Ruth Field - Market Access Director, AstraZeneca, South Africa

‍EF: How has access changed -if it has- before and after the pandemic? What are the lessons learned?

RF: From an access point of view, the most important lesson learned in Africa has been collaboration. The National Department of Health has been collaborating with other ministries and with research centres and it has put committees together to get advice and for the first time, they have reached out to digital companies in the private sector, looking for digital solutions to have the right statistics and record-keeping objectives. The PPE donations have come from the private sector, from organizations like BUSA. The pandemic has caused a surge of collaboration that didn’t exist before and partnerships between the private and public sectors have made innovative solutions possible. Another consequence has been that the government has come out in full force on a weekly basis to make announcements on progress and for the first time, the population has known what has been happening in healthcare -a new experience for us and a positive demonstration that the government cares about the lives and health of the people. Doctors and general practitioners generally rely on their protocols and guidelines in terms of the products they use and they tend to be quite inflexible about using anything different but now, because of the pandemic, they are becoming more flexible on medicines or interventions they are using for the patients. The approach is more patient-centric and this is a positive change as it is a way for patients to access clinical innovations that they normally don’t get. The pandemic has also brought out a lot of systemic issues that usually are not talked about; changes have been necessary for some time but are not in place as they have been ignored with the government dealing with the bare minimum of problems. They were not prepared for a pandemic and the door has opened to new discussions. Digitalization widens the perspective of what is happening in the patient’s journey and there would be a huge improvement in healthcare if patient records could be accessed electronically, but essentially we must start from scratch.

EF: How do we keep momentum on the importance of health for the country into the future?

RF: Historically, South Africa has focused mainly on HIV and TB. Now with the focus on COVID-19, they have been relegated but people are still dying from non-communicable diseases. The question is, can we apply what we do for Covid-19 to diabetes or cancer or asthma or any other non-communicable disease once the system is in place, covering all disease areas? If this can be managed for the different disease areas, connected through the health ministry to other ministries, it could be an ongoing project and plan for the country. South Africa has been learning about Covid from other countries, from China, from Italy, so in the same way, they can also learn about other diseases. There are some very good examples of how some countries have worked with non-communicable diseases; Cuba, for instance, has done an amazing job in terms of primary care. Our government has a partnership and relationship with Cuba and has sent people to learn from their system. Now that a lot of countries are leaning towards universal healthcare coverage, the National Health Insurance is working on the following concepts:

1. Task shifting: for healthcare practitioners and doctors, whatever their speciality to focus on what they do best, on their core business. In South Africa, there are about 60 thousand community healthcare workers paid by the government going into the community households just for HIV and TB. Work needs to be done in this area to achieve a more patient-centric approach and look for other non-communicable diseases, bringing tools into the household to cover pre-screening or screening as a way of detection. We need our population to be educated in prevention, take responsibility and look out for their own health, get into the system and not leave the responsibility of their personal health in the hands of the healthcare professionals.
2. Digitalization: the Covid information has been digitalized and the same must be done for all the health systems. To have digitized care solutions, the equipment to read the data must be linked to a digital platform so when a primary care system observer encounters a problem in a possible patient in real-time, that patient can then be included in the system. In other countries, a patient in the primary healthcare system can be linked to a digital platform and the protocols and guidelines and there is a record in real-time showing the patient’s journey. The importance of management of care in real-time lies in the four levels of care and immediately knowing if the patient has been in a district hospital or at a tertiary level institution and for what reason. The timelines will help in checking the times spent in each place, accelerating the diagnosis, bed availability, and referral systems –which don’t work that well in South Africa- and allowing for new protocols like the ones in place that are outdated. With all this in place, we could improve the management of care tremendously. The best doctors, the best medicines, and the best systems are of no use if they don’t go hand in hand with good management of care.  
3. At the moment, digitalization is not in place in the public sector and we lose a lot of patients who arrive in the system late. For example, patients with curable cases of stage 3 or 4 cancer or even patients that come in early with stage 1 or 2 are lost because the healthcare practitioners are not well trained and do not know what to look for, the patient can be in the system two years and still not be referred up, they don’t have a diagnosis due to lack of equipment or for whatever reason and the result is sure death for the patient.

EF: How do you see the level of digital adoption in South Africa in both public and private sectors, and what would be a good way to manage the challenge of adopting digital solutions for the physicians?

RF: There is quite a lot of digitalization in the private sector despite the fact that the influential doctors that could be pushing technology are sometimes older and can have a tendency to cling to what they already know or maybe be technophobic. They have had technology somewhat forced upon them by Discovery who gave out iPads containing a lot of information and formulas and even sent people to train the doctors to use them so in the private sector now, 95% of the healthcare professionals are using technology. Hospitals as well are becoming more and more digitized and most of the doctors are digital smart with different organizations using App-Pool technology. In the public sector, the heads of the departments are older and have worked most of their lives in the government sector which doesn’t have a lot of digital stuff, even the lack of WIFI can be among the obstacles encountered. On the other hand, there are companies in the digital space that are piloting a lot of digital platforms in the private sector in the different provinces that have done an excellent job in educating people in digital with the users becoming quickly aware of its advantages. In the areas where a lot of piloting is happening, the heads of departments are administrators and it´s the consultants that work on the webs making the difference. They are very young capable people building their own apps and an example of this is the Chris Hani Baragwanath Hospital where the consultants built their own apps and rolled them out there, fully digitalized and in real-time, linked with other departments (urology, oncology, etc.). They designed a multi-disciplinary App that can be used on the one hand to inform a renal failure of a patient with all its necessary detail and which also works for communications and meetings. This is good for the patient and the departments because it creates a relationship among the users and is helpful at hospital meetings, pharmaceutical therapy committees, or budget discussions because due to their prior relationship. they are more informed, are willing to understand issues better, and reach the decisions more amicably, so it has been a great success. 

The National Department of Health is the ministry in charge of the country´s health and they are very involved in policies with the Minister of health reporting to the president. In the provinces, the provincial structure is such that the head of department reports to the heads of the province that report to the president and in each casework as two big silos with practically no intercommunication. The clinics report to their municipalities that report to the mayor and the mayor reports to the president making another silo. The system works in favour of no cross-sector collaboration, no organized shared budgets, and no interaction. Each province runs its own tenders and does whatever they think best and this is why I think having committees is very important to create intercommunication and collaboration. The first point of contact for the patient is the clinic but the education, protocol, and guidelines cannot be controlled in the clinic because they are not linked to other levels of care. A digitalized platform organized from A to Z would force all the parts to work together, to collaborate regardless of the policies independently implemented. The policy for breast cancer says that it should be an open access system and this means any woman should have access to any hospital close to where she lives but in practice, the policy doesn’t work. If a patient goes to a stationary breast clinic, they will ask her for a reference letter from a clinic and to follow a series of pit stops which means many queues and many hours invested in getting a diagnosis. It is the responsibility of the government, the civil society, the private sector, and any other stakeholder involved to ensure the people are taught and educated to understand step by step the importance of health and that the systems be used properly which will mean addressing a lot of inefficiencies in the system. Education must be provided as it is the only way to go forward.

EF: What is your personal definition of access? 

RF: Access to me is making sure every patient has what they need in terms of necessary healthcare outcomes. Access is not just about medicines, it has a broader meaning. It is about the patient´s journey and the socio-economic factor. Even with a fully equipped hospital, if I don’t have the money to take a taxi to go to the hospital, I don’t have access. A patient not having the education to realize they are sick and then dies is a variation of lack of access. Other socioeconomic factors are obstacles to access, for example, a patient having no food to take with prescribed medication is an obstacle to access as is the lack of education. If policies are in place but not working, or if there are systemic issues, this for me is lack of access. Education is at the root of a lot of our problems and the government is aware of this fact but lacks the tools to make necessary important changes. The pharma industry and other healthcare stakeholders aim to improve the patient’s life and we are all here to play a part and it´s clear we need to work together to focus on the entire patients’ journey. 

EF: Do you have an example of an initiative you would like to highlight?

RF: AstraZeneca has a project, an initiative called Phakamisa, “to uplift” in Zulu, based on three pillars: 

1. Training: we train healthcare practitioners to look for: i) ordinary symptoms of primary healthcare at a clinical level so the patients can be identified and navigated into the system, and ii) advanced service for breast cancer patients. We have an alliance with Stellenbosch University ensuring trained specialists work in one area and are not moved around from hospital to hospital -specialists are really needed in South Africa- and through them, we are trying to accelerate the process of an earlier diagnosis for the patients with breast cancer, which is an area that needs to be worked on. We train them to work and be passionate about their communities and the people and for the communities to know where to go to have their health problem seen and we encourage interaction between them.
2. Awareness: educating women to self-examine their breasts and know what to look for, understanding what steps to take so they can own their health, and have information on the subject. We are working toward patients having access to their needs and are pursuing results.
3. Phakamisa is a multi-stakeholder project, it touches many points in the patient’s journey. We actually do just one step in the A to Z partnering with the government and other stakeholders which all contribute to the different and necessary areas. We have even partnered with media companies to take the initiative more generally known, radio talk shows with the participation of specialists, nurses, and heads of internal medicines, traditional healers, and alternative medicine representatives. We include all parties that can help with the identification of cancer to help bring patients to the system, something we successfully did with HIV and TB, so we are doing the same with this program. We are trying to raise awareness all along the patient journey and it is easier to do this with all the stakeholders involved because we pick up on what doesn’t work much quicker and are solving those issues much faster.

Before, we used to outsource the money to an NGO and walk away but now, we have taken the power back and we own the system with each stakeholder working the different stages, taking the responsibility and not expecting others to be held accountable. We have a digital launch planned for November 17th and a face-to-face launch at a hospital and we are working with media, TV, and radio. By this time next year, I want everybody in South Africa to know what Phakamisa is, I want every woman of a certain age to know how to self-examine her breast, to know what a clinical breast examination is and where it can be done. Most importantly, with this project we want the clinicians and healthcare practitioners to become role models and activists fighting for the best interests of the patients. We also want to use this project as a platform to bring the best breast sharing practices from other countries. Our digital platform will be aligning with the government in quality and aims to show we are working together with them and the civil society for the good of the country. That is the aim of Phakamisa. 

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