Aids, tuberculosis, tech innovation and the NHI

When it comes to developments in healthcare, innovations in medicine and the technology that ties it all together

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When it comes to developments in healthcare, innovations in medicine and the technology that ties it all together, predicting the future can be a thankless process

However, the fact of the matter is that technological innovations have dramatically transformed healthcare more than any other force, and especially over the last 30 years. Therefore, it is important to regularly take the pulse—so to speak—of the continuous developments in this area.

Even when, on the face of it, the innovations have had more to do with policy and how the issue of healthcare reform is addressed in the country, technological initiatives are vital. One just has to take a closer look at the upcoming transformation to be wrought by the forthcoming implementation of the National Health Insurance (NHI) Scheme.

The proposed NHI promises to be one of the biggest and certainly one of the most controversial initiatives in South Africa’s health sector since democracy.

Seemingly, the NHI is a benign, even much-needed, innovative development of the nation’s healthcare system. According to the literature available, the NHI will bring about a new system for medical aids while simultaneously providing a universal, state-run healthcare system. The government says the NHI is meant to replace the current unequal system, which forces the poor to use a low-quality public healthcare system while the wealthy are able to attend top-level private facilities.

Gazetted in June this year along with the Medical Schemes Amendment Bill for public comment, the NHI Bill has divided opinions across the country with some believing the NHI will be a panacea and others wondering whether the NHI will ever take off, given the issues of corruption and inefficiency that are pervasive in the health system as it is.

For instance, I spoke to Dr Tlaleng Mofokeng, a Medical Doctor and an opinion leader in the profession. Mofokeng is also the Vice-Chairperson of the Sexual and Reproductive Justice Coalition (SRJC) in South Africa and sits on a Global Advisory Board for Sexual Health and Wellbeing.

Dr Mofokeng said that while, “as a principle of ensuring healthcare, the NHI is okay, there are current issues with the system today that need fixing urgently and cannot and should not have to wait for the NHI to be implemented”. She pointed to procurement, the training of nurses and graduate employment as just a few of the problems the system is facing.

Dr Mofokeng also questioned how the NHI would tackle the perennial issue of medicine shortages asking “how are we still having [issues of medicines] being out of stock?”

While the arguments between those in the pro and anti-NHI camps could go on forever, the question to be asked in this era of technological innovation is will the NHI simplify patient access to care, while supporting people in managing their own health?

Around the world, the way in which people use medical services has changed over the years and people now expect to be in a position to access services online, for instance. At the same time, of course, it is important to remember that, ultimately, healthcare is about people and patients generally wanting and needing the reassurance of talking to a real person face to face.

On 1 November this year, South Africa’s Health Minister, Dr Aaron Motsoaledi, spoke to the University of Stellenbosch Business School about the implementation of the NHI Bill and the government’s intention to bring South Africa a step closer to achieving its aim of universal healthcare.

Admitting that there are problems in the healthcare system, the Minister said, “There is corruption in the healthcare system, as there is elsewhere in the country.” However, he claimed that mismanagement and corruption are secondary to the primary problem of inequality in the health system.

South Africa spends a total of 8.7% of GDP on health while the World Health Organization recommends that countries spend 5%. Dr Motsoaledi said, “The private sector spends 4.5% of GDP on health but only provides care to 16% of the population while the public sector spends 4.2% of GDP on health to care for 84% of the population. People believe that by some miracle, without corruption and mismanagement, the state can provide quality healthcare for 84% of the population on 4.2% of GDP, when 16% of the population receives healthcare on 4.5% of GDP. This is gross inequality.”

He told the audience that as far as he was concerned, the NHI’s implementation was necessary because “90% of South Africa’s healthcare system is designed for well-to-do people, and not poor people”.

It is against this backdrop of healthcare reform that innovative medical technology is focussing more than ever on products that deliver cheaper, faster, more efficient patient care than has been available in the last three decades.

Procedures and treatments that may have seemed like science fiction just 30 years ago, have become routine in our lifetimes. For instance, in 1988, few could have predicted that in less than 20 years, being diagnosed HIV-positive would no longer be a death sentence, thanks to just one antiretroviral pill taken on a daily basis.

There are roughly 270 000 new HIV infections in South Africa every year. Despite the huge gains made in the fight against HIV, South Africa remains a country with the highest HIV prevalence in the world. Over the last decade or so, there has been an increase in the adoption of medical technology innovations to get to grips with these other intractable healthcare challenges facing the world today.

South African innovation and technology have not been left behind in this quest. For instance, at the end of September—which was marked as Pharmacy Month—this year, a groundbreaking “ATM pharmacy” that gives patients with chronic illnesses repeat medication in under five minutes, was unveiled in Bloemfontein.

This piece of innovative technology is known as the Pharmacy Dispensing Unit™ (PDU™). It works like an ATM for medication, with Skype-like audio-visual interaction between the patient and a remotely located telepharmacy contact centre. Patients are able to talk to pharmacists in a call centre 400km away in Centurion, Gauteng, showcasing the benefits of telepharmacy to patients in rural and outlying areas. This allows patients to access accurate medical information and counselling from qualified pharmacy staff.

It was developed by a team comprising experts from Right to Care, a non-profit (Section 21) organisation in Johannesburg, and Right ePharmacy, an innovative, strategic solution provider for the dispensing, distribution and collection of medicine, and deployed in collaboration with the Free State Department of Health.

The PDU in the Free State is at Twin City Mall, a central community shopping centre, which is on main transport routes and is open for extended hours including weekends and public holidays.

At the launch, Right to Care’s CEO, Professor Ian Sanne, said: “Our alliances made this innovation possible and we are grateful to the Free State Provincial Health Department for partnering to make this work. We also thank the Global Fund for the monetary support. PDUs ensure the accurate dispensing and quick collection for clinically stable patients on chronic medication. Driven by sophisticated technology, patients’ concerns and information needs are still handled personally by telepharmacists.”

Speaking at the same event, the MEC for Health in the Free State, Montsheng Tsiu, said, “This is a great step forward for patients in our city as this technologically advanced pharmacy will dramatically reduce waiting times and congestion in public healthcare facilities in Mangaung.”

Tsiu added, “The system is run by qualified pharmacists and pharmacy assistants and integrates with the clinical management processes of patients with chronic conditions at public facilities. It also reminds patients when to collect their medication, which improves adherence. The date for the next collection is shown on the patient’s receipt and prescription collection reminders are sent by SMS. Late collections are immediately identified and flagged for follow up. Patients are serviced in all eleven languages and there is onsite support to help patients interact with the technology.”

Dr David Motau, the Head of Department for the Free State Department of Health said the launch of the initiative was to honour the “pharmacists in the province through initiatives that advance improved access pharmaceutical services”. He added that the initiative “supports the National Department of Health’s Strategy for Improving Medicine Availability (SIMA)” and that “ultimately, this new PDU at Twin City shopping centre in Bloemfontein is about improving the patient experience, providing quality clinical care and decreasing patient numbers and congestion at our surrounding public health facilities”.

Ian Hove, the Programme Manager for the Global Fund to Fight AIDS, TB and Malaria, also spoke, saying, “This ATM-like medication dispenser demonstrates innovative thinking to overcome the challenges we encounter in ensuring people stay on HIV treatment or treatment for other chronic illnesses.”

Hove explained that the launch was “only phase one of a larger programme. We are pleased to have partnered with Right ePharmacy on this and other innovations for people living with HIV. The PDUs are innovative solutions that use technology to move beyond traditional healthcare delivery. It is an example of the Global Fund’s commitment to the people of South Africa to create a healthier future for all.”

Rufaro Ngulube, Technical Specialist: Pharmaceutical Services, Right ePharmacy, explained the mechanics of the technology. He said, “The technology was developed with the aim of addressing some of the challenges compromising medicine access in the resource-åconstrained public healthcare environment.”

Ngulube explained: “A PDU comprises integrated layers of various technology, which includes an interactive information touchscreen and a user-friendly interface, which allows for two-way Skype-like audio-visual interaction. It has Barcode ID scanning to initiate dispensing, it needs a patient PIN code for authentication and activation and relies on cloud-based dispensing software and an electronic dispensing record.”

He said that the “barcode linked the product database and product identification capability, worked with a versatile product printer-labeller, a customised, temperature-controlled compact medicine unit and a robotic arm for the accurate and swift picking of medicines.”

Fanie Hendriksz, the Managing Director of Right ePharmacy explained the referral process that leads to using the PDU. “A patient on chronic medication who has been identified as clinically stable and demonstrating responsible health behaviour at any of the surrounding referral clinics can be given the option of collecting their chronic prescription from a convenient PDU pharmacy.

“The clinic issues the patient with the first prescription and provides a date for the next collection of medicine from the PDU. The patient’s prescription is verified and loaded onto the electronic dispensing software by a pharmacist in preparation for dispensing from the PDU,” he said.

He described the process of a patient’s first visit, saying, “On the patient’s first visit to a PDU pharmacy, personal details are verified and linked to a pharmacy card, which is issued at registration. The patient assigns a PIN number to the card to authenticate medicine access at the PDU.” Hendriksz explained that at a first visit, “PDU orientation is provided by onsite PDU staff”.

The medicine is dispensed in a simple five-step process as follows:

  • Scan barcoded ID book, ID cards or pharmacy card and enter a PIN
  • Talk to a pharmacist
  • Select a prescription
  • Collect the medication
  • Take a receipt

When it comes to subsequent PDU visits, Hendriksz said, “An SMS reminder is sent two days prior to the next collection date. At the next collection, the patient can proceed straight to an available PDU machine and follow the five-step dispensing and collection process. The patient can collect their prescriptions from the PDU until the repeats on the prescriptions run out. Patients are then notified to return to their referral clinic for a follow-up clinical visit and the issuing of a new repeat prescription and the first supply of medicine as the process and cycle repeats.”

Referral to a PDU site and the use of this service is free to selected patients collecting their chronic medication from surrounding primary healthcare clinics. According to Hendriksz, “The cost of setting up a single standalone PDU is around R2 million.” He said the technology offers far-reaching sustainable benefits due to its scalability and that the cost of the PDU operation decreases with increased use or patient uptake.

As to fears that the technology will destroy jobs for pharmacists, Hendriksz said, “There is a real shortage of pharmacy staff in the South African primary healthcare sector. This technology will help pharmacists to focus on the pharmaceutical care of the patient, which includes counselling, the appropriate and safe use of medicine, side-effect aversion, lifestyle modification and disease prevention.”

He went on to suggest that PDUs and pharmacy automation actually create jobs and offer the pharmacy professional additional and diversified career opportunities in a new niche market—telepharmacy.

Earlier in July this year, the HIV/Aids NGO Shout-It-Now successfully piloted what they are calling “Test and Treat technology.”

Described as the world’s most advanced HIV testing technology, Test and Treat piloted in the Ekurhuleni area. The mobile clinic consists of two trucks working in tandem, one dedicated to HIV testing and the other to antiretroviral therapy (ART) initiation.

The test trucks are equipped with self-help kiosks and, using interactive touchscreens and audio-visual aids, the programme can be navigated in English, Zulu and Sepedi. Test and Treat offers not only cheaper and faster on-site testing but also uses a biometric finger scanner function that protects client confidentiality (a critical reason why people are not getting tested in this country).

The Test and Treat technology provides a better, cheaper, faster solution to HIV testing that gives you results in as little as five to 10 minutes via SMS. The system captures perfect data that can be analysed in a way that’s never been done before,” says Shout-It-Now’s founder and Chairman, and Silicon Valley veteran, Bruce Forgrieve.

Forgrieve retired from a successful technology career and founded Shout-It-Now in 2007 to channel his energy into giving back. As Shout-it-Now’s founder and Chairman, he brings to public health the tools that helped him found and grow six technology start-ups in the USA over a period of 27 years. Along with the public health professionals Forgrieve has partnered with to deliver Shout-it-Now’s services, he has overseen numerous innovations in high-throughput screening (HTS)—a method for scientific experimentation especially used in drug discovery—and has led Shout-it-Now to test more than 1.1-million clients in four provinces. Today, Forgrieve lives in Cape Town, overseeing Shout-it-Now’s operations and constantly looking for new ways to make improvements to South Africa’s fight against HIV/Aids.

Forgrieve explained, “With Test and Treat, the organisation plans on reaching inaccessible areas and communities, such as hostels, factory sites and rural townships, where the prevalence of HIV is often the highest. Long queues at clinics, a lack of time, the fear of being asked embarrassing questions and the shame often attached to being HIV-positive are some of the reasons people don’t get tested. Test and Treat aims to process up to 150 clients a day in these previously inaccessible areas, with a quick, streamlined process.”
He said that since 2007, “Shout-It-Now has been working hard to relieve pressure on the public health system by providing community-based initial HIV screening and links to care.” He added that, to date, “Shout-it-Now has successfully performed over 1.1-million HIV tests in South Africa and the NGO’s aim is to assist the National Department of Health (and other public health stakeholders) in reaching their 90.90.90 target—that is, that 90% of people living with HIV know their status, 90% of these patients receive antiretroviral (ARV) therapy and 90% of these ARV patients achieve viral suppression.”

A big part of the Test and Treat programme is to dispel many of the myths around HIV and to reinforce the message that living with HIV is no longer a death sentence. Shout-It-Now believes strongly in providing ongoing support and care for those too ashamed to confide in loved ones about their HIV status.
“Because we know that an HIV-positive diagnosis can be traumatic, the Shout-it-Now Clinic Clubhouse aims to ease the integration into the clinic system by providing fast and friendly service within a warm and welcoming environment,” says Dr Kathryn Pahl, the Managing Director of Shout-It-Now.

Well-known in the South African social development sector, Dr Pahl’s career has included heading the social development department at Valkenberg psychiatric hospital in Cape Town, being the CEO of Epilepsy South Africa and a researcher within the Department of Psychiatry at the University of Cape Town, focusing on HIV/Aids programmes in South African schools. She has been Managing Director of Shout-it-Now since its inception in 2007.

Phase 2 of this service will see Shout-It-Now exploring an adherence programme, providing medication to clients on a monthly basis as a way of enhancing services to clients and complementing the clinical system. Hopefully, this will see Shout-It-Now assisting the Department of Health in meeting the third and most challenging part of the 90.90.90 target—that 90% of HIV patients on ARVs achieve viral suppression. 

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