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Meeting highlights:
- KwaZulu-Natal’s potential and opportunities for health development: one of the richest provinces in South Africa, vast rural areas and minerals, and a hub for research, innovation, and robotics.
- The importance of prioritising universal healthcare coverage in South Africa to provide access to quality services to the entire population and not just minorities, NHI’s impact on healthcare delivery.
- IT is the future: reducing waiting times by connecting health facilities.
- Kwazulu-Natal Department of Health promotes strategic collaborations to advance e-health and clinics to build a preventive health ecosystem.
- Dr. Sandile Tshabalala celebrated 5 years as head of the Kwazulu-Natal Department of Health, acknowledging recuperation after COVID-19, NHI implementation, and teamwork to promote sustainable health systems in South Africa.
EF: Can you briefly elaborate on the KwaZulu-Natal province and your role in the health department?
ST: I am currently the Head of the Department of Health in the KwaZulu-Natal province of South Africa. Regarding population, KwaZulu-Natal is the second-largest province, with approximately 12.8 million residents. The province is a mix of urban, semi-urban, and rural areas, reflecting varying poverty levels and a diverse disease profile depending on the region. This also influences the distribution of healthcare services, with rural areas often having less access compared to urban regions.
When it comes to healthcare, there are essentially three sectors: the private sector, which is accessible based on financial means; the public sector, which is available to everyone regardless of income; and non-governmental organisations, which support the public sector but operate somewhat independently. Because of these differences, access to healthcare varies significantly, influenced by factors such as poverty, economic status, transportation, and literacy levels.
In South Africa, it is crucial to understand that over 87% of the population lacks medical aid, meaning they cannot access private healthcare. This situation becomes even more pressing around May and June when medical aid benefits run out for free consultations with private doctors. At that point, the public healthcare sector is left to serve nearly the entire population.
When someone is diagnosed with TB, for example, the private sector often immediately refers them to the public sector. Similarly, if a patient has a non-communicable disease like hypertension, diabetes, or hypercholesterolemia and requires chronic medication, they may also be directed to the public sector in some cases. As a result, the public sector becomes overwhelmed with the responsibility of providing services not only to those who rely on it for free care but also to those who, for one reason or another, cannot continue in the private system. This highlights the significant divide in our country’s healthcare system.
EF: Regarding the “Batho Pele” principle, what service do you put into place to focus on people who cannot access private healthcare?
ST: The South African government has adopted a principle of prioritising people when delivering services—what we call 'Batho Pele,' meaning 'People First.' This principle applies to both the public and private sectors. In the public sector, we do not consider a person’s financial status; we focus on delivering the service. My interpretation is that while the public sector needs funding to provide these services, the private sector operates on a model that requires people to generate profit. That is the key difference.
I strongly advocate for the National Health Insurance (NHI) system. NHI aims to ensure universal healthcare coverage, which is critical. We do not just need NHI; we need a healthcare system that offers universal coverage with consistent quality and is accessible to everyone, regardless of financial status, race, or location. Currently, those with better access to private healthcare tend to be more literate, live in urban areas, and are often white, while black people, particularly in rural areas, are suffering. It is impossible to address this disparity without an inclusive system like NHI.
EF: Could you elaborate on your current goals, especially regarding the challenges facing KwaZulu-Natal compared to the rest of South Africa?
ST: Our department's vision is to provide optimal health to everyone in the province, regardless of their circumstances. Our goals include ensuring service delivery equity, high-quality care, and client satisfaction.
Our clients come to us not by choice but out of necessity. When they arrive at our facilities, they may be in pain, but our aim is for them to leave, relieved of that pain and with a smile on their faces, fully satisfied with the care they have received.
If patients do not leave our facilities satisfied, then at the very least, their relatives should feel that, even in the unfortunate event of a loved one's death, they are grateful for the quality of care provided. That is one of our key priorities.
Additionally, I have asked my team to reflect on whether our current vision remains relevant. Should we continue with this vision, or should we aim to provide people with access to quality healthcare at all levels while striving to create an optimal healthcare system? We're at that point right now, evaluating how best to move forward.
EF: What digital and collaboration strategies are you implementing to provide healthcare in rural areas?
ST: As a province, we have recognised that IT is the future of healthcare. One of the main complaints we receive from our clients is the long waiting times, often due to the time it takes to locate their files. Additionally, if a patient moves from one district to another—from eThekwini to Amajuba—we often have to create a new file for them. However, this process would be seamless, with an integrated IT system connecting all our facilities. Patients could visit any facility, and their full medical history, test results, and details would be instantly accessible, eliminating the need to start from scratch. We aim for this with our E-Health system, which we plan to integrate with the National Department of Health's Health Patient Registration System (HPRS), primarily used in clinics.
Focusing on clinics is crucial because we want the NHI system to emphasise preventive care. By strengthening our clinic network, we can provide quicker, more effective treatment, leading to better health outcomes and reduced costs. Currently, we are spending about 8.5% of our GDP on healthcare. By implementing NHI with a preventive, community-based approach, we aim to reduce this expenditure while improving overall health.
EF: How do you think NHI will impact your operations?
ST: The private and public sectors must acknowledge that when we took our oaths as healthcare workers, it was never about making as much money as possible. We did not commit to providing better care for some while neglecting others based on geography or income. Collaboration between the public and private sectors is essential, and we all must accept that a healthy population is vital for economic growth.
Even though we use advanced IT systems to communicate from different parts of the world, people make this possible. If we fail to care for our people, the economy will stagnate. This collaboration might mean that the private sector will not see the same profit level as before, as healthcare access will become universal, regardless of a person's financial status. We also need to agree that the costs we charge patients should be more reasonable, leading to a more ethical, equitable country that provides quality healthcare to all, no matter who they are or where they live.
EF: Why is a dollar better invested in Kwazulu-Natal than in a different province?
ST: KwaZulu-Natal is one of our richest provinces, and South Africa is blessed with abundant resources, including minerals. But beyond that, our country is a fantastic destination for tourism, with countless opportunities yet to be fully tapped. We recognise the need for change and investment, but investment must not come from loans that turn us into debtors. Instead, true investment should empower our people, ensuring that when investors eventually leave, our citizens can sustain themselves independently without relying on external aid.
The goal should be to create a lasting system that benefits the present and future generations. Investors should focus on building human and infrastructural capacity so that the benefits remain with the country and the province. For example, the health sector has immense potential for health tourism. Countries like Turkey have shown how successful this can be, where people receive top-quality medical care but also enjoy the support of their loved ones, leading to better outcomes. We have the potential to do the same, but this requires strong, thoughtful investment. There are numerous opportunities in South Africa waiting to be explored and developed.
EF: What accomplishments are you most proud of as the head of KwaZulu-Natal's health department? Additionally, what are your aspirations for the future—both for yourself personally, for the department, and for South Africa as a whole?
ST: Personally, the ultimate benefit would be creating a system that I can rely on when I am 70 years old, no longer known or influential. A system that provides for me when I have no money cannot walk, and need assistance. That would mean I have contributed to something lasting that outlives me and continues to serve even when I’m no longer able to give back.
Professionally, I am proud that the department achieved two unqualified audits for the first time in its history—an important milestone under my leadership. We have also seen significant improvements in our HIV and TB outcomes, which had dipped due to the impact of COVID-19. For instance, our performance indicators, around 48-50% in 2019, have now climbed to 62%, a notable achievement.
Looking forward, I want to see more teamwork within the Department of Health, breaking down silos to foster collaboration both within the department and across other sectors. Health is not just the absence of disease, as defined by the World Health Organization; it is a holistic state of well-being. Achieving this requires cooperation between health units and other government departments and the integration of alternative medical practices like homoeopathy, traditional medicine, and even Indian and Chinese remedies. By addressing the social determinants of health, we can help people live longer, healthier lives, much like the 116-year-old recently celebrated in China. If I can help our province reach that level of holistic well-being, I will feel that my work is complete.
