Implementing the Tobacco Bill will give the NHI extra muscle

South Africans need no reminder that we are the most unequal country in the world, with our lived experiences telling the story of this inequality and a Gini coefficient of 0.63 confirming this statistically. With 84% of South Africans using the public health system, we commend the government for the steps it has taken towards implementation of National Health Insurance (NHI), as this will ensure access to healthcare for all, irrespective of family income.

Disease and injury continue to exacerbate poverty among working and unemployed families whose limited resources cannot cope with medical costs. The NHI intends to remove this unequal access to healthcare, and we need to continue to monitor plans to ensure that the quality of healthcare reflects the needs of our population.

During his State of the Nation Address (SONA) on Thursday 13 February 2020, President Cyril Ramaphosa is expected to update the nation on when we can expect a roll-out of universal healthcare through NHI. We would like to hear him say that along with ensuring universal access to treatment, the NHI will integrate prevention of disease as an essential component of healthcare.

Prevention is about the quality of life, but it is also about access to healthcare and the cost of illness. It is estimated that for diabetes alone, public sector costs of diagnosed patients for 2018 were approximately R2·7-billion and would be R21·8-billion if both diagnosed and undiagnosed patients are considered. The accumulated losses to GDP between 2006 and 2015 from diabetes, stroke and coronary heart disease alone are estimated to have cost the country around R26-billion. Estimates show that the economic cost due to productivity losses arising from absenteeism, presenteeism and early retirement due to ill health in South Africa, largely from non-communicable diseases (NCDs), equated to a total of 6.7% of GDP in 2015 and is expected to increase to 7.0% of GDP by 2030.

Each day, tobacco-related diseases kill 115 people in South Africa and the economic costs of tobacco to the country are R59-billion per annum. This includes healthcare expenses, and lost productivity through absenteeism. Smoking has negative impacts on all the major non-communicable diseases, including lung and other cancers, chronic obstructive pulmonary diseases (COPD), heart disease and diabetes. At the same time, we only earn an estimated R13-billion to R14-billion a year from tobacco taxes. So tobacco adds to the economic and human resources costs of the NHI and these costs are subsidised by the taxpayer while the industry takes the profit.

Smoking also has an impact on communicable diseases, worsening TB and HIV and AIDS. Smoking and exposure to second-hand smoke account for one in five cases of TB, triggering inactive TB and making treatment for TB less effective. In people living with HIV-AIDS (PLWH), tobacco use triples the risk of getting TB and makes antiretroviral therapies less effective.

Each year, 115,000 South Africans are diagnosed with cancer, and treatment is expensive: a report by the Campaign to Fix the Patent Laws and the Cancer Alliance notes that a year’s supply of lenalidomide for one cancer patient can cost up to R882,000. In 2018, KwaZulu-Natal faced an oncology crisis, with an increasing backlog of cancer patients awaiting treatment caused by a lack of equipment for screening and treatment, indicative of the demand placed on the health system and the inability of the system to meet that demand.

Our disease burden and the annual increase in the budget for healthcare point to a lack of attention being given to prevention. Many diseases that we suffer from are preventable with the right policies and screening. Policies such as banning alcohol marketing, listing ingredients on food products, taxing unhealthy food higher and making healthy food cheaper and more accessible, can help consumers make healthy choices. These are prevention policies that have worked around the world and that are easy and cheap for the government to implement. They have been shown to change behaviour relatively quickly, thereby reducing disease and demand for healthcare while improving health and quality of life.

The Control of Tobacco Products and Electronic Delivery Systems Bill (Tobacco Bill) is an example of an effective prevention policy because it will introduce more protection for non-smokers from second-hand smoke, legislate e-cigarettes and introduce pictorial health warnings to inform smokers of the harm from tobacco, among other changes. 

These proposals – in particular 100% smoke-free public places, health warnings and a complete ban on all marketing and advertising – together with tax increases on tobacco products, have been identified as the best interventions to address tobacco consumption in low- and middle-income countries by the World Health Organisation (WHO) in 2011. They come at low or no cost to the state, and the evidence base used by the WHO shows that they contribute to the largest drop in tobacco consumption.

The Tobacco Bill, when passed, will make the NHI more affordable as it will reduce the number of smokers and disease caused by tobacco. It is well known that prevention of disease is cheaper than treatment, but prevention also improves the quality of life and makes people more productive. With 8.5 million smokers in SA, the health burden caused by tobacco is likely to increase and limiting tobacco use and exposure to second-hand smoke will lessen diseases, save lives, increase economic productivity and lessen the burden on the public health system.

The WHO’s global business case for NCDs shows that if low- and low-middle income countries put in place the most cost-effective interventions for NCDs (including for both prevention and management), they will see a return of $7 per person for every $1 invested by 2030. Investing in prevention and control of NCDs is essential for growth and development and, when carefully planned and implemented, is highly cost-effective, according to the WHO.

Passing the Tobacco Bill is a win for individual and family health, the NHI and the economy of South Africa. DM

Savera Kalideen is the executive director of the National Council Against Smoking. Dr Sharon Nyatsanza is the council’s project and communications manager.