For the first time ever a group of experts came together this week to find solutions to one of the country’s main stumbling blocks in the fight against HIV/Aids – the failure of the private health sector to treat sexually transmitted infections (STIs).
The widespread presence of STIs in South Africa is one of the main driving forces behind the spread of the Aids epidemic and the early and successful treatment of STIs can halve the rate of new HIV infections. While the public sector hospitals and clinics are following the correct diagnostic and treatment protocols, efforts are being undermined by the private sector GPs and district surgeons who have ‘appalling rates’ in treating the infections, said Helen Schneider, head of the Wits Centre for Health Policy.
The challenge was to find ways to get the private sector to comply with the WHO management guidelines. Many of the GPs surveyed had never even heard of the guidelines, and research by the Centre for Health Policy found that in some categories of STIs only 4% of the patients who visited GPs received effective treatment.
Cost and being out of date with new medical knowledge were cited as the reasons for the poor quality of STI care in the private sector. As GP services are driven by profit, patients received only the treatment that they could afford to pay for and in most cases this was ineffective.
Yet in the absence of any legal or policy framework which would allow the National Health Department to rein in the private sector it is difficult to know how to proceed.
The workshop group comprised the Health Department, the South African Medical Association, medical schools, the Medical Research Council and Health Systems Trust, and focussed on influencing private doctors through continuing medical education and through public/private partnerships. However, the high level of mistrust between the public and private sector has always been an impediment to these initiatives.
The situation is further compounded by the fact that most people with STIs prefer, for reasons of privacy, to go to a GP rather than to the local clinic. Even in the poorest and most rural areas, private practice doctors outnumber those in the public sector. In light of this, bringing patients back to the public sector clinics would mean that they would get better treatment, but in order for this to happen clinics would have to pay far more attention to the principle of ‘Batho Pele’ (‘People First’) and ensure that their patients were treated more humanely and afforded more privacy.
A key solution suggested at the workshop was to strengthen consumer power and to encourage patients to demand quality services and effective treatment.
Pharmaceutical manufacturers who gave GPs incentives to prescribe their drugs, rather than the recommended drugs, are major culprits in this tangle. University of Durban-Westville pharmacology professor Andy Gray believes that the Medicines Control Act (Act 90) would have a strong impact on STI care as it would make drugs more affordable to both the public and private sectors. It would also improve prescribing practices and influence the way in which pharmaceutical companies could market their drugs.
But health economist Alex van den Heever said that the because the Medicines Control Act affected pricing of medicines, pharmaceutical companies would always find a way to get around price controls and so this piece of legislation would not be of much help in this scenario.
Instead, Van den Heever argued that the proposed new regulations to the Medical Schemes Act would hold the greatest sway in this area as they would force the funders and providers to redesign the way in which they interact. By enabling medical schemes to contract primary care clinical services, GPs would become more accountable to their patients.
Other solutions that were discussed included getting the state to supply GPs with the correct drugs and to give them incentives for following the correct protocols.
In the end it was evident that the state on its own did not have sufficient regulatory or financial power to improve the quality of private care and, as fraught with complexities as they were, it was only partnerships between government, professional associations and groups of private doctors at local level that would bring about improved care.
‘ Health-e News Service