OPINION | Samu Dube: Let's address inequalities in healthcare brought to the fore by Covid-19

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The Covid-19 pandemic prompted us to reconsider what primary healthcare looks like, writes the author.
The Covid-19 pandemic prompted us to reconsider what primary healthcare looks like, writes the author.
PHOTO: Getty Images

South Africa has an overburdened public health system that cannot cope with the demands to provide healthcare to the millions of people who need it. Dr Samu Dube outlines the opportunity to fix the country's healthcare off the back of a global pandemic.


Human beings have imagined and built skyscrapers, created unbelievable technologies and even put people on the moon – but what is the significance of all these remarkable achievements when we cannot build a health system that ensures universal coverage? What does this say about our priorities? How will we overcome the inequalities and inequities that we see in our healthcare system?

As a concept, the health system is generally centred on what is known as primary healthcare.

The World Health Organisation defines primary healthcare as "a whole-of-society approach to health that aims at ensuring the highest possible level of health, wellbeing and their equitable distribution by focusing on people's needs". This concept was agreed upon at the Alma Ata conference in 1978, and continues to gain momentum as an approach to increase access to appropriate care.

A healthcare ecosystem should provide more than just care – it should extend to the social determinants of health. The Covid-19 pandemic prompted us to reconsider what primary healthcare looks like. There was an urgent need to address the massive inequalities that were brought to the fore by the pandemic. The crisis, then, provided us with the opportunity to rethink our health system and how we deliver healthcare.

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One of the challenges of primary healthcare has always been about packaging what it means to meet people's health needs. It is not enough to focus on curative aspects of care, primary care is about packaging the appropriate care that can be offered at a primary level, including some aspects of preventative care. It is about empowering people to take charge of their own health.

More importantly, primary healthcare is not about gatekeeping or rudimentary basic care. There is a misnomer that primary healthcare should just promote good health, prevent disease and provide rehabilitation in a way  that is only fit for the poor. That is not the case. It should encompass all these things and more while providing a level of care that is ubiquitous in quality for all who depend on it – rich and poor alike. 

Why do we need to act now? 

There is a demographic shift happening at present, particularly in Africa. I believe many countries missed the first wave of the demographic dividend by not investing appropriately in primary care. Anticipating the second wave of this population dividend will require a shift on how we advance universal health coverage.

To put the shift into perspective, we have a relatively young population and high rates of urbanisation that will require us to invest differently in our populations. As the years go by, and populations age, dependencies on healthcare will also shift – and this demands a different investment philosophy in healthcare that requires a collaborative approach.

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There has been a shift toward a consumer with different expectations of their own health, but largely the healthcare system does not meet those needs. The healthcare consumer of today wants to become more self-reliant and become more active in the healthcare that they receive. This consumer is looking for value through outcomes that can be measured over time. This is an opportunity that should not be missed. 

Add to this the new therapies and technologies that are bolstering the progress and possibilities of healthcare. Digitalisation is connecting people in a way never before imagined, with targeted therapies and precision medicine that evolves exponentially. These are possibilities that could be advanced through effective primary healthcare approaches. 

With all this change in mind, we need to be pioneers of what is relevant and what works in our healthcare economy. This starts by capitalising on the window of opportunity that Covid-19 has opened for us to act, and the need to invest in the demographic dividend. Primary healthcare is crying to be fixed, and we have the power to do so. 

How do we fix it?

Today's delivery model for primary healthcare is constrained, hampered by an inadequate and often inefficient spend on healthcare, reduced quality outcomes, regulatory hurdles, litigatory conundrums, reduced capacity and the need for innovation. The result is the expenditure disparity between the public and private sectors – a result of a pursuit for citizens for access and perhaps quality outcomes.

South Africa has an overburdened public health system that cannot cope with the demands to provide healthcare to the millions of people who need it. But the better-resourced private healthcare sector is beyond the affordability levels of most South Africans, with only 16.4% of all individuals in the country being members of medical aid schemes as of 2018, according to Statistics South Africa. The economic disruption of Covid-19 has worsened this picture. As unemployment rises, more people exit medical schemes.

The solution lies in the private sector – joining the public sector to provide the resources needed to build a stronger health system. As Gift of the Givers founder, Imtiaz Sooliman, aptly pointed out at the recent South African Healthcare Summit, the private sector should focus more on building infrastructure in public healthcare rather than dishing out teddy bears. 

Importantly, there needs to be an increased focus on strengthening governance and accountability to ensure that resources are directed at the right interventions. Only then can we start building a better primary healthcare system. 

What does better look like?

The future that we aspire to is one that moves away from dysfunctional gatekeeping, fragmentation, inequities, and fragility. This future requires an ambitious shift that strengthens the range and quality of services that people can obtain at their local health facilities.

We need a system that is based on value powered by analytics. It needs to have integrated offerings with strong partnerships with an accessible tech-enhanced patient journey from hospital to home and home to the hospital that focuses on wellness. 

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By building a functioning health economy, the South African healthcare sector can provide the right care to the right people at the right price. This would create a healthy nation in which people are able to make the right lifestyle choices, and as health economy participants, they will in turn become more productive citizens. By doing so, we create a more resilient and ubiquitous healthcare system that is aligned with changing consumer needs. 

To create this system, we need to broaden our healthcare access, but there also needs to be structural reform. First, we need to look at the regulatory environment and transform it towards one moving us in unison to achieve good health for all. Then we need to look at our financing mechanism – determine how it is exactly that we fund healthcare. We also need a reformed health workforce where health provider incentives are aligned with what we want to build as a country. 

A compelling case has been made to South Africa to seize the opportunities presented to us by the Covid-19 crisis and invest better in health. As practitioners in the health ecosystem, we need to create a more resilient healthcare system with more capacity, save more lives and ultimately create an environment that aids our economic ambitions. It is through a selfless collaborative approach that we can start to plant trees whose shadow we might not enjoy – leadership, after all, is about creating a future that doesn't yet exist. 

- Dr Samu Dube is General Manager for Medical Advisory and Health Policy at the AfroCentric Group.

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