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Taking a Pill: Not So Counted On in South Africa

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.

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WHO and Privatization Agenda

Donor countries (the US in particular) continue to push WHO towards working with industry through ‘multi‐stakeholder partnerships’, rather than giving WHO the chance to implement regulatory and fiscal strategies that could make a real difference. (David Legge) Moreover, bilateral donors (and big philanthropies) demand WHO provides data according to their particular interests. Therefore, the types of data produced by WHO (and other UN agencies) are greatly influenced by a donor mandate that goes beyond the simple compilation of country-reported statistics

C Schuftan

By Claudio Schuftan*

People’s Health Movement – PHM

Substantive Work of WHO, particularly in  Relation to Health Systems Development, Should Counter the Privatization Agenda, but Does It?


Donor countries (the US in particular) continue to push WHO towards working with industry through ‘multi‐stakeholder partnerships’, rather than giving WHO the chance to implement regulatory and fiscal strategies that could make a real difference. (David Legge) Moreover, bilateral donors (and big philanthropies) demand WHO provides data according to their particular interests. Therefore, the types of data produced by WHO (and other UN agencies) are greatly influenced by a donor mandate that goes beyond the simple compilation of country-reported statistics. We know that donors seek to add value primarily through providing technical interventions (and not right to health or social determinants, for instance). So, here we are clearly faced with a biased stumbling block?* (Elizabeth Pisani, Maarten Kok)

*: Consider: While economics is not WHO’s core expertise, the impact of poverty and income maldistribution on population health clearly justifies WHO working with other agencies within or outside the UN system to focus much more attention on these questions of disparity.

Things being the way they are right now, it is difficult to make sense of the shrinking scope of WHO’s role in global health governance, partly because of the ambiguity of the slogans about ‘stakeholders’ and the fait-accompli of ‘multistakeholder platforms’ and ‘public-private partnerships’ now used profusely. The continued use of the term ‘stakeholders’ (and the bundling together of public interest civil society organizations with international NGOs, private sector enterprises and philanthropies under the term ‘non-state actors’) appears to endow all of these private ‘stakeholders’ with having the right to have a ‘seat at the table’, with only the tobacco and arms industries declared off limits. Such ‘sitting rights’ sharply jeopardize the human rights enshrined in the various human rights (HR) instruments that address the rights of real people –the right to health prominently included.** (D. Legge)

**: It is important to note that the treatment of WHO by the rich countries is part of a wider onslaught on the UN system generally. The whole UN system is held hostage to short-term, unpredictable, tightly earmarked donor funding. The same strategies of control have been applied across the UN system generally through: freezing of countries’ assessed contributions, tightly earmarking voluntary contributions, and creating dependence on private philanthropy, as well as periodic withholding of assessed contributions and applying continued pressure to adopt the multi‐stakeholder partnership model of program design and implementation that, as said, gives global corporations an undeserved ‘seat at the table’.

The Reform of WHO, aimed at realizing the vision of its Constitution, will require a global mobilization around the urgently needed democratization of global health governance; and this is not separate from, but part of, a global mobilization for HR and greater equity. Why? Because to claim that global health governance is somehow independent of global economic and political governance, is simply absurd. Nonetheless, such claims, still voiced by many, play an important political role for them in that they help to obscure the vested interests and power relations at play in the constraining (shackling) of WHO. (D. Legge)

Is WHO tinkering with a bureaucratic model inherited from the postwar era?

WHO actually seems strangely detached from the broader political turmoil unfolding around the world. Globalization has created new collective health needs that cross old spatial, temporal and political boundaries. In response, we need global health governance institutions that represent the many, not the few; are sufficiently agile to act effectively in a fast-paced world, on top of being capable of bringing together the best ideas and boundary-shattering knowledge available. (Kelley Lee)

WHO may point to its 193 member states and claim to be universally representative, but it is far from politically inclusive. Like the political alienation felt by millions around the world, many members of the global health community have turned elsewhere to move issues forward and get things done. What we see is a steady decline of WHO, clinging furiously to obsolete political institutions and bureaucratic models, yet kept alive by member states as an essential public institution. This decline is not because WHO is not needed, but because it has not adapted to and is not publicly financed for a changing world; it is not the WHO that we need today. (K. Lee)

Political innovation must become a fundamental part of the process of WHO reform. Think: How might virtual and interactive town halls improve communication between global health policy-makers and the constituencies they serve? How might the closed world of global policy-making be opened up and strengthened through virtual public consultations, feedback systems and monitoring systems –all of them also aiming at reforming WHO? How might the concept of global citizenship become institutionalized within our global health institutions, especially WHO? (K. Lee)

Prescribing “LEGO models’?

Otherwise, in the first decade of the new millennium, donors have pushed for increases in development assistance for health, yes, but in particular for medicines. This has clearly contributed to the re-legitimation of the ‘free trade agenda’ in health and has strengthened intellectual property (patents) protection regimes with their well-known negative consequences. Furthermore, in that development assistance, the mantra they preach to recipient countries is the one called ‘realistic costing of outputs’ that prescribes a LEGO model of program implementation, i.e., with each program comprising a set of planned outputs each of which comprises a known number of prescribed activities all of which have known costs. This approach leaves little, if any, room for flexibly managing complexity in planning and carrying out program implementation.*** (D. Legge)

***: WHO is made wary of prolonged project implementation processes, in part because they disrupts the ‘production schedule’ demanded by its paymasters. (Elizabeth Pisani, Maarten Kok)

What is missing from the whole discourse is carrying out a robust analysis of the root causes of the preventable global disease burden. Only this will provide clearer criteria regarding which ‘stakeholders’ (duty bearers in the proper HR lingo) are part of the problem and which are part of the solution –and therefore which of them can be trusted to have a seat at the table. Human rights principles provide such criteria and so does the WHO report on Social (and political) Determinants of Health of 2008.****            (D. Legge)

****: The importance of non-medical factors is largely recognized as being a key predictor of health. In 2008, the WHO Committee on Social Determinants of Health stated: “Social injustice is killing people on a grand scale and constitutes a greater threat to public health than a lack of doctors, medicines or health care services”. The general conditions under which people live and work thus have a major impact on health outcomes. These social determinants of health further comprise, among other, the structural determinants of socioeconomic development, working conditions, education, housing, sex and high-risk behavior… What this implies is that health care is just one of the factors to influence health and can, therefore, only be considered part of the solution. (Koen Detavernier)

The influence/control of donors over ministries of health in the South is nowhere more evident than in having kept any possibility of these ministries focusing on the human rights based approach in their agenda beyond mere lip service. Instead ministry officials keep pushing the newest slogans such as ‘universal health coverage’, ‘development assistance ‘and public-private partnerships’ that, in essence, are part of a common agenda consistent with the program of the 1% richest. They thus speak for the priorities of the 1% perhaps not realizing that they do so from within a worldview that accepts as natural and unchanging the global inequalities, the environmental degradation and the beneficence of private enterprise. (D. Legge)



* article originally published in The Social Medicine Portal, February 11th, 2017

Claudio Schuftan, M.D. (pediatrics and international health) was born in Chile and is currently based in Ho Chi Minh City, Vietnam where he works as a freelance consultant in public health and nutrition.

He is an Adjunct Associate Professor in the Department of International Health, Tulane School of Public Health, New Orleans, LA. He received his medical degree from the Universidad de Chile, Santiago, in 1970 and completed his residency in Pediatrics and Nutrition in the Faculty of Medicine at the same university in 1973. He also studied nutrition and nutrition planning at the Massachusetts Institute of Technology (MIT) in Cambridge, MA in 1975. Dr. Schuftan is the author of 2 books, several book chapters and over fifty five scholarly papers published in refereed journals plus over three hundred other assorted publications such as numerous training materials and manuals developed for PHC, food/nutrition activities and human rights in different countries . Since 1976, Dr. Schuftan has carried out over one hundred consulting assignments 50 countries in Africa, Asia, Latin America and the Caribbean. He has worked for UNICEF, WFP, the EU, the ADB, the UNU, , WHO, IFAD, Sida, FINNIDA, the Peace Corps, FAO, CIDA, the WCC (Geneva) and several international NGOs. His positions have included serving as Long Term Adviser to the PHC Unit of the Ministry of Health (MOH) in Hanoi, Vietnam under a Sida Project (1995-97); Senior Adviser to the Dept. of Planning, MOH, Nairobi from 1988-93; and Resident Consultant in Food and Nutrition to the Ministry of Economic Affairs and Planning, Yaounde, Cameroon (1981). He is fluent in five major languages. He is currently an active member ( of he Steering Group of the People’s Health Movement and coordinated PHM’s global right to health campaign for 5 years.

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Breaking News Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings


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Do the Credit Policies of the WB, IMF & EC Damage Health?

Despite recent positive rhetoric by the IMF, WB and the EC to reform conditionality policies, a gap persists between the declared intentions and the general practice. It is time for the three institutions to turn the rhetoric into reality


by  Daniele Dionisio*

PEAH – Policies for Equitable Access to Health

Do the Credit Policies of the WB, IMF & EC Damage Health?


The mandates of the International Monetary Fund (IMF) and the World Bank (WB) include the obligation to facilitate financial stability, international trade, and economic growth, while securing assistance in the form of loans to countries suffering from balance-of-payments constraints. The European Commission (EC) provides both Budget Support – accounting for approximately 25% of EU development aid – and Macro Financial Assistance (EUMFA) in the form of loans and grants for non EU countries facing a balance-of-payments crisis, provided the country has an IMF programme.

This context gives these three institutions great power to shape domestic policies in other countries, through quite identical prescriptions.

Conditionalities: a threat to health?

As creditors, the three institutions seek to ensure that they recover their loans from borrowers by setting strict ‘conditionalities’ on lending. Loan disbursements have been linked to economic and trade liberalization with regressive consequences for poor people.

In most cases, conditionalities encompass cutting public spending, including  government subsidies and ceilings on government wage bills (common in Africa), as well as privatization of public services such as health and education and removal of barriers to international trade.

Critics have charged macroeconomic reform programmes with a narrow vision on economic stability and for not protecting social spending on health and education. For example, ceilings on governments’ wage bills disrupt the much needed expansion of the health workforce, thus impairing the ability of the health sector to recruit and retain health workers.

The impact of the reform recipes has been highlighted especially in Africa in terms of cuts in public spending and adopting user fees policies which are known to act against poor people, especially women. However, recently the same recipes have been implemented in high income countries such as Greece where cuts in public spending and dismissal of health workers have led to deterioration in the health of the population.

Moreover, cuts in the health spending affect the supply of medicines, which can have tremendous negative consequences on the health of a population, including fueling transmission of infections like HIV/AIDS, tuberculosis (TB), hepatitis and sexually transmitted diseases. For example, a study of the link between the IMF loans and TB in the former Soviet Union and Eastern European countries documented a 16.6% rise in annual TB mortality from early to mid-1990s.

The WB, IMF and EC defend themselves by denying fixing targets for specified expenditures or wages and stating that governments are accountable for expenditure priority allocations. They thus deny any responsibility for their actions.

However, regular reviews by the WB, IMF and EC determine whether a loan is released depending on economic performance, not on protection of social spending. As contended, ‘this is an example of how the power dynamics between WB, IMF, EC and the recipient of their programmes make it very difficult for the latter to ignore policy prescriptions, even when they are not legally binding.’

Basic requirements to reform

Given the influence of these institutions on domestic policies, they should focus on helping countries explore a wide range of options for dealing with fiscal deficits. These options should ensure the protection and increase in social spending, especially on health and education, and the removal of the budget ceiling on the recruitment and retention of health workers.

A key problem underlying the damage of the macroeconomic reform recipe is that negotiation is usually limited to a narrow circle of finance ministries in the absence of public participation or scrutiny. Transparency of negotiation and participation of other relevant ministries and civil societies are essential to ensure pro- human development policies.

Despite recent positive rhetoric by the IMF, WB and the EC to reform conditionality policies, a gap persists between the declared intentions and the general practice. As maintained in a recent Eurodad analysis, ‘…The IMF continues to attach problematic conditions to its loans, notably by suggesting reforms in sensitive economic areas. The World Bank continues to make loan decisions on the basis of the assessments made by its rich country-dominated board on the economic agenda of recipient countries. Finally, the EC’s Budget Support was originally created to support the local ownership of its recipients and its guidelines reflect that. In practice, though, it sometimes incentivizes economic reforms that are not part of partner countries’ development strategies…’

It is time for the three institutions to turn their new rhetoric into reality.  But, will they be up to this at this time of  Trump, Brexit, and the rising success of so-called populist/nationalist movements – which perhaps mirror the mounting unpopularity of the idea of globalization as the driver for economic prosperity?


*article originally published in International Health Policies

Daniele Dionisio is a member of the European Parliament Working Group on Innovation, Access to Medicines and Poverty-Related Diseases. He is an advisor for “Medicines for the Developing Countries” for the Italian Society for Infectious and Tropical Diseases (SIMIT), and former director of the Infectious Disease Division at the Pistoia City Hospital (Italy). Dionisio is Head of the research project PEAH – Policies for Equitable Access to Health. He may be reached at