(Why) is SA the sickest nation on the planet?

South Africa came last in a survey of 150 countries and was named the world’s unhealthiest nation!

Canada first, SA last

Canada is said to be the healthiest country, though they are more overweight than us, and equally depressed. Having personally survived the cold, dark night of several Canadian winters fortified by doughnuts this bit seems real to me.

Highest and lowest scores: Canada vs South Africa (source: http://global-perspectives.org.uk/volume-three/infographics)

People love a score

People love to compare, so they love scores and rankings. But I’m not sure how much credibility the Indigo Wellness Index has. It is an idiosyncratic mix of health inputs and outputs, and proxy or process measures:

• Blood pressure
• Blood glucose
• Obesity
• Depression
• Happiness
• Alcohol use
• Tobacco use
• Exercise
• Healthy life expectancy
• Government spending on healthcare

The index is produced by LetterOne – an “international investment business.” Few details on how it is derived and from which data sources are provided. The Top 10 includes high income countries with recognised top performing health care system like Iceland and Netherlands, but also Laos, Cambodia, Maldives (GDP rank: 169) and the Philippines. Guatemala, Honduras and Myanmar, which have major political and economic problems not usually associated with good population health metrics, are in the top 15, putting the credibility of the index further in doubt.

Why are we sick?

South Africa’s bottom ranking on this index has drawn a few headlines but no surprise or protest. The SA media and probably the public seem to know we are sick – and possibly why. We face a quadruple burden of disease – HIV/AIDS, violence/trauma, non-communicable disease, and diseases of poverty – and the public health system is ailing. This is despite the country spending a reasonable overall proportion of GDP on medical care.

Journalists interviewed various health authorities for a response to the bottom of table ranking. The status of the public health system is claimed as the main reason for the poor state of our citizens’ mental and physical health. Some address deficiencies in mental health, others primary care, and there are naturally allusions to the government’s much delayed attempts at health care reform (“National Health Insurance”).

Social determinants of health

SA clearly has high rates of substance use and abuse, obesity, diabetes and high blood pressure, and worsening mental health. But are these failures of the health care system? Is the disease burden, and our inadequate response to it, a failure of health care or rather of society in general?

It seems clear that our “socio-economy” is sick, with unemployment, poor education, low income and bad conditions of living for the majority of our population. Rampant protest action is symptomatic of the societal malaise. How can we be a healthy nation under these circumstances?

It is well known that social determinants of health – not the health care or medical care system – are the major drivers of health.  The World Health Organization’s Commission on the Social Determinants of Health (SDH) defines these as “the conditions in which people are born, grow, live, work and age” and “the fundamental drivers of these conditions.” SDH drivers include income, wealth, and education. Conditions include environment (clean air and water) and sanitation; today, the very real threat to global health posed by climate change.

High GDP on its own is no guarantor of health, nor is access to the latest technical advances; the United States ranks poorly on population health measures, below much less affluent countries like Cuba and others. And overall figures mask huge disparities. For example, traveling just a few miles on the London Underground, or across Baltimore, takes you to areas of the same city with a 20 year lower life expectancy.

What can QI professionals do?

Is it useful to think of SA’s high rates of poverty and unemployment, criminal and domestic violence, poor diet, and substance abuse as health care problems? How can we improve health without attention to these factors? What role do the disciplines of QI and Improvement Science have to play in addressing social determinants of health?

Some feel that social determinants should be addressed at an individual level, engineered into each patient journey, addressed by multidisciplinary care teams, providing suitable “doses” of social support for each patient, just like a medicine or surgery. Others argue that these are political and economic issues that can only be addressed at societal level.

A few suggestions:

• Understand the driver diagram of health. Even if not all drivers are our responsibility we should at least know what they are and who can be held accountable. Clinical leadership should have a broader system view, help join the dots and publicise the connections between them. Where are we drawing the boundaries of the health system? Possibly not wide enough.
• Take QI methods into the community e.g. into civic society, government departments other than health, the educational system – where they can be used to address key drivers of health
• Mental health services can’t fix all our mental health problems, nor can primary care address the huge burden of disease but we need to ensure an appropriate mix and distribution of funding to primary and mental health which have always been at the interface of health problems most closely associated with social determinants
• We need appropriate measurement; the Indigo index draws attention to some of the factors that affect health but is not a representative or robust measure of anything, nor can it be used to guide improvement
• We should all be activists. Answers to our poor health status as a country lie in areas outside the traditional boundaries of the health system, for which government has major responsibility.  We cannot leave the job to professional economists, politicians and policy makers. At the very least we must use our votes wisely, holding decision makers and senior managers and politicians accountable.

Even accepting the dominance of social and economic factors that may be outside our direct control, health professionals have the authority to direct attention to those factors, and the responsibility (and the possibility) to construct a better medical care system that can maximise individual and population health within available resources. But we can’t do this alone; our poor health as a nation is a collective responsibility. South Africa, blessed with more sunshine and as much human potential as Canada can and should move up to the top of the league table of health.