Microsoft co-founder Bill Gates has underscored the importance not only of primary healthcare, but in particular the role community health workers play in preventing the emergence and spread of multidrug-resistant diseases.
After receiving an honorary doctorate last week from the Addis Ababa University in Ethiopia, the mogul-turned-philanthropist shared his thoughts with the
Mail & Guardian's
Bhekisisa on South Africa's HIV treatment programme and on which health challenges deserve the most investment.
Ethiopia has a successful community health worker programme that has strongly contributed to a two-thirds drop in under-five child mortality rates over the past two decades. In the Free State in June, thousands of community health workers were dismissed. What should South Africa learn from Ethiopia?
I'd be careful not to act like I'm an expert on South African healthcare. South Africa is quite a lot richer than most of the countries in Africa. [Yet] it's got a really substantial HIV and tuberculosis epidemic by all measures – one of the worst in the world.
In Ethiopia community health workers spend about a third of their time going around making sure people are educated and compliant [with treatment]. For example, they make sure people are taking their TB or HIV drugs. In some countries that has proven to be very, very important to get the compliance level up.
I don't know the particular province [the Free State]. [But] if somebody is getting rid of them [community health workers] then they have to say what is their plan for compliance. Do they have a way to make sure that will still happen? Because in HIV and TB compliance is huge – if you don't have good compliance, you will get almost no benefit from the drug regimes.
[Last week the
M&G reported on Free State patients who developed drug-resistant TB due to noncompliance with treatment after community health workers stopped working in June.]
Our health minister announced last week that South Africa will expand its antiretroviral treatment (ART) programme by increasing the CD4 count at which people qualify for treatment to 500 (a CD4 count is measure of the strength of someone's immune system). It's the largest ART programme in the world. What do you think of our programme?
South Africa's antiretroviral treatment programme started later than it should have. The country is to be congratulated that, when it did start, it was able to ramp it up quickly.
The interesting question, however, is why are people still dying of HIV? What you really need to do is to take all the deaths, say of people between 20 and 40, that aren't about car accidents or gunshots or pregnancy, and try to understand why death rates are so elevated in those age ranges and compare that [with] countries with a similar income level where you don't have an HIV epidemic.
Are there people who never tested for HIV, or people who were tested and then [sought] care, but didn't comply with the treatment, or were they complying and for some reason it still didn't work for them?
The important thing to understand in an age of ART is why people are still falling through the cracks.
Even if you have a policy of initiating treatment at a CD4 count of 500 you often get people starting treatment at a lower level because they wait until they're symptomatic. It is amazing that there are people who, even if they become symptomatic, still don't seek treatment. Understanding why that would happen is pretty interesting.
You're on the record as saying countries that invest in health are likely to prosper. But South Africa invests 8.5% of its GDP in health, far higher than the World Health Organisation recommendation, and our health incomes remain relatively poor. We spend about half of the 8.5% on the private healthcare system and the other half on the public system. How can we improve?
It's not really an overstatement to say South Africa really has two health systems: it has a private health system that spends a lot of money and gets quite good results – for a minority of the population – and it's got a public health system that spends a lot less money and has some things it really needs to measure carefully and see where it can do better.
South Africa is hard to compare [with] any other country because the HIV and TB epidemics are really intense. There is no country at that income level that's got an HIV or TB epidemic that's anywhere like that. So it's a challenge and a situation where South Africa is rich enough to also experience some of the health challenges that rich-world health systems face in terms of diabetes, obesity and cancer on top of the country's infectious disease burden.
You really have to look at the public system and its performance in isolation and say, how can that be made to perform? It's unlikely to ever be funded at the level of the private system.
Budgets are tough everywhere, but one of the things I would suggest is that public health is going to need more investment to really bring these epidemics to a close.
I wish the United States was such an exemplar with running its healthcare system that I could say, look at how the US is doing it. But the US is not an exemplar. We spend over 17% of our GDP on our health system.
What, in your opinion, is Africa's biggest health challenge?
There is a lot of competition for that title: the HIV epidemic, malaria, the fact that vaccines aren't getting delivered to over 35% of the kids in sub-Saharan Africa. If I'd actually have to pick one, I'd pick malnutrition to go at the top of the list. Malnutrition is under-appreciated as an incredible health problem. A very high percentage of children don't achieve full physical and mental development because of malnutrition. This affects their lives and their ability to learn and contribute to society.
There is also the issue that we just don't know how to measure it. When you say malnutrition reduces physical and mental development, it's unfortunate that we really can't quantify that. Malnutrition is tough to assess in terms of knowing how big it is and knowing exactly which approaches would fix it.
What is the one most significant health-related investment that would bring about the most change in Africa?
Running high-quality primary healthcare systems that focus on prenatal care, delivery and vaccination, among other issues – that's where the opportunity is. There are countries like Rwanda, Ghana and, increasingly, Ethiopia, where such systems are run effectively at a fairly reasonable cost.
In contrast, many other countries, including northern Nigeria, are not running their primary healthcare systems well. If you look at premature deaths, the one wish you would want is for good primary healthcare systems. If all those systems were working as well as in Ghana or Rwanda, the number of children's lives that would be saved would be very, very dramatic.
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Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.