.

Despite free TB diagnosis and care, patients incur substantial direct and indirect costs particularly prior to the treatment starting. The poorest groups of patients are incurring higher costs, with fewer resources to pay for. Presently, individuals earning Rand 6000, around 422€, or more a month (roughly, 20% of the overall population) are required to pay for public healthcare system costs, though they’re subsidized.

If the public sector has some flaws, the private sector does not help. South Africa’s private healthcare system has long been regarded as among the best in the world. But, over the last 15 years, private healthcare costs as a whole have risen 59% in real terms due to an almost doubling in private hospital costs (due to an oligopoly of 3 hospital providers), a 70% increase in specialist prices (due to continuous shortage), and the rising cost of medicine and medical technology worldwide. Those looking to private care can either pay out-of-pocket or buy private prepaid plans (medical schemes), with nearly 16% of the population opting for the latter largely because they can afford it. Medical schemes are unlike medical insurance in other countries due to the Medical Schemes Act of 1998 which drew a distinction – medical schemes are non-profit organizations that belong to their members, not their owners or shareholders, and thus are forced to abide by certain rules such as not being able to discriminate against individuals based on age or health history. To this end, the Act laid out several cost-intensive scheme requirements such as the need to offer at least a lengthy list of “Prescribed Minimum Benefits”, which has pushed up scheme plan prices and discouraged innovation in more affordable coverage products.

The issues on stage are huge. Medical prescription adherence is fundamental and a governmental key challenge. In the last July, the Government unveiled machines dispensing antiretroviral drugs to people with HIV to be installed in both urban and rural areas. The aims are to reduce patient waiting time  and improve adherence mainly in rural areas. Something similar could just be useful for TB too.

Institutional changes are strongly needed. These should include a revision of the Medical Schemes Act -so that more affordable schemes could be structured and provided-, and the development of reasonable guidelines for telemedicine aligning with international standards. Furthermore, the quality of services should be improved together with the involvement of communities in the treatment programs.

Last, but not least, the Government should manage to put an end to rural areas marginalization and rooted traditional remedies by countering ignorance and mistrust as the leading factors undermining  good adherence to medical prescription.