Category: Healthcare Politics and Regulations

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ANC and its Ministers Reject Reports of NHI ‘Concessions’

On By ModernMedia
Photo by Hush Naidoo Jade Photography on Unsplash

By Chris Bateman

Recent media reports over the future of NHI have been contradictory and hard to make sense of. Spotlight chased up those in a position to know where things stand – it seems the ANC has not in fact made any major concessions on NHI. There is however agreement that medical schemes won’t be phased out in the next few years, something that likely wouldn’t have happened in any case given the poor state of the economy and the long timeline for NHI implementation. 

The ANC is holding firm on the NHI Act with Health Minister Dr Aaron Motsoaledi and the National Health Department “unaware of any compromise deals”, and the President’s office saying engagement with Business Unity SA (BUSA) is “ongoing”.

In spite of recent media reports to the contrary, neither President Cyril Ramaphosa nor Motsoaledi have conceded to any BUSA proposals on amending sections of the NHI Act. BUSA is the country’s apex business association and represents the banking, mining, and retail sectors, including the Health Funders Association, the Hospital Association of South Africa, and the Innovative Pharmaceuticals Association of South Africa.

BUSA, and several other critics of the Act, have argued that provisions should be removed that prohibit medical schemes from covering any health services covered by the NHI fund. The NHI Act has not yet been promulgated. If promulgated in its current form, the role of medical schemes will be dramatically reduced.

The DA’s spokesperson on health, Michele Clarke, told Spotlight that at the establishment of the recent GNU-convened Medium Term Development Plan (MTDP), agreement was reached that the health department would “not de-establish medical aids during the current government’s term of office”.

Spotlight understands that this amounts to a commitment not to promulgate the relevant sections of the Act in the next few years – it does not amount to a commitment to remove those sections from the act.

This is a pyrrhic victory, given that the implementation of NHI was always going to be a long-term project and that even in the most pro-NHI scenarios, the effective phasing out of medical schemes in the next few years was highly unlikely. There are also four legal challenges being brought on procedural and constitutional grounds that may further delay things.

Mist of confusion

Last week’s mist of confusion lifted when both the Presidency and Dr Stavros Nicolaou, speaking to Spotlight on behalf of BUSA, said no concessions have been made on NHI. Motsoaledi’s office also flatly denied reports that there had been any ANC or GNU compromise to remove parts of the NHI legislation that would render medical aids almost obsolete. The Spokesperson for the National Department of Health, Foster Mohale, added that he was unaware of any MTDP agreement on medical aids.

Vincent Magwenya, a spokesperson for the president, told Spotlight he was “unaware of any process leading to the amendment of the NHI Act”, claiming that Maropene Ramokgopa, Minister in the Presidency responsible for Planning, Monitoring and Evaluation, was misquoted last week.

She was quoted in news reports as saying the ANC and the DA had reached an “unofficial understanding on the NHI” following an ANC compromise to remove parts of the NHI legislation that would collapse medical aids. “Ms Ramokgopa tells me she was misreported,” said Magwenya.

Chris Laubscher, the DA’s communications head, told Spotlight: “There was never confirmation by [DA leader who is also Minister of Agriculture] John Steenhuisen that the NHI in its entirety had been excluded from the government’s Medium Term Development Plan.”

The new MTDP has not yet been made public.

Charity Ophelia McCord, the spokesperson for Steenhuisen, said the MTDP had yet to be completed and passed, but was on the Cabinet agenda for Wednesday, February 12. Spotlight was not able to verify if this was discussed.

Meanwhile, Mohale said both the health department and the minister were unaware of any compromise deal, “thus the implementation of the NHI Act continues as per the plans”.

Cannot be changed over night

If at some point the NHI Act is to be amended, the process is likely to take several years, according to Professor Olive Shisana, Social Policy Special Advisor to Ramaphosa on the NHI and health systems strengthening.

“Any process for changing an enacted law normally goes through Parliament, including an amendment from the executive,” Shisana explained. “There would first have to be consultation with the public before it even got to Parliament. Then, when it gets to Parliament there’s more consultation, this time in each of the provincial legislatures, after which it goes to the Portfolio Committee on Health which also takes written submissions. The committee then decides whether to submit it to the National Assembly. If the National Assembly passes it, it goes to the National Council of Provinces which considers each province’s input. Government took five years to get this NHI Act in place, so you can imagine it might take about as long to get parts of it excised or reversed. That’s the normal route it would have to take, I’m afraid.”

However, both the DA and BUSA are adamant that the Act needs to be changed.

Clarke said the DA remained of the view that “multiple parts of the [Act] remain problematic and dangerous for the future of healthcare in South Africa”.

She added: “The DA wants the model underpinning the NHI to be completely reworked and multiple problematic clauses amended by Parliament to ensure that the healthcare model is protected and strengthened.”

BUSA met with Ramaphosa in September last year and tabled a proposal which included striking Section 33 – which effectively collapses private medical aids as they now exist, creating a single national fund – from the NHI Act. It also calls for the implementation of mandatory health insurance which it is argued will take pressure off the public health system and bolster existing medical aids. The president has since passed it on to Motsoaledi’s office.

Neither BUSA nor the responding government parties have given any indication of when they might next meet or pronounce on the proposal.

Rejection of NHI

Meanwhile, the United Healthcare Access Coalition (UHAC), a grouping claiming to represent 80% of all private healthcare stakeholders, lodged a detailed alternative proposal with the president’s office. This entirely rejects the NHI and focuses on rehabilitating the healthcare system based on a synthesis of far-reaching recommendations which various commissions and experts have made over several decades, including the Taylor Commission and the more recent Health Market Inquiry (HMI).

In January this year, Motsoaledi promised to pronounce on the implementation of the HMI recommendations from 2019 “within weeks”. As reported by Business Day, there indeed seems to now finally be some movement on the HMI recommendations with Minister of Trade Industry and Competition Parks Tau having gazetted an exemption that newly opens the door for tariff setting in the private health sector – a move that may help rein in runaway healthcare costs.

UHAC spokesperson Dr Aslam Dasoo described their report as “everything that the NHI is not”.

“Our health pathway requires easy legislative changes and is within current fiscal constraints. We can start the process immediately. It requires a change in governance structure of the provincial health systems where politicians relinquish all direct authority over health care institutions and instead focus on strategic policy,” he previously told Spotlight.

In an online briefing launching the UHAC on Wednesday, February 12, Dasoo warned all parties in the GNU to “consider their options” as they would be “held jointly responsible” should the NHI be implemented to the detriment of South Africa.

Another UHAC executive member and CEO of the SA Private Practitioners Forum, Dr Simon Strachan, said the focus of their universal healthcare plan was on providing equitable, implementable, and sustainable healthcare.

“We need to ensure that those who can look after themselves, do (financially), while subsidising those who cannot afford to. It’s one hundred percent dependent on improving health service delivery within the public sector and creating a competitive market for people to decide where and how they access healthcare,” he said.

The UHAC coalition includes NGO’s, patient advocacy groups, the SA Medical Association, the South African Private Practitioners Forum, and the Progressive Healthcare Forum.

Asked what UHAC’s “Plan B” was if they “hit a brick wall” on their detailed proposals, Dasoo said the GNU was obliged to respond to such a widely representative proposal “otherwise they’re not fit to govern”.

Referring to the ANC, he said the party “neglected the two major healthcare systems, allowing real degradation of the public sector and an unregulated private sector with no market growth, resulting in prices going up”. He added: “If there’s any brick wall, it’s the one they’ve built.”

Republished from Spotlight under a Creative Commons licence.

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No Clear Government Plan Yet to Confront US Aid Cuts

On By ModernMedia
Photo by Reynaldo #brigworkz Brigantty

By Ufrieda Ho

South Africa’s National Department of Health is still to outline a clear contingency plan as a United States (US) funding freeze puts lives at risk, spells job losses, and presents threats to keeping HIV and TB under control.

The ripple effects of US President Donald Trump’s 90-day freeze of funding on foreign aid programmes have hit South Africa hard. The damage is being counted at multiple levels – even as some limited funding flows are being restored.

For the country, the fallout has heightened civil society’s calls for a prompt, implementable plan to fill the gaps in care and services. Also needed, they say, is clarity on longer-term strategies for greater self-sufficiency in the country’s HIV responses as donor-funded models look increasingly precarious. Such an argument for increased independence in Africa and the global south was made by president of the South African Medical Research Council (SAMRC), Professor Ntobeko Ntusi, writing in the journal Nature.

South Africa should have been better prepared and not caught off guard to be left in the position it now finds itself in, some beneficiaries of US-funded projects told Spotlight. They were speaking on condition of anonymity, given the risk of public comments jeopardising their prospects of having their funding restored.

The immediate need is to ensure that the country’s overburdened and under-resourced public clinic system is able to absorb the tens of thousands of people living with HIV who will have to use public facilities. This is partly because the NGOs they have relied on have been forced to close shop – virtually overnight. Clinics catering to specific groups, such as men who have sex with men, have been particularly hard hit.

South Africa is the largest global recipient of President’s Emergency Plan for Aids Relief (PEPFAR) funds. These funds make its way to South Africa through the United States Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC). Through PEPFAR, USAID has been funding and supporting local NGOs and our Department of Health for around two decades. According to USAID’s website, it invested $5.6 billion (roughly R100 billion at the current rand/dollar exchange rate) between 2004 and 2020 towards prevention and treatment of HIV and TB in South Africa.

Trump’s initial executive order, signed on 20 January, halted funding received via USAID. USAID is an agency of the US government that now falls under the State Department under the leadership of Secretary of State Marco Rubio. Since taking office, Trump has slated USAID as “corrupt” and run by “radical left lunatics”.

The Washington head offices of USAID were closed on Friday 7 February as per Trump’s orders and even as the 90-day review period had just got underway, signage on the building was being removed or taped over. Trump’s actions have now been challenged in courts with successful temporary blocks to his orders to place 2 200 USAID workers in the US on paid leave and to reinstate 500 US-based staff who were already placed on administrative leave from when the order was first signed. The situation is highly fluid and several court actions remain in progress.

Some limited relief

In South Africa, NGOs that received USAID funding remain largely in limbo. Although the United States mission in South Africa confirmed that some PEPFAR-funded services could continue in the country, it is subject to some relatively strict limitations and with no assurances of longer term support. As is clear from reporting by Bhekisisa, the process to get at least some funding to flow again to PEPFAR-supported projects is not straight forward.

There was some good news this week linked to PEPFAR-funding channelled through the CDC – a US federal agency under the Department of Health and Human Services. Following a court order, organisations getting these funds should for now be able to continue their work. However, the court process is far from over and the future prospects of NGOs that depend on CDC funds remains precarious.

Given these ongoing uncertainties and severe disruptions to cash flows, Spotlight understands that some large NGOs may have to close down, while others may have to drastically reduce their services. As reported by Spotlight and GroundUp, several NGOs have appealed to the private sector for assistance. As it stands, thousands of people employed or contracted by local NGOs face the loss of their jobs, cut-backs and deepening anxiety over income security. These people include community health workers, peer counsellors, patient navigators, community activists and advocates, support and administrative staff members, and contract workers who keep these organisations functioning.

At stake too are specialised services for so-called key populations such as sex workers, men who have sex with men, the LGBTQI+ community, and people who use drugs. Until recently, a focus on improving services for key populations was generally accepted, including by PEPFAR, to be the right strategy given the disproportionate risk of HIV infection in these groups. But under the Trump administration’s “anti-woke” agenda, it seems likely that many services aimed at key populations are set to be defunded.

A White House media note on 29 January made clear the US’s stance: “The previously announced 90-day pause and review of U.S. foreign aid is already paying dividends to our country and our people. We are rooting out waste. We are blocking woke programs. And we are exposing activities that run contrary to our national interests. None of this would be possible if these programs remained on autopilot.”

A timeline of the US aid cuts

20 January

90-day pause 

In an executive order, US President Donald Trump orders a 90-day pause in US foreign development for “assessment of programmatic efficiencies and consistency with United States foreign policy”. 

26 January

USAID funding paused 

US Secretary of State Marco Rubio pauses all US foreign assistance funded by or through the State Department and US Agency for International Development (USAID) for review. 

28 January

Waiver issued 

Subject to certain conditions, Rubio issues a waiver stating: “Implementers of existing life-saving humanitarian assistance programs should continue or resume work if they have stopped.” 

1 February

Waiver clarified 

The extent of the January 28 waiver is clarified in a memo from the US Department of State. 

5 February

Health portfolio committee briefing 

South Africa’s Health Minister Dr Aaron Motsoaledi briefs Parliament on the US funding cuts and their impact on healthcare services. 

7 February

South Africa singled out 

In an executive order applying only to South Africa, Trump orders that “the United States shall not provide aid or assistance to South Africa”. 

10 February

Waiver still applies 

The US mission in South Africa releases an FAQ in which they state that PEPFAR activities that fall under the limited waiver will resume despite the February 7 executive order. 

12 February

CDC grants reinstated 

The grants of NGOs receiving support through the CDC are reinstated following a court order issued in a US court. 

Crisis of fear, silence, and uncertainty

Spotlight understands that staff of affected NGOs have essentially been forbidden from speaking publicly about the 90-day funding freeze. Many declined to speak on the record to Spotlight, even anonymously – too afraid it might affect the decision on their funding after the 90-day review period.

According to an FAQ by the US mission in South Africa that was published on February 10, they have been communicating with the South African government, though it is not clear when this happened. Five days earlier on 5 February, Health Minister Dr Aaron Motsoaledi told Parliament’s Portfolio Committee that he had not had any official communication from the US government on the matter.

Figures from Motsoaledi’s presentation showed that in 2023/2024, PEPFAR funding to South Africa’s health department amounted to 17% of its spending on HIV. Funding totals R4.6 billion for staffing and R2.9 billion for running costs for NGOs. These NGOs include organisations working directly with people living with HIV, mobile units and youth organisations and programmes. PEPFAR focuses on the 27 districts in South Africa with the highest disease burden.

The health department did not respond to Spotlight’s questions on contingencies, or details of next steps to fill the funding gaps or how capacity and resources will be redirected to avert catastrophe. Motsoaledi did not give any of these details in his presentation to Parliament either.

What he did say was that since Trump’s executive order came into place, the health department had hosted a meeting with the provincial leads on HIV and TB; conducted assessments on the immediate impacts of the executive order; met with people living with HIV and engaged with SANAC to finalise a sustainability framework.

A collective of activist organisations, including the Health Justice Initiative, SECTION27, the Cancer Alliance, Treatment Action Campaign, Sweat, PSAM and the African Alliance, have pressed the Department of Health to create an “urgent co-ordinated emergency plan” along with an increased budget to avert a looming disaster.

The activists highlighted that despite the announcement by the Trump administration that some NGOs could apply for a waiver, many have had no practical way to do so without ways to communicate with their USAID contacts. This as USAID employees were placed under a work stop order and were shut out of their offices and denied access to their work emails.

The appeal from the collective also extends to protecting the work of academic and clinical research in the fields of HIV, TB, and cervical cancer that will also be affected by the funding freeze. As Spotlight reported, around 28% of the South African Medical Research Council’s budget for 2025/2026 was set to come from the United States government.

An ‘unreal world’

Professor Linda-Gail Bekker, chief executive officer at the Desmond Tutu Health Foundation, said Trump’s actions put in jeopardy the goal to finally have epidemic control of HIV – and right at the final hurdles.

“We have made amazing progress. And thank you to PEPFAR that helped us to get this far, but the work is not over. For the US to pull out at this point is a massive loss of investment; it’s also regression. It’s like getting to the end of a book but having the last chapters torn out before you can read it,” said Bekker.

She said PEPFAR funding has made it possible to build a formidable cohort of lay and professional people trained and dedicated to their roles that supported public healthcare in the most critical ways.

“These are individuals who distribute antiretrovirals, distribute pre-exposure prophylaxis, find and trace individuals who’ve been lost to care. They take services into communities, to outside of the health facilities, and made the effort to go the last mile to find those individuals – that is how you close down the epidemic,” Bekker said.

Her caution too is that loosening a grip on HIV control means potential surges in tuberculosis. “HIV and TB track together all the time, and an HIV epidemic that is once again out of control, almost certainly means what will follow is a TB epidemic that is out of control,” Bekker said.

Trump has created an “unreal world”, said Dr Andy Gray of the University of KwaZulu-Natal, who has also worked with the World Health Organization (WHO) in various capacities over two decades. “People are being held to ransom; and people are scared.”

“We have always been used to the oscillation between the United States’ Republican and Democratic administrations; things may be a little uncomfortable or there may be some disruption, but not this ‘let’s burn down the house’ approach taken by the Trump administration,” he said.

“There is no consideration of human rights or for human beings anywhere in the world, including America,” he added, pointing out too that the CDC has for the first time in 60 years been instructed to cease publishing weekly mortality and morbidity data, despite a breakout of avian flu (H5) in the country.

For Gray, South Africa’s strategic health response in the wake of this crisis should be to shift from a donor-funded model. His concern, however, is that with a stretched South African purse and with competing priorities, the HIV response will slip down the list.

Gray said that better self-sufficiency comes from eliminating waste, investing in employing the right people in the right jobs as well as investing in efficient systems.

He added that National Treasury will have to redirect money for the interim shortfall left by the US funding freeze, and provinces will have to step up by getting their houses in order.

South Africa, he warned, should ready itself for the “worst case scenario” once the 90-day review period is up.

SANAC response

The South African National AIDS Council (SANAC) role is meant to bring together government, civil society and the private sector to create a collective response to HIV, TB and STIs in South Africa. But if there is a crisis strategy from the council, it has not yet been announced.

SANAC head of communications, Nelson Dlamini, said that they have been left in a position of not being able to engage publicly because they haven’t had any direct communication with PEPFAR’s and USAID representatives based in Pretoria.

“PEPFAR is a government-to-government agreement and there ought to be official communication with the government of South Africa so we know what this means for our working relationship, but nothing has been forthcoming,” said Dlamini. “SANAC is a co-ordinator so we have to still coordinate. We are engaging in the background with relevant structures but we can’t say we are doing X, Y, Z till we have a sit down with PEPFAR,” he said.

Republished from Spotlight under a Creative Commons licence.

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SA Health Research Facing Catastrophic Financing Cuts

On By ModernMedia
Professor Ntobeko Ntusi is the president and CEO of the South African Medical Research Council. (Photo: SAMRC)

By Catherine Tomlinson

Cuts to United States funding of health research could have “catastrophic” consequences, says Professor Ntobeko Ntusi, who is at the helm of the country’s primary health research funder. He says the South African Medical Research Council is “heavily exposed” to the cuts, with around 28% of its budget coming from US federal agencies.

After an unprecedented two weeks of aid cuts by the United States government that left HIV programmes and research efforts across the world reeling, the Trump administration took the drastic step of freezing aid to South Africa in an executive order on 7 February.

The order – which is a directive to the executive branch of the US government and holds the weight of law – was issued to respond to what the White House called “egregious actions” by South Africa. It specifically points to the Expropriation Act and the country’s accusation of genocide against Israel at the International Court of Justice as the primary reasons for the funding freeze.

While there are some limited wavers and exceptions to the cuts, Spotlight understands that these have so far been poorly communicated and many HIV services remain in limbo.

The funding cuts, following an earlier executive order issued on 20 January,  are interrupting critical health research underway across South Africa and will ultimately undermine global efforts to stop HIV and TB.

The US is a major source of financing for health research in South Africa. Many of the country’s research institutes, groups, and universities receive funding from the US through the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), USAID, and the President’s Emergency Plan for Aids Relief (PEPFAR).

Over the past few weeks, these funding sources have come under siege by the Trump administration resulting in a gaping, and most likely insurmountable financing gap, for many health research endeavors in the country.

US spending accounts for just over half (55%) of all spending on global health research around the world. In 2022, the super power spent $5.4 billion on global health research, according to Impact Global Health –  an NPO that tracks health research spending.

While the US gives money to global health research through several different government departments and programmes, the largest source of funding for global health research is the NIH. The NIH contributed 65% of global financing for HIV research between 2007 and 2022, according to Impact Global Health and 34% of tuberculosis research financing in 2023, according to New York-based policy think tank, the Treatment Action Group.

South Africa has the biggest HIV epidemic in the world in absolute terms and is among the top 10 countries in terms of TB cases per capita.

Catastrophic consequences

“South Africa is the biggest recipient of NIH funding outside of the US”, Professor Ntobeko Ntusi, president and CEO of the South African Medical Research Council (SAMRC), told Spotlight. “[T]he consequences will be catastrophic if [funding] is stopped… for science that is important for the whole world,” he said.

South Africa plays a critical role in advancing HIV science, said Ntusi, adding that “many of the major trials that have advanced our understanding of both the effective strategies for HIV management, as well as understanding the mechanisms of disease emanated from South Africa”.

People in the US, for example, are now able to access long-acting HIV prevention shots, largely because of research that was conducted in South Africa and Uganda. Research conducted in South Africa has also been critical to validating new tuberculosis treatments that are currently the standard of care across the world.

Heavily exposed

Stop work orders were sent to research groups receiving USAID funding at the end of January. These stop work orders coupled with the halting of funding have already interrupted critical HIV research efforts, including efforts to develop new vaccines against HIV.

Ntusi said that the SAMRC is currently “heavily exposed” to the halting of grants from USAID and the CDC, with research programmes supported by USAID and the CDC already being stopped.

The SAMRC’s research on infectious diseases, gender-based violence, health systems strengthening, as well as disease burden monitoring are also affected by the funding cuts.

“In addition to support for HIV research, we have significant CDC grant funding in our burden of disease research unit, the research unit that publishes weekly statistics on morbidity and mortality in South Africa,” said Ntusi. “Our health systems research unit has a number of CDC grants which have been stopped [and] in our gender and health research unit we had a portfolio of CDC funding which also has been stopped.”

Along with programmes being impacted by the halting of USAID and CDC funding, Ntusi said there will also be major staffing ramifications at the SAMRC as well as at universities.

He said that if funding from the NIH is stopped “there would be huge fallout, we just wouldn’t be able to cover the hundreds of staff that are employed through the NIH granting process”.

The SAMRC’s combined annual income from US grants (NIH, CDC and USAID) is 28% of its total earnings (including both the disbursement from the SA government as well as all external contracts) for the 2025/2026 financial year, according to Ntusi. “So, this is substantial – effectively a third of our income is from US federal agencies,” he said.

Pivot away from infectious disease?

In addition to the executive order freezing funding to South Africa, it is unknown whether the NIH will remain a dominant funder of global health. Robert F. Kennedy Jr., the US health secretary nominee, has called for cutting to the NIH’s infectious disease research spending to focus more on chronic diseases.

Looking beyond health, Ntusi said the executive order halting aid to South Africa will be felt across a range of different development initiatives such as water and sanitation, and climate change.

Republished from Spotlight under a Creative Commons licence.

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Over 15 000 South African Health Workers’ Jobs are at Risk as US Cuts Aid

On By ModernMedia
Photo by Scott Graham on Unsplash

By Jesse Copelyn

If the US President’s Emergency Plan for AIDS Relief (PEPFAR) is halted, the South African public health system “will face a severe crisis” that could endanger millions of lives. This is according to a coalition of 17 health service organisations in South Africa, including large ones such as Anova Health, Health Systems Trust, TB HIV Care, The Aurum Institute and Wits RHI.

In a statement, they appealed to private sector donors and “high net-worth individuals” to help fund the shortfall caused by US aid cuts.

Read the statement

PEPFAR is a multi-billion dollar US initiative that supports HIV and TB-related health services around the world. In South Africa alone, over 15 000 staff (mostly health workers) are funded by PEPFAR, according to the national health department.

But a series of executive orders issued by US President Donald Trump has suspended some of this funding and the rest remains precarious. The orders include a 90-day pause on all US foreign development assistance and another that explicitly bars South Africa from aid (with some leeway allowed).

Some health service providers in South Africa continue to receive money from PEPFAR under a limited waiver that allows for the continuation of certain “life-saving HIV services”. But the waiver hasn’t protected all PEPFAR beneficiaries. As a result, some organisations have had to close their doors, while many others have had to curtail what they can provide.

The waiver doesn’t cover all health services, and many health programs that target high-risk groups (such as people who use drugs) have not been protected. This is even if they provide life-saving HIV services.

Services suspended for the most vulnerable

Under the waiver, PEPFAR can continue to fund programs that offer treatment and testing for HIV, including antiretroviral (ARV) services. Projects can also continue to provide condoms and HIV prevention medication, known as PrEP, but only to pregnant and breastfeeding women.

The waiver does not allow for continued funding of PrEP medication or condoms to anyone else. It also doesn’t cover crucial research, like population surveys which tell us how many people have HIV and where they’re located. Additionally, it doesn’t allow for continued funding of methadone maintenance programs for people who use heroin. This is despite the fact that this is the most effective way to help people to stop using heroin and to curb the sharing of drug needles (something which contributes to the spread of HIV).

Dr Gloria Maimela, who represents the coalition of organisations behind the statement, told GroundUp and Spotlight: “The staff who are providing [HIV] testing and treatment [are] back at facilities to provide those services, but staff that are providing other services not included in the waiver have been stopped, and are waiting for further guidance.”

In addition, organisations that help key populations have not been protected by the waiver, according to Maimela. Key populations are groups that are more at risk of becoming infected with HIV, such as people who inject drugs, sex workers, transgender people, and men who have sex with men. South African policy documents and the World Health Organisation recommend that health programs focus on these groups since they’re more likely to acquire and transmit HIV.

Despite this, US-funded organisations that target key populations have been forced to shut their doors in South Africa. Maimela says that this is even in cases where they were offering the kind of life-saving ARV treatment covered in the waiver.

“For us, this is of grave concern,” Maimela says, “because we know that right now that is where most of the [HIV] infections lie”.

So far, organisations which provide HIV treatment and prevention services to LGBTI people have been forced to shut down, including the Ivan Toms Centre and Engage Men’s Health.

Additionally, GroundUp and Spotlight have identified two PEPFAR-supported harm reduction centres that have had to close. These centres provided methadone and clean needles to people who inject drugs (when drug users have access to clean needles, they’re less likely to resort to sharing them, which brings down HIV transmission).

Ricardo Walters, who provides consulting services to health service organisations across Africa, told Spotlight and GroundUp that a similar trend could be seen across the continent.

“Many organisations that were specifically offering services to key populations were not suspended; their project funding was terminated,” he said. “They will not be coming back.”

These organisations were assisting patients “who often could not access services in a general [health] setting”.

Walters says the reasons given for the termination of these programs vary across organisations and countries.

“Where there are reasons, it’s often [stated] that it’s because the program contains components of DEIA [Diversity, Equity, Inclusion and Accessibility] and gender ideology, which is directly from a previous executive order [in which the Trump administration terminated all federal funding for DEIA]. The terms are never defined … no one says don’t treat gay men.”

Appeal to private sector

Beyond the shuttering of existing organisations, providers that are covered under the waiver remain unsure about whether funding will restart after the 90-day period. Also large sections of the US aid establishment have been gutted.

The recent statement by health organisations argues that if this aid is terminated “patients, including children, will lose access to life-saving antiretroviral treatment, while thousands of healthcare workers will be unable to provide essential HIV care. The consequences will be immediate. Fewer people will receive timely testing and treatment, leading to more undiagnosed cases, rising infections, and the spread of drug resistance. Mortality will increase, opportunistic infections will surge, and TB rates will escalate – putting the entire population at risk.”

As such, the statement calls on private corporations, donors and philanthropists to assist in supporting these health services.

“We encourage people to get in touch with us,” says Maimela, “so that even as we hold dialogues with the government, [those people] could be part of [the conversation] and step in and say how they want to help.”

To find out how to support organisations that provide HIV and TB related health services in South Africa contact Gloria Maimela at gloriam@foundation.co.za.

Published jointly by GroundUp and Spotlight.

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Good Governance in SA’s Health System is ‘Patchy’ – Experts Unpack Report on How to Fix it

On By ModernMedia

By Elri Voigt

A timely report on governance in South Africa’s healthcare sector released last year identified several serious shortcomings. As the political and administrative wheels again start turning in 2025, we unpack the report and ask if government is paying attention.  

The signing of the National Health Insurance (NHI) Bill into law last year, sparked a renewed conversation on how the healthcare sector is governed, making the release of a consensus study on what was needed to achieve good governance and management in the South African healthcare system a few months later particularly timely. Commissioned by the Academy of Science of South Africa (ASSAF), the report was a three-year endeavour led by a panel of experts from multiple fields.

The spark for the project was concerns over the performance of the country’s healthcare system and the Life Esidimeni tragedy in particular, according to the chairperson of the ASSAF report panel Professor Lilian Dudley. The Life Esidimeni tragedy, in which 144 mental healthcare users in Gauteng died due to starvation and neglect, highlighted what the public health medicine specialist described as “not just poor performance but corruption and unethical practices in the health system”.

“There were concerns about the overall governance or oversight and leadership of the health system, and the panel was essentially asked to try and look at some of the challenges, as well as to go over the evidence and make recommendations which could be implemented to address it,” she told Spotlight.

After describing the “magnitude, the spread, and the effects of the governance challenges in the health system” as well as finding examples of where good governance was taking place, the report went on to make eight recommendations on practical strategies to improve the situation. This article focuses on three of these recommendations, so it is by no means exhaustive. The recommendations are interdependent, as is evident from the full report which can be found here.

Good governance is ‘patchy’

Sharon Fonn, Professor of Public Health at the University of the Witwatersrand who also worked on the report, told Spotlight it found that good governance in our healthcare system is “patchy”. She said there were two issues contributing to this: There are some people without the necessary competence and skills or sometimes motivation in key positions, and in some cases dysfunctional or inappropriate systems undermine the best efforts of those who are competent or have the right intentions.

There is no quick fix though. “You need to see this as a 10-year project,” Fonn said. “There’s some political leadership that’s needed, and then there’s some technical interventions that are needed. It’s about having a plan and getting people around the table,” she added.

Foundations for good governance are present but no longer ‘fit-for-purpose’

To contextualise governance within the healthcare system, the report needed to look at the past, according to Dudley. She explained that democratic South Africa “inherited a very flawed, fragmented health system, which was not being governed in order to address the needs of the majority of the population”. Thus, a lot of work had been done after 1994 to set up a unified healthcare system and establish systems and structures to lay foundations for good governance. “But we seem to have lost the plot along the way,” she said.

“One of our key findings was that there were some foundations that were put in place, but they would not be effective as governance structures and were no longer fit for purpose,” Dudley said. “Even though we have some structure, some systems, they are not really supporting and promoting the kind of governance that is needed.” In this regard, Dudley points to key legislation and policies such as the National Health Act (NHA) and the White Paper on Transformation for the Health system.

“The other context within which we are operating is the overall political environment, and health is political at the end of the day with levels of political interference,” Dudley added. “[H]aving the right people, the right competence and the right ethics in place has been a problem because a lot of senior managers in the health system are not necessarily accountable to the people they serve”.

The report stated that a conflict between two pieces of legislation – the Public Finance Management Act (PFMA) and the Public Services Act (PSA) – could be contributing to some of these problems with senior leadership and so-called “cadre deployment” in some provincial health systems. At issue are apparent contradictions and overlaps between the roles of purely political appointments, such as Members of the Executive Committees (MECs) for health, and those of senior officials like heads of health departments.

The PFMA is legislation aimed at regulating the financial management of government and providing for the responsibilities of the persons entrusted with that financial management. According to the report, the Act grants the power and responsibility for financial management, service delivery and human resource management to “accounting officers”, who are either the Head of Department or the Director-General – depending on the level of government being referred to.

By contrast, according to the ASSAF report, the PSA aims to regulate the organisation and administration of the public service, grants Ministers and MECs in the provinces the power of “executive authority” giving them the authority to, among other things, appoint people to government positions.

It is not unusual to have contradictions between pieces of legislation that were developed at different times and by different Ministers or Departments, Dr Andy Gray, a senior lecturer in the Division of Pharmacology at the University of KwaZulu-Natal’s School of Health Sciences, told Spotlight.

He said Section 38 of the PMFA describes the responsibilities of “accounting officers”, which is clearly describing a managerial function. However, every Head of Department is also subject to governance by a minister. The PSA repeats the same definition for an accounting officer as the PMFA but adds an additional definition for an executive authority.

Within the PSA, who the executive officer is depends on the level of government being referred to, for example in relation to “a provincial department or a provincial government component within an Executive Council portfolio”, the executive officer will be the member of the Executive Council responsible for that portfolio.

In the case of a provincial health department, this would mean the MEC for Health is an executive officer, who is granted by this Act all the powers and duties necessary for, among other things, “the recruitment, appointment, performance management, transfer, dismissal and other career incidents of employees of that department”.

“That does appear to contradict the separation between management and governance, so the ASSAF criticism appears to be valid,” Gray said.

Another function of governance that has not been working as it should, according to Dudley, has been the community participation aspect. She said that the NHA has delegated a lot of the power and responsibility for enabling community participation to the provincial governments. And in the cases where provincial governments have created appropriate regulations for the health committees that allow for community participation, it’s still inadequate.

As summarised by the report, the lack of clarity between these three Acts – NHA, PFMA, and PSA – “have contributed to conflicting mandates between politicians and senior managers in the public health sector, across levels of government, and between the health sector and structures for community representation”.

Legislation needs to be refined

To address some of these issues, the report recommended updating legislation and governance structures “to insulate them from vested interests and give them executive rather than merely advisory functions”.

To do so, it called for making accountability structures more effective by amending the conflicts within legislation that weaken or undermine the delegation of governance. This includes, among other steps, aligning the PFMA and the PSA, as well as clarifying and strengthening the way the NHA delegates authority between levels of government, particularly to health districts and health facilities.

The report also proposes taking steps to strengthen community governance structures like clinic committees, hospital boards and other entities. This included, among other things, reforming legislation to ensure “harmonised policies on roles and functions of such structures across all provinces” and extending community participation structures to the private sector. It also called for a common policy defining the “criteria and processes for appointments, role and functions, reimbursement of community committee members for costs, induction, and continuous capacity building”.

Systems are not working

Also hindering good governance, according to Fonn, is dysfunctional systems, such as overly complicated procurement processes and ineffective information systems. She said that whenever a problem arose with procurement, another layer of control was added, making the systems impossible to navigate.

“It must be possible to review it and to work out a more manageable process around procurement. And procurement is particularly important because it’s sort of what keeps things turning over. It’s also the space where vested interests can be exercised,” Fonn said.

Accurate information is another essential component of the health system that overall isn’t working very well, though there are exceptions. Fonn explained that the report found functional information systems in some provinces. Part of what can be done to improve governance, she said, is to take what worked in those instances and try to replicate or adapt it to work in other provinces.

Need functional fit-for-purpose systems

One of the recommendations in the report is to “surround managers and leaders with functional fit-for purpose systems (including human resources, procurement, health information systems) so that they can do their work”.

Part of this was a call to improve procurement processes by simplifying the existing overly complex and sometimes contradictory rules and delegating more of the actual procurement to facilities and district or sub-district managers.

“Overly complex procurement systems are inhibiting decentralisation, as the complexity of existing rules makes it difficult for decentralised managers,” the report stated. “This does not mean that every facility should be issuing its own medicine tenders, but there is no reason why strong sub-district offices or larger facilities should not be ordering supplies off transversal tenders without multiple layers of high-level signoff.”

Some of the suggested reforms include greater development and use of electronic systems like electronic catalogues, stock management systems, ordering systems and e-procurement systems. It also suggested including medical supplies and medical equipment in transversal tenders to achieve economies of scale.

The report also advocated for giving health institutions greater power, where appropriate, over hiring, firing and disciplinary procedures. “Within labour law and labour agreements, space must be made to allow managers to follow agreed procedures without sacrificing the public value mission of the service,” it stated.

Implementing the electronic National Health Information System of South Africa (NHISSA) was also identified by the report as an urgent priority so that patient-linked data can be collected.

Alleged lack of vision and stewardship by the National Department of Health

Another trend observed by the panelists, Fonn said, is an overall lack in a vision of the healthcare system that is being communicated by government – particularly the National Department of Health. She used the example of the NHI, where the government has been, as she described it, “unable to communicate that [NHI] in a way that captures the public imagination and in a way that makes sense to people on the ground who are actually [healthcare] providers”.

“The argument from government is that the NHI Act is simply setting in place the fund, that’s all it’s supposed to do. I understand that…and it’s a legitimate argument. The problem is then that doesn’t tell people what it means,” she added. “It’s that kind of lack of stewardship, lack of communicating a vision.”

Fonn also pointed out an apparent reluctance by the National Department of Health to engage with stakeholders and instead foster a “command-and-control environment”.

Another layer of this issue is that the healthcare system is set up in a way that makes the National Department of Health responsible for steering the system but, according to Fonn, they haven’t done this effectively and have focused on the wrong things.

“The way the South African health system is set up currently is that the National Department [of Health] is responsible for stewarding the system, for making sure that the right legislation exists, the right checks and balances exist, and the right controls exist,” said Fonn.

“I think that at least in part, they haven’t [fulfilled that responsibility]. It’s a complex thing to do so I’m not suggesting it’s easy. But I don’t think they’ve had their eye on the right place,” she said.

“What our report does acknowledge is that there are many good people in the health system who actually want to see improvements, who are committed to good leadership and management and governance,” Fonn said. “But I think we need leadership to kind of show the way and one of the first things that we felt was important was to revisit what our public values are, what are the social goals that we want to set for the health system, and can we all agree on that and move towards that? [We need] that kind of leadership and stewardship from the political and national government level.”

Mixed response from government

Spotlight asked the National Department of Health and Minister of Health Dr Aaron Motsoaledi for their responses to the report and its findings. The spokesperson for the health department indicated he had only been able to access an abstract of the report and would not be able to respond without seeing the full report. A copy of the report was then sent to the spokesperson, but no response or comment was received by the time of publication (more than a week later).

However, according to Dudley, the report was presented last year to the Minister of Health, senior managers in the provinces, and health MECs.

“There was actually quite a bit of interest from the new MECS [for health] … the MECs were quite keen to hear more about it, engage more about it and wanted to know what we need to do to actually respond and to start implementing some of these recommendations,” she said.

By comparison, Dudley said there was less interest from the National Department of Health.

She however pointed out that the burden of changing governance in the healthcare system doesn’t rest entirely on the health department’s shoulders.

“There are multiple stakeholders that need to take action, we do try to emphasise that in the report. Yes, government and politicians do have particular roles, but everybody has a role,” Dudley said.

These include academic institutions, she said, which need to ensure when training health professionals and leaders they are provided with the kind of competencies that will improve the management, leadership and governance of the health system.

Research institutions also have a role to play in addressing some of the unanswered questions around governance and how to implement interventions that can bring about change. Civil Society will also have a part to play through activism to hold those in positions of power to account.

Republished from Spotlight under a Creative Commons licence.

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Stopping Health Funding in Africa Weakens America

On By ModernMedia

This is an opportunity for President Ramaphosa to lead

Photo by Andy Feliciotti on Unsplash

By Nathan Geffen and Marcus Low

President Donald Trump’s administration took a cruel decision this past week to freeze US foreign aid for health, potentially leaving millions of people in many African countries without their life-saving antiretroviral treatment.

On Wednesday morning, Trump’s secretary of state Marco Rubio backtracked on part of that decision. But if it is not reversed permanently we can expect advances in life expectancy in sub-Saharan Africa of the past two decades to start coming undone. We can also expect HIV infection rates to start picking up again, as people with HIV start getting viral rebound and become more infectious.

The President’s Emergency Plan for AIDS Relief (PEPFAR) was started by the Republican administration led by George W. Bush in 2003. The complexity of world politics is such that the president who perhaps did more than anyone else to unravel confidence in global rules and norms – by invading Iraq – also championed a programme that has saved many millions of lives. Bush described PEPFAR as “compassionate conservatism”.

PEPFAR had bipartisan support. It is one of the greatest contributions the US has made to the world. It is now under threat by people claiming with straight faces – who came to power while the US economy is booming – to make America great again.

About $5-billion went into PEPFAR last year. Although it’s a huge amount of money it’s a tiny fraction of the US budget. It’s not straightforward to measure how many lives PEPFAR has saved but it is in the millions. This is a lot of bang for the buck.

The US government is also the largest contributor to the other major funder of global health: the Global Fund. Its future is also bleak.

Already in South Africa, vital services for extremely vulnerable clients had to pause, such as those provided by the Wits Reproductive Health and HIV Institute clinics in Johannesburg. Hopefully with Rubio’s announcement these can now resume but the situation remains chaotic and the future of this and other US-funded health programmes across Africa is fraught with uncertainty.

Opportunities

America’s abandonment of foreign aid for health relinquishes soft power. There is an opportunity here for the European Union, Canada, Australia, Japan and China to step into the breach and increase their contributions to the Global Fund, or even to directly plug holes left by PEPFAR using bilateral aid – though such funding may come too late for some.

This would not merely be an act of charity. In the post-World War II world, what has made countries great, powerful, prestigious and influential is not nastiness and murder, but investing in projects of solidarity that make the world a better place. US wars in Vietnam, Afghanistan and Iraq degraded US power. Its arming of Israel, especially during the war on Gaza, has shown US concern for universal human rights to be hypocritical and worsened its global standing. By contrast PEPFAR unequivocally enhanced its superpower status.

President Cyril Ramaphosa can display great leadership by meeting with leaders of wealthy countries and convincing them to increase spending to support the health systems of poorer countries.

But perhaps the biggest opportunity is for African countries themselves. Many remain far too dependent on foreign aid to run their health systems. A country like South Africa should be able to pay for every last cent of its health systems. Corruption and mismanagement have had an inordinate role in making this difficult.

For countries like Malawi, Mozambique and others, there is a long way to go before they can pay their own way for HIV treatment. But pressure, from within and out these countries, must be put on their governments to build robust economies capable of delivering tax revenue to spend more on health.

In a very divided world where illiberal nationalist populism is on the rise and African governments are for the most part still weak and corrupt, these opportunities seem unlikely to be seized. But we hope we are proven wrong.

Geffen is the editor of GroundUp. Low is the editor of Spotlight. Both served in the Treatment Action Campaign which successfully campaigned for HIV medicines in South Africa, as well as other countries.

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Pressure Grows for NHI Compromise Ahead of Cabinet Lekgotla

On By ModernMedia

By Chris Bateman

Whether or not the ANC and DA can find common ground on the future of medical schemes is set to be a major test of South Africa’s Government of National Unity. Ahead of a Cabinet lekgotla where the issue is expected to be on the agenda, momentum has been gathering behind a compromise option. 

Little more than a month after President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law in May last year, the ANC entered into a government of national unity (GNU) following a large drop in their share of the vote in South Africa’s 2024 elections. This raised questions over the future of NHI, given that the second largest party in the GNU, the DA, is vehemently opposed to NHI.

The NHI Act has not yet been promulgated and could be amended if the ANC and DA agree to do so. But whether the parties can agree to a compromise remains unclear, especially since there appears to be a hardline faction in the ANC that is committed to NHI as currently encapsulated in the NHI Act. As it stands, the Act foresees a dramatically reduced role for medical schemes whereby they will not be allowed to cover services that are already covered by the NHI fund.

Also in play are at least four High Court challenges to NHI legislation – by the Board of Healthcare Funders (BHF) challenging Ramaphosa’s assent to the NHI Bill just before the elections last year, Solidarity, and the SA Private Practitioners Forum, both claiming government overreach which impacts on people’s right to choose their own health cover and run their own businesses. The South African Medical Association (SAMA) is also preparing a legal challenge.

Two proposals

Meanwhile, momentum has been growing with two compromise proposals: one from Business Unity South Africa (BUSA), the country’s apex business organisation broadly representing the banking, mining and retail sectors, but more pertinently here, the Health Funders Association, the Hospital Association of South Africa, and the Innovative Pharmaceuticals Association of SA. The other is from the United Healthcare Access Coalition (UHAC), a large coalition of healthcare worker groups including, among others, SAMA, the South African Private Practitioners Forum, and the Progressive Healthcare Forum.

BUSA last year met with Ramaphosa and, on his request, provided a detailed yet currently “confidential” proposal, wanting key sections of the NHI Act amended and/or thrown out to enable medical schemes to remain in play by punting mandatory health insurance.

“The BUSA proposal is being processed by the Department of Health and National Treasury. Once processed, a response to BUSA will be formulated accordingly,” presidential spokesperson Vincent Magwenya told Spotlight this week.

The fundamental difference between the two objecting groups is that the UHAC thinks the NHI Act should be thrown out completely and replaced with their detailed blueprint, while BUSA wants the existing Act amended to accommodate private funders. In its proposal, the UHAC urges implementation of long delayed fundamental systemic reform in both healthcare sectors to enable what they say would be efficient, pragmatic and more politically neutral, consultation-driven universal healthcare measures.

We understand that in a meeting between the two groups, shortly before BUSA lodged its proposal with the Presidency, not enough common ground could be found to join forces.

But there are significant overlaps in their proposals. Both groupings embrace mandatory health insurance and dismiss a single central fund as envisaged under NHI as dangerous and financially unfeasible.

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DA spokesperson for health, Michelle Clarke, said her party backs mandatory insurance. She also said the party agrees with the UHAC proposals – and would not hesitate to mount a legal challenge should the NHI go ahead without substantial amendments.

Mandatory health insurance was part of government’s longer term health reform plans until the pendulum swung in favour of NHI at the ANC’s national conference in Polokwane in 2007 when Jacob Zuma became president of the party. The idea was placed back in the spotlight last September when Dr Richard Friedland, immediate past CEO of the Netcare Hospital Group and a key member of BUSA’s health delegation, made the case for it at the HASA conference.

Under mandatory health insurance, everyone who is in formal employment, or who earns above a certain threshold, would be forced by law to be a member of a medical scheme. This, it is argued, would result in medical scheme membership swelling substantially and pressure being taken off the public healthcare system. It is also expected to result in medical scheme premiums being reduced because more healthy, younger people will join the schemes. People who are unemployed or who cannot afford health insurance will still be taken care of by the public healthcare system, which would also take paying medical aid members.

Friedland said at the time that mandatory healthcare insurance would triple the medical scheme market from 9.2 million to potentially 27.5 million beneficiaries over time and reduce those dependent on the state from 53.8 million to 35.5 million.

This week Friedland declined to reveal the contents of the BUSA proposal, saying it was with Ramaphosa and thus confidential.

Meanwhile, Health Minister Dr Aaron Motsoaledi last week rubbished media reports that the cabinet lekgotla scheduled for month end would be taking on board the BUSA proposal. He did however confirm that he will shortly announce which of the far-ranging and long-outstanding recommendations of the Competition Commission’s Health Market Inquiry (HMI) into the private healthcare sector will be implemented, something many have been calling for in recent years.

Far-reaching reforms

Adjunct Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, who with Dr Aslam Dasoo, founder and chair of the Progressive Health Forum, forms part of the UHAC, said their fundamental point of departure is that the status quo is unacceptable.

According to the UHAC report, irregular provincial health expenditure levels provide a proxy indicator for corruption. The combined irregular expenditure for eight of the nine provinces from 2017/18 to 2022/23 consistently averages around 12.3% (around R9 billion per annum) of non-personnel expenditure compared to 0.1% for the DA-run Western Cape.

“The difference in performance between the Western Cape and the other eight provinces is reasonably attributable to governance differences,” the report reads.

Observes Van den Heever: “We’re losing an enormous amount of performance in the public sector because of political appointments into the system. It compromises leadership and results in a massive waste of resources. The Western Cape shows you the difference governance can make.”

He said that in the “dismally” regulated private sector, funding the pooling system was identified as a problem even before 1994, “but you don’t now disrupt the system to amalgamate into a monopoly fund to solve this (i.e. NHI). Risk equalisation would force medical schemes to compete on the value of what they cover, and nobody would be discriminated against in accessing healthcare.”

Van den Heever says the NHI intention to increase taxes and move funding money from the private to the public sector is “unworkable”.

He added: “The way to address pooling problems is to separate pooling from purchasing. The NHI process has pooling and purchasing in the same organisation, centralising everything – which is highly inefficient, unworkable and with negative consequences all the way through.

“The UHAC proposal separates them out with the provinces and medical schemes remaining as purchasers while strategic pooling or resource allocation is a national function. So, risk equalisation and taxation form part of strategic national pooling functions, while the purchasing and provision of health services are protected from political appointments – including national ministers and provincial MECs.”

Dasoo, who is also a founder member of trade union NEHAWU, said the UHAC collaborative proposal draws on all the research developed over several decades including the Taylor Commission, which made recommendations on an effective social security system for South Africa, the HMI, and numerous other official inquiries.

Dasoo described the UHAC report as “everything that the NHI is not. This health pathway requires easy legislative changes and is within current fiscal constraints. We can start the process immediately. It requires a change in governance structure of the provincial health systems where politicians relinquish all direct authority they have over health care institutions and instead focus on strategic policy.”

BHF hearing in March

A spokesperson for the BHF, Zola Mtshiya, confirmed their NHI legal challenge, set for hearing in March, but said the BHF was only invited to sign up to the UHAC proposal after it was made public. The BHF represents most medical aid schemes – except for the largest, Discovery Health.

BHF Managing Director, Dr Katlego Mothudi, said his organisation is “engaging the association [UHAC] on the document”. he added: “We welcome the willingness to collaborate as an industry as strengthening health systems is everybody’s business.”

Cabinet lekgotla next week

Despite all these developments, whether the ANC is open to a potential compromise on NHI remains unclear. On the one hand, the presidency says they have asked Treasury and the Department of Health to consider the BUSA proposal, on the other, Motsoaledi has rubbished suggestions that the ANC’s position on NHI has shifted and appears committed to an NHI system that dramatically limits the role of medical schemes. His position is thus incompatible with that of the DA.

According to media reports, things got very heated between Motsoaledi and DA ministers when NHI and the future role of medical schemes were discussed at a Cabinet meeting last October.

The matter is likely to again be on the agenda at the Cabinet lekgotla set to take place next week.

Asked about how the GNU might eventually influence universal healthcare, Clarke said: “ANC arrogancy has tapered down a lot compared to what I’m used to. There’s a lot more transparency – but we cannot allow for a very badly written law with huge implications for people’s lives and the economy to go ahead.”

Foster Mohale, spokesperson for the national health department, declined to provide comment for this article, referring Spotlight to the Presidency and Motsoaledi. “What I can say is we’re still working on the Health Market Inquiry recommendations and will let you know when there’s an announcement,” he said.

Magwenya did not provide responses to most of Spotlight’s questions, other than saying that both Treasury and the health department are considering the BUSA proposal and confirming that the President had met with BUSA.

Republished from Spotlight under a Creative Commons licence.

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Healthcare Organisations React to US Withdrawal from the WHO

On By ModernMedia

One of the first acts President Trump took on assuming office again on January 20, 2025, was to unilaterally withdraw the United States from the World Health Organization (WHO). Trump complained of the WHO’s “mishandling” of the COVID pandemic, influence by other countries, and the US financial support was excessive compared to China, which “has 300 percent of the population of the United States, yet contributes nearly 90 percent less to the WHO.”

The WHO released a statement, expressing its regret at the decision and pointing out its importance: “WHO plays a crucial role in protecting the health and security of the world’s people, including Americans, by addressing the root causes of disease, building stronger health systems, and detecting, preventing and responding to health emergencies, including disease outbreaks, often in dangerous places where others cannot go.”

The organisation also took aim at Trump’s criticism of its lack of reforms: “With the participation of the United States and other Member States, WHO has over the past 7 years implemented the largest set of reforms in its history, to transform our accountability, cost-effectiveness, and impact in countries. This work continues.”

Critics say that the move would only hand China the opportunity to effectively take control of global health if it chooses to becomes the WHO’s main contributor: though the US is the single largest contributor, it contributed only $1.3 billion in the 2022-23 biennium. An affordable amount compared to the vast sums both countries spend on their militaries. While the WHO did lavish praise on China, many experts saw it as undue and perhaps concerning – but China’s contribution, while currently small, is rising: $86 million in the 2018-19 biennium. After the US, the next largest contributors are Germany ($856 million) and the Bill and Melinda Gates Foundation ($830 million).

The Society for Healthcare Epidemiology of America (SHEA) stressed the importance of global health cooperation. In a statement, the organisation wrote: “It is essential that the United States continues our connection with the WHO to coordinate surveillance, monitoring, detection, prevention, research, and response to public health threats including outbreaks, antimicrobial resistance and high consequence pathogens such as viral haemorrhagic fevers (Ebola, Marburg), Mpox, and highly pathogenic avian influenza (eg, H5N1).”

Indeed, Trump may not simply be able to withdraw by presidential decree; since the US joined the WHO by an act of Congress, it would likely take congressional approval to leave it and Trump may face a lawsuit over this.

Trump previously announced his intention to withdraw the US from the WHO in 2020, something which Gostin et al. warned in The Lancet would not work out well for the US and the world. “Withdrawal from WHO would have dire consequences for US security, diplomacy, and influence. WHO has unmatched global reach and legitimacy.” Additionally, they warned of the sheer difficulty of such a messy divorce: “The US administration would be hard pressed to disentangle the country from WHO governance and programmes.”

Categories : General Interest Healthcare Politics and RegulationsTags :

Health in 2024: The Year in Fewer than 1000 Words

On By ModernMedia

By Marcus Low and Adiel Ismail

From the NHI Act to major advances in HIV prevention, it has been another busy year in the world of healthcare. Spotlight editors Marcus Low and Adiel Ismail recap the year’s health developments and identify some key trends in fewer than 1000 words. 

For a few weeks in June, it seemed that the surprising outcome of South Africa’s national and provincial elections would usher in far-reaching political and governance changes in the country. As it turns out, some significant changes did come, but not in the health sector. 

Rather than a new broom, it was déjà vu as Dr Aaron Motsoaledi returned as Minister of Health – he was previously in the position from 2009 to 2019. In both Gauteng and KwaZulu-Natal – the country’s most populous provinces – ANC MECs for health from before the elections kept their jobs. The ANC garnered well under 50% of the votes in both of those provinces and nationally and accordingly had little choice but to form national and provincial coalitions. 

To be fair, five of the nine MECs appointed after the elections were new, but these changes were mainly in the less populous provinces. 

Policy-wise, the trajectory also remains much as it was a year ago. Two weeks before the elections, President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law (though most of it has not yet been promulgated). While Ramaphosa has since then asked Business Unity South Africa (BUSA), the country’s largest employer association, for new input on NHI and while talk of mandatory medical scheme cover had a moment in the headlines, there is no solid evidence that the ANC is open to changing course – if anything, Motsoaledi has doubled-down in the face of criticism. The Act is being challenged in various court cases. 

The sense of discord in healthcare circles was further deepened in August when several organisations distanced themselves from Ramaphosa’s updated Presidential Health Compact. The South African Medical Association, the South African Health Professionals Collaboration—comprising nine associations representing over 25 000 public and private healthcare workers—and BUSA all declined to sign the accord. BUSA accused government of “unilaterally” amending the compact “transforming its original intent and objectives into an explicit pledge of support for the NHI Act”.  

Away from these reforms, a trend of health budgets shrinking year-on-year in real terms continued this year. This funding crunch, together with well-documented shortages of healthcare workers, has meant that even well-run provincial health departments are having to make impossible trade-offs – that while governance in several provincial health departments remains chronically dysfunctional. This was underlined by a landmark report published in July that, among others, highlighted leadership instability, lack of transparency, insufficient accountability mechanisms, and pervasive corruption. New reports from the Auditor General also didn’t paint a pretty picture. 

Gauteng health has again been in the headlines for the wrong reasons. The provision of cancer services in the province remains mired in controversy as the year comes to an end, with plans to outsource some radiation services to the private sector apparently having stalled, despite the health department having the money for it. A deal between the department and Wits University was also inexplicably derailed. With high vacancy rates, serious questions over senior appointments, reports of corruption at Thembisa Hospital, and much more, it seems that, if anything, governance in the province has gotten even worse this year. 

In a precedent-setting inquest ruling in July, Judge Mmonoa Teffo found that the deaths of nine people moved from Life Esidimeni facilities to understaffed and under-equipped NGOs “were negligently caused by the conduct of” former Health MEC Qedani Mahlangu and former head of the provincial health department’s mental health directorate Dr Makgabo Manamela. 

Outside our borders, Donald Trump’s election victory in the United States is set to have far-reaching consequences. A return of the Global Gag Rule seems likely, as does major changes to the Food and Drug Administration, the President’s Emergency Plan for AIDS Relief, and the National Institutes of Health – the latter funds much HIV and TB research in South Africa. 

Away from politics and governance, the biggest HIV news of the year came in late June when it was announced that an injection administered every six months was extremely effective at preventing HIV infection. It will likely be several years before the jab becomes widely available in South Africa.

Another jab that provides two months of protection per shot is already available here, but only to a small number of people participating in implementation studies. 

It is estimated that around 50 000 people died of HIV related causes in South Africa in 2023 and roughly 150 000 were newly infected with the virus (reliable estimates for 2024 will only be available in 2025). A worrying one in four people living with HIV were not on treatment in 2023. There was an estimated 56 000 TB deaths and around 270 000 people fell ill with the disease. While these HIV and TB numbers have come down dramatically over the last decade, they remain very high compared to most other countries. 

There are some concerns that a new TB prevention policy published in 2023 is not being universally implemented. We have however been doing more TB tests, even while TB cases are declining – as we have argued, this is as it should be. Also positive, is that a massive trial of an TB vaccine kicked off in South Africa this year. 

With both TB and HIV, South Africa is making progress too slowly, but we are at least trending in the right direction. With non-communicable diseases such as diabetes, there are unfortunately signs that things are getting worse. As we explained in one of our special briefings this year, our diabetes data in South Africa isn’t great, but the little we have painted a worrying picture. As expected, access to breakthrough new diabetes and weight loss medicines remained severely constrained this year, largely due to high prices and limited supply. 

Ultimately then, at the end of 2024, South Africa is still faced with chronic healthcare worker shortages, severe governance problems in several provinces, and major uncertainties over NHI – all while HIV and TB remains major public health challenges, though a shift toward non-communicable diseases is clearly underway. 

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags :

The NHI Act: a Flawed Execution of a Laudable Idea

On By ModernMedia

By Prelisha Singh, Partner, Martin Versfeld, Partner and Alexandra Rees, Senior Associate, Webber Wentzel

Robust contestation on how to best fulfil the fundamental rights of South Africans complements and strengthens our constitutional democracy. Recent debate has centred on the effective realisation of the right to access healthcare, which the state is required progressively to realise for all South Africans, irrespective of their background and income.

The right to access healthcare came into sharp focus on 15 May 2024, when President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law, prompting the initiation of constitutional challenges by concerned stakeholders. The most recent of these was filed on 1 October 2024 in the North Gauteng High Court, Pretoria by the South African Private Practitioners Forum (SAPPF), represented by Webber Wentzel.

According to the government, the NHI Act is intended to generate efficiency, affordability and quality for the benefit of South Africa’s healthcare sector.

An assessment of South Africa’s current healthcare landscape shows a stark difference between private and public healthcare. The country has a high quality, effective private healthcare offering. However, it is currently inaccessible to the many South Africans who cannot afford private care or medical aid payments. Public healthcare, on the other hand, is understaffed, poorly managed and plagued by maladministration and limited facilities.

The NHI Act has been positioned as the vehicle to address this disparity and a desire to take steps towards achieving universal healthcare in South Africa. But a closer reading of the Act highlights numerous problems with its content and implementation design. The absence of clarity, detail or guidance contained in the Act makes it impossible to assess how the Act will actually be implemented (or, by extension, what the effects of this implementation will be).

This is particularly concerning given that years have passed since the economic assessments, on which the Act was based, were undertaken. Also problematic is the apparent lack of consideration given by the government to submissions made by affected stakeholders during multiple rounds of constitutionally required public participation.

SAPPF underscores these deficits in seeking both to have the President’s decision to assent to the Act reviewed and set aside, and the Act itself declared unconstitutional.

President Ramaphosa was obliged, in terms of sections 79 and 84(2)(a) to (c) of the Constitution, not to assent to the Act in its current form. Section 79 requires the President to refer back to Parliament any bill that he or she believes may lack constitutionality. In this case, it is difficult to conceive how the President, or any reasonable person in the President’s position could not have had doubts regarding the constitutionality of the NHI Bill. The decision by the President to sign unconstitutional legislation into law, instead of referring it back to Parliament for correction, is also irrational.

The President’s duty properly to have referred the NHI Bill back to Parliament is affirmed by the fact that the President is enjoined, by section 7(2) of the Constitution, to respect, protect, promote and fulfil the rights contained in the Bill of Rights.

SAPPF’s application demonstrates that the NHI Act, in its current form, infringes upon the rights to access healthcare services, to practice a trade, and to own property. Patients, including those using private healthcare, will be forced to use a public healthcare system that currently fails to meet its key constituents’ needs. Practitioners’ rights to freedom of trade and profession will be infringed upon, and the property rights of medical schemes, practitioners, and financial providers will be unjustifiably limited.

On its current text, the Act could make South Africa the only open and democratic jurisdiction worldwide to impose a national health system that excludes by legislation private healthcare cover for those services offered by the state – notwithstanding the level or quality of case.

Concerns regarding the rights infringements in the NHI Act are exacerbated by its lack of clarity and the fact that crucial aspects of its implementation are relegated to regulations, with no clear guidance provided in the Act itself.

For example, section 49 provides that the NHI will be funded by money appropriated by Parliament, from the general tax revenue, payroll tax, and surcharge to personal tax. However, this stance does not reconcile with section 2, which provides that the NHI will be funded through ‘mandatory prepayment’, a compulsory payment for health services in accordance with income level. Crucially, the extent of the benefits covered by the NHI’s funding mechanism and its rate of reimbursement, which impact affordability and the provision of quality healthcare, remain unknown.

The Act is, at best, a skeleton framework, seemingly assented to in haste. It is conceptually vague to the extent that the rights it seeks to promote will, in fact, be infringed if implemented. This renders the Act irrational, in addition to its other constitutional defects.

The NHI Act represents a radical shift of unprecedented magnitude in the South African health care landscape. This should be – and is required to be – underpinned by meaningful public participation, up-to-date socio-economic impact assessments and affordability analyses and final provisions that provide a clear and workable framework for implementation.

It is not sufficient for these vital issues to be addressed after the fact. Further engagements with stakeholders and the solicitation of proposals by the government cannot be used to splint broken laws. Collaborative engagement, including the solicitation of inputs for meaningful consideration, should take place during the law-making process, not after its conclusion.

A shift of the magnitude proposed by the Act, absent compliance with the structures of the law-making process and adherence by the state to constitutional standards, including rights protections, would be detrimental to the entire healthcare sector – public and private – and not in the best interests of patients and practitioners.

Notwithstanding the legal contestation surrounding the Act, it and the laudable goals underlying it can also be a watershed. The achievement of universal health coverage is an opportunity for the different stakeholders in South Africa’s healthcare system to meaningfully collaborate and inform well-supported, factually informed, rational and genuinely progressive legislative steps by the state.

Given the questions surrounding the Act and the evident need it seeks to address, the space exists for healthcare stakeholders to align around shared goals and values. They can leverage their available resources to design a healthcare system that serves all of South Africa’s people fairly and equitably, using the significant existing resources invested in the country’s healthcare sector.