Covid-19 is not our first epidemic and it probably won’t be our last. In fact, there were a couple of others already in full swing when Covid-19 arrived. But this one has been special in a number of ways, not least because of the response to it.
Let’s talk about TB for a minute: The World Health Organisation (WHO) estimated that 310,000 people became sick with TB in South Africa in 2018, and 63,000 people died of TB that year.
In the 8-week period from 5 March to 30 April 2020, 5,647 people in South Africa were diagnosed with Covid-19 and 103 died. The estimated number of people who died of TB in the same period was 10,500 (100 times more than from Covid-19).
The comparison is not intended in any way to reduce alarm over Covid-19, or the response to it; rather the point is to raise the level of concern over TB. It is nearly 100 years since the first effective treatment for TB was made available, yet the disease continues to be the leading cause of death in South Africa.
“To end TB, we will need the same leadership, multisectoral collaboration, resources and real-time active surveillance with geographic information systems for TB that has been mobilised for Covid-19,” says Professor Harry Hausler, chief executive officer of TB HIV Care.
TB is similar to coronavirus in that it is airborne and that tracking and tracing contacts of sick people is a very effective intervention. But, so far there seems not to have been the political will or the health resources (or whatever it is) to get on top of TB, never mind get ahead of it. Who outside of public health has ever heard of an attempt to flatten the TB curve.
Now that Covid-19 has proved what can be done when there is political will and society’s buy-in isn’t it time we tackled the scourge of TB?
So what could be done immediately?
Prof Hausler says: “We need to integrate TB testing at all Covid-19 testing sites in South Africa to find the missing people with TB and get them on treatment.”
(The missing people with TB are the estimated 73,000 (24%) of the 310,000 people sick with TB in South Africa who were not notified in 2018 and/or remained untreated in communities with a risk of dying and further transmitting the disease. This includes sick people who ignore symptoms, many of whom can’t or don’t go to health facilities because of fear of the cost or of stigma. It also includes those who go to facilities with symptoms, get tested and receive positive results but don’t get started on treatment for one of a number of reasons.
Prof Hausler added that contact investigation of household contacts for TB should be done at the same time as contact investigation of Covid-19 contacts, and TB preventive therapy for household TB contacts should be implemented at scale.
We can only hope that somehow the lessons learnt in this pandemic and the global response to it can be applied in the fight against TB.
Unfortunately for now, the response to Covid-19 is only making things worse. The restriction of movement and work during the Covid-19 pandemic, said Prof Hausler, has resulted in “catastrophic costs, increasing desperation and hunger in TB-affected communities”.
In additional to nutritional support, he noted that community education on Covid-19 and TB was desperately needed to mitigate against stigma and discrimination against both Covid-19 and TB patients.
More from the Conversation:
Covid-19 shows that where there is political will there is a way to work across sectors
South Africa reported its first case of coronavirus disease 2019 (Covid-19) on 5 March 2020. In the weeks that followed the country saw decisive, strong leadership from President Cyril Ramaphosa. It has also seen significant, important and necessary co-ordination between different ministries. These have included education, justice, health, trade and industry, transport, public works and infrastructure and finance.
The rapid pace at which steps were taken was impressive. More important was the all-encompassing intersectoral approach. Ministries with different mandates and areas of focus are working in concert for a common cause.
Intersectoral action recognises that health and wellbeing is influenced by where and how people live, where they work, what transport they use, and their access to water, sanitation, economic hubs and services. Health is socially determined. To improve health, co-ordinated action is required between ministries that don’t have health as their core mandate.
This is what “Health in All Policies” is about – a coherent approach to health policies set out by the World Health Organisation that’s been adopted by a number of countries, but by no means all. Without this co-ordination a long and healthy life for all cannot be achieved.
Covid-19 has dramatically highlighted the need for a more integrated healthcare system.
In a letter published in the South African Medical Journal we argue that the threat that Covid-19 presents has resulted in both leadership from government and apparent willingness of all South Africans to play their part. It presents a number of opportunities that should be exploited to the full.
One stark insight is that pooling resources across the health sector is needed to address this pandemic. This includes the rational use of hospitals, high care beds and laboratory testing capability.
Exemption to help co-ordination
The trend for pooling resources is being encouraged by South Africa’s Competition Commission, which published a Covid-19 block exemption for the healthcare sector.
The exemption seeks to promote co-ordination, sharing of information and standardisation of practice across the entire healthcare sector. The aim is to facilitate cost reduction measures, allowing possible procurement efficiency in purchasing of diagnostic tests, treatment and other preventive measures.
In particular the exemption seeks to promote agreement between the national department of health and the private sector to make facilities available to the public sector. For example, if government wants to use private sector bed capacity it may be able to use its drug related single exit price experience to negotiate the cost.
The makings of a roadmap
Late last year South Africa released a Health Market Inquiry report. It found excessive use of private health care; more care was delivered than could be explained by the level of illness of the private sector population.
The report also found that the sector would benefit from better regulation.
It made a number of recommendations that promote standardisation and knowledge-sharing as well as a method to deal with pricing within the functions of the proposed supply-side regulator.
The supply-side regulator includes systems which would allow for a real time description of:
- providers – which ones exist and where they’re operating
- where beds are located, their purpose (medical or surgical) and level of care (general, high care or intensive care), and
- information on utilisation rates.
The report set out how the regulator could rationalise various functions which are currently poorly coordinated or absent across the private and public sector.
The report emphasised that the efficiency of, and access to, care required having information about health sector capability and quality across the entire health sector. This would enable resources to be used rationally.
The Covid-19 pandemic has underscored that such an approach is essential.
Set up this way, the regulator would form an essential mechanism going forward to ensure that South Africa was prepared for possible future emergencies.
Learning from Covid-19
There are two lessons here. For the health sector the need for more coherent integration is undeniable. Perhaps this exemption and working together to protect South Africa from the effects of this pandemic can build trust between players and will ease South Africans into a more rational and integrated healthcare system.
The second lesson is about intersectoral action and Health in all Policies that South Africa has seen illustrated to mitigate the threat of Covid-19. Poverty, inequality and unemployment similarly threaten the wellbeing of individuals in South Africa.
Equally urgent is the need to develop a mindset that understands that all policies aimed at development require integrated action. This means involving a range of players across government departments, across the public private divide, and must include social mobilisation and engagement with communities. The response to Covid-19 illustrates this well.
South Africa has managed to do this for health. It must be possible to do it in other areas of public policy. This needs to be extended further to build a more equal South Africa.
Lungiswa Nkonki, Senior Lecturer, Department of Global Health, Stellenbosch University and Sharon Fonn, Professsor of Public Health; Co-Director Consortium for Advanced Research Training in Africa; Panel Member, Private Healthcare Market Inquiry, University of the Witwatersrand