South Africa: Why Don’t Public Healthcare Incentives Work in Private Healthcare?

Aug 15, 2023 | Health | 0 comments

Eating healthily, exercising, or getting an annual HIV test or blood pressure check is difficult. Rewards and incentives may encourage these “good” choices. Discovery Health Medical Scheme’s Vitality programme is the greatest local incentive scheme.

South Africa’s public sector has yet to notice incentive programmes, while private healthcare has. The only significant public sector incentive we know of was SARS-CoV-2 vaccination vouchers. As shown in this overview of cash transfers for HIV prevention, there have been many scientific studies of cash transfers and other incentives, but the data is few, and the discrepancies across research are large.

Targeted public sector incentive programmes have demonstrated promising outcomes in other nations. In 2005, the Indian government started Janani Suraksha Yojana (JSY), a conditional cash transfer programme to promote hospital births. The approach reduced 4.1 perinatal deaths and 2.4 neonatal deaths per 1000 pregnancies.

South Africa’s public sector has yet to notice incentive programmes, while private healthcare has.

According to Spotlight, South Africa performs better on HIV than diabetes and hypertension. The Department of Health has not considered incentive programmes in these areas.

Such programmes may be excessively pricey and untested. A public sector Vitality copy is wishful thinking. Is there anything worth imitating or modifying for the public sector?

“It has always puzzled me that incentives are always so Fine for affluent people like me, on Discovery, but yet inappropriate for poor people ‘who should do it for their own advantage’ in the public system,” says University of the Witwatersrand Ezintsha director Professor Francois Venter. It’s condescending.

I’ve always wondered why Discovery rewards affluent individuals like me but not poor people “who should do it for their own benefit” in the public system. Francois Venter, Ezintsha

Venter argues incentives can’t address massively complicated challenges like managing non-communicable diseases (NCDs) and obesity, but they can be added to the extremely limited toolkit used to avoid sickness or death via early identification, testing, and screening. He adds incentives “certainly should not be discarded right off the start when it comes to the 84% of people who depend on the public system”.

Points’ power

A 2022 International Journal of Environmental Research and Public Health research found that unhealthy lifestyles cause 60% of all ailments. Discovery’s Vitality initiative promotes healthier lifestyles in accordance with such findings.

“Vitality wants to harness behaviour modification strategies, most notably employing incentives, to urge or push members to adopt healthier behaviours,” says Vitality Wellness Chief Dr. Mosima Mabunda. Most NCDs are caused by four main factors: poor nutrition, lack of exercise, smoking, and alcohol abuse.

It’s crucial to recognize that numerous environmental, social, and structural issues make it hard for individuals to “do the right thing” regarding health. Harsha Thirumurthy

The Vitality programme offers monetary refunds for healthy food purchases, subsidized gym membership, and a sophisticated points-based system that rewards a variety of healthy lifestyle choices. Cash or local shops accept these points. Vitality offers a wide range of discounts, from flights to films.

Discovery reported that Vitality’s “overall effect on mortality rates is considerable”. They believe “making people healthy” has reduced mortality by 13%.

Spotlight specialists say much of this data has yet to be published in peer-reviewed papers. Vitality’s yearly incentivized health check may help detect hypertension, diabetes, and HIV sooner. Points may also encourage activity. Without independent investigation, Vitality’s additional health advantages may be questionable.

Early detection

Savings from behaviour modification or early identification usually justify incentives. So, the private sector is helping individuals remain healthy and save money. State-run incentive programmes have varied costs and advantages, but rewards may be worth it.

Public sector consumers may require incentives more than private sector users. “The majority of Vitality members don’t suffer hurdles like commute fees,” says University of Pennsylvania behavioural economics and health incentives specialist Harsha Thirumurthy.

In the public sector, treating type 2 diabetes for one-year costs between R1000 and R3500.

Late diagnosis and illness management cost the public and private sectors human and economic. In 2009, uncontrolled diabetes in South Africa caused 8,000 blindness cases and 2,000 amputations, according to a 2013 report in Global Health Action. Recent numbers show deterioration. In 2018, KwaZulu-Natal MEC for Health Dr Sibongiseni Dhlomo disclosed that six amputations occur daily, totalling over 2100 a year.

It’s huge financially. A 2022 literature analysis projected the public sector cost of treating one individual for one year with type 2 diabetes medication at R1 000 and R3 500. The research also examined diabetes complications treatment costs. Diabetes-related kidney illness costs around R67 000 per year.

Diabetic retinopathy screening, which causes visual loss, costs R110–R370 per person. Diabetes-related ocular illness treatment costs R59 000 per year.

These are health system expenditures, not the costs of major consequences and lasting incapacity to people, families, and communities.

Healthy lifestyle obstacles

Most experts feel the Vitality initiative needs to be simpler and more costly to scale up in the public sector. The National Directorate of Health cannot assist the majority of people in adopting healthy lifestyle choices, including nutrition and exercise.

Thirumurthy notes that various environmental, social, and structural elements make it hard for individuals to “do the right thing” when it comes to health-related behaviours. People are continuously exposed to harmful food advertisements, and many live in situations that make it impossible to eat properly, even if they want to.

“To make a difference, we must step back and find the broader system-level or structural changes that might affect people’s diets and other health behaviours. “We need to think about what types of government regulation and policy levers can be used to achieve better health outcomes,” says Thirumurthy, who co-founded South Africa’s first “nudge unit” at Wits University, Indlela: Behavioural Insights for Better Health, which finds low-cost behavioural solutions to public health challenges.

As Spotlight reported, many of these issues are flagged in South Africa’s recently published Strategy for the Prevention and Management of Obesity in South Africa 2023 – 2028. However, most experts we interviewed agreed that the strategy needed to provide a realistic plan for addressing them, costing a lot of money.

In 2018, the public sector cost of treating patients diagnosed with diabetes alone was R2.7 bn “and would be R21.8 bn if both diagnosed and undiagnosed patients are considered,” according to a 2020 SAMRC report on NCD health promotion. By 2030, the cost of all type 2 diabetes cases is expected to rise to R35.1 bn.

“I’m not suggesting incentives or rewards-based systems are going to rescue the day, so to speak,” Thirumurthy said. They are a tiny but crucial component of an NCD policy package. “World experience shows this policy package should prioritize regulatory measures, including tariffs on sugary sweetened drinks and other unhealthy foods, but incentive-based interventions may undoubtedly be a beneficial complement to a wider strategy or policy package,” he adds.

Public sector yearly health check?

Public sector early detection might benefit from private sector incentive schemes.

Vitality’s yearly health check is a free screening and testing consultation that includes HIV testing, mental health screening, body mass index review, blood pressure check, and blood glucose test. Members get points for attending; these tests are available at many pharmacies.

According to Vitality Wellness Specialist Belinda Kahler, members who complete the screening and are flagged as high-risk are over three times more likely to seek professional help, which “fosters early detection and management which reduces complications and ultimately r

One way a public sector version of this could work is for the state to contract with nurses at private sector pharmacies and GPs to provide checkups in addition to public sector clinics. This would make it easier for people to access these checkups and may boost early diagnosis of diabetes, hypertension, and other diseases, especially if an incentive is included. For this to work, public sector data systems must facilitate capturing measurements.

“But incentivizing a once-off or annual behaviour, such as going for a vaccination or health check, is not only more likely to succeed compared to daily behaviours like going to the gym or taking a certain number of steps,” Thirumurthy said.

He says addressing healthy lifestyles is complex, and preventive care interventions are a more attainable goal for the National Department of Health. Screening, preventative care, and early detection save money and lives, but it is notoriously difficult to get patients to engage in the health system before they get sick or experience noticeable symptoms. Patients often seek care too late to prevent costly complications.

“Depending on the precise behaviour, test or screening combination that is incentivized, a scheme like this might actually move the needle on the targeted health result and amount to money well spent in future saved healthcare expenses,” adds Thirumurthy.

“We are going to have a collision of comorbidities in the next seven to eight years” due to an ageing HIV population, says Southern Africa Labour and Development Research Unit Chief Research Officer Dr. Brendan Maughan-Brown. “All these NCDs are going to become even more burdensome to the health system – already in some areas, over 25% of people over 50 are living with HIV.” This will be a huge problem for the health system, insurers, and the NHI; therefore, thinking about solutions now, such as a yearly health check or screening, is a smart start.”

What motivates?

“They would take a degree of cooperation, but there are many firms who I’m sure would be eager to join on board as sponsors,” says Indlela Co-Director Dr. Sophie Pascoe. “The big supermarket chains could subsidize grocery vouchers or incentives could be in the form of airtime backed by one of the big mobile networks, for example,” she says. These partnerships would “benefit everybody” by encouraging those targeted behaviours, while sponsors would profit from exposure and customer growth.

“I believe part of the difficulty is when we say ‘incentives’, everyone imagines a lot of money and great prizes. “But incentives don’t need to be huge or pricey,” she argues.

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Maughan-Brown, an expert in behavioural economics and HIV risk, says that for an incentivized preventive programme to succeed, there needs to be a comprehensive understanding of the various “hassle factors” faced by those who rely on the public health sector. What would be valuable to people? Transport, airtime, grocery vouchers, child care, paid leave from work, or something else?

Pascoe advises adding an affordable lottery incentive to an immediate but modest reward following a health check or screening action.

Another challenge in lobbying for this kind of programme is that real advantages or outcomes will only be evident in the long term, whereas government prefers programmes with immediate results.

“I find it weird that I am incentivized left, right and centre by Discovery, but every time we raise it for impoverished people, I get told ‘they should be doing it, anyhow’,” Venter adds. Venter adds that harmful and prevalent views must be addressed before policy-makers, government officials, foreign donors, civil society, and the media would accept any incentive-based programme.

Already incentivized

Foster Mohale, National Department of Health Spokesperson, told Spotlight that “public health benefits of health checks and health screening” can “result in early detection and reduced costs to the health system”.

Nonetheless, he adds that these services are already incentivized, so proposing Vitality-inspired remedies is “wrong”. When asked about the present public sector incentives, he stated, “[It] depends on what one views as an incentive! Gym memberships, Fitbits, expedited check-in lines, and inexpensive flights disgust me. Others hurry to “benefit”. A community health worker visit motivates most South Africans! ”

“In the real spirit of incentives,” Mohale says, “testing and screening services are incentivized via health promotion at ALL public health clinics, and in school health programmes”.

“The massive programme for HIV testing [is] incentivized through free testing [and] specific clinics,” he says. The department also offers adherence clubs, where groups of about 30 people on chronic medication meet regularly, share their experiences, and receive screening and counselling from healthcare workers.

This article quotes Professor Francois Venter, a member of Spotlight’s Editorial Advisory Panel, which advises the editors on the quality and relevance of their public interest health journalism. The editors are editorially independent and make all editorial decisions. Read more about the panel here.

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