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SA’s new NCD strategy-prevention and control of tobacco

24 out of 29% of all NCD deaths can be linked to smoking. These deaths can be broken down into;11% Cardiovascular disease, 7%, Cancer, 3% respiratory disease and 3% diabetes.

According to the South Africa’s new Non Communicable Disease strategy, the World Health Organisation’s, 2008 mortality chart showed that smoking put citizens at risk of most of the NCD’s.

Moreover, tobacco use accounted for 9% of all deaths. 2003 data showed men between the ages of 35 and 54 and women between 35 and 54 use tobacco more than their younger or older counterparts. Additionally, men smoked more than women. In 2009, statistics showed 23.7% of adults smoked cigarettes.

Although, statistics showed a 7% decrease of cigarette smokers from 1995 to 2009, recent research suggested otherwise. Many attributed the decrease in smoking to the introduction of anti-tobacco legislation in 2005. The legislation is also tied to a 22% reduction in smoking behaviour.

However, research done in 2013, by Prof Olalekan Ayo-Yusuf and Bukola Olutola implied the increase in the excise tax on factory cigarettes were linked to the decrease in smoking. Their study suggested that smokers who shifted from factory rolled cigarettes to roll-your-own as a less expensive choice had not been considered. Their studies showed from 2007 and 2010 factory cigarette smoking declined 'at an aggregate' and roll-your-own smoking increased.

Cost-effective interventions for addressing tobacco use was explored. The cost of implementing tobacco interventions was less than 1 U.S dollar per person. Raising taxes on tobacco products had the largest impact while packaging, labelling and awareness counter measures, showed modest impacts. Other interventions like enforcing bans on tobacco advertising  and working on smoke free workplaces had ‘best buy’ implications but had modest impact.

Moreover, cost-effective interventions to address diabetes, cardiovascular disease, cancer and respiratory disorders that were linked to smoking were identified, and assigned interventions as well.

Furthermore, population and community based interventions included controlling the use of tobacco and tobacco products.

The NCD 2013-2017 strategic plan said finance, trade and industry department’s, South African Revenue Service, civil society and non governmental organisations will carry out the interventions. These interventions included enforcing existing legislation, strengthening compliance of legislation, finalising regulations on smoke free public places, display of tobacco products at point of sale, pictorial messages, warnings on packages and intensifying education and support for quitting smoking.

According to the strategy, ‘the tobacco control legislation strongly influenced a decline in smoking prevalence between 1993 and 2008’. Recent years have experienced a plateau in smoking prevalence thus tobacco policies were being re-evaluated.

With the MPOWER package, the new NCD strategy built on the WHO’s Framework Convention for Tobacco Control measures. The MPOWER package included cost-effective policy intervention.  The package consisted of monitoring tobacco use and tobacco prevention policies, protecting people from tobacco smoke in public places and workplaces, offering help to people who want to stop using tobacco, warning people about the dangers of tobacco, enforcing bans on tobacco advertising promotion and sponsorship and raising tobacco taxes and prices.

Meanwhile, the Department of Health's action plan is to reduce tobacco use by 20% by 2020, to finalise regulations on display at point of sale’s in retail stores, smoke free public areas and pictorial health messaging and warnings on packages. Lastly, they want to reach a target of reduction in smoking of 5% by 2015 and a reduction of 10% by 2017.

Shifting to a ‘people centric’ NHI

Academic essay:

It is argued that health care should be founded on the needs of South African citizens in the form of a ‘people centric’ NHI. In this ‘people centric’ NHI, citizens willingly survey health services and enable a transparent, efficient, accountable, management, system. In the former instance, citizens play an active role in policing the quality of public health care services. This essay briefly looks at why the public health system needs to shift into a ‘people centric’ NHI. It looks at how this is possible, while simultaneously learning from, mirroring where possible and considering  ‘people centric’ private sector contributions, on how to make ‘people centric’ work for the public system. This essay briefly explains a ‘people centric’ public sector approach to Dr Brian Ruff's argument that we need to deliver good quality services to more people using the existing resources. He suggests that South Africa spends too much on treating patients in hospitals rather than in primary health care facilities (Dr Brian Ruff, 2013). Additionally it discusses the Witwatersrand University, Chair of Social Security Systems, Administration and Management Studies, Professor Alex Van den Heever’s idea of how the proposed National Health Insurance can be made accountable by using ‘people centric’ public participation to correct health management accountability (Alex Van den Heever 2013).

Then, Dr Jonathan Broomberg and Dr Craig Nossel from Discovery Health Insurance share their private health care concepts and innovative advancements in ‘people centric’ private health care that could be mirrored and applied in the public sector

Firstly, citizen’s have lost faith in public, primary, preventative care due to inefficient, service delivery, non existent and unpleasant treatment therefore sick people bypass primary care to curative hospital care.  Linked to the previous issue is that health consumer behaviour leads to the over utilisation of resources at hospitals. However, Health minister Aaron Motsoaledi is determined to make preventative care work. On the 15 May 2013, in the Health Budget speech he said that, ‘[p]revention of diseases and promotion of health is going to be the heart beat of NHI in South Africa’ (Department of Health 2013). 

On the way to reform, making the NHI[1] ‘people centric’ would involve the public in the creation of primary facility systems that sufficiently serves the healthcare needs of all (Wikipedia 2013). In the context of a ‘people centric’ NHI, information sharing at all levels; government, the department of health, hospitals, medical practitioners and patient is driven by public participation. With information sharing all health stakeholders are privy to information that can enhance policy, systems, medical treatments and service delivery. The previous coupled with Dr. Nicola Christofides’s  concepts and practices of social behavior change[2], could work toward building and embedding trust among community members which could eventually spread to the larger public. The previous solution could lead to redistribution from hospital-centric usage to primary care usage and thus free up resources to be reallocated and used toward good quality care for more people, using the existing resources (Dr Brian Ruff 2013).

SA’s political patronage model[3] [4] has been in play since the inception of the African National Congress government[5] in 1994.The patronage model allowed government to centralise the health system[6], appoint all public health practitioners and increase salaries (Van den Heever 2013).  In the year 2000, despite having no qualifications for the jobs, politicians were appointed to do civil servant jobs (Van den Heever 2013). Because the politicians were only accountable to government and not to society. Accountability failure seeped in and degraded the’ top and senior levels of management’ in hospitals (Van den Heever 2013).  Salary increases in the public health sector eventually ran the health budget into ‘structural deficit’ thus hospitals were unable to pay their bills, ran out of supplies and staff, with a result ‘people died during this period’ (Van den Heever 2013).

Professor Van den Heever says,

Part of the problem that we are having in SA is that really, there is no sufficient public dialogue on health systems reform and therefore a lot is just driven by special interests[7] (Van den Heever 2013).

 

He continues to say that theoretically, government should be accountable to society but they are not (Van den Heever 2013). The public needs to get involved and start holding government accountable for lives lost. According to Van den Heever, a systems design approach to the political patronage model is to ‘make services below the political level accountable to the rest of the population’ (Van den Heever 2013) He says that independent supervisor boards[8] would be in charge of appointing and firing the Chief Executive Office, the Chief Financial Officer and the Chief Operation Officer of a hospital and in this way the ‘CEO’s role is linked to performance (Van den Heever 2013).’

In addition, in an article by Anso Thom, in the Argus, on 6 May 2013, ‘Outcry over public-sector doctors in private practice’, doctors are shown to be milking the system by doing Remunerative Work Outside Public service (Thom 2013).  While doctors are still registered as being on duty in the public sector, they are additionally working in the private sector.  The afore mentioned doctors would earn approximately R 1.2 million in the public sector plus whatever their private sector salary (Van den Heever 2013). A ‘people centric’ NHI based on public participation would adjust systems that rectify this kind of abuse and create a more accountable system.

Furthermore, Dr Jonathon Broomberg, from Discovery Health, on the 29 May 2013, at the Discovery Health Head Office in Sandton, argues that South African ‘health care looks like manufacturing in the early 20^th Century’ (Broomberg 2013).  He suggests that hospitals should specialise rather than provide all curative care[9] (Broomberg 2013). In an article in Business Day, by Tamar Khan, on the 30 May, Specialist Clinics are Key to Cutting Costs and Waste, she demonstrates Broomberg’s point, that time and costs for treatment in hip replacement studies in the United Kingdom and the U.S is drastically reduced:  ‘average length of stay was halved from 7.34 days to 3.5 days, surgery was reduced from 126 minutes to 75 minutes’ (Kahn 2013). Dr Broomberg continues to say that ‘a gap exists between health consumers and suppliers’ (Broomberg 2013). Discovery Health Insurance has bridged the gap with ‘big data innovations’ (Broomberg 2013) and have implemented the patient history ID which has given doctors and specialists mobile access to patient histories.

Similarly, telemetrics have enabled practices to keep a close watch on patients via telemetry devices. Now a diabetic can be monitored by a doctor via a device and be notified in case of an emergency (Broomberg 2013). Lastly, Dr Craig Nossel, head of Vitality Wellness, says that behaviour economics is the way forward in studying health consumers and is another example of ‘people centric’ health innovation. Although Discovery Health contributions to a ‘people centric’ health care model is a private initiative and seem out of reach for the public sector, Public Private Partnerships have created space for private investment in the public sector and empowering it to serve South African citizens.

A ‘people centric’ NHI is one solution that is implementable without the need of financial resources. Likewise, a people centric’ NHI is the one thing that can solve both problems of management and accountability. Public partnership with a ‘people centric’ private sector is realistically achievable.

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[1] Van den Heever claims that there is no such thing as the NHI there is only the public system and that the NHI is political speak (Van den Heever 2013)

[2] Discussions at this seminar was held on how to rebrand healthy food into a status symbol to encourage people to eat healthier and thus follow disease prevention steps.

[3] The patronage model will need to be done away with for the ‘people centric’ NHI model to work. Based on how hard they have worked to keep it in, it is apparent that the ANC will first need to be voted out before the ‘people centric’ model will take effect.

[4] The political patronage model in the United States of America sunk their public system and will do the same to the SA system (Van den Heever 2013)

[5] Special mention of the ANC and government is mentioned here to show that party politics gets in the way of managing the health system efficiently

[6] Even though government seems decentralised, they are not. Patronage appointments at the top level of management are still centralised. Van den Heever says that, ‘if the MEC appoints somebody it means they don't actually have to be accountable to anybody. They just have to be accountable to the political hierarchy and therefore they have a conflict of interest with society’ (Van den Heever 2013)

[7] SA is supposed to be a democracy but we seldom vote on things as intrinsic as whether our public health system is going to be managed by government and maintain a central management system or whether public bodies will lead the public health system.

[8] These could be made up of public members like the example of private medical scheme boards.

[9] Alex Van den Heever says that ‘a hospital is actually a complex service and its not being treated as one’ (Van den Heever 2013)  supports Broomberg’s statement that hospitals should specialise to save time and money (Broomberg 2013).

Bibliography

Alex van den Heever. 2013. Everything you ever wanted to know about the NHI. Retrieved on 10 June 2013 from Audio Clip

Discovery Media Summit. 2013. SA Private Healthcare 3.0. Retrieved on 10 June 2013 from Audio clip

Dr Christofides, Nicola. 2013. What is new in Public Health? Retrieved on 10 June 2013 from Audio clip

The Department of Health. 2013. Health Budget speech by Dr Aaron Motsoaledi, MP, Minister of Health, National Assembly. Retrieved on 10 June 2013 from http://www.doh.gov.za/show.php?id=4240

Tamar Kahn. 2013. Specialist Clinics are Key to Cutting Costs and Waste. Business Day Live. 2013. Retrieved on 31 May & 11 June 2013 from http://www.bdlive.co.za/business/healthcare/2013/05/30/specialist-clinics-are-key-to-cutting-costs-waste

Thom, Anso. 2013. Outcry over public sector doctors in private practice. The Argus. 6 May 2013

Wikipedia. 2013. Patient Centred Care. Retrieved on 10 June 2013 from http://en.wikipedia.org/wiki/Patient-centered_care

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Portal to Nigeria - Pets

By Renee Petzer

Hi All

This week we have been babysitting a friend’s x-Labrador (yes in our flat!).  Bella is well trained and very gentle, but she is one of only 2 dogs that I have come across in Lagos.  Imagine a city of 20Million + people with no stray dogs or cats. Zuma recently pronounced that it is a Western cultural habit to have pets, well it certainly applies here.  Taking Bella for a walk is interesting – people literally cross, read run, the street when they notice the 2 of us.  We are to be avoided at all costs.  Locals are petrified of dogs and big strapping 6 Ft well built men freeze at the sight of her. Rogastein, our steward, luckily loves taking her for a walk and scaring off all his mates!  I think it gives him a macho status of sorts The 3 stray cats at the boat club and one advert for a cat from departing expats are also unusual. Interesting enough, the expats kids are also all frightened, simply because they don’t grow up with pets and animals around them.

So what’s the catch – Rats!  Large, ugly, 30cm brutes.  Over December, David had received food hampers as gifts from various people.  These were left in his office until we returned in January.  Opening the baskets revealed everything that could be chewed and eaten by the rats, was – even the paper off the tins – and the alcoholic liqueur chocolates.  Yuck!  Despite having the office bins cleaned after lunch and encouraging staff to eat in the canteen, he says rats are rampant as soon as the office quietens down in the evening. 

Sitting outdoors at a local pub, I noticed some movement in the Palm tree next to me.  A rat nesting in the tree trunk, it had eaten holes into the trunk and was running up and down popping “stuff” into the nest. Yuck yuck – needless to say we didn’t stay for dinner.  Thank heavens I’ve not noticed any rats in and around the compound.  I think the monthly, very toxic, fumigation takes care of them. 

Large lizards survive the monthly fumigation though.  20-30cm in length, with very colourful males dressed in orange, purple and black.  These don’t scurry away when you approach them, just hiss and do lizard push-ups.  Apparently they bite if caught!  Not so small transparent geckos, Dragon flies and Kites (a large eagle like bird) abound.  We also have a “Hoopoe” looking like bird and a “Kwe” bird (you know the ones that make the kwe kwe sound – say it out aloud phonetically and you’ll get me). No mosquitoes though. We have no standing water in the compound, the rainy season hasn’t started and we are on the 4^th floor – apparently a contributing factor.  So up until now, we go out in the evening and can sit outdoors without worrying about being bitten.  Which is one of life’s little luxuries here as most of one’s time is spent indoors in air conditioned rooms – another yuck.

For the next 4 weeks, I’m home in beautiful Cape Town – so no Living in Lagos Editions due until Friday 12^th.

Have a great weekend and an awesome week
Renee

Portal to Nigeria - Plod

by Renee Petzer

Hiya

So for those of you looking for Lagostian intrigue, Naija skinner or local West African insights – this is not the week to get it.  This week, is all about moi.  For those of you that planted the little seed of running a 21.5km race in March, “they who must not be named”, know who you are. 

Play in the tune of the Golden Girls TV show, think of me a Sofia and picture this: Lagos March 2013:  30°C  +  humidity of 80%  +  2 hours on the treadmill  + facing a blank white’ish wall + one wall clock stuck at 09h15 with a jumpy second hand + one iPod playlist = insanity.   

The running guru’s say, you must be able to go the distance, I wonder if they include “plod” in their vocabulary?  What on earth was I thinking on my little 4 km in 40 minutes plods around Cannon Rocks in Dec 2012? What on earth were “they who must not be named” scheming when they planted the seed? Is my belief that we can do and achieve whatever we want that apparent?  Today my pace on 16km was exactly 5 seconds faster than my average pace in week 1’s training, depressing  - so I’m not even going to divulge my total time, except to say I did include little 2 min walks every 10 to 15min and that the 21.5km is going to take a looooong time. 

When does one start to feel like a runner? Are the slightly numb toes at 12km an indication that you are feeling like a runner? Or the short breaths at 16km’s (OK that cheating, it’s the smoking I know).  Maybe it’s the surge of energy that kicks in after 1h40? Or the knowledge that singing at the top of your voice to rock music  (thank you David) for the last 3 km’s – cause that is all that’s going to keep you going that makes you know you’re a runner? Or maybe it’s the awesome burst of energy about 5 minutes after you’re finished running that gives you enough energy to dance around the gym for at least 3 air guitar songs?  I don’t know, I still think I’m a swimmer and a canoeist.

So to Jen who tackles World Triathlons and Marlene who’s shaved her hair – respect.

26 more days of plodding to race day.

Have a great week all

Hugs & love