Dr Anja Smith | October 2020
Covid-19 and its secondary impacts on the health system became very real to me one day in March, shortly after the identification of Patient Zero in South Africa, when a doctor colleague of ours at Percept announced he was going back to his primary care clinic in a metro area of Cape Town. Our doctor colleague was going back to the public health system to figure out a way to keep medication and services for chronic patients flowing, while minimising contact with potential Covid-19 patients. It was at this point that I knew our health system faced an unprecedented challenge. Not only would it have to find the best possible ways to serve Covid-19 positive patients who required more care, it would also have to keep all its existing services going, at least as far as possible. Would it be able to do this? How would the system and the people working in the system make choices about who and what conditions to serve, and which patients to not focus on immediately? More importantly, how would it keep patients coming for the visits and medication they need if they are going to be afraid of catching the virus?
Data allows us to understand the impacts of the pandemic on the health system
These were questions I asked myself in March and April. Since then, evidence on the unintended secondary effects of the pandemic on health outcomes have emerged as both administrative data (public and private sector) and survey data on health seeking have become widely available and shared in the media from different data sources. One such source is the National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-CRAM).
NiDs-CRAM is a broadly nationally-representative panel survey of 7,000 South African individuals repeated over several waves. The same person is phoned each month and is asked a range of questions on their income and employment, their household welfare, receipt of grants, and about their knowledge and behaviour related to COVID-19, as well as their general health seeking behaviour. There are five waves of the study planned. The first wave’s data were released in July, while the second wave’s data is set to be released at the end of September.
I’ve recently been involved in two studies that draw on some of the NiDs-CRAM data in some way. The first study considered the unintended public health consequences of the pandemic on health seeking behaviour. In addition to using the NiDS-CRAM household data, we also used data from a sample of pregnant women or women who had recently given birth who all use the National Department of Health’s MomConnect e-platform for the receipt of health messages. The second study focused on the various channels through which the Covid-linked economic recession are likely to affect health outcomes. Both these studies provide a picture of the secondary Covid-related health system impacts that have either already played out and are likely to play out in the medium term.
Overall decreases in health seeking behaviour visible in vulnerable areas
While the overall level of care seeking reported in the NiDS-CRAM sample was good, there were concerns about care seeking among individuals with acute health needs. 96% of those with chronic conditions, but only 78% of those with acute care needs, reported seeking care when needed in the last four weeks before the survey. Fear of the virus was the most frequently cited reason for not seeking care. More concerningly, 1-in-6 mothers and pregnant women in the CRAM-MATCH (MomConnect) sample reported at least a 2-month gap in care, and the biggest reason provided for not seeking care was fear of the virus. Furthermore, 1-in-10 mothers and newly pregnant women reported running out of ARTs in May and June. Of this group, 40% selected fear of the virus as their main reason for not collecting or accessing ARTs. The fear of the virus as a barrier to care was largest amongst the poorer groups of women.
Economy-linked health effects will manifest over the coming months and years
We know from evidence from other low- and middle-income countries that economic recessions can potentially increase total mortality. There exist several channels running from the economy to health. These channels of influence are situated on both a macro and micro level. Macro level channels include a potential reduction in health budgets because of austerity policies. Alternatively, health budgets can also purposefully be increased to counter-act the negative effects on health from an economic recession by taking a counter-cyclical fiscal approach. Some of the micro channels through which the economy affects health include job losses leading to a reduction in household income (and therefore also access to proper nutrition). Households that have less income may also choose to decrease their health expenditure or expenditure on travel to health facilities. On a more positive note, a reduction in jobs may mean less road travel which could contribute to fewer deaths due to road accidents.
One of the most concerning channels for South Africa, running from the economy to health, is through nutrition. From the Wave 1 CRAM data, we know that 26.3% of respondent who were using chronic medication also reported hunger in their household. For those with non-communicable diseases (NCDs), and infectious diseases such as TB and HIV, adequate nutrition is an important part of maintaining one’s health.
Looking forward: what can we do?
Irrespective of the source, whether from the economy, coronavirus infection fears or even clinic shutdowns, we know many South Africans who rely on the public health system will be reducing their health seeking behaviour over the coming months and potentially even years. This means the system has to reorientate itself and ask what it can do to prevent a deterioration in all sorts of health outcomes, including in child and maternal health, infectious diseases (HIV and TB) and NCDs (e.g. diabetes and hypertension). A number of proactive policy actions are possible. For certain types of services, mop-up or catch-up operations especially in the area of preventative health services like immunisations or cancer screenings can be implemented. Large-scale campaigns can be undertaken to ensure infants receive all the necessary immunisations. Where immunisations have previously occurred at schools, for example for the HPV vaccine, catch-up campaigns can now be rolled out where children are back at school. The system can also experiment with alternative ways of delivering care in ways that recognise and deal with people’s fears, e.g. through telehealth and the home delivery of chronic medication. A system thinking approach will also have to be taken which recognises the economy’s impact on health: grants will have to be expanded and where expanded, maintained.
Has the landscape of healthcare in South African changed forever? We don’t know. Humans are social beings and it is likely that we may return to our old ways of living sooner rather than later as the number of Covid-19 cases decrease. However, this moment provides an opportunity to innovate and steer our system in a direction that better serves more people in ways that can improve health outcomes over the longer term. But first, we must recognise the health aftermath that has come our way and purposefully deal with it in innovative and reflective ways.