Category: Healthcare Politics and Regulations

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NHI Act Offers no Answer to High Medicines Prices

On By ModernMedia
Photo by Gustavo Fring:

By Fatima Hassan

The National Health Insurance Act does not deal with the systemic issues that cause high prices and inequity in medicine access, and government is not listening, argues Fatima Hassan.

As the department of health lunges forward with implementing a system of National Health Insurance (NHI), with business and other interests trying to thwart that, what lessons from the COVID-19 pandemic can help us to ensure health equity for all – for both users of the public and private health sectors?

A few key themes come to mind: market power, secrecy, transparency, accountability, timely access, and affordability.

COVID’s lessons

The human cost of COVID-19 globally was at least fourteen million people who died in just two years. In South Africa, COVID was the leading cause of death in 2020 and 2021, outstripping deaths due to other diseases in those years.

To mitigate the COVID pandemic and to move forward, we needed vaccines. Then, the creed of intellectual property fundamentalism preached to us by the ultra-wealthy and by pharmaceutical corporations was to tell us to monopolise and privatise the manufacture and supply of publicly created vaccines and medicines, while relying on voluntary market measures – not effective regulation or compulsory measures – to ensure access. That creed failed us.

At the time, agreements with private manufacturers for the supply of vaccines were entered into, and at the request of a very powerful industry, treated as a secret. The Health Justice Initiative (HJI) litigated to compel disclosure, and we won.

Our analysis showed a set of one-sided terms, including conditions that required Non-Disclosure Agreements with significant advance payments without legal obligations on suppliers in terms of delivery volumes or dates. The contracts provided sweeping indemnity terms, limits on international redistribution/donations, and overly broad intellectual property protections. We also found that in several instances, South Africa overpaid for vaccines compared to higher middle income countries.

Where we live

We live in a country with worsening health outcomes, a high burden of HIV and TB, and alarmingly high levels of gender-based violence.

Politically, we have had multiple health ministers in the space of just five years – even during a pandemic – due in part to corruption allegations and now, a new Government of National Unity (GNU). We have an unaccountable rotating door system for appointing ministers, deputy ministers, and health Portfolio Committee members, seriously blurring the Legislature’s oversight function. This is not good governance.

We have outstanding laws and regulations that could address some of the “now” issues but which are not being prioritised. For example, we are still subject to an apartheid-era Patent Law that is deferential to patent seekers, resulting in over patenting or evergreening. Vested interests, we believe, are blocking key amendments that would limit patent protection in favour of the public interest.

We do not have a robust local, properly state-subsidised health manufacturing industry in South Africa, often making us reliant on external manufacturers. We have xenophobia seeping into our health system, where patients have been attacked in state hospitals because of their nationality.

And on top of all of that, we have growing reports not just of provincial health product stockouts but also reports of widespread health sector tender corruption, and targeted assassinations of whistleblowers. Finally, given, among other things, our outdated patent system and inability to reign in medicine prices, our medicine costs are astronomical, needlessly (even when compared to other BRICS countries).

The NHI as the GNU’s test (and ours)

It is in this context, that even before the 2024 national elections, NHI has become a lightning rod of disagreement even within the GNU, including for business, creating a hostile climate for civic engagement. Sadly, the political gamesmanship over NHI especially at the Executive level, is coming across as unaccountable, arrogant, and non-engaging. This will not build our health system. In this debate, government has rarely admitted it made any mistakes so that is why it was surprising that in a recent Bhekisisa interview, the health minister conceded that restricting NHI basic health services (so non-emergency care) to South African ID holders may be self-defeating for public health. He said that that is a “mistake” that needs to be “rectified” in the NHI Act.

NHI and state-led procurement

The NHI Act envisages a single state procurement entity for all health products for NHI users (as selected by a benefits committee). In theory, this should provide greater negotiating power and leverage.

With the lessons of COVID and more recently Mpox, we can expect that may not be so. Even under NHI, there will be a scramble for much needed supplies, where South Africa will have to compete on the international market for often scarce and high priced supplies.

Thus, addressing the pharmaceutical industry’s power, and by virtue of that, the global and local medicine patent (reward) system and its abuse matters – but we need to do it now, not incrementally or at some later or undefined point.

For the NHI to financially sustain itself (and assuming here for a moment that it has sufficient funds to begin with), it will have to either overthrow or better regulate the current medicine over-patenting and pricing transparency system to survive, failing which, NHI money could dry up just on health products and medicine costs alone.

At present, South Africa on average pays more for medicines than comparator countries. Business is eerily silent about this aspect in its critique of NHI. Since medical schemes will continue to operate under NHI for some time, one would expect greater concern about the disproportionate use of scheme members’ resources in this respect too, from business.

On top of this, under an apartheid era drafted law (the Patents Act), South Africa is still also doling out patents allowing companies to evergreen their patents on several essential medicines including for TB and HIV, and cancer with limited regulatory and legal repercussions.

While the HJI vaccine procurement judgment should be having far-reaching implications, not just for the next set of pandemic procurement negotiations, but also for substantial state-led procurement due to take place under NHI, we would be naïve to think that the industry and powerful global and local actors in the pharmaceutical sector will change its ways for the better just because South Africa is implementing NHI.

The NHI, we are told, will be based on the principles of “universality and social solidarity” and will “unify” our health system. Yet, if we focus on just one aspect included in the Act – the medicine access system – it is a far cry from the promised system of unification. This is because it is drafted in a way that by our count and reading, creates at least four medicine access systems, operating in parallel (NHI for NHI users; Medical Schemes for scheme beneficiaries – while schemes are permitted to operate under NHI (could be decades); complementary cover via insurance coverage for NHI users; over the counter via out of pocket payments/insurance coverage for non-NHI users such as foreign workers, foreign students, resident non-nationals, etc.).

Either way, for all of its admirable “equity” intent, NHI in South Africa will be fully dependent on the global medicines access market whether we like it or not because we are not operating in a neutral, access friendly global system. Nor are we operating in a context where the executive has any real, public, and committed plan to drive down medicine prices before or while NHI is implemented – and without business interests interfering in the execution – it is leaving that totally to the market, to whimsical unenforceable donations and voluntary business conduct. That is not sustainable.

The President is fully aware of how the latter affected our vaccine access and procurement strategy and costs in the COVID-19 pandemic. What is he going to do about it?

NHI and “top-ups”

Under NHI, the Act will allow top-up products and complementary cover via insurance offerings to presumably fill the gap for those health products, services or medicines that the state may not select or include in the NHI Formulary because of affordability constraints. So how will those complementary cover products and medicines be priced and regulated? Will the current imperfect and expensive system, called the Single Exit Price System, for non-state medicines be used?

Imperfect, because in South Africa, public sector medicines prices are largely determined by the bids companies submit in response to advertised government tenders. In the private sector, companies are free to launch a medicine at any price, although once launched, annual price increases are regulated – so that every drug in the private sector has a single exit price. In rare cases, excessively high medicine prices have been challenged using competition law, but this is the exception.

There have been moves toward reference pricing – where maximum prices for specific medicines would be determined by reference to prices for that medicine in a basket of other comparable countries – but none of several rounds of regulations proposing such a system have been implemented, mainly because pharmaceutical companies usually litigate against the state to prevent it from implementing such a comparator system – in other words, like elsewhere, while we face exorbitant medicine costs, we also face powerful corporate lobbies that do not want proper transparent systems for setting medicines prices. This only serves a profiteering agenda.

NHI and medicine access questions

Just on the narrow point of medicine access under NHI there are critical issues that need to be clarified. They include the following:

  • Whether we can be guaranteed transparency and information, including about the deliberations of the various NHI ministerial advisory, benefit and selection committees, and procurement structures under the NHI – or will we have to litigate every access to information request, as we did in COVID?
  • How will the NHI Fund (Office of Health Products Procurement) negotiate with the global pharmaceutical industry without, for example, the bullying we witnessed in the COVID-19 pandemic?
  • And specifically for medicines and health products:
    • Will manufacturers be permitted to sell to health providers other than the state? If so, how will this be done, and how will the maximum price be determined or regulated?
    • Which medicines and health products will be covered under NHI benefits as part of the NHI Formulary and how will the price of those not covered (top-ups/complementary cover) be regulated?
    • What role will the current private sector pricing system play including the single exit price system – and how and when will it be amended?

As our country pushes ahead with the NHI, there are some immediate concerns like these that we believe will affect implementation.

Of course, we all support the vision of a unified, equitable health system. But aspirations aside, the NHI Act does not deal with the systemic issues that cause high prices and inequity in access. Instead of investing effort into systems that control prices better at the outset, it is investing in systems to deal with the consequences of unaffordable drugs, hoping for self-correction, all while deferring to powerful vested interests including business lobbies that have the President on speed dial.

Regulatory bodies and civil society actors can only take on the tip of the medicine pricing iceberg – the question to the President is, while the Executive dithers on amending keys laws including the Patents Act, under NHI: who exactly will fight for every single patient and for every single medicine?

Since the NHI Bill was signed into law, the President (and his Cabinet) are now duty bound to take constitutional steps to remedy the deficiencies in the NHI Act, and at the very least, to listen to all sectors, not just business.

*Hassan is director of the Health Justice Initiative. This piece is drawn from her key note address at the 2024  Annual David Sanders Lecture in Public Health and Social Justice hosted by the University of Western Cape’s School of Public Health and Peoples Health Movement South Africa.

Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

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South African and Australian Health Product Regulators to Share Regulatory Information and Expertise

On By ModernMedia
Photo by Kindel Media

The South African Health Products Regulatory Authority (SAHPRA) and the Australian Therapeutic Goods Administration (TGA) have signed a Memorandum of Understanding (MoU), which will strengthen collaboration between the two health product regulators.

The MoU builds on the existing relationship between the health products regulators to improve capabilities in the assessment of medical products and therapeutic goods and their monitoring for continued efficacy, safety and quality once they are registered.

Areas of cooperation

SAHPRA and TGA will engage in data sharing aimed at improving the regulatory functions executed by both regulators. This will particularly focus on the assessment and approval of medical products and therapeutic goods, their monitoring for continued efficacy, and the surveillance for safety and adverse reaction (event) concerns.

According to SAHPRA’s Chief Executive Officer, Dr Boitumelo Semete-Makokotlela, the agreement with the TGA expands the geographical reach for both regulators’ pharmacovigilance programmes and augments their internal expertise.

“This partnership enables us to rely on each other’s strengths and regulatory outputs in the evaluation of health products both before they are registered and once they are approved for public use. This would improve therapeutic outcomes for the populations we exist for and increase the robustness of our post-registration surveillance for efficacy, safety and quality,” says Dr Semete-Makokotlela.

Deputy Secretary at the Australian Government Department of Health and Aged Care and head of the TGA, Professor Anthony Lawler, said: “TGA is very pleased to have strengthened our collaborative relationship with SAHPRA with the signing of this international agreement. We look forward to working alongside our regulatory counterparts in South Africa to share important regulatory information to ensure the continued safety, quality and efficacy of therapeutic products approved for market.”

Source: SAHPRA

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Mandatory Health Insurance for SA is an ‘Upgrade’ on NHI, Proponents Say

On By ModernMedia
Photo by Hush Naidoo Jade Photography on Unsplash

By Chris Bateman

The idea of mandatory medical scheme coverage for employed people has made a comeback after the case for it was made at a recent conference. The policy move was previously on the cards in South Africa but faded after the ANC opted for National Health Insurance (NHI) at its 2007 national congress where Jacob Zuma was elected as the party’s new leader. Chris Bateman unpacks how a system with mandatory medical scheme membership for the employed might work and asked local experts whether it represents a viable alternative to government’s NHI plans.

A vigorous public debate has ensued since outgoing Netcare CEO, Dr Richard Friedland, on behalf of the Hospital Association of South Africa (HASA) delivered a strongly argued case for a return to what he described as the original ANC healthcare plan. He was speaking on “Viable and Near-term Opportunities to Providing Enhanced Healthcare in South Africa,” at HASA’s annual conference in Sandton held early in September.

Since then, the leadership of Business Unity SA (BUSA) met with President Cyril Ramaphosa and Health Minister Dr Aaron Motsoaledi, and his deputy and other senior officials, in mid-September to discuss “matters of concern” related to the NHI. The President requested BUSA to put forward specific proposals on “the remaining matters of concern” as a basis for re-engagement.

Some observers have suggested to Spotlight that these consultations are a first sign of government openness to changing or tweaking its NHI plans. But whether this means the door is actually open for a system of mandatory health insurance, or for mandatory health insurance as a stepping-stone toward NHI, is still unclear.

The NHI Act, that was signed into law by Ramaphosa in May, envisages a single-payer system where medical schemes are only allowed to cover health services that are not covered by the NHI fund.

How mandatory health insurance would work

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 will result in medical scheme membership swelling substantially and some 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 dependent on the public healthcare system.

Friedland said such mandatory healthcare insurance will 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. In so doing, it would boost public healthcare per capita spending by 52%, (from R5 054 to R7 659), without any additional funding of the public sector budget, alleviate the strain on public hospitals and clinics, shorten waiting lists, and free up money to hire more staff and improve infrastructure. He said it is a “far faster and more efficient tool” for achieving health equity.

Responding to the counter argument that a mandatory health insurance system would entrench existing health inequalities, Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, said the opposite is true. “It accelerates convergence between the two systems faster than the NHI proposals,” he told Spotlight.

The relief for people who can afford medical scheme cover could also be significant. Friedland said mandatory medical scheme membership would bring more young and healthy people into the system, thus reducing the cost of monthly premiums by 25% to 30%.

Mandatory contribution schemes for civil servants have been implemented in more than half of the countries in Africa, while Thailand and many other Asian countries have started with mandatory cover for the formal sector before expanding to the non-formal sector. Such systems with what amounts to many medical schemes, rather than a single large fund, are also in place in several European countries, including the Netherlands and Germany.

Not a new idea

Mandatory health insurance, or an expanded role for medical schemes, are by no means new ideas in South Africa. Friedland told Spotlight that the ANC government’s own broad ranging 2002 inquiry into the various social security aspects of the South African health system concluded that national health insurance or the complete nationalisation of the private sector, could not be seriously considered as a reasonable option. (The inquiry itself was based on the Health Subcommittee Findings of the Committee of Inquiry into a Comprehensive System of Social Security.)

That 2002 report concluded: “National health insurance is not an option that emerges overnight as an alternative to social health insurance. Instead, it becomes feasible within market economies where formal employment levels are high. Prior to this, mixed systems are inevitable.”

One indication of how committed government was to such a mixed system with an expanded role for medical schemes in the early and mid-2000s, is the fact that the legislative framework to enable the expansion of medical scheme coverage was incorporated into the 2008 Medical Schemes Amendment Bill. That bill did not go as far as making scheme membership mandatory, but a mandatory system was clearly a next step on the reform agenda, as outlined in the very wide-ranging 2002 Taylor report on social security in South Africa. But presumably because of the NHI proposals, the 2008 amendments were allowed to lapse – and the scaffolding for a progressive expansion of medical scheme coverage collapsed.

There have since been several committees of inquiry and technical processes that validated an ongoing role for medical schemes, of which the Competition Commission’s Health Market Inquiry (HMI), that ran for five years (2014 to 2019), was the most technically detailed, consultative and authoritative. The HMI report did not recommend that medical scheme membership be made mandatory for people who are employed, but it did recommend a continued role for medical schemes and suggested that the most viable path to NHI may well involve first fixing the regulation of medical schemes.

Van den Heever said South Africa needs to quickly return to the pre-2008 reform trajectory to help stabilise the health system, “before more harm is done”. Government needs to summon up the political will to address the systemic governance failures of the public health system, removing the “bad actors and provincial cabals” that were destroying the integrity of South Africa’s free public health services, he added.

Better regulation also needed

For a system of mandatory health insurance to work, medical schemes will have to be more effectively regulated. Here the HMI report found that government had dropped the ball. It attributed the private health market failure and rampant medical inflation directly to government neglecting to regulate the private healthcare industry.

Health actuarial consultant, Barry Childs, joint CEO of Insight Actuaries and Consultants, told Spotlight private healthcare sector reforms urged by the HMI were ignored, resulting in ongoing confusion, high costs, complicated products and waste, among other problems. “Our incomplete medical scheme regulation keeps costs up, (for example anti selection, Prescribed Minimum Benefits), with benefits out of reach of most. We still don’t have a proper framework for lower cost-lower benefit products for those who cannot afford medical schemes,” he said.

The HMI report recommended a framework that went “way beyond naïve approaches to price control”, said Van den Heever, and addressed the powerful incentive structures driving unproductive forms of competition. In addition, he said, the industry-wide pooling approaches (risk equalisation and social reinsurance) followed international best practice and fully addressed issues of pooling fragmentation.

In the five years since the publication of the Commission’s HMI report, none of its major recommendations have been implemented.

Jobs and taxes

One common thread running back to the 2002 report, is the idea that South Africa is not economically ready for NHI and that a mixed system, possibly with mandatory health insurance, is more compatible with the current realities of high unemployment and a relatively small tax base.

“The root cause of inequity and inequality is not just a new form of apartheid. The real reason is the catastrophic level of unemployment. Until we address that, we will not solve an entire range of inequities, including food security, housing, education, and healthcare,” said Friedland.

On joblessness, Childs said South Africa was on track with the rest of the world’s growth up to 2008 but thereafter flat lined for over a decade. “We have dramatically underperformed the rest of the world and our peer group of middle-income countries in long term economic growth.”

In South Africa, unemployment is at an extremely high 33.5%, while in 2002 it was at 26%.

“If an NHI was unaffordable in 2002, how much more so is it today?” Friedland asked. He said that in this context, strong partnership, collaboration, and co-operation between the public and private sector is needed to bridge the polarisation that has arisen.

Analysis commissioned by BUSA found that raising the extra R200bn the health department says it needs to fund NHI would entail unrealistic and unaffordable tax hikes. It would either increase personal income tax by 31%, push VAT from 15% to 21.5%, or require the collection of a payroll tax of R1 565 per month from everyone in formal employment.

Van den Heever said that while government has a discretion to increase tax rates to any level it chooses, it cannot control the resulting amount of funds raised. He said that once tax capacity is reached, a hard ceiling on government revenue results at any given level of economic growth. The only way to grow revenues thereafter is through economic growth, failing which, revenues stagnate beyond government control.

The “big idea”, he said, was that new taxes would fund the move of medical scheme members to the public sector, in the form of a single NHI Fund, such that both public sector and medical scheme populations were covered in the same system – with net gains in coverage for both.

However, contrary to what was “correctly understood” from 1994 to the 2002 Taylor Commission, “the maths for such an approach, just does not add up”, said Van den Heever.

“The fastest way to de-segment the system is to allocate all new government revenues arising from economic growth to the people who need it most. This is not what the NHI proposals envisage. They want to dilute the public spend by trying to cover higher income groups. It is dangerous magical thinking that allows government to avoid dealing with the complex problems of the health system. Government needs to get back to its day job and do the heavy lifting needed to get our health system working again.”

Government response

Spotlight shared an earlier draft of this article with the National Department of Health for comment. While the department did not comment directly on mandatory health insurance, Foster Mohale, the department’s Director of Communications, emphatically reiterated their support for NHI and the NHI Act that was signed into law in May.

“There is no better time than now to reform South Africa’s health system. It is time to do away with the apartheid type of health system, and to reconfigure it into one that ensures that every South African gets the health care that they need, when they need, where they need and without incurring financial hardship. With the enactment of the NHI Act, the time for piecemeal approaches that retain benefits for the few and leave the majority to the whims of the market is no more,” Mohale told Spotlight.

He said that many countries, including Japan and the United Kingdom, have implemented health system reforms directed at achieving universal health coverage during times of crisis and low economic growth. “Therefore, to say that South Africa must sit and wait for some oracle numbers to emerge before instituting NHI is merely to argue that we must consciously let those that are carving profits and dividends from the anomalies that characterise our health system to continue. This is an irresponsible position that the Department cannot adopt as health is a constitutionally enshrined right for every South African, not just a privileged few,” he said.

On the questions of taxes, Mohale said: “We will not delve into the projected tax implications because we believe this is a matter that squarely falls under the purview of the National Treasury and the Minister of Finance. Suffice to say at the right time, and after necessary deliberations through formal government structures and processes, any information relating to this will be communicated to the public for comments prior to finalisation.”

Note: The 2002 Tailor report titled ‘Transforming the present – Protecting the future’ is not readily available online. There is this PDF version (unfortunately not searchable and with poor accessibility). For ease of use, we have created a Word version of the document that you can access here. Health is discussed in chapter 8.

Republished from Spotlight under a Creative Commons licence.

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All the Premier’s HODs: High-stakes Head of Health Post Trapped in a Merry-go-round

On By ModernMedia
Northern Cape Premier Dr Zamani Saul is tasked with appointing heads of department in the province. (Photo: Northern Cape Provincial Government/Twitter/X)

By Refilwe Machoari and Adiel Ismail

The Northern Cape health department has had several heads of department in the last five years. Spotlight unpacks the implications of this leadership instability and asks what it means for good governance in the public health sector.

The Northern Cape health department has seen a fast-revolving door of heads of department (HODs) in the last five years, with one person being at the helm for a mere two months.

This is because the two people to hold the powerful post permanently are dogged by claims of alleged financial transgressions and corruption. The health HOD position is one of the most multiplex jobs in provincial government with oversight of what is typically one of the two largest lines of provincial budgets.

At R20 billion over the next three years, the health department got a massive slice of the Northern Cape’s R68.1 billion budget for the period. By contrast, over the same period, R6 billion was allocated to the Department of Roads and Public Works, R3.1 billion to the Department of Social Development, R1.3 billion to the Department of Sport, Arts and Culture and R1.1 billion to the Provincial Treasury.

Financial management

While the National Department of Health leads on health policy, the implementation of policy and the day-to-day running of public healthcare services is managed by provincial departments of health. As the accounting officers in provincial health departments, HODs play a crucial role when it comes to proper accounting and financial management.

Compliance to regulatory frameworks and standards though are lacking according to the latest Northern Cape Department of Health annual report. It shows that the department incurred irregular expenditures of more than R144 million in the 2022/2023 financial year. The department also incurred fruitless and wasteful expenditures of almost R15 million in 2022/23 compared to R13 million in the previous year.

The department received a qualified audit opinion. This means that the financial statements contained material misstatements or there is insufficient evidence to conclude that amounts included in the financial statements are not materially misstated.

The auditor-general wrote: “I was unable to obtain sufficient appropriate audit evidence that public money was spent with the approval of a properly delegated officer”, that the financial statements “submitted for auditing were not prepared in accordance with the prescribed financial reporting framework and supported by full and proper records”, “effective and appropriate steps were not taken to prevent irregular expenditure”, and “effective steps were not taken to prevent fruitless and wasteful expenditure”.

The auditor-general’s qualified audit opinion reflects on leadership and practices in the department, and is reputational damage with a growing trust deficit with communities it serves, Dr Beth Engelbrecht, former HOD of the Western Cape Department of Health, told Spotlight.

“Health is one of the most complex departments with the largest budget, compared to other 12 provincial departments. This includes the largest budget of all for goods and services, which must be purchased from private providers. This reality brings complexity in the management of its finances within all the rules and regulations, but also makes it prone to those who wish to do corruption,” said Engelbrecht.

Indeed, this appears to be the quandary facing the office of the health HOD in the Northern Cape. Two HODs have been arrested over alleged corrupt dealings or contravention of the Public Finance Management Act (PFMA).

A brief history of HODs

In 2020, then health head Dr Steven Jonkers was charged with contravening provisions of the PFMA. It is alleged he concluded a multi-million rand contract in 2017 without following the correct procurement processes. Jonkers declined to comment on this case, which is set to be back in the Northern Cape High Court in Kimberley in November. Premier Dr Zamani Saul has seconded Jonkers as a deputy director-general in the Office of the Premier since 2020.

The head of health position was then filled by a string of people acting in the role, including Dr Deon Theys who would also have a brush with the law. Despite this, Saul appointed Theys as the new health head on a fixed five-year contract in July 2023.

But a month later, the Specialised Commercial Crimes Court in Kimberley found Theys guilty of not following proper PFMA prescripts and procurement processes. It related to R13 million in lease deals which he signed between 2011 and 2012 while he was the acting HOD. Theys was sentenced to a fine of R150 000 or three years imprisonment, of which R100 000 or two years imprisonment is suspended for five years, on condition that he is not found guilty of the same offence during the time of suspension. Theys is appealing this court ruling and declined to comment on the matter.

Theys’ problems is far from over. In a separate court matter, along with other senior public servants, he is facing charges in relation to a multi-million rand tender for the procurement of Covid-19 equipment.

He will be appearing in the Kimberley Magistrate Court in October on charges of fraud, corruption and contravening the PFMA. This was confirmed to Spotlight by the spokesperson for the National Prosecuting Authority in the Northern Cape, Mojalefa Senokoatsane.

With these new charges hanging over his head, Saul has since redeployed Theys to the position of provincial medical director – a post he held previously.

‘Saving money’

Without responding to detailed questions from Spotlight, the Premier’s spokesperson Bronwyn Thomas-Abraham said Theys’ role as medical director is helping to save the health department money.

“This decision was taken mindful of Dr Theys’ experience and served to save costs in appointing another Medical Director,” she said.

Thomas-Abraham noted that any “course of action” against Theys hinges on the outcome of his appeal. It would therefore appear that Theys’ appeal stalled the necessary formal internal inquiry that should follow, according to the Senior Management Service Handbook, within 60 days after he was transferred as a precautionary measure.

She also dismissed concerns that appointing acting health heads could negatively impact the department’s operations, insisting that service delivery remains unaffected.

“The appointment of an Acting Head of the Department did not have any adverse effect on the Department’s operations as it receives additional Financial Management and Human Resource support from the Provincial Treasury and Office of the Premier respectively,” Thomas-Abraham said.

Acting HODs

Having acting HODs is clearly not the way governance is generally supposed to work. For example, according to the Public Service Act and the Public Service Regulations, an official may not be in an acting position for more than 12 months.

Dr Alastair Kantani was appointed as acting head of the Northern Cape health department in September 2023, followed by Mxolisi Mlatha who has been acting in the role since December 2023.

“Whilst people in acting positions have the legal authority to take decisions and be accountable for these, they lack the required power to be transformational and bring changes that will improve delivery and functioning. Their authority when negotiating for funds are limited compared to appointed full time HODs,” said Engelbrecht.

She added: “Even communities view these acting persons not with the same regard as fully appointed leaders. Staff may also view an acting person of having less power, making it more difficult to bring coherence and alignment in a department.”

And it is precisely this that has led to protest action by workers affiliated to Nehawu, Denosa and Cosatu who took to the streets on 2 August, demanding that Mlatha step down and that a clinician with a medical background serve as HOD.

‘Negative impact’

Speaking to Spotlight, Nehawu provincial secretary Moleme Moleme said the continuous change of health heads has a negative impact on workers. “In many ways it has an impact on the direction that the department wants to take. It also places uncertainty on members which leads to low staff morale.”

Moleme said that the Premier needs to be decisive by bringing stability into the health department. “The corrupt-centric, crises ridden and unstable provincial department of health is unlikely to change its course from the sixth to the seventh administration because it is led by the same individuals who has landed the department into a crisis where it is at the brink of collapse,” he added.

Spotlight previously reported on the dire state of the healthcare system of the country’s largest, but most sparsely populated province. During an oversight visit last year, the Northern Cape’s Director-General, Justice Bekebeke told MPs on Parliament’s Portfolio Committee on Public Service and Administration that the health department is among the worst-performing when it comes to frontline services, disciplinary cases, payment to creditors, and leadership instability.

The DA leader in the Northern Cape, Harold McGluwa, said the health department faces a laundry list of challenges, including surgery backlogs, medicine stockouts and flailing emergency medical services hampered by a lack of operational ambulances.

He told Spotlight that his party, which is the official opposition in the legislature, is not prepared to endure a repeat of the sixth administration under the ANC, which lost its outright majority in the province in the May general election.

The DA therefore wants Public Service and Administration Minister Inkosi Mzamo Buthelezi – an IFP member serving in the government of national unity – to step in to bring stability to the office of the HOD.

“The department is in critical need of stability and that can only come with stable management and  firm decision-making of a fixed-term appointee to the position of HOD,” said McGluwa.

Corruption concerns

The EFF ‘s provincial secretary in the Northern Cape, Zen Kwinana, claimed the health head post with its huge budget responsibilities is being “abused for corruption” and to “accumulate personal wealth”.

“Saul will not appoint an HOD because he wants to control the position, and they also want the acting individual to entirely depend on their mercy,” he alleged. “Unfortunately amidst all of this, it is the people who suffer the most, services are poor, there is a shortage of medication and the infrastructure at hospitals and clinics are in a dire state,” added Kwinana.

Pervasive corruption in our public health sector was underscored in a recent report that explored critical governance issues impacting the country’s health sector.

To address corruption, co-authors of the report Professor Lilian Dudley and Professor Sharon Fonn told Spotlight urgent steps are required to prevent as well as to mitigate it. And where corruption has occurred, they say clear, visible and swift action is needed to charge and penalise managers and employees involved. “To do this, the health system needs to work closely with the various role-players in the criminal justice system and groups such as the Health Sector Anti-Corruption Forum.”

Dr Aslam Dasoo, convener of advocacy group Progressive Health Forum, is scathing of political leaders and public servants abusing their office for nefarious means.

“What you’ve got is a budget and people with an eye on the budget, and they will do everything they can to purloin as much of it as they can for personal use… that is what this is about, that is why you have this merry-go-round of appointments and acting appointments.

“Why do they keep these guys still in their jobs, or redeploy them somewhere else when they are under scrutiny? It is because they [appointees] are under scrutiny, they can’t have these guys thrown to the wolves, they put them there, that is the simple answer. It has got nothing to do with healthcare and health policy,” he told Spotlight.

‘Difficult decisions’

Political analyst Dr Ina Gouws said political infightings, factionalism, and interference are the biggest factors that hammer the filling of critical government positions and it is a matter the ANC has grappled with for many years.

She said being a leader requires one to make difficult decisions regardless of what the political situation looks like.

“This situation is not beyond the control of the Premier. He cannot say that there are no capable candidates, because that would be a lie. There are many qualified people who can fill this position, but it is the political interference that is standing in his way of appointing a credible candidate,” said Gouws.

The health department is not the only Northern Cape department impacted.

The education department, which was allocated the biggest budget in the province at R25.3 billion over the next three years, has an acting HOD. The agriculture department with a much smaller budget of R2.3 billion also has an acting HOD. The premier’s office told Spotlight that advertisements for both positions have been placed and processes related to recruitment are underway.

And another department’s HOD is also in the crosshairs of law enforcement authorities.

Dr Johnny MacKay, the HOD of the Department of Public Works and Infrastructure, is facing 271 charges of contravening the Pension Funds Act involving an amount of R9 million. Asked for comment, the department’s spokesperson Zandisile Luphahla said the HOD cannot comment on the matter because it is before the courts.

It is alleged by the Hawks that between September 2021 and March 2022, while he served as the Acting Municipal Manager of Kai !Garib, MacKay failed to ensure that contributions deducted from municipal employees were paid to the consolidated Retirement Fund for Local Government. This matter will be in court in November for trial, Senokoatsane told Spotlight.

Saul has not acted against MacKay who is still in his HOD post.

The right people in the right positions

Dudley and Fonn stressed that the current instability, with many provinces still having acting HODs, allows greater political interference which undermines good governance and leadership within provinces.

They said in the public health sector, the right people must be in the right positions, with the right capacity to do what needs to be done. “Politicians need to be held accountable to appoint appropriately competent and ethical HOD’s, and to support them in their mandates.”

Engelbrecht added that appointing strong accountable and good character leaders should not be directed by politics, but by capability and people who are fit for purpose.

“The health HOD has one of the most complex jobs in government and often must deal with political pressure especially due to the large goods and services budget to its avail,” she said. “The HOD therefore must be of good character with ethical leadership capabilities, well versed into health, with humility to lead and be visible across the whole service to be able to unblock blockages and support staff who must work under difficult circumstances.”

To do this, Engelbrecht said, the HOD needs to build a strong team around him or her as well as across the layers in the system, with accountability mechanisms that happens in an enabling environment, where staff are allowed to innovate and feel supported in their work.

“Whilst health is a political matter, it is more a matter of social justice. The HOD should have the dedication and capability to stretch the health rand to do the greatest good to the greatest number and prioritise the vulnerable.”

Republished from Spotlight under a Creative Commons licence.

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Demand for Transparency Intensifies as Unanswered Questions around NHI Act Persist

On By ModernMedia

Craig Comrie, chairperson of the Health Funders Association

Wednesday, 25 September 2024, The passage of the National Health Insurance (NHI) Bill into an Act of law has set the stage for one of the most significant overhauls of South Africa’s healthcare system. As the government embarks on this ambitious plan, the stakes have never been higher. The NHI Act is more than a mere piece of legislation; it stands as a test of constitutional rights and the nation’s commitment to fostering a more inclusive and equitable society.

The Health Funders Association (HFA) welcomes the meeting between President Cyril Ramaphosa and Business Unity South Africa (BUSA) leadership on Tuesday, 17 September, to discuss the NHI as a positive step.

As a member of BUSA, we find it encouraging that the Minister and Deputy Minister of Health, along with other senior officials, were part of this constructive and forward-looking discussion. We can only hope that these recent discussions will mark the start of a series of engagements with key stakeholders, as the South African government must engage in open dialogue with all stakeholders, including private healthcare providers, medical schemes, and the general public. HFA will provide industry input to BUSA’s presentation to the President to help propose workable solutions to set South Africa’s healthcare train on the right track with inclusive mechanisms that will benefit all.

Constitutional rights and freedom of choice

The critical questions about the Act’s constitutional validity, economic feasibility, and potential impact on both public and private healthcare sectors, specifically the role of medical schemes, remain unanswered.

Recently, during a Q&A session, the President reaffirmed his belief that the Act is constitutionally sound but he declined to share specifics on how this conclusion was reached. In response, the Health Funders Association (HFA) will test various aspects of the NHI’s constitutionality, which is crucial for establishing a stable healthcare framework that delivers quality health services for all South Africans.

This is a critical juncture for politicians, policymakers and every South African who relies on the nation’s healthcare services – private and public sectors alike. Against this background, the HFA is seeking to strike a balance between much-needed healthcare reforms and the hard-hitting risks of the NHI Act that demand amendments.

Government has been adamant about the NHI’s transformative potential to address inequalities in healthcare access, contending that the NHI is aligned with Section 27(1) of the Constitution, which guarantees the right to access healthcare services, including reproductive healthcare.

On the other hand, this part of the Act cannot be read without the consideration of Section 36 which indicates that existing rights should not be compromised if there are alternative ways to achieve, in this case, universal health coverage. This is a key part of responding to the President’s invitation for alternative proposals that stand a more realistic chance of achieving a partnership with the private sector for improving healthcare for consumers.  

Any alternative proposals provided by the private sector will come with the need to amend the current. The Act, if left unchallenged in its current form, can be likened to letting the healthcare train run on a single track of public sector inefficiency. By adding the private sector as a parallel track – both heading in the same direction towards universal healthcare coverage, we can stabilise and accelerate the journey.

The medical scheme sector effectively provides funding to the majority of services in the private sector with less than 10% of health consumers paying for services out of pocket in the private sector. This population group serves a significant portion of the taxpaying population, yet its role in the new system remains ambiguous. Will private healthcare consumers be forced to rely solely on centrally procured services, or will there be room for a coexistence that stands a better chance of laying the track towards a successful healthcare future that can benefit all South Africans?

Transparency and collaboration are essential in addressing the questions surrounding the NHI’s financial viability, human resource capacity, and broader economic impact. The future of South Africa’s healthcare system hinges on finding a balanced approach that ensures quality, accessibility, and economic sustainability for all citizens.

The government proposes funding the NHI through general taxes and mandatory payroll contributions. However, this plan has been met with scepticism as it raises considerable questions about the economic burden on taxpayers, particularly given the country’s high unemployment rate of 33.5% and sluggish economic growth rates of around 0.4% in the second quarter of this year. Critics argue that increasing tax rates to fund the NHI could backfire, reducing overall tax revenue, as highlighted by the Laffer Curve, which suggests that higher taxes can lead to lower revenue if they exceed an optimal rate.

Where will the healthcare professionals come from?

The public healthcare sector faces its own set of challenges. Reports indicate that the quality of care in public health facilities is often subpar, with systemic inefficiencies and resource constraints leading to poor health outcomes. The sector is grappling with high vacancy rates for healthcare professionals, exacerbating the strain on an already overburdened system. As it is, South Africa is already facing a severe shortage of medical personnel, with the vacancy rate for doctors ranging from 22.4% in the Free State to 5.5% in the Western Cape, while the national average vacancy rate for nurses stands at 14.7%.

The current system is struggling to fill thousands of vacancies for doctors, nurses and allied healthcare professionals, with over 2 000 unfunded vacant posts for medical doctors across nine provinces requiring an estimated R2.4 billion to fill them. Many provinces report alarming doctor vacancy rates: 18.5% in Mpumalanga, 17.6% in Limpopo, and 11.3% in KwaZulu-Natal, among others. The shortage is not just a numbers game; it affects the quality of healthcare that can be delivered. These figures raise serious concerns about the system’s capacity to deliver reliable and accessible healthcare services hampered by corruption and lack of proper leadership and management.

We must consider the strain this places on those simply trying to cope with the current healthcare demand from a growing population. The NHI aims to provide universal health coverage, but where will the necessary healthcare professionals come from?

The way forward

The NHI is not the only solution to South Africa’s healthcare challenges and is certainly not a panacea in its current form. The government must take a more collaborative approach, engaging with all stakeholders, including the private healthcare sector, medical schemes and the general public. Open dialogue is crucial to finding sustainable solutions that work for everyone. Critical decisions must be made, and these should not be taken behind closed doors. The nation’s healthcare needs are too important to be dictated by a select few without broader consultation.

The government has a constitutional obligation to ensure every South African has access to quality healthcare services. However, this must not come at the expense of freedom of choice, job losses and economic stability.

I urge President Cyril Ramaphosa to protect the constitutional rights of all South Africans and engage in meaningful dialogue with all stakeholders. The future of South Africa’s healthcare system depends on our collective ability to find innovative and inclusive solutions.

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Competition Law has again Worked to Fight a Bad Drug Patent, but We Need Other Solutions

On By ModernMedia

By Fatima Hassan and Leena Menghaney

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.

Hundreds of thousands of people in South Africa died prematurely because they did not get access to these medicines in time.

The landmark Hazel Tau case

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.

Republished from Spotlight under a Creative Commons licence.

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Slow Growth in Health Spending in Sub-Saharan Africa Projected to 2050

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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.”

Provided by PLOS

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SAHPRA Counters ‘Falsehoods’ Circulating over Its Draft B-BBEE Policy

On By ModernMedia
Photo by Tingey Injury Law Firm on Unsplash

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.

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A Holistic Approach will Build a Stronger Rural Healthcare System

On By ModernMedia
Photo by Hush Naidoo on Unsplash

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/ 

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Nomantu Nkomo-Ralehoko’s Comeback as Gauteng MEC for Health Sparks Mixed Reactions

On By ModernMedia
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.

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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.”

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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.

Republished from Spotlight under a Creative Commons licence.

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