Dialysis crisis in South Africa means that access is not equal for all

Role-players in the dialysis community – yours truly included – were quoted in an article about the dire state of access to dialysis in yesterday’s Sunday Times newspaper. The article reflects a number of important points.

Two-tiered health system

Firstly, SA has a “two tiered” health system. In the private sector people pay for their healthcare, usually through membership of a medical aid or “out-of-pocket” payments. About 15 – 25% (a conservative estimate) of the population is sufficiently well-off to access the private sector. The rest have no choice but to (try to) access healthcare in the state sector – which is funded by the government. In perspective, in 2012 the amount spent across each sector was much the same (ZAR 139.7bn in private vs ZAR 140.7bn in state)[1]. But when you consider that far more people are seeking care in the state sector, you get a sense of how little there is to go round. Compared to the private sector where care is pretty much ‘on-demand’.

Inequitable access to dialysis facilities

Secondly, the state sector has very few dialysis facilities. Many state patients are turned down for dialysis because there are simply not enough machines to provide for everyone. The consequences are disastrous. Unless these patients can stump-up the cash to pay for private access (sometime charities help) then they will die. There is no middle ground here. It’s different in the private sector, where dialysis is a “Prescribed Minimum Benefit” (PMB) which means that no-one on a medical aid can be refused dialysis treatment. The result: about 10 times more people receive dialysis in the private sector than the state sector.

Our history

Thirdly, we cannot ignore SA’s history. Many of those who were historically disadvantaged during apartheid are socio-economically disadvantaged now. These are the people who (try to) access healthcare in the state sector. These are the people who are being sent home without treatment.

The South African Constitution and human rights

Prima facie, this situation seems wrong. It’s probably also unconstitutional. The SA Constitution says that all people have the right to access healthcare services (NB: it doesn’t say that people have the right to health – so count yourself lucky if you are healthy). The Constitution also says that the government must facilitate progressive realisation of the right to access healthcare within its available resources. When it comes to dialysis, it does not seem like progressive realisation has taken place for state patients, but that it has been exceptional for private patients. Surely this situation is untenable, and I think this is ripe for legal challenge.

In oncology too…

And it’s not only dialysis where progressive realisation isn’t evident. A few weeks ago, the last state-based oncologist in KwaZulu-Natal province quit. This means that state patients in KZN do not have access to a single oncologist now. This is not progressive realisation of the right to access healthcare.

[1] Why 2012 numbers? So old and out of date? It’s because these numbers are taken from the Government’s “National Budget Review” which is released every year. 2012 was the last review that addressed total spending across both health sectors. In more recent reports (2013 – 2016) no mention is made of private health spending. Only government spending is detailed. This speaks for itself.

The views published in this blog are entirely my own (informed) opinions. They are open to debate, discussion and disagreement.

Categories: South African Health Sector

Tagged: Constitution, Dialysis, Ethics, kidney disease, Progressive realisation, Right to access healthcare, South Africa

Why you shouldn’t share your medical information on social media – A latent aspect of the Noakes case

Dr. Harriet Etheredge

Posted on April 24, 2017

Don't share your personal medical information (or that of anyone else) online. The ethical issues from the Tim Noakes Case

Last week, a disciplinary committee of the Health Professions Council of South Africa (HPCSA) ruled that Prof Tim Noakes was not guilty of professional misconduct. The HPCSA regulates most main-stream health professions in South Africa – medicine, dentistry, physiotherapy etc. The complaint against Noakes revolved around the use of Twitter to dispense ‘medical advice’ and can be viewed in detail here. I’m no expert on these issues – and I’m not going to debate the merits of the case or the ruling. Rather, I want to highlight a ‘hidden’ risk of social media and medicine, one that I don’t think patients are always aware of.

Information and Communication Technologies (ICT) are often used in medical environments to share important information about patients with their treatment team. This is a significant innovation, because it enhances the speed and quality of medical treatment that patients receive. Health professionals are, however, bound to keep this information confidential. Think of it like this – you go to your doctor because there is something amiss and the symptoms are very embarrassing. You tell your doctor about your symptoms. You feel comfortable doing this because you know that your doctor has to keep your information private. If you didn’t trust health professionals, you probably wouldn’t feel comfortable sharing embarrassing information with them, and you might not seek-out the care you need to restore your health.

But then you go further – and share information about your condition on Twitter. It is your information, and you can do what you like with it. But I often wonder if people appreciate the implications of publishing their own health information (or someone else’s for that matter). By tweeting Noakes, the breastfeeding patient inadvertently made her medical information (granted, it wasn’t really embarrassing) – which a doctor would be bound to keep confidential – available for the world to see.

There are two main problems with patients publishing their own medical information on social media (this excludes specialist support sites by the way – which are probably more selective and attract an audience with specific interests).

It may result in unsolicited medical advice which isn’t accurate or evidence-based. This could potentially derail a treatment plan.
It raises questions about patient expectations of confidentiality.

Yes – we should all absolutely expect health professionals to keep our information confidential. But we do seem a bit silly if, along with this expectation, we go and share our health information online ourselves. If you publish your own (or someone else’s) medical information it makes the job of the person treating you that much more complex. They have to counter with all the advice that your publication has solicited. You could also put well-meaning health-professionals in a ‘grey area’ where, like Noakes, they may easily trip-up when trying to assist you. In terms of guidelines and legislation, the role of social media and ICT in medicine still needs to be extrapolated. In the meantime, the road to hell is paved with good intentions, and your confidential medical information is your own. Don’t share it on social media.

The views published in this blog are entirely my own (informed) opinions. They are open to debate, discussion and disagreement.

Categories: health communication

Tagged: Confidentiality, Ethical, Ethics, Noakes, Social Media, Tim Noakes, Twitter

Dr Harriet Etheredge

Medical Bioethicist. Health Communication Specialist. Speaker. Author. South Africa.

Posts tagged “Ethics”

SA Healthcare in a crisis – Human rights and questions of access