A Competition Commission probe recently resulted in a patent on an important tuberculosis medicine being dropped in South Africa. Twenty years ago, a similar Competition Commission case resulted in a settlement that helped drive down the prices of several antiretrovirals, thereby helping to set the stage for the country’s HIV treatment programme. Fatima Hassan and Leena Menghaney connect the dots between the two landmark cases and map out what has and has not changed over the last two decades.
In the late 1990s and early 2000s, South Africa faced a major uncontrolled AIDS epidemic, worsened by state sponsored AIDS denialism. South Africa was at the epicentre of a global epidemic, with hundreds of thousands of people getting sick and dying, needlessly, because lifesaving antiretroviral medicines were out of reach.
This was in the main because of the Mbeki government’s deadly science denialism denying public sector patients antiretrovirals and the high cost of some of these medicines, which at the turn of the century was available in the private sector but only for the very rich or medically insured. The private sector price for the combination of three antiretrovirals needed by most people living with HIV was exorbitant.
This was because of patent monopolies held at the time by multinational pharmaceutical companies, particularly GlaxoSmithKline (GSK) and Boehringer Ingelheim (BI). In essence, people in South Africa living with HIV had to beg to live – by seeking donations and charity or pressuring their respective medical schemes to provide coverage. Meanwhile, lifesaving antiretrovirals were generally available in the Global North and in some parts of the Global South where governments like those in Thailand and Brazil had taken action to reduce prices.
Looking for a way to challenge the high prices of key antiretrovirals, activists turned to South Africa’s newly revamped post-apartheid competition law. In September 2002, the Treatment Action Campaign, Hazel Tau, a woman living with HIV and several others lodged a complaint with the country’s Competition Commission. They alleged that the price that GSK and BI were charging for important antiretrovirals was excessive and anti-competitive, undermining not just Competition Law but also the right to health as enshrined in the country’s still fairly new Constitution.
The Competition Commission agreed to investigate. Several months later, they announced that there was a prima facie case of excessive pricing and that they would be referring the matter to the Competition Tribunal (the next phase of a complaint to the Competition authorities). Almost immediately after that announcement, TAC was approached by GSK and BI to “settle” the matter. This meant there would be no public hearings, and the companies would not have to defend their pricing decisions in the dock.
The terms of the settlement, negotiated by the TAC’s legal team, mirrored what TAC had publicly demanded at the beginning of the case. Most importantly, GSK and BI agreed to grant voluntary licenses to several generic manufacturers that would allow them to make and sell the antiretrovirals in question. It was this generic competition that would drive down the prices of antiretrovirals in the years that followed.
Even though the Competition Commission only has jurisdiction in South Africa, the licenses included many other African countries, which meant those countries could also benefit from the generic competition and lower prices. The settlement (including the terms of the voluntary licenses) was agreed to by the Competition Commission, made an order and publicly announced, leading to the conclusion of the complaint.
The case, which came to be known as the Hazel Tau case, would in the years to come be recognised as one of the foundations that made large HIV treatment programmes possible in South Africa and other African countries. Despite this victory, the ongoing effects of AIDS denialism meant that it would in reality be several years before the more affordable generic antiretrovirals would be made widely available in South Africa.
20 years later, the spotlight is on TB drugs
HIV has not been the only health crisis to affect SA. According to the World Health Organization (WHO), Tuberculosis (TB) is one of the leading infectious causes of death globally, and drug-resistant TB (DR-TB) remains a public health crisis. The WHO estimates that around 304 000 people fall ill with TB in South Africa per year, and it claims over 50 000 lives, which means it remains one of the country’s top killers. While TB rates are slowly declining, there is concern that rates of drug-resistant forms of TB (DR-TB) are increasing. DR-TB requires newer, more expensive treatments.
Slow growth in health sector spending is projected in Sub-Saharan Africa as reported in a study published in the open access journal, PLOS Global Public Health. The decline is expected to continue to 2050, according to Angela E Apeagyei and researchers at the Institute for Health Metrics and Evaluation, University of Washington, Seattle, and is driven by tepid growth in the share of government spending that is allocated to health and reductions in development assistance for health.
The research analyses data from databases covering development assistance for health, global health spending and gross domestic spending (GDP) per capita as well as an expected health spending database which provides projected health spending data to 2050. It finds that except for central and eastern Europe and Central Asia, around the world total health spending is expected to rise as a share of GDP, but in Sub-Saharan Africa (except in southern sub-Sahara Africa) it is expected to decrease.
Beyond the challenge of a low prioritisation of the health sector in the government budget, another major driver of this decline is a reduction in development assistance for health. The Millennium Development Goals led to a period of growth in health funding, and development assistance for health grew on average 11.1% annually from 2000 until 2015. It has since dropped to just 4.6% and was particularly hit by the global economic issues caused by the COVID pandemic and subsequent economic shocks such as the war in Ukraine. Although government spending on health in Sub-Saharan Africa has increased, and is expected to continue to rise, the gap left by decreases in development assistance will not be met.
Without improvements, this trend will pose a significant challenge to meeting health-related Sustainable Development Goals and the African Union’s Africa Agenda 2063. The authors hope that their analysis will help policymakers understand future health spending patterns and can translate the insights into tangible actions that can help navigate the region’s complex economic and health challenges.
The authors add: “For countries in sub-Saharan Africa, the projected growth in donor and government funding for health is expected to be significantly lower compared to countries in other regions. This worrying trend underscores the need to prioritise innovative financing strategies to strengthen health systems in line with the region’s economic growth and the broader health needs of its population.”
In a press release, the South African Health Products Regulatory Authority (SAHPRA) has hit back over what it terms “unfounded fallacies and misrepresentation” that has been “churned out by some media organisations without verification” over its draft B-BBEE Policy.
SAHPRA states that this policy “is proposed in order to comply with requirements of the Broad-Based Black Economic Empowerment Act, 53 of 2003, in particular Section 10(1)(a), which demands of all state entities to enact policy that can encourage inclusive economic participation.”
It states that the draft B-BBEE policy does not set “racial requirements” for the registration of medicines, as the first falsehood suggests, stating that it is not reflected in any of the documents.
The second falsehood is that “SAHPRA will use the B-BBEE to assess medicine registration applications and thus affect access to medicines”, which it says is a deliberate misrepresentation. The product registration processes “would continue to solely rely on the safety, quality, efficacy, and performance of the health products.”
The third falsehood is that the draft policy is aligned with NHI, seeking to exclude certain persons from state procurement. SAHPRA says that the policy is a move develop sector codes and/or criteria to comply with the B-BBEE Act, as has been done in other sectors of the economy.
SAHPRA states that the fourth and final falsehood is that the policy will deny participation by pharmaceutical SMEs as they may be unable to get B-BBEE certificates. The agency contends that compliance affidavits will be an acceptable alternative, and that in any case, the B-BBEE level of a business does not affect the medicines registration process – which will remain the case even after policy implementation.
As part of a series of podcasts titled “Advancing Healthcare” that examine the critical issues that must be addressed to achieve universal healthcare, Russell Rensburg of the Rural Health Advocacy Project calls for a focus and prioritisation of rural health.
Across rural South Africa, the health profile of South Africans is changing. Thanks to the rollout of antiretroviral drugs, South Africa’s life expectancy has increased, and with that, the population is getting older. While this is good news, an ageing population does bring new challenges to the healthcare system.
Rensburg noted that as part of the success of the HIV response in the last 10 years, there has been an increase in life expectancy. But the challenge is that as disease profiles change, health care needs change too. “We need to respond to the differing health needs of young people and older populations,” he adds.
According to Rensburg, available data shows we must start taking differentiated approaches to delivering healthcare for different population segments. However, more data is required because no one knows the prevalence of certain diseases, like cancer. Also, lacking management data means little information on how facilities are run. Without the right data, he says, “We haven’t figured out a way of doing health promotion and health literacy.”
The Rural Health Advocacy Project is a division of Wits University’s health consortium, and it aims to promote better health care for rural communities. However, providing meaningful rural health care requires understanding that each province within South Africa has its own challenges.
In Kwazulu-Natal, for instance, a recent study involving basic screening found high levels of diseases like diabetes and tuberculosis in people who had never accessed the healthcare system.
The Eastern Cape, says Rensburg, has too many hospitals that are expensive to run. “Some of those hospitals they don’t need,” he said. “There are, like, 91 district hospitals in the Eastern Cape; many of them are like old mission hospitals that, in my view, are sometimes too expensive to run.”
Limpopo, says Rensburg, has a malnutrition problem. “They have severe acute malnutrition rates that are quite high, which is ironic because it’s kind of a breadbasket province,” he said.
Another overreaching problem that healthcare professionals have to deal with in the rural districts of South Africa is that patients often bypass the community clinics and go to the hospitals when they need medical attention.
These clinics are bypassed because of negative experiences where patients endure day-long queues and medicines that aren’t in stock. “They go to the hospital, which costs probably five or six times more for the state to deliver that care,” explained Rensburg.
Rensburg believes more community health workers should be hired, and their training should be standardised to improve rural health care. “We need to professionalise them because it’s an opportunity to create employment in parts of the country with low economic activity,” he said.
According to Rensburg, other interventions that could improve rural health care could include cutting queuing times, improving antenatal care, and making maternity care easier to access. Pregnant mothers can wait up to 14 hours to access a bed.
Access to better management data would help in the better running of facilities. “I think the first baseline into improving healthcare is getting more people to understand their health status. And I think how we do that is being much more focused on gathering information. And then using that information for decision-making,” Rensburg said.
However, improving the well-being of South Africans living in the rural parts of the country goes beyond what the health sector can offer. “So maybe something like a Basic Income Grant could have a massive impact on people’s health, particularly in the rural areas where unemployment is 90%.” The basic income grant could help reduce malnutrition, Rensburg adds.
What could influence rural health soon is NHI. “I think the NHI is an opportunity to change how we deliver healthcare,” said Rensburg. “But when you look at the NHI proposals, it was about restructuring public-funded health care services. The whole thing talks about how we better manage hospitals by giving them their budgets.” Rensburg adds that restructuring publicly funded services, prioritising district health services, and improving the efficiency and efficacy of central, tertiary and regional hospitals by giving them greater autonomy should also be considered key to improving rural health.
This podcast, which is part of a series that aims at creating critical discussion around achieving universal health care, can be accessed at https://hasa.co.za/hasa-podcasts/
Nomantu Nkomo-Ralehoko is sworn in by Judge Lebogang Modiba as the new MEC for Health. (Photo: Gauteng Provincial Government)
By Ufrieda Ho
ANC support in Gauteng dipped below 40% in the recent provincial elections and an ANC-led minority government is now at the helm. Among those in Premier Panyaza Lesufi’s new Cabinet is Nomantu Nkomo-Ralehoko who’s been reappointed as MEC for Health and Wellness.
Nomantu Nkomo-Ralehoko was first appointed Gauteng’s MEC for Health and Wellness in October 2022. A long-time ANC member, she previously served as MEC for Finance and e-Government and has been a member of the provincial legislature since 1999.
She returns to the critical role at a time when the province’s health department, based on extensive reporting by Spotlight and other publications, remains mired in a chronic cycle of administrative and service delivery dysfunction.
At just under R65 billion for the current financial year, the department gets a massive slice of the Gauteng budget. While the National Department of Health leads on health policy, the day-to-day running of public healthcare services is managed by provincial departments of health.
The Gauteng health department has a high number of vacancies. On the administrative side this includes the critical position of a chief financial officer (CFO). The previous CFO, Lerato Madyo, was suspended in August 2022. Her case is still to be concluded. Research conducted last year by community healthcare monitoring group Ritshidze found that the majority of healthcare facility staff and public healthcare users that they surveyed felt that healthcare facilities were understaffed.
Madyo’s case is connected to ongoing investigations into corruption at Tembisa Hospital undertaken by the Special Investigating Unit. This was also the issue that whistle-blower Babita Deokaran was investigating before she was assassinated in August 2021. Deokaran was acting chief finance director before she was killed. Since her death it’s been confirmed that there was corrupt spending to the tune of R1bn at Tembisa Hospital.
When Nkomo-Ralehoko answered 10 questions from Spotlight shortly after her appointment in 2022, she said: “One of my immediate focus areas is to ensure that the department’s systems across delivery areas such as Finance, Human Resources, Monitoring and Evaluation, Risk Management, etc. are strengthened so that processes are not dependent on human vulnerability but there are clear checks and balances. An environment that has no consequence management breeds ill-discipline and a culture of ignoring processes and procedures as prescribed in our legislative framework.”
Gauteng also faces mounting surgery and oncology treatment backlogs. Its clunky supply chains and procurement systems have often left suppliers unpaid and facilities struggling without basic medical consumables as well as not being able to procure large pieces of equipment when it’s been needed. Some hospitals have had periods when patients have had to go without food.
There remains questions about governance capacity in the department. Notable examples from Nkomo-Ralehoko’s tenure so far include inaction over utilising a March 2023 Gauteng Treasury allocation of R784 million for outsourcing radiation oncology services. These ring-fenced funds were secured following sustained pressure and protests by activists and civil society. To date, this money has still not been spent.
The department is also still to implement a June 2022 memorandum of agreement with the University of Witwatersrand. The agreement sets a framework for the department and the university to mutually address many of the health sector challenges in the province, while ensuring the academic training of the next generation of doctors takes place.
Another key challenge for Nkomo-Ralehoko will be how to navigate a changed Gauteng Provincial Legislature in this seventh administration. There is no outright majority and there is no unity government deal that includes the largest opposition party, the Democratic Alliance (DA). This will represent distinct hurdles for passing budgets or garnering enough votes for approvals in the house.
Despite these challenges, the reappointment of 58-year-old Nkomo-Ralehoko is being welcomed by some. They say that she brings stability to a portfolio that has been plagued by shaky, short-lived tenures in the top role. They say she has a flexible leadership style, and that she is open to working with many different stakeholders. But her critics charge that she cannot deliver the overhaul that the department needs and that she has not been tough enough on corruption.
‘More of the same’
Jack Bloom is the DA shadow minister for health in Gauteng. He says: “I don’t think the present MEC deserves to be reappointed, but that’s for the ruling party to determine. What we will get going forward is more of the same. The Gauteng Department of Health needs wholesale change but it’s not going to happen under the present situation.”
Bloom says Nkomo-Ralehoko’s comeback is “cadre deployment and political protection” and he adds: “I’m afraid that the corruption is across the board and the looting is going to continue.”
He says the MEC slow-walked disciplinary action on many suspended senior staffers and has also failed to tighten up on the likes of pre-employment checks on would-be employees, resulting, he says, in weak candidates being appointed.
The EFF is the third largest party in the Gauteng legislature. Nkululeko Dunga was contacted to weigh in on Nkomo-Ralehoko’s reappointment but he declined to take our calls and didn’t respond to written questions.
‘Delays that cost lives’
Speaking briefly to news channel eNCA after she signed her oath of office on 3 July, Nkomo-Ralehoko mentioned oncology and radiation services as one of her priority areas. She referred specifically to the building of bunker-like facilities in order to house specialist cancer treatment equipment procured for Chris Hani Baragwanath Hospital and George Mukhari Hospital.
However, for Salome Meyer of the Cancer Alliance, the fact that equipment has been procured but is sitting in storage amounts to delays that cost lives. She says there are currently 3 000 patients in the province on waiting lists for cancer treatment.
“Our facilities are operational but they aren’t operating at full capacity because the equipment is not in use or we don’t have staff to operate the equipment,” Meyer says.
“What we’re seeing is resignation after resignation of radiation therapists because they aren’t on the correct pay grade. So even when we do get equipment there is not enough people to operate the equipment.
“The MEC has to start looking after her own people – the people who work in our clinics and hospitals,” she says.
‘Ensuring stability’
For the Democratic Nursing Organisation of South Africa (Denosa) in Gauteng though, Nkomo-Ralehoko has used her 20 months in the MEC role so far to start making the right turnarounds for the health department.
Bongani Mazibuko of the nursing association says: “We believe that this welcome appointment of the MEC will go a long way in ensuring that there’s stability in the department and it’s something that Denosa has long been calling for”.
Lack of stability has been a feature of Gauteng health over the last decade or so. When Nkomo-Ralehoko was appointed in 2022, she replaced Nomathemba Mokgethi, who had been in the job for less than two years. Prior to Mokgethi, Bandile Masuku was also in the position for less than two years. Gwen Ramokgopa filled in for a bit more than two years, and before her, Qedani Mahlangu was forced to resign after the Life Esidemeni tragedy.
Denosa in Gauteng also call for the finalisation of CEO appointments and for senior management posts to be filled. They also say fixing of infrastructure is critical “so that the department can be more functional”.
Mazibuko adds: “We need to ensure that appointment of nurses is prioritised as they are the backbone of the system. But we have faith that we can continue working together to ensure that the people of Gauteng get the health that they deserve.”
Right direction, but needs to act on corruption
Treatment Action Campaign Gauteng chairperson Monwabisi Mbasa also supports Nkomo-Ralehoko’s reappointment. He says compared to her predecessors, Nkomo-Ralehoko has so far been someone they feel they can work with.
“We have seen that in the past nearly two years the MEC has been trying to address some issues plaguing public healthcare at provincial, district and clinic level. She is hands-on and flexible, so we have confidence in her still,” Mbasa says.
But Mbasa says she must be held to account on not taking “drastic action against corruption”. He says 26 of Gauteng’s 37 public hospitals have in recent times run out of food but Nkomo-Ralehoko’s intervention included using suppliers and service providers who were not properly registered. He says it is a red flag and they will continue to hold the MEC to account.
Mbasa says to move forward now for health in the province will require alignment of the health department with the departments of infrastructure and development and of finance.
“Infrastructure of our health facilities is an emergency. We are also calling for the improvement of supply chain management and procurement of goods and services and we need to improve human resources.
“There are challenges and weakness in the Cabinet but it’s good that we are not working with completely new people in these portfolios. This is the time to accelerate and to ensure that we use the seventh administration to improve the delivery of public health,” Mbasa says.
After long and tense talks, negotiations with the DA to form part of the provincial executive deadlocked. This resulted in Premier Panyaza Lesufi naming a Cabinet with seven MEC positions for the ANC and one each to the PA, IFP and Rise Mzansi.
In some respects, Dr Aaron Motsoaledi was the right person for the job when he was appointed as South Africa’s Minister of Health in 2009. But in 2024, the healthcare context in the country looks very different. Spotlight editor Marcus Low asks what we might expect from this new chapter with Motsoaledi in the top health job.
When Dr Aaron Motsoaledi first became South Africa’s Minister of Health in 2009, the number one task in front of him was clear. He had to rapidly expand the country’s HIV testing and treatment programme.
Over the next decade, he did exactly that. When he left the health portfolio in 2019, there were around 5.1 million people on HIV treatment in the country – roughly six times the 850 000 there were in 2009. Driven largely by this expansion in the HIV treatment programme, life expectancy in the country increased from 58.4 years when he started to 64.9 when he left.
But while Motsoaledi largely succeeded on HIV and tuberculosis, there was a sense that he was not a details man and struggled to see through important health system reforms. He never got on top of fundamental challenges like healthcare worker shortages and poor governance in provincial health departments. That is why we were cautiously optimistic when Motsoaledi was replaced by Dr Zweli Mkhize in 2019. We thought it likely that Mkhize would be better at turning rhetoric into actual reform. As it turned out, any hopes of that happening were derailed first by the COVID-19 pandemic, and then more definitively by the Digital Vibes scandal.
The return
In a recent editorial considering possible health ministers after South Africa’s 2024 national elections, we argued that President Cyril Ramaphosa might feel that he can get more out of Motsoaledi back in the health portfolio than at home affairs, where we think it is fair to say he struggled. Even so, hearing Ramaphosa read out Motsoaledi’s name on Sunday night came as a surprise. Our money was on Dr Joe Phaahla staying in the job – as it turns out, he was demoted to again serve as Deputy Minister of Health.
What to make of all of it?
From one perspective, Motsoaledi’s return is understandable. He is a close and loyal ally of Ramaphosa and therefore someone the President would want to keep in his Cabinet. He is a medical doctor who knows the health portfolio. He is a staunch supporter of National Health Insurance (NHI) and his impassioned leadership style is probably considered an asset by the President.
If one considers the Health Minister’s number one task to be the implementation of NHI, and if one sees the implementation of NHI to be an essentially political process, then you can see a case for Motsoaledi’s return.
But even if one accepts this line of argument, it does come with some kinks that are hard to straighten out. For one, the NHI Act is now law and the political battle has thus, to some extent, already been won, and it is time to move from the broad strokes of political rhetoric, that Motsoaledi excels at, to the detail of implementation, which hasn’t been his strong point. And, to the extent that the political battle surrounding NHI has been reopened due to the ANC losing its parliamentary majority, the type of leadership required now will involve building consensus beyond just the ANC, and arguably more challenging for Motsoaledi, making strategic concessions such as allowing a greater role for medical schemes than envisaged in the NHI Act.
But all that only really matters if one accepts the premise that implementing NHI should be the top priority for the Minister of Health.
There is an argument that implementing NHI will take many years and there are much more urgent healthcare issues that need to be dealt with right away. The harsh reality is that provincial health budgets have been shrinking, healthcare worker shortages remain acute, governance in provincial health departments is often a disgrace, and health sector corruption remains a far from solved problem.
During his previous stint as health minister, Motsoaledi faced many of these problems and, while he often said the right things, the bluster wasn’t ever really backed up with a sustained programme of reform. To be sure, there were important successes like the establishment of the Office of Health Standards Compliance and attempts to revitalise health facilities, but when it comes to the fundamentals of having a well-managed healthcare system with enough healthcare workers, the picture was bleak when he left the health ministry in 2019 and it remains so today. In short, there is a view, only reinforced by his struggles at home affairs, that Motsoaledi is not the right person to have in charge if you want to implement the complex, systemic reforms required to sustainably address South Africa’s urgent healthcare problems.
That may be a bit harsh. Ministers are after all politicians and their roles are meant to be political. While it certainly helps to have ministers who are serious about, and committed to the details of implementation, they should be working in conjunction with government departments and directors-general (DGs) in particular. It certainly hasn’t helped our Health Ministers that our National Department of Health has often been overstretched and arguably lacking in strong leadership.
One underlying problem here is that over the last two decades, South Africa’s DGs and heads of provincial government departments for that matter, have too often been yes-men or people appointed as a political favour. While that may in some ways make a minister or MEC’s life easier, it does not make for good governance when a DG or a head of department is a walk-over. Ministers need to lead on policy, but have DGs and deputy DGs who are trusted and empowered to get on with implementation.
One criticism of Motsoaledi’s previous stint in the job is that even though he had a good DG in Precious Matsoso and a few decent deputy DGs, rather than shield them from the political crises of the day, he drew them into those crises. One expert we spoke to this week suggests that Motsoaledi loved the limelight and wouldn’t let others lead while another charged him with not being hands-on enough – maybe the key insight is that those things might all have been true to some extent.
Either way, given Motsoaledi’s strengths and weaknesses and the very complex health challenges South Africa faces, it is now more important than ever that as Minister he leads on political and policy matters, but gives the actual administration the space to lead on implementation. For that to work, he will need a DG who is not just another politician or cadre, but one who is an excellent manager and implementer, and maybe above all, who has the guts to say “no minister” when he or she needs to.
*Low is editor of Spotlight.
Note: Spotlight is editorially independent and is not affiliated with, nor does it endorse any political parties. Spotlight is a member of the South African Press Council.
Non-profit organisations whose funding by the Gauteng Department of Social Development has been withdrawn say they are being unfairly punished for “frivolous” and “flimsy” findings made by forensic auditors.
Among the organisations concerned are women’s shelters, drug rehabilitation centres and organisations that provide meals and social work services to homeless people. Many say they have no choice but to scale down their services and even close their doors.
Only seven in-patient drug rehabilitation centres, out of 13 that received funding last year, will be receiving funds for the first two quarters of this financial year, the department confirmed to GroundUp on Wednesday. Six rehabs are under investigation, the department said.
A manager at a children’s home told GroundUp earlier this week that they had to send a teenager struggling with substance use disorder back to their family because there were no state-funded in-patient drug rehabilitation centres available in the West Rand.
Forensic auditors were appointed by the department in 2023 to probe allegations of maladministration and fraud in the non-profit sector. The department’s budget for non-profit organisations is R1.9-billion for 2024/25, but Gauteng premier Panyaza Lesufi has promised it will be increased to R2.4-billion. Fourteen department officials have been suspended based on findings of forensic audits, the department has said.
The forensic audits were supported by outgoing MEC Mbali Hlophe. Hlophe has claimed several times that non-profit organisations in the province were “stealing from the poor” and that there has been extensive corruption in the sector.
A report provided by the department to the Gauteng Care Crisis Committee last week, on the orders of the Gauteng High Court, contains a list of 53 organisations that are under investigation, out of several hundred funded by the department.
Among the organisations on the list are Daracorp and Beauty Hub which received millions of rands in subsidies for training, while others have had their budgets cut.
But while organisations such as these have received large amounts of funding under questionable circumstances, the department has not provided evidence that this applies to all organisations on the list.
In May, almost two months into the new financial year, organisations flagged in the investigations started receiving letters informing them that they would not receive funding due to the findings made by the auditors. Some only received the letters in June.
When they requested clarity from the department, some received details in writing. But others were only given reasons for the suspension of their funding during a meeting with the department’s lawyers on Wednesday.
GroundUp spoke to representatives of five organisations who attended Wednesday’s meeting. They said the findings they were presented with on Wednesday were minor issues that should have been picked up by the department’s own monitoring and evaluation teams and would have been quickly resolved. They said they did not understand why a forensic audit was necessary.
The organisations have not received any funding from the department since the end of the financial year in March, and are battling to keep going.
“Flimsy and frivolous”
Derick Matthews, CEO of the Freedom Recovery Centre, which until March was funded for 52 beds for in-patient drug rehabilitation, told GroundUp that the allegations against the centre are “flimsy” and “frivolous”.
Matthews was told at Wednesday’s meeting that Freedom Recovery Centre had not submitted audited financial statements for 2022. GroundUp has seen evidence that he submitted the audited financial statements.
Matthews said the department had never before raised concerns about the organisation’s compliance with legislation. He said every quarter the department’s monitoring and evaluation officials would check the centre’s financial statements and that no concerns had ever been raised.
The auditors also found a “high turnover of security personnel” at Freedom Recovery Centre which was causing “instability in the organisation”. Matthews explained that this was because the security staff are employed from the centre’s skills development programme, through which a person who has been sober for a year works for three to six months at the centre.
“They are paid salaries from DSD funding. Our security is not working directly with the residents so they cannot impact the stability of the centre,” Matthews said.
The third finding against Freedom Recovery Centre was that staff members were being given “loans”. Matthews explained that sometimes when the department paid subsidies late, the centre would pay part of staff salaries from the tuck shop’s funds, which would later be deducted from their salaries.
Matthews says that they are in the process of discharging their last state-funded patients. “Both government-funded centres that we have been told to send people to during this crisis are full, they can’t help us. In the last week, I’ve received about 12 phone calls of people that needed urgent help and we can’t even help or intervene,” he said.
Representatives of other organisations GroundUp spoke to had similar concerns about the findings against them but did not want to be named for fear of victimisation.
They also raised concerns that their meeting on Wednesday was with only one department official and the department’s lawyers, while the organisations themselves did not have lawyers present.
They were told they have until Monday to provide evidence to dispute the allegations against them.
At the meeting on Saturday convened by Gauteng Premier Panyaza Lesufi, it was agreed that the organisations would receive an interim service-level agreement from the department by Monday, which would be finalised once the organisations were cleared. But not one organisation GroundUp spoke to has received an interim service-level agreement. Then on Wednesday they were told they will receive the agreements next week.
One organisation under investigation, Child Welfare Tshwane, was finally paid by the department last week after Gauteng High Court Judge Ingrid Opperman issued a directive that the organisation be paid to prevent harm to the beneficiaries.
GroundUp sent detailed questions to the Gauteng Department of Social Development, but we were told that the department will not be responding to media queries relating to the non-profit sector until further notice.
Is complementing in-person care with virtual care (hybrid care) a key part of the answer to South Africa’s NHI aspirations, asks Deon Bührs, Managing Director of Genie Health SA, who suggests that technology is the ‘unreasonable man’ in complementing decent universal healthcare and that self-empowerment is the only solution to sustainable wellness.
“The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
George Bernard Shaw
There is a school of thought that a young democracy can benefit from a well-considered blend of socialism and capitalism, particularly when it comes to healthcare and education. I would second that, to a degree. That South Africa requires a more equitable health system goes without saying though, as the apparent disparity and divisions between the haves and have nots is ever widening.
The status of our public healthcare system and the spiralling costs of the private offering need to find parity. A sad situation indeed, because at one stage, South Africa had one of the best public health sectors in the world, where groundbreaking heart transplants, for example, were done.
To the question of universal healthcare then. If it means that universal healthcare is a fundamental human right that everyone should aspire to, then it’s a yes, the NHI is essential. It should not be a matter of political affiliation, and let’s be clear, there is already healthcare for all in South Africa, through the public health system, free at the point of care for those who cannot afford care. But it is the quality of this care, and the effective management of these services that lie in stark contrast to that of the private healthcare system.
Signed in literally at the 11th hour before the country went to general elections, the National Health Insurance (NHI) bill is a polarising topic for many. The massive cost of providing a functioning NHI as per the bill, has been estimated conservatively at more than R200 billion a year, while some estimate closer to R1 trillion. With an already strained tax base, we must adopt new thinking as to how to deliver healthcare in a cost sensitive and effective way.
To my mind, one of the most effective ways of ensuring there is universal care that works, is recognising and supporting the role the patient plays in empowering their own health, recovery and wellness journey. They appear, however, to have been forgotten in the conversation that is the NHI bill to date.
For me, in its current guise, the NHI will unfortunately not bridge the quality divide. In fact, if we are not careful and if we do not find common ground, and hold government and the private sector to account, our entire healthcare system could well be in danger of failing – completely.
The unreasonable man test – laying the groundwork for new ways of healthcare delivery
Although expediently signed into law with little regard to comments or concerns raised from many sectors including health and business, the NHI does lay the groundwork for new ways of delivering healthcare and sets the scene for changing the mindset from the current sick-care system mentality to one of a patient-empowered HEALTHcare system.
Change must happen, but the extent of that change often depends on what Irish playwright and political activist, George Bernard Shaw, once stated as: “The reasonable man adapts himself to the world: the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.”
At present, Prof Nicholas Crisp who has been tasked with helming the delivery of the NHI, could be seen as Shaw’s “unreasonable man” in his efforts to equalise and deliver universal healthcare. Ensuring that the lever of technology is utilised in an effective way is critical though, to ensure that we don’t try and replicate previous perceived successes, and not move forwards.
With a challenged healthcare system, both public and private, we are called to not give up hope, but to lean into the solution, and at the same time, avoid a defensive posture of that which only served the few. I believe that these circumstances force us to innovate, and to seriously consider new ways of providing healthcare for all. It should be seen as an exciting time of just where we can push the future of healthcare.
For instance, we already know that a traditional healthcare delivery system, with its associated costs and accessibility challenges for those living in remote parts of our country just won’t cut it. But unlocking technology as the new delivery channel of healthcare complimented by affordable and fast internet, could well be the solution to cracking the code of healthcare for all.
Through technology we can drive the patient-centric approach to health and open the door for patients to more easily access the multi-disciplinary team of healthcare professionals they need.
The best of both worlds – prevention, and when required, recovery
An example of doing things differently, is a new approach to musculoskeletal health that has been facilitated by digital transformation, and which is finding growing adoption in South Africa. With objective improvements in patient outcomes, satisfaction scores and recovery times, virtual care teams can support patients through their recovery programmes, ensuring improved compliance and ownership of their health journey. And empowering patients to embrace exercise and activity over surgery and pharmaceuticals where appropriate, has a dramatic impact on the overall healthcare spend.
Imagine patients having the choice to access a multi-disciplinary team of experts anywhere in the country – from the comfort and convenience of their own home or workplace, all at the tips of their fingers. No need to be transported to a clinic or hospital every time they need healthcare services. This is entirely possible, with platforms like Genie Health, that provide a hybrid approach in complimenting in-person care with virtual care.
NHI needs a strong front loader like these hybrid platforms that provide the full range of allied healthcare services, to reduce the burden of care and cost on an already strained system, by reducing unnecessary hospital admissions, surgeries, medication and travel costs and allowing for the existing framework to be brought up to date and even surpass expectations.
With ICASA reporting over 75% of the population having Internet access in South Africa and more than 90% smartphone penetration, pressure on Mobile Network Operators to provide zero rated data for healthcare applications (as they have done in education and other areas) mounts.
If measures like this can be implemented, they will have a tremendous impact on reducing the burden on the existing healthcare system through a self-health-empowered approach, with the backing of a full clinical team on the ready to assist the patient.
The ultimate question is how do we make healthcare more affordable and accessible to all South Africans, which is the core aim of the NHI?
The answer – we need to renew our focus on the key stakeholder, our patients – and empower them to drive their own health, by using technology as the backbone for sustainable wellness. It could well be, that with a renewed mindset and health-empowered citizens, the NHI is the true gamechanger for progress in HEALTHcare that we all need.
While cancer survivors are increasing in countries like the United States, South Africa faces a different reality, with 4000 people dying from blood cancer every year. Dr Sharlene Parasnath, Head of the Department of Clinical Haematology and Stem Cell Transplant Unit at Inkosi Albert Luthuli Central Hospital and DKMS Africa board member, believes that this discrepancy is largely due to the quality of care provided to patients who rely on the state healthcare system.
Counting the costs
She explains that South Africa’s state sector relies predominantly on conventional chemotherapy to treat patients as opposed to newer targeted immunotherapies. “These may be accessible to some patients in the private sector and standard care in developed countries but are out of reach for public healthcare due to their unaffordability. Countries that use more targeted therapies not only improve overall survival but also decrease the undesirable adverse effects of cancer treatments. These therapies may be given with chemotherapy or on their own and work by attacking specific genetic mutations in cancer cells. Examples include monoclonal antibodies (MABs) and Bispecific T cell engagers (BiTES), which mimic the immune system to destroy cancer cells. There are also tyrosine kinase inhibitors (TKIs) which block the signals that promote cancer cell growth.”
“The prohibitive costs of these treatments are why stem cell transplants are being encouraged in South Africa since they offer those with blood cancers a chance of a cure,” points out Dr Parasnath. “However, this approach comes with challenges. For instance, the state will not pay for a transplant from an unrelated donor, despite two thirds of patients in need of a transplant being unable to find a suitable donor from within their family.”
Fewer nurses, fewer transplants
“Human resource constraints, particularly the shortage of specialist nurses, is another factor hindering more stem cell transplants from being carried out,” she notes. “Currently, there is no formalised training for nurses in haematology in South Africa. So, what tends to happen is that the majority of blood cancer patients end up being cared for either by oncology-trained nurses or registered general nurses with limited practical education and training in the kind of care they require. Important aspects of nursing which can improve patient outcomes include dietary restrictions, visitor guidelines, decreasing bleeding risk, infection control and early detection of potential complications such as graft rejection, graft vs. host disease and veno-occlusive disease that can develop following a stem cell transplant.”
She stresses that human resource constraints in terms of mental health support is also detrimental to patients with blood cancers. “Unfortunately, this tends to be the case both in the public and private sectors, as one out of three people diagnosed with cancer ends up struggling with a mental health disorder such as anxiety or depression as well, yet less than 10% of patients are referred to seek help. The South African Society of Psychiatrists has even warned that if left untreated or undiagnosed, this could impact the patient’s ability to function on a daily basis, including undergoing treatment.”
Dr Parasnath emphasises another glaring gap in mental health support. “NGOs offer on-site social workers for hospitalised children with blood cancer, but adults, especially those who are not members of medical aid schemes, often have no options available to them. Not only do they grapple with the emotional toll of their diagnosis and treatment side effects, but this is further complicated by anxieties around their finances and the wellbeing of their children.”
The Cancer Association of South Africa’s (CANSA) Fact Sheet on Cancer and Mental Health highlights that there remains a huge unmet need for mental health in cancer care, calling for more effective clinical integration of relevant services, which must be informed by patient choice and clinical need, and accessible throughout the patient’s whole cancer journey. It also stresses the need for measurement of patient quality of life as a marker of treatment effectiveness.
“The Department of Health must recognise clinical haematology as a discipline in its own right with its own unique needs. For too long, it has had to feed off of the limited oncology budget. But if we are to up the blood cancer survival rate, funding must be provided for necessities such as more modern treatments, unrelated stem cell transplantation and formalised training of nurses,” says Dr Parasnath.
She also urges South Africans to increase the pool of available stem cell donors either by registering themselves or supporting organisations like DKMS Africa which connects patients with potential matches by providing access to a global registry of over 12 million donors. Financial donations directly address two critical needs: funding the registration of new donors and assisting patients facing financial challenges as a result of the transplant process.”
“With focused efforts, South Africa can join the global trend of increasing blood cancer survival rates, offering a brighter future for patients and their families,” concludes Dr Parasnath.
Despite the promise of Universal Health Coverage (UHC) for all, the recent signing of the NHI Bill has brought with it several misconceptions around medical schemes that undermine the very foundation of our healthcare system, writes Dr Katlego Mothudi, Managing Director at the Board of Healthcare Funders (BHF).
In a historic move aimed at transforming the South African healthcare landscape, President Cyril Ramaphosa signed the National Health Insurance (NHI) Bill into law. This landmark decision promises to move South Africa towards Universal Health Coverage (UHC) for all citizens, regardless of socio-economic status.
While the goal of UHC is commendable, the rhetoric leading up to the NHI Act’s announcement has created misconceptions about the role of medical schemes.
With many believing that they should cancel their memberships immediately to enjoy free health services for the foreseeable future. However, Dr Katlego Mothudi clarifies that the implementation of NHI will take several years, dispelling this misconception.
The NHI Act introduces a single-payer system, central to the idea is that healthcare is a ‘public good’, suggesting all healthcare funding should exclude medical schemes, and should be government-funded. Dr Mothudi counters that healthcare is more accurately described as a social good. A public good, like military services, is one that the government must provide and from which no one can be excluded, regardless of payment. While healthcare is essential, it is not feasible to provide it as a public good.
The Board of Healthcare Funders (BHF), concerned about the numerous misconceptions propagated by government representatives since 2009, commissioned Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at Wits Health Consortium, to investigate these claims. Despite their hyperbolic nature and lack of systematic research, these statements have significant weight due to their endorsement by influential individuals. Prof van den Heever’s report identified frequently repeated assertions that he concluded were unsubstantiated and untrue.
Key Findings from the Report:
1. Medical Schemes are Unsustainable – False
In 2009, claims suggested that many medical schemes were headed for collapse due to unsustainable financing models, with 18 schemes reportedly nearing insolvency. Prof van den Heever’s report refutes this, showing stability in medical schemes from 2005 to 2022. The number of beneficiaries increased by over one million from 2009 to 2022, with consolidated reserves of R114 billion in 2022, far exceeding the required 25% reserve ratio. Broker costs have not been a systemic concern, and total non-health costs per average beneficiary per month for all medical schemes decreased by 34.7% in real terms from 2005 to 2020.
2. Health Services are a Public Good – False
In 2011, Health Minister Aaron Motsoaledi claimed that private healthcare was a “brutal system” due to commercialisation. However, Prof. van den Heever clarified that healthcare is not a public good in the economic sense, as it does not meet the criteria of being jointly consumed without exclusion. Healthcare is a crucial service but providing it as a public good is not feasible.
3. Most Medical Scheme Beneficiaries are White – False
Last year, Prof Olive Shisana, an honorary professor at the University of Cape Town and special advisor to President Ramaphosa, stated that the private sector predominantly serves the privileged white population. However, Statistics South Africa’s 2021 research indicates that of the total population utilising private healthcare services, 50.2% are Black African, 32.3% are White, 9.8% are Coloured, and 7.6% are Indian/Asian.
Need for Balanced Perspectives
While the BHF supports healthcare reform, it raises concerns about the NHI Act’s constitutionality and calls for a factual review of claims about medical schemes. It is crucial to present both sides of the debate to understand the implications fully. Including government perspectives and addressing how the NHI will affect individual citizens would provide a more comprehensive view.
Medical schemes remain a valuable national asset that plays a crucial role in ensuring the long-term viability of South Africa’s healthcare ecosystem. BHF advocates for a balanced approach to healthcare reform that considers both public and private sectors’ strengths and weaknesses.
