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EF: What was the purpose of renaming the Department of Health to the Department of Health and Wellness?

SK: We officially changed our name to the Department of Health and Wellness. It signifies our intention to shift from a disease-focused approach to a wellness-focused approach. Our data shows us interesting dynamics in terms of the massive trauma burden that we have in the Western Cape province and the rest of South Africa. There is a massive increase in the mental health burden and chronic lifestyle diseases like hypertension, diabetes, and cholesterol. We intend to focus on prevention and health promotion. 

Similar to Singapore, we are shifting the focus of the health system toward wellness and prevention. We have a wellness unit that will be looking into the programs and interventions that we can work towards. We are cross-collaborating with other government departments, particularly the Department of Social Development, which looks after the vulnerable in our society, and the Department of Education. They have good mental health programs that complement our work. Our efforts, as the social welfare collective, are aimed at preventing ill health and promoting wellness.

EF: How do you measure the success of this initiative?

SK: We have broken down our goals into different categories. For example, trauma and violence are big problems in the Western Cape. We have got a program on violence prevention, and one of the indicators of success is the establishment of a violence prevention unit inside the Department of Health and Wellness. The violence prevention unit is responsible for coordinating all the violence prevention activities across the different government departments. One of the targets that we've set for ourselves is the reduction of murder rates by 50% within 10 years, and this is one of our key indicators. We also want to reduce the number of admissions to our hospitals due to trauma and violence, and we've got the data systems to measure that.

We are also focusing on reducing the impact of alcohol abuse. Our data has shown a clear relationship between alcohol consumption and violence. We've got several programs on alcohol harm reduction, and they range from legislative changes to law enforcement changes. We will have a violence prevention unit within our department, from which we will be establishing "area-based teams." We will set up intersectoral teams in the areas where violence is prevalent. These teams will be made up of representatives from all government departments and non-governmental partners to help reduce violence in those areas. It will be the same team that will also be looking into mental health issues. Our data has shown an increase in mental health admissions. This is another area where our indicators and measures for success would be to try and reduce the number of mental health admissions.

We are also trying to reduce the number of readmissions. These are patients who have been admitted before, but because the hospitals are so busy, they are turning them over without significant treatment, and they come back into the hospital after relapsing.

We are also going to be focusing on HIV and tuberculosis (TB) because those are big programs for us. Regarding tuberculosis, we want to reduce the number of new infections and the number of "lost to follow-up." We discovered that people in our system enter the healthcare system, are diagnosed with TB, and then disappear. They don't come back for the treatment, and that's a danger to public health and society because they have active tuberculosis and they're not on treatment. It's a fairly high percentage of around 20% of people who are lost to follow-up.

To reiterate, we've got a focus on violence prevention, mental health, tuberculosis, and HIV. We will work in these intersectoral teams to try to reduce the numbers in all these areas.

EF: How do you ensure that the community is involved in the healthcare system?

SK: Luckily for us, we've got a long history of social activism and community work. We ensure that the community remains involved in a variety of ways. Around each of our clinics and big hospitals, there's a board of community members, and they form part of the management team of that clinic or hospital. The clinics and hospitals take their input into account when they're designing their programs. Over and above that, in the Western Cape, we've got an active system of partnering with community organizations. We provide funding to community organizations to help us further the work of the Department of Health and Wellness.

We have many community-based organizations throughout the rural and urban Western Cape. We provide funding to enable them to focus on community health workers. These community health workers go out into different areas and look for people with tuberculosis. They go out and screen for hypertension, diabetes, and other diseases. They do health promotion and prevention by going door to door, particularly in areas with a high burden of disease. They check up on people to see whether they have taken their medication, whether they need to go back to the hospital or clinic, measure blood pressure, and test if they are diabetic. 

We have a formal system where we've got community members who sit on boards attached to each of our facilities. We've also got a system of partnering with nonprofit or community-based organizations, and through the community-based organizations, we fund them to train and deploy community healthcare workers into all of the areas. The Western Cape has about 3800 community healthcare workers whose purpose is to go into the communities and, actively look at health promotion and prevention.

EF: Can you elaborate a little bit more on your data research team and how they are working?

SK: This is one of the innovations in the province. We are currently being used as a place for benchmarking in many different areas, and all the other provinces have been visiting the Western Cape to benchmark against us for our data and research capacity. We use data to guide us to where our focus should be as a department, which is why I can confidently tell you that the focus, based on the data, should be on violence, trauma, mental health, tuberculosis, HIV, and diabetes because our data has shown that to us. The data even highlights the regions with the highest burden of disease.

We recently had a team from Cambodia that visited about two weeks ago. Their goal was to benchmark against the Western Cape Province regarding our whole system response. That is how we were responding to the health crisis and health issues that we all face around the world, and they were impressed with our structure.

We've got very good universities in the Western Cape, and we have been partnering with our academic colleagues in developing our data capacity. They've done a lot of research into how the system should look and where the burden of disease is. It's been a very strong partnership with the academics in the Western Cape, and together with our capacity to implement, we've combined those forces and produced live dashboards. We've had phenomenal success because we used that data and research to guide the response. For example, we know we have included our colleagues from Social Development as another government department in our response to mental health. Now, we are mapping the facilities that provide mental health services in different areas so that people will know where they can access care and what services are being provided.

We've done the research, and the data is now available. It's time for us to formulate a response. We had this conversation with our colleagues from Cambodia about how we can respond as a health system, bearing in mind that we've got to bring other government departments as well as the private sector into our response. Working with the private sector is very important for us because it falls under our stewardship responsibility. We see ourselves as the Western Cape's stewards of public and private health. There are places in the world where those are completely separate systems, and it's difficult to provide a comprehensive picture of the healthcare landscape when private and public healthcare systems are so vastly different.

EF: What would be a holistic approach to achieving an integrated healthcare system in South Africa?

SK: I think our move toward national health insurance (NHI) and universal health coverage should be the framework within which we are moving towards a sustainable health system in South Africa. The current expenditure is not sustainable at the moment. My colleagues in other provinces are struggling, but we are fortunate in the Western Cape because we've had decades of focusing on healthcare and strengthening the health system response. The development of an NHI is where our focus should lie because that will bring together several different elements. It will bring together public and private funding and increase the pool of funding that's available for healthcare so that we can spread that funding further. It will also avoid duplication of different services. We'll have the data and research capacity at a national level to be able to understand the burden of disease.

Under the umbrella of the NHI, we will be able to bring together innovations, public-private partnerships, data research, and intelligence. This will put in place the data systems needed to track the impact over time. It will enable us to measure KPIs such as the impact on infant mortality rates and maternal mortality rates. We need to understand what impact it will have on hospital admissions, community healthcare, and the prevalence of diseases such as tuberculosis and HIV.

It's important that we have the data and research capacity at the national level. It doesn't yet exist at that level, but I know that under the NHI, the systems are being assembled. The Western Cape is also concerned about the sustainability of our health system in the future. One of our key focused areas is climate change and our impact on the environment. We want to try and move towards green energy in our hospitals and clinics as fast as possible. South Africa is currently facing an electricity problem, with load-shedding at an all-time high. We are also installing inverters and all kinds of systems to try and keep our facilities running in an attempt to extend our green energy footprint in the province.

EF: What is the level of awareness of sustainability in the province?

SK: The impact of load-shedding has increased our awareness levels. I think there are high levels of awareness about sustainability in our health facilities and health system. Implementing sustainable measures has become more urgent because the health systems in the other eight provinces are in a dire situations. There are many reports of medication not being available in other provinces or ambulance vehicles not having sufficient consumables on board.

I think the energy crisis and the fact that the health systems in some parts of the country are under significant pressure have increased awareness about the need for sustainable health systems. Past research and literature tell us a healthier society is a more productive society. A healthier society has a positive impact on health, which then has a positive impact on the economy. To be sustainable as a country, we need healthier people who are also educated.

EF: How would you rate your department in terms of innovation, and do you see yourself as a leader who is setting future trends?

SK: I can confidently say yes. The data, research, and innovation that we've brought into the Department of Health and Wellness have been showcased throughout the province. Our premier, who is our most senior politician in the province, has showcased our department's innovations that were brought about and accelerated by COVID. 

Provincially, the Health and Wellness department is regarded as a leader in innovation. Other departments have been challenged to also bring forward innovations in their relevant areas because we're not going to be sustainable as a health department or as an economy if we're not going to be innovating.

The Department of Economic Affairs in the Western Cape has used our innovations and benchmarked against them to develop an economic strategy for the province. We had a presentation from them about how they've taken some of the lessons learned from health and wellness into the broader economy. I think the innovations that we spoke about last year have had a significant impact on the Western Cape and I do believe it as a province we are going to become that leader in innovation.

One of the projects we want to expand as part of our wellness approach is the use of food gardens. We want to increase community access to food gardens. We are working with our colleagues in the Department of Agriculture on being able to expand food gardens. We've got about 100 food gardens in the Western Cape, but we want to expand that and make that a sustainable economic activity for those communities. These are the intersectoral projects where we see that the focus on wellness is quite important.

We've also had a project in a town called George that we have emulated from the Icelandic "Planet Youth" model of prevention. It's a comprehensive approach focusing on youth. Social scientists came together to work with youth by focusing on upstream prevention factors. The model focuses on social protective factors for young people. We found that it's an interesting model of trying to bring prevention aspects into making sure that the youth are educated, empowered, and have jobs when they graduate. We are working with other departments and are now seeking to expand and implement that program in other areas as well. Our focus on prevention is the key change that we want to make from disease to prevention.

EF: What are your expectations for the healthcare sector in 2023?

SK: I'm hoping for two things. The first is to ensure the sustainability of the health system and the economic viability of regions around the world. I'm also hoping that we can make or accelerate the shift to wellness. We need to focus on wellness rather than disease treatment. We need to begin shifting society's thinking towards the social protective factors that will make us healthier societies. To achieve these goals, we need everybody in society to participate. This is a collaborative effort.

May 2023
South Africa