Private vs. Public Sector
He explained that South Africa has a two-tier system of healthcare, the private sector and the state sector. Both of these sectors, Dr. Tikly noted, suffer from a shortage of rheumatologists. In the state sector, an issue with access to care is the limited formulary for medications. In the private sector, rheumatologic medications may be somewhat more accessible, but biologic medications are often still restricted and very expensive.
Dr. Tikly described several methods South Africa has used to increase access to rheumatologic care, including “borrowing” physician posts from general medicine and using privately funded posts to staff rheumatology clinics, encouraging rheumatologists from teaching hospitals to help staff outreach clinics in the community and providing rheumatology workshops for general practitioners and nurses in the community.
Regarding drug access in the state sector, many medications on the national essential drug list, such as mycophenolate mofetil, tacrolimus and rituximab, are used off-label in cases of autoimmune disease. Physicians have also sought to engage pharmaceutical companies and ask for price reductions when possible. In addition, an effort has been made to enroll patients in clinical trials to provide access to expensive medications, though this poses ethical dilemmas when these trials end and patients are left once again without access to the medications.
Within the private sector, strategies include lobbying efforts to increase the range of biologics available to patients and to waive copayments for patients, as well as assistance with copayments via donations from pharmaceutical companies and private hospital groups. These and other strategies continue to be deployed to help patients access the care that they need.
Strengthening Musculoskeletal Care
In the latter portion of this session, Andrew Briggs, PhD, FACP, professor, Curtin School of Allied Health and Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Australia, spoke on the subject of strengthening health systems for musculoskeletal care. Dr. Briggs notes that, even though the World Health Organization (WHO) has listed good health and well-being as part of its sustainable development goals, musculoskeletal conditions are relatively under-prioritized in this framework despite the burden of disease in all regions and across the life course.
Instead, the WHO focuses on mortality as a main issue to address. Dr. Briggs thus asked: where does musculoskeletal health fit into the broader list of priorities for non-communicable diseases around the world? Looking at the Organization for Economic Cooperation and Development countries, he indicated that most goals focus on conditions like cancer, cardiovascular disease and diabetes, though about 50% of these countries did include musculoskeletal health and/or pain and mobility issues among their health policy priorities. Among lower income countries, however, musculoskeletal issues are essentially absent from lists of national health priorities.
