South Africa: Fighting Inequality Through Health Economics

"Health economics must be a core part of how we run health systems and make decisions on resource allocation. I actually believe it has to be part of the foundation courses for health professionals at the undergraduate level."

This is the view of Tryphine Zulu, a University of Cape Town (UCT) PhD graduate. She is a fierce proponent of her area of study and has shared her thoughts and expertise locally, nationally and on the world stage.

Health economics, said Tryphine, forces the practitioner to think not only about the patient in front of them but also about the wider health system and resource allocation at a population level. And, as is evident with the outbreak of COVID-19, this is not just an African or South African conversation.

"As the world moves towards universal health coverage, health economics has become that tool we will all have to lean on to guide decision-making," she said. And as a country, outside and beyond COVID-19, health economics could not be more relevant as talk about National Health Insurance grows louder.

According to Tryphine, health economics will help answer questions such as: "How do we get the biggest bang for our buck?", "Is it more money we need or is it more efficiencies?" and "Where should we focus our attention to address the inequalities due to the social determinants of health?" They are all serious, necessary questions ─ both on a national and global level; ones that she is working hard to help answer.

But who is Tryphine and what sparked her interest, or rather passion, for health economics?

Educational journey

Tryphine was born just outside of Bulawayo in Zimbabwe. She was raised mostly by her mother while her father worked in Johannesburg, having moved there in the late 1960s.

"So, we are a product of the unfortunate migrant labour system that separated families," she said.

Despite her father being a long distance away, there was no shortage of support, encouragement and discipline in their home and at school: Her mother, "the family general", was a strong disciplinarian and a firm believer in the power of education. Tryphine also found a role model in her grade 7 teacher.

Following her schooling in Bulawayo, she obtained her undergraduate degree in pharmacy at the University of Zimbabwe (UZ) in Harare. An interest in health economics was already surfacing, with the focus of her undergraduate thesis being the cost of antiretrovirals in the health sector.

Following her graduation from UZ, she joined her father in Johannesburg after her mother passed on, where she worked as a pharmacist and also enrolled for a postgraduate degree in clinical pharmacy at the University of the Witwatersrand (Wits).

"It's quite an honour to be the first black woman PhD holder in health economics."

Although her studies were aligned with the work she was doing at the hospital pharmacy at Chris Hani Baragwanath Hospital, Tryphine found herself increasingly drawn to "the health economics side of things". Before she could explore the subject more fully as an academic discipline, however, there was the small matter of first completing her masterʼs in pharmacotherapy, also at Wits.

In 2012, while at Baragwanath, and as part of the hospitalʼs Pharmacy and Therapeutics Committee, she realised that a tool in addition to clinical appropriateness was needed to manage the hospital medicines formulary while taking cognisance of the pharmaceutical budget. The search for this additional tool led her to UCT's website where she found a Master of Public Health (MPH) programme in Health Economics at the School of Public Health and Family Medicine.

"It seemed to address the question of economic evaluation as a tool for decision-making - not only in medicines management or formularies but for the entire health system," said Tryphine.

Needless to say, she enrolled for her second masterʼs and "never looked back after that".

The PhD

The MPH programme presented her with more than she had bargained for: costing, cost-effective analysis, cost-benefit analysis, cost-utility analysis, the economics of health systems, healthcare financing, health systems, health policy and microeconomics, among other things.

"So intrigued was I about health economics that I decided to come back for a PhD," she said, adding that she believed a doctorate would help her in building econometric models to answer questions related to health policy.

Her PhD research looked at the extent of wealth-related inequalities in non-communicable diseases' (NCD) risk factors, their prevalence and clinical outcomes, and assessed the impact of the social determinants of health in mediating these inequalities.

"After HIV, NCDs are the biggest drivers of ill health and, dare I say, we are facing a tsunami of chronic diseases of lifestyle such as hypertension, diabetes and other cardiovascular diseases."

The aim of her thesis was, therefore, to "quantify the extent of inequalities in the field of NCDs and then decompose the drivers of the observed inequality by looking at the contribution of the social determinants of health".

No walk in the park

Tryphineʼs PhD journey was no walk in the proverbial park. She lived far from "traditional academic corridors", had no holidays and spent most weekends typing away on her laptop. And for the entirety of her studies, she held down jobs outside of academia, including her current job in the corporate environment and rarely with a "structured nine-to-five sort of vibe".

She recalled an instance when she had to run an analysis of 1 000 iterations on a statistical data software package called Stata. It needed to run through the night and the next day. But she needed to be on a flight to Cape Town. She took a chance and when she eventually opened her laptop upon landing, the analysis had fortunately continued uninterrupted.

"The inequalities in health are strongly mediated by the inequalities in education."

Tryphine is particularly grateful to her supervisor, Associate Professor John Ataguba, who, she said, was "totally supportive" and on one occasion even brought his wife along to give feedback on one of her chapters before the couple headed off on a date.

He was also the reason she submitted two papers to the International Health Economics Association (iHEA) congress. Much to her surprise, particularly because she was initially reluctant to submit, both papers were accepted for oral presentation. iHEA covered the costs of her accommodation in Basel, Switzerland, and her supervisor organised her flights through UCT.

"What a complete shocker!" she said. "I was totally humbled. It was an amazing experience to be able to present at a platform of that magnitude."

She is equally grateful to "one of South Africa's best minds in health economics", Professor Di McIntyre who mentored her and was a "big influence" during her MPH.

The thanks do not stop there: Tryphine is deeply appreciative of the funding she received from the Bongani Mayosi National Health Scholars Programme for the later part of her MPH and the support of programme director, Dr Thabi Maitin, who "always kept in touch", cheering her on. She was offered funding for her PhD studies but felt she would pass it over to someone more deserving as she was working full-time and there were full-time students who needed it more.

More the merrier

Tryphine finds it hard to believe she is the first black female to obtain a doctorate in health economics.

"It's quite an honour ... But on a serious note, I think it's an indictment of our society if only in 2020, we are capping the first black woman to have obtained a PhD in health economics."

It is, she added, a reflection of the same inequalities she wrote about in her thesis.

"The inequalities in health are strongly mediated by the inequalities in education. So, it is important that if we are to address socio-economic inequalities in healthcare, we start with addressing inequalities in education."

Others must take up studies in health economics too, she urged: "I always encourage all my friends considering postgraduate studies to consider health economics - the more the merrier!"

Tryphine said she is planning to take some time out to recuperate from the "hectic schedule" of the past four years. But by "taking time out", she means publishing findings from her analyses, writing papers and continuing her work on the World Health Organization's advisory committee on the governance of the private sector for universal health coverage.

In addition, she will juggle all that with her work for a healthcare funder responsible for public service employees, and where she is able to apply her health economics way of thinking, which, according to her, "is very exciting".

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