Effie Schultz

Health Systems
Health Systems

What can be called the medical industry has usurped the concept and semantics of health. Instead of medical service provision we talk of health care. The social and economic determinants of health and of the separate but subsumed issue of medical care have been relegated to a subsidiary role. This health care is preferentially directed at technological applications in disease diagnosis and management and is an ever expanding and lucrative component of international industry and commerce.

I subscribe to another paradigm, that Victor Sidel called social medicine, which includes:

  1. social well-being —

    the attainment and maintenance of the socioeconomic and political conditions necessary for health and social well-being;

  2. public health —

    the advocacy and implementation of appropriate public health measures to protect and promote health, and to prevent disease in communities and in the nation as a whole;

  3. preventive medicine —

    the protection and promotion of health, and the prevention of disease in individuals and families;

  4. medical care —

    the provision of efficient, effective, safe, affordable, accessible and equitable facilities to all in need for the diagnosis and treatment of individuals and families so as to cure and/or control their disease, for assistance in rehabilitation after illness or injury and for care and comfort.

Health Systems encompass all four domains. See examples:

1 The Amurt Ahanang Primary Health Care Clinic

My 1999 proposals for a clinic in a socially deprived and impoverished urban community is situated within medical care and addresses practical arrangements. It could hopefully be useful to others planning something similar.

Amurt Ahanang Primary Health Care Clinic - summary of proposal
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Amurt Ahanang Primary Health Care Clinic - a proposal
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2 Healthy and healing neighbourhoods

Sustainable spaces for healthy living and healing may be attainable within a decentralised structure. Dreams are made of this. Here are two of my dreams.

  1. Healthy Cities, Villages, and Neighbourhoods — the presentation

    I pursued an interest in the healthy cities initiative by interviewing role-players in public and environmental health. I wanted to convince them of the relevance of the concept in South Africa and to explore with them its feasibility. In line with international thinking I expanded the concept to embrace smaller geographic areas by renaming it the healthy cities, villages, and neighbourhoods (HCVN) concept.

    A presentation made in 1990 at the Centre for the Study of Health Policy at the University of the Witwatersrand in Johannesburg, is available below. There have since then been many successful developments internationally but none in South Africa. The issues raised and the proposals made then are still relevant today especially in the light of proposed legislation on environmental health and medical service funding.

    Healthy Cities, Villagrs, and Neighbourhoods — the presentation
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  2. A Healing Village called Village 31

    I stay on a large plot in the greater Johannesburg metropolitan area. The family wants to retain it as an urban lung to be enjoyed by more than myself and a lone gardener – and especially by Colin our schizophrenic son and brother. We have found a developer who shares our vision and propose to develop a facility that could provide Colin and people like him, people convalescing from surgery, and selected elderly with a safe and happy home in a healing and supportive setting.

    A Healing Village — Slide Presentation
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3 Action on food and diet and the other determinants of obesity and other non-communicable diseases

It has long been obvious that the unfolding epidemic of non-communicable diseases is a public health issue which lies within the social well-being domain and which can only secondarily be addressed at a patient-carer interface. Unfortunately in the current market-driven socio-economic milieu medical care dominates practice.

  1. Southern African Hypertension Society (SAHS)

    Medical service providers have a responsibility to locate disease within society even while acting within the confines of personal care. It was in this context that in 2004 I prepared at the request of the Southern African Hypertension Society a framework proposal on lobbying the South African government on food and diet.

    SAHS action on food and diet
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  2. WHO: Global Action Plan for the Prevention and Control of Non-communicable Diseases. 2013–2020

    These comments are in response to a WHO draft document on non-communicable diseases and were submitted to an e-group platform on nutrition and non-communicable diseases which coordinated and forwarded comments to a WHO secretariat.

    WHO Global Action Plan – my comments
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  3. South Africa: Strategic Plan for the Prevention and Control of Non-Communicable Diseases. 2013–2017

    In 2013 South Africa published its own plan on non-communicable diseases. I read it when preparing for a work-shop convened by the South African office of the WHO and the School of Public Health at the University of the Witwatersrand in Johannesburg on research in support of targets outlined in the plan that related to the prevention of obesity. The following comments on South Africa's plan should be read in conjunction with my comments on the WHO plan.

    South Africa's Strategic Plan – my comments
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  4. WHO–SA and University of the Witwatersrand School of Public Health. Workshop on obesity and its prevention.

    The high and rapidly escalating prevalence of obesity with its associated debilitating morbidity, high mortality, and negative social and economic implications should be reversed. Medical and surgical interventions – medical care – can have a limited effect; the other components of social medicine – social well-being, public health, and preventive medicine – could be definitive. This then is the challenge.

    Participants at the workshop held in December 2013 at the University of the Witwatersrand as referred to above were asked to submit suggestions for research projects and for a framework for cooperation between academia, the state, and civil society. Here is a slightly edited version of my suggestions.

    Workshop on obesity – my suggestions
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4 Legislation on matters directly related to health

The South African constitution provides for public participation in the affairs of the state. To comply with this the public is offered opportunities to comment in writing or at specially-convened public meetings on policy and legislative proposals. I have submitted comments on several bills and other documents.

  1. National Health Insurance 1995

    In 1995 in response to a request for comments from the public from a committee of enquiry into national health insurance, I submitted a memorandum on the funding of medical services. It was sent to the South African Constitutional Assembly which was then sitting because implicit in the proposals were recommendations for the devolution of functions and power from the central government to local authorities.

    The issue was not further pursued by the government and national health insurance was not included in the National Health Act of 2003. It was only in August 2011 that national health insurance was again formally addressed by the South African government when it published a policy paper and accompanying documents.

    National Health Insurance 1995 – memorandum on funding
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  2. South African National Health Bill 2001

    The comments on the National Health bill were sent to the South African Medical Association (SAMA). I do not know whether SAMA included any of my comments in its submission to the Department of Health or whether SAMA forwarded individual member's submissions. It is possible that my comments were just "lost".

    The National Health Act which was passed in 2003 did not contain any of my recommendations. More's the pity as the state when drafting new documents such as the National Environmental Health Policy was confronted with the confusion and irrationality due to the overlap in functions between the different tiers of government as in the Act. The overlap also undermined efficient and effective service delivery.

    National Health Bill — my comments
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  3. National Environmental Health Policy 2011

    I did not comment on the separate clauses in the policy document. Instead I referred in the document that I submitted to the government to the WHO's healthy cities concept and to the parameters of the pilot healthy cities programme that I had prepared in 1990 for the greater Sandton/Alexandra Township area. The pilot programme can be read in Healthy Cities, Villages, and Neighbourhoods (2 above).

    National Environmental Health Policy — my submission
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