SOUTHERN AFRICAN HEALTH JOURNAL / 2020 Pushing Beyond. Solutions for Change. Exploring the expected, unexpected and everything in between SOUTHERN AFRICAN HEALTH JOURNAL / 2020 PRODUCTION Published by the Board of REGISTERED OFFICE Editor in Chief: Charlton Murove Healthcare Funders South Tower, 1Sixty Jan Smuts Copy Editor: Peter Wagenaar Tel: +27 11 537-0200 Jan Smuts Avenue Cnr Tyrwhitt Project Co-ordinator: Camille Shamburg Fax: +27 11 880-8798 Avenue, Rosebank, 2196 Layout & Design: Mariette du Plessis Client Services: 0861 30 20 10 Web: www.bhfglobal.com COMPANY REGISTRATION Email: [email protected] 2001/003387/08 From the EDITOR'S DESK The BHF is pleased to present the second edition of the Southern African Health Journal. The breadth of topics is considerable, yet the common thread is ‘health system strengthening for the benefit of the health citizen’. he papers presented explore emerging treads in and there are two papers covering what is needed to Ttechnology and how patients have taken their own bridge the gaps in implementing value-based care in our initiatives to manage their health – health care practitio- environment. ners need to follow and adapt to this emerging trend. One paper focuses on how asthma can be managed In the course of 2020 the coronavirus impacted almost using an automated system; this may be translatable all aspects of life. Health care was not spared; we have to other chronic conditions. Another, focusing on preci- a special section covering how health systems have re- sion medicine, also presents an opportunity to improve sponded to the pandemic. It is easy to draw parallels patient care using technology, with potentially huge cost between the impact of COVID-19 on South Africa and and health benefits. Germany. The challenges were similar, though it ap- pears the German system was able to respond faster Topical issues in health care, such as out-of-pocket ex- and better than South Africa. In South Africa, one of the penditure, human resources for health and medicine major changes in response to the pandemic was the compliance, are also covered. A trend analysis of increas- introduction of telemedicine, which was met with great ing out-of-pocket expenditure looks at potential solu- excitement. The paper on telehealth warns that while we tions to limit this. There are two papers on the uneven believe it increases access to health care, there is a risk distribution of human resources for health, one looking that it may further deepen inequalities if digital barriers at eye care and the other at general practitioners. Both are not breached. Access to technology may become a are essential for effective primary health care. The paper significant determinant of health. On a micro-level, we on medicine compliance, a key component of managing also learn of the journey of Polmed (a medical scheme chronic disease; investigates the threshold for compli- in South Africa) and how it responded to the pandemic ance with regard to three chronic conditions. with agile strategies and a holistic view of the risks faced by its beneficiaries. When it comes to the sustainability of health funding, the paper on underwriting and managing investments Lastly, we would like to extend our appreciation to the for medical schemes offers interesting perspectives authors and peer reviewers who made this publication and should be seriously considered. The introduction of possible. underwriting led to significant financial benefits for the scheme in the study, thereby protecting risk pools from Charlton Murove anti-selection. Value-based contracting remains topical Head of Research, Board of Healthcare Funders 2020 SOUTHERN AFRICAN HEALTH JOURNAL PUBLISHED BY THE BOARD OF HEALTHCARE FUNDERS 1 SOUTHERN AFRICAN HEALTH JOURNAL / 2020 04 COMPREHENSIVE 48 COLLABORATION & PRIMARY EYE CARE REIMBURSEMENT Comprehensive primary eye care is a Better together: how collaboration can population health imperative: Human fast-track alternative reimbursement resource development for eye health AUTHORS: Kelly Chennells; system strengthening in KwaZulu-Natal Shivani Ranchod; Anja Smith AUTHOR: Lungile Buthelezi PEER REVIEWER: Graham Hukins PEER REVIEWER: Eustasius Musenge 55 PRIMARY CARE OUTCOMES 17 IMPROVING DISTRIBUTION -BASED CONTRACT OF HEALTH WORK FORCE First port of call: Developing an outcomes- Improving distribution of the health work based contract for primary care force – achieving equity: An analysis of the AUTHORS: Victoria Barr; Odwa Mazwai distribution of general practitioners paid PEER REVIEWER: Buddy Modi by medical schemes across district level healthcare markets 61 IMPACT OF UNDERWRITING AUTHORS: Phakamile Nkomo; Mondi Govuzela PEER REVIEWER: Laetitia Rispel Impact of underwriting on a South African medical scheme 27 OUT-OF-POCKET AUTHORS: Barry Childs; EXPENDITURE Mudanalo Shavhani; Rachael van Zyl PEER REVIEWER: Paresh Prema Out-of-pocket expenditure by beneficiaries of medical schemes: 2013-2019 74 IMPACT OF REGULATION 30 AUTHORS: Carrie-Anne Cairncross; Martin The impact of Regulation 30 on Moabelo; Michael Willie; Sipho Kabane PEER REVIEWER: Anja Smith investment performance AUTHORS: Petri Greeff; Jonathan Brummer; 41 ZIMBABWE: THE ROLE OF Mubeen Abdulla; Ketlo Ledimo NON-STATE ACTORS PEER REVIEWER: Shivani Ranchod The role of non-state actors in 83 AFRO-INCLUSIVE strengthening health systems: Changing PHARMACOGENOMICS the narrative – the case of Zimbabwe A case for Afro-inclusive AUTHORS: Godknows S Muperekedzwa; Kudzai M pharmacogenomics precision medicine CONTENTS Vere; Deloune C Matongo; Chitando Mutsawashe PEER REVIEWER: Anusckha Coovadia AUTHOR: Stewart Masimirembwa PEER REVIEWER: Buddy Modi 2020 SOUTHERN AFRICAN HEALTH JOURNAL 2020 SOUTHERN AFRICAN HEALTH JOURNAL 2 PUBLISHED BY THE BOARD OF HEALTHCARE FUNDERS SOUTHERN AFRICAN HEALTH 2020 / JOURNAL 93 CHRONIC DISEASE MEDICINE 107 HEALTH DISRUPTION The impact of chronic disease medicine Driverless health disruption: the rise of compliance on patient outcomes the iDoctor's relationship with the health th AUTHORS: Evan Bradley; Alice Bock consumer in the 4 Industrial Revolution PEER REVIEWER: Graham Hukins AUTHOR: Grant Newton PEER REVIEWER: Jodi Wishnia 118 ORGANISATIONAL IMPACT 141 AUTOMATED SYSTEM The organisational impact of COVID-19 Design of an automated digital system on health systems and health sector to measure asthma control ecosystems AUTHOR: Praneet Valodia AUTHOR: Michael Thiede PEER REVIEWER: Denis Evans PEER REVIEWER: Waasila Jassat 147 TELEHEALTH 124 MINIMISING THE IMPACT Telehealth: Leaving no one behind Polmed’s role in minimising the impact of – Understanding the digital divide COVID-19 on its members as a social determinant of health AUTHORS: Jaco Makkink, Vuyokazi Mpongashe AUTHOR: Selaelo Mametja PEER REVIEWER: Shan Naidoo PEER REVIEWER: Charles Hongoro 130 BIPOLAR MOOD DISORDER Factors associated with COVID-19 admissions in patients diagnosed with bipolar mood disorder: A restricted scheme case study AUTHORS: Michael Willie, Sipho Kabane PEER REVIEWER: Edmore Marinda 2020 SOUTHERN AFRICAN HEALTH JOURNAL 2020 SOUTHERN AFRICAN HEALTH JOURNAL PUBLISHED BY THE BOARD OF HEALTHCARE FUNDERS 3 COMPREHENSIVE PRIMARY EYE CARE IS A POPULATION HEALTH IMPERATIVE: Human resource development for eye health system strengthening in KwaZulu-Natal AUTHOR Lungile Buthelezi PEER REVIEWER: Eustasius Musenge EXecutive summary Optometrists have increasingly been employed in KwaZulu-Natal’s (KZN) public health facilities to deliver primary eye care services. However, health outcomes relating to visual impairment remain poor. The World Health Organization (WHO) health systems framework was applied in KZN, to assess the Department of Health’s (DoH) capacity to provide comprehensive primary eye care services. This study aimed to analyse the resources available to optometrists for comprehensive primary eye care service delivery within the public health sector in KZN. An exploratory-descriptive cross-sectional design was used. A mixed-method (QUAL + QUAN - equal-status concurrent) design was utilised. Data were collected using questionnaires, observation and interviews. The majority (53%) of respondents were from facilities based in rural areas. Most facilities represented in the study lacked the basic equipment required to provide comprehensive primary eye care services. The shortage of funds for eye health was attributed to a lack of health information for planning and leader- ship’s not understanding primary eye health service needs. Participants felt that to improve capacity, there needs to be collaboration between all eye health cadres, as well as planning and representation for optom- etrists within policy and planning. The KZN DoH lacks the capacity to deliver comprehensive primary eye care services. Capacity development of optometrists to effect change within the system and promoting a collaborative strategy between eye health cadres will create strong eye health teams and improve the efficiency and quality of services. 2020 SOUTHERN AFRICAN HEALTH JOURNAL 4 PUBLISHED BY THE BOARD OF HEALTHCARE FUNDERS COMPREHENSIVE PRIMARY EYE CARE Introduction Background Globally, there are 2.2 billion people who suffer from visual impairment, of which one billion cases could be prevented (World Health Organization, 2019). According to the South African national DoH, the prevalence of blindness in South Africa is estimated to be 0.75% (South African Department of Health, 2002); 80% of those affected are classified as having avoidable blindness and live in rural areas. With