The ironies of robust primary healthcare policies in a resource-constrained environment – The example of HIV-related lymphoma in South Africa
Dr. Harriet Etheredge
Posted on May 29, 2017
Rationing in healthcare
Rationing in healthcare is not novel. It is based on economics and the package of resources available to a government. Each country has a limited amount of money to spend on healthcare and the people setting health policy have to decide which diseases or conditions will be prioritised. It’s simply not possible to pay for everything that each person needs.
Primary healthcare in South Africa
Decisions about how to spend the health budget depend on the amount of money available and the health needs of the population. In the South African (SA) state sector we have a relatively small health budget which serves the needs of a relatively large population. We also have a ‘dual-burden’ of disease with communicable diseases (like HIV and TB) as well as non-communicable diseases like diabetes and hypertension. Because a lot of people in SA are affected by these diseases, and because there isn’t much money, our government prioritises a policy of primary, preventative care. This involves trying to prevent illness through things like extensive vaccination programmes and encouraging people to visit district clinics at the very first signs of being ill.
HIV and AIDS-related illnesses in South Africa
A large number of people in SA are HIV positive, and a primary healthcare approach to HIV has enhanced the way that it is managed. All people in SA who test positive for HIV are put on medicine called antiretrovirals, and this helps them to lead healthier lives. We have a nationally endorsed, robust system for treating people with HIV. This is the same regardless of whether you are on a medical aid or get treatment in the state sector.
But – and this may come as a surprise – there is sometimes a downside. HIV positive people on antiretrovirals live longer, and this means they can develop other illnesses. These include some cancers, and one of them is a cancer called Lymphoma. In SA, HIV-related lymphoma is very complicated. It’s difficult to diagnose, and it is often mistaken for TB. It is also very difficult to treat. It requires expensive chemotherapy which can have a negative interaction with the antiretroviral medication. Because the treatment is so complex, it needs to be administered by medical specialists in tertiary hospitals with the necessary facilities available.
When it comes to spending our healthcare budget, illnesses like HIV-lymphomas pose huge challenges. Treatment is often so expensive that patients – especially in our SA state sector – cannot access it at all. When treatment is available, there can be a long wait for a patient to actually to get a bed in hospital.
In my opinion, it’s ironic that our provision of tertiary care for HIV positive people has not kept up with our robust primary care system for treating HIV in general. Of course, it is more expensive, and this needs to be considered. It’s all well and good to advocate a primary healthcare policy, but when it is as successful as our HIV policy in SA, it seems unethical not to adequately provide the corresponding management for HIV and AIDS-related tertiary diseases.
The views published in this blog are entirely my own (informed) opinions. They are open to debate, discussion and disagreement.
 Kautzkyi, K. and S Tollman. 2008, “A Perspective on Primary Health Care in South Africa”. Retrieved 19 November, 2015 (http://www.hst.org.za/publications/south-african-health-review-2008).
 Patel M, Philip V, Omar T, Turton D, Candy G, Lakha A, et al. The impact of human immunodeficiency virus infection (HIV) on lymphoma in South Africa. Journal of Cancer Therapy. 2015;6(06):527.
Tagged: AIDS, health policy, HIV, HIV-lymphoma, primary care, rationing, resource constraints, South Africa