Dr Ali Hamdulay, Chief Executive Officer (CEO) of Metropolitan Health, a subsidiary of Momentum Health
As we commemorate Universal Health Coverage (UHC) Day on Thursday, 12 December 2024, it is essential to reflect on the progress made in advancing healthcare access and quality in South Africa. Universal health coverage means ensuring that all individuals and communities receive the health services they need without facing economic barriers. In the South African context, this involves addressing the disparities in our healthcare sectors and ensuring that every citizen, regardless of their financial or social status, has equitable access to quality care.
In South Africa, a large portion of the population lacks medical protection cover, underscoring the urgent need for affordable healthcare solutions. Employed and insured individuals seek comprehensive yet affordable healthcare, while the employed but uninsured (6 to 8 million) face financial strain accessing quality care. Workers in the informal sector and SMEs often lack medical cover too, exposing them to significant out-of-pocket expenses. Those unable to afford any medical funding rely heavily on overburdened public healthcare facilities, highlighting the necessity for accessible and inclusive universal healthcare across all economic groups.
For over 60 years, South Africa’s healthcare sector has been characterised by a dual system of providers. Government has invested heavily in healthcare infrastructure and services and has made notable strides in improving access to quality healthcare. However, there is a significant opportunity for greater collaboration and meaningful partnerships within South Africa’s healthcare sector, focused on developing solutions that cater to the diverse needs of the population.
The healthcare ecosystem relies on the interdependence of various role players, including healthcare professionals, facilities, funders, administrators and government entities. Each of these contributors play a crucial role in ensuring the health and wellbeing of every citizen.
For the system to be sustainable, we must understand, recognise and cater to the unique contributions and requirements of each role player. This approach is vital for maintaining service continuity, quality, and access to necessary healthcare services through collaboration. Effective partnerships across these functions are critical to the success of the healthcare ecosystem.
To address the needs of low-income earners who are privately employed but uninsured, Momentum Health launched Health4Me, a healthcare insurance product that enables employer groups to provide affordable healthcare cover to those who might not otherwise be able to afford it. Our approach goes beyond merely paying claims; we focus on promoting health, wellbeing, and productivity, ultimately enhancing quality of life. This is achieved through primary healthcare facilities, technology, and incentivising wellbeing. The rapid growth of this healthcare insurance solution speaks to its success and its impact on offering more healthcare for more South Africans, for less. By expanding access to universal healthcare through primary healthcare, technological capabilities, and healthcare-strengthening initiatives, there are opportunities to collaborate and address the needs of additional population cohorts.
Through our vast experience in the design and management of healthcare solutions, we have learned valuable lessons that enable us to effectively collaborate across sectors. One of the critical lessons is the importance of clear communication and defined roles for all stakeholders involved in working towards establishing universal healthcare access. Successful partnerships have demonstrated that when goals are aligned across sectors to achieve a common objective, such as improving patient outcomes, success is possible.
As such, the success of creating a healthcare sector that ensures access for all hinges on flexibility and adaptability. The healthcare landscape is constantly evolving, and partnerships must be adaptable to address new challenges and opportunities. This includes being open to innovative solutions and technologies that can enhance service delivery and patient care.
Healthcare is essential not only for individuals and households, but also as a cornerstone of the economy. Without a healthy workforce, productivity declines, leading to far-reaching ripple effects on business sustainability. In this evolving landscape, preventative measures, therefore, become increasingly important. Providing wellness programmes that support both the mental and physical wellbeing of employees is crucial. Equally important is equipping healthcare consumers with the tools and knowledge to understand and improve their health status.
By investing in community health programmes and early interventions, we can address health issues before they escalate, easing the burden on healthcare systems. Collaboration across sectors can significantly increase access to preventative care by leveraging the resources and expertise of both sectors. Integrating preventative care into primary healthcare shifts the focus from reactive to proactive care.
It is advantageous to focus on co-creating platforms and mutually solving for the needs of our population through collaboration. This approach fosters consistency in service delivery and builds trust between entities. Metropolitan Health, a subsidiary of Momentum Health, has demonstrated its commitment to health strengthening by supporting leadership and professional development through its partnership with the National School of Government. By sharing and imparting knowledge, we are supporting the education and empowerment of future healthcare leaders through regular joint training and capacity-building programmes. This further improves collaboration by fostering a culture of continuous learning and development.
Building on these collaborative efforts, innovative models such as health hubs can further enhance healthcare delivery. These hubs combine offerings from both sectors, providing a range of services from primary care to specialised treatments under one roof. Telehealth is another innovative approach that has shown great promise. By utilising digital platforms, we can extend healthcare services to remote and underserved areas, ensuring that more people have access to quality care.
While effective collaboration is key to providing access to quality healthcare for more people, success cannot be achieved without fostering an environment that encourages innovation and supports conducive partnership development. By creating a more enabling environment, we can facilitate smoother collaboration and attract more private sector investment in healthcare.
Looking towards 2025, the vision for healthcare in South Africa is one of greater access, integration, and collaboration. By working together, we can create a more resilient and responsive healthcare system that meets the needs of all citizens. I envision the future of healthcare delivery as one that drives innovation and improves access to care. By leveraging partnerships and co-creation, I believe we can make significant strides towards achieving universal health coverage and ensure that no one is left behind.
Nomantu Nkomo-Ralehoko is the MEC for Health and Wellness in Gauteng. (Photo: GautengHealth/X)
Several opposition politicians and commentators have flagged what appears to be chronic leadership problems at the Gauteng Department of Health.
Criticism of leadership and governance at the Gauteng Department of Health (GDOH) is amping up as the department repeatedly makes headlines for questionable appointments. This unfolds alongside a damning auditor-general report, all while hospitals and clinics across the province grapple with ongoing challenges.
Arguably, the most controversial appointment is that of Arnold Malotana. He was quietly named head of department shortly after the May 29 national elections, following a year of serving in an acting capacity. Malotana has been with the department in various positions since 2008, according to his LinkedIn profile.
SIU investigation
Malotana has been implicated in a case being investigated by the Special Investigating Unit (SIU). It relates to the alleged manipulation of supply chain processes in 2016 and 2017 in favour of a company called BAS Medxpress (BAS Med). It has been alleged that Malotana and two senior officials – Edgar Motha and Sheriff Lecholo – took bribes to the tune of R8 million. The case made headlines a year and a half ago when amaBhungane lifted the lid on an affidavit from a whistleblower, who himself was part of the alleged tender-rigging scheme. The SIU investigation was however only ordered by presidential proclamation this November. According to amaBhungane’s reporting last year, all those implicated in the matter have denied wrong-doing.
SIU spokesperson Kaizer Kganyago said the probe will focus on two supply contracts – one for plastic containers and another for orthopaedic instruments – to determine if any actions broke laws, policies, or Treasury or health department rules, and whether they may be fraudulent.
“Such conduct may include manipulation of the department’s supply chain management processes by service providers, suppliers, officials, or other third parties, often in collusion with departmental employees or those in entities under its control, to secure undue benefits for themselves or others. This can result in unauthorised, irregular, or fruitless and wasteful expenditure incurred by the department, its entities or the State,” he said in a statement.
Questions over qualifications
Malotana has also been under separate investigation regarding his qualifications when his appointment as head of department was made. His LinkedIn profile lists his education as two years (2013 – 2014) at the Durban Institute of Technology and a master’s degree in public management from Regenesys Business School, with no dates provided.
Earlier this year, Jack Bloom, a DA member in the provincial legislature, wrote to the Public Protector to ask that they investigate Malotana’s appointment. Public Protector passed the matter to Parliament’s Portfolio Committee for Public Service and Administration. In turn, the committee chair requested the Public Service Commission (PSC) to investigate.
In mid-November, the PSC “reportedly” cleared Malotana on the allegations relating to his qualifications and appointment. The PSC report was leaked to The Star newspaper with the complainants – the DA – as well as the portfolio committee chairperson not yet having had sight of the report. Spotlight also hasn’t yet been able to access a copy.
According to The Star, the PSC found that a master’s degree was not explicitly listed as a required qualification, and as a result, the commission found that Malotana did meet the requirements.
Bloom told Spotlight: “It’s highly irregular that the PSC report is leaked to a specific newspaper.”
Meanwhile, the SIU investigation continues, and the DA has reiterated its call for Gauteng Premier Panyaza Lesufi to remove Malotana from his post. Heads of departments are appointed by provincial premiers.
The Office of the Premier did not answer Spotlight’s questions about Malotana or the SIU investigation. However, according to a statement from the DA, Lesufi said in a Gauteng Legislature meeting last week that he would wait for the SIU investigation to be completed before taking any action against Malotana.
Millions spent on suspended staff
In September, responses to questions posed by Bloom in the Gauteng Legislature revealed that the provincial health department spent over R13 million on salaries for nine suspended staffers in recent years. Among these were Advocate Mpelegeng Lebeloane, former chief director of legal services, who received R4.7 million while on suspension from July 2019 until 2023. He was later reinstated and then retired in July 2024.
Bloom said in a statement at the time: “Three senior staff were suspended since 26 January 2022 for alleged financial misconduct concerning the refurbishment of the Anglo Ashanti Hospital. One has recently resigned, but more than R6 million has been spent so far on their salaries in this inexcusably long-running matter.”
The other staff members had been suspended on a range of charges, including sexual assault, assault and a job-selling scam.
Bloom said the long delays in concluding disciplinary processes smacked of a failure of accountability and were a drain on taxpayers’ monies and resources.
Spotlight put questions to the health department about its mechanisms and processes to ensure efficient and appropriate disciplinary action. The department’s spokesperson Motalatale Modiba said the cases in question “cut across various departments”. He added: “The employees were suspended with full pay and the delays mainly had to do with ongoing SIU investigations.” This includes cases that were “handled through the Office of the Premier”.
Hospital CEOs
Also on Bloom’s radar are the appointments of Dr Nthabiseng Makgana, Dr Lehlohonolo Majake, and Dr Godfrey Mbara to positions of CEOs of Chris Hani Baragwanath, Steve Biko and George Mukhari academic hospitals respectively.
The appointments were made in March, and health MEC Nomantu Nkomo-Ralehoko responded to Bloom’s questions about them in October. Bloom highlighted irregularities, noting that none of the three appointees met the requirement of 8 to 10 years of experience for hospital CEO roles, while one also didn’t have the required education qualification level. These are contraventions of regulations, according to Bloom, adding that he is still to see proof of qualifications, as he’s requested.
Another high-profile appointment under scrutiny has been the redeployment of Dr Nozuko Makabayi – the former CEO of the Rahima Moosa Mother and Child Hospital. A doctor’s open letter in June 2022 exposed poor conditions at the hospital, leading to a Health Ombud investigation. The damning report criticised Makabayi for several failings, including being absent from work for nearly 100 days without explanation. The Ombud recommended that Mkabayi be removed as CEO, but she was shifted within the department to serve as acting director responsible for HIV and Aids, STIs and TB.
Bloom’s follow-up questions to Nkomo-Ralehoko brought to light that Makabayi has not been reporting for work, due to mental health stress, but continues to receive her salary. “This is outrageous. After all the trouble she caused, she is now on a long running paid holiday at taxpayers’ expense. If she can’t do any useful job, she should be medically boarded and leave the department,” he said in October.
“There has not been a permanent HR director for years in the department and the systems of appointments follow a consistent pattern of people placed in acting positions, protecting interests, and ensuring cadre deployment rather than service delivery,” Bloom told Spotlight.
“We have the wrong people in these key positions by design. We are talking about control, looting and siphoning of one of the largest budgets in the province,” he alleged.
Modiba said that “relevant bodies are investigating” and pertaining specifically to Makabayi, he said “internal processes are unfolding” but cannot be released to the media because of an “employer-employee clause”.
Scathing Auditor General report
Recently, the Gauteng Department of Health received another scathing report from the Auditor-General for the 2023/24 financial year.
The department underspent by R1.1 billion, including R590 million underspent on the National Tertiary Service Grant intended for specialised medical treatment. This in spite of backlogs and long patient waiting lists. In addition, the report showed that the health department racked up R2.7 billion in irregular spending, R17 million in wasteful spending, and lost another R2.7 billion in income.
Action SA member in the provincial legislature Emma More described the performance of the department as “clearly lacking effective leadership and management”.
She slammed the health department for providing incorrect and misleading statistics, as highlighted by the auditor-general. “For an institution like the [Gauteng] Health Department to provide such misleading information undermines public confidence in it and compromises the lives of our citizens in this province,” More said. “It is unacceptable that while our healthcare facilities are under-resourced and struggling to meet the needs of the population, significant portions of the budget are being wasted or mismanaged.”
Responding to More’s comments, Modiba said that the department had spent 98.9% of its budget allocated for 2023/2024. He said that of the 1.1% (R1.1 billion) under expenditure, R580 million has already been provisionally approved by Treasury to be carried over to the current fiscal year, subject to audited financial statements.
“While the department aims to spend every allocated cent, achieving this goal is not always feasible due to various factors impacting the operational environment. For instance, some of the money was committed to purchase orders or invoices that could not be processed within the previous financial year leading to a rollover of funds. The amount covers grants for human resource training, national tertiary services, district health programmes and the national health insurance,” Modiba said.
A ‘structural’ problem
Professor Alex van den Heever, chair of social security systems administration and management Studies at Wits University’s School of Governance, said the health department’s leadership crisis at its core is a structural one.
“South Africa has a huge pool of talent, and we are not short on good managers or people who understand health, and how to run a health service – but these are exactly the people the [Gauteng] department of health don’t want,” he said.
“Why would they want a Babita Deokaran [an acting chief financial officer who was assassinated in August 2021 after flagging what appeared to be corruption at Tembisa Hospital] or someone who is actually going to root out the nonsense or someone who is going to properly manage patient care?” Van den Heever asked.
Describing the department’s leadership as an “hourglass model”, Van den Heever said at the top are leaders with all the power, but little focus is on delivery. The pressure falls on an overstressed, underfunded middle management with limited decision-making power, which then trickles down as problems for those at the bottom.
He added: “Hospitals can’t afford this kind of leadership, they fall apart. There is no strategy behind anything, so no maintenance, proper training and supervision of staff or clinical governance. Problems aren’t solved, they’re hidden.”
Spotlight questioned the department’s alleged failure to attract “fit for purpose” candidates, resulting in more leadership and governance challenges for the department that filter down to hospital and clinic level.
In response, Modiba stated that, for the first time since 2006, they have reviewed organisational structures, which have now been submitted to the Office of the Premier.
“This is a major step towards ensuring that the Gauteng Department of Health has a structure fit for purpose that is geared to meet the service needs of the growing Gauteng population. Furthermore, a service provider has been appointed for the next three years to conduct ‘personnel suitability checks’. This will assist the department in its recruitment of suitably qualified employees who will be able to contribute meaningfully towards the achievement of the organisation’s strategic objectives,” he added.
Offering a solution to fix some of the challenges crippling the health department, Van den Heever said that changing leadership structures to orient towards service delivery could mean better governance and management, improved staff motivation, renewed public confidence and ultimately better patient care. This, he said, would require the decentralisation of powers so that competent people can take charge in hospitals, make impactful decisions about appointments and budgets, and be accountable for pockets within a complex provincial health system.
It’s acknowledged in key policy documents, well known at the coalface and much ventilated in the media: South Africa’s public healthcare system has too few healthcare workers, especially medical doctors, certain specialists, and theatre nurses. Less recognised however is the shortage of public sector pharmacists. We lift the lid on this until now largely hidden problem – and its impact.
There are too few public sector pharmacy posts across South Africa to deliver a comprehensive service, with no clear staffing norms, and an uneven distribution of pharmacists, especially in rural districts. This contributes in part to medicine stockouts and the emergence of deadly hospital-acquired drug-resistant infections.
This is according to Dr Andy Gray, a senior lecturer in the Division of Pharmacology at the University of KwaZulu-Natal’s School of Health Sciences and co-head of the World Health Organization Collaborating Centre for Pharmaceutical Policy and Evidence Based Practice. His views are echoed by at least two other key local stakeholder organisations.
Flagging the alarming rise in resistance to antimicrobials – an urgent global public health threat – driven by the misuse of antibiotics in hospitals and ambulatory care, Gray told Spotlight that there are not enough pharmacists to intervene if they see inappropriate use of medicines.
“This just continues without any effort to fix it. Inadequately trained and understaffed prescribers are working under immense stress, so they are prone to use the wrong medicines at the wrong time with the wrong doses,” he said. “There are also very few microbiologists and certainly not enough pharmacists at the bedside. They’re not doing what’s necessary to ensure the proper use of medicines – for example, better control over antimicrobials.”
The excessive dependence on antibiotics has resulted in the emergence of antibiotic-resistant bacteria, commonly known as superbugs. This is called bacterial resistance or antibiotic resistance. Some bacteria are now resistant to even the most powerful antibiotics available.
South Africa has been ranked 67th out of 204 countries for deaths – adjusted by age per 100 000 people – linked to antimicrobial resistance. It has been estimated that around 9 500 deaths in the country in 2019 were directly caused by antimicrobial resistance, while 39 000 deaths were possibly related to resistant infections.
The National Department of Health warned in a background document that rising antimicrobial resistance and the slow-down of new antibiotics could make it impossible to treat common infections effectively. This could also lead to an increase in the cost of healthcare because of the need for more expensive 2nd or 3rd line antimicrobial agents, as well as a reduced quality of life.
Low numbers
Gray said that while not matching the paucity of public sector doctors and nurses, pharmacists stand at 24% of the staffing levels calculated as necessary to deliver a comprehensive service.
“We need just over 50 pharmacists per 100 000 uninsured population as a target, but we’re sitting at around 12,” he said.
Gray said the SA Pharmacy Council (SAPC) has no data on the total number of pharmacists actually working in the country, or the number working in particular settings. A SAPC spokesperson said they had only provincial statistics, but could not track pharmacist movements.
“You can’t use their database to find out how many pharmacists are working where. The Health Systems Trust SA Health Review Indicator chapter has figures of public sector pharmacists per province and per 100 000 uninsured population,” Gray pointed out.
As at February 2024, there were 16 856 pharmacists registered in South Africa, (working and not working), excluding the 971 community service pharmacists.
The 5 958 pharmacists employed in the public sector represents the full complement of funded posts, but it is well below the number needed – and varies dramatically between provinces. While almost all funded posts are filled, Gray said the number of posts is less than needed to deliver a comprehensive, quality service.
Taken across South Africa’s population of around 62 million, there are around 28 registered pharmacists (working or not working), per 100 000 people (insured and uninsured). According to data from 2016, the mean global ratio stands at 73 per 100 000.
“We’re better than many other African countries, but that’s cold comfort,” said Gray.
Increases spread unevenly
There are some positives. The number of pharmacists in the public sector has grown since 2009, rising from five to 12 per 100 000 uninsured people by 2023. However, the ratio varies markedly by district – for example: from 15 in the best-served Western Cape district to a mere three in the poorest served Northern Cape district.
Gray said the more rural districts suffer the most when it comes to understaffing of pharmacists and this contributes to medicine stockouts. While the causes of medicine stockouts are complex, one of the major contributors is the refusal of suppliers to deliver any more stock until accounts are paid.
Understaffing of pharmacists often results in nurses managing patients without any pharmaceutical oversight, Pharmaceutical Society of South Africa Executive Director, Refiloe Mogale, told Spotlight. She associates such task-shifting with medicine misuse and inappropriate prescribing, noting that while it’s a vital strategy in budget-tight environments, medication errors are on the rise. This, she argues, could be solved by ensuring appropriate pharmaceutical personnel are placed to support primary healthcare facilities – such as pharmacist assistants.
“A Primary Care Drug Therapy (PCDT) trained pharmacist can diagnose, treat, and dispense medications. So, this is not as much about task-shifting as about the pharmacist providing comprehensive care. These PCDT pharmacists can do family planning, screening for diabetes, hypertension, and other clinical tasks that take the burden off doctors. We need more of them,” she said.
‘No clear staffing norm’
Addressing the human resources quandary, Gray said the core problem had always been that the number of pharmacist posts per hospital or clinic were not evenly distributed. “There’s been no clear staffing norm. The old ‘homeland’ hospitals are likely to be under resourced with pharmacists and pharmacists’ assistants. Posts are poorly distributed and by global standards, we’re nowhere near where we should be,” he said.
The National Department of Health’s most senior pharmacy official Khadija Jamaloodien agreed that pharmacy posts should be distributed better. But she said work protocols dictate that state pharmacists must visit each clinic in their district at least once per month. She said there are 3 000 primary healthcare facilities in the country and 6 000 (albeit maldistributed) public sector pharmacists.
Nhlanhla Mafarafara, President of the SA Association of Hospital and Institutional Pharmacists, told Spotlight too many of the almost 6 000 pharmacists in the public sector are doing stock management, dispensing, administration and management work in hospitals and pharmaceutical depots. He says the numbers do not necessarily reflect pharmacists in clinical or patient facing areas.
“The reality is that pharmacists are restricted to trying to get drug stock in and out,” Gray observed.
However, the lack of pharmacists and pharmacist assistants at clinics and hospitals means timely and/or knowledgeable ordering often results in shortages of essential medicines, something all experts interviewed for this article agreed on.
Mafarafara said that by defining what services a pharmacist should render and what’s needed to enable a quality service, more realistic staffing numbers could be reached. Pharmacies are central points in all hospitals, with closure for even an hour crippling a hospital. Thus, adequate staffing is critical to ensure uninterrupted access to good quality pharmaceutical care.
South Africa, Mafarafara added, was far behind many other countries in the effective use of pharmacists’ clinical expertise in leading evidence-based care in hospitals. “I’d even go so far as to say doctors should be stopped from dispensing in favour of pharmacists to improve quality of patient care,” he said.
‘If you don’t have a pharmacist, nothing gets done properly’
Jamaloodien said the cost of having too few pharmacists is more far-reaching than just antimicrobial resistance. “You can have stock outs because there’s nobody to manage the supply chain. In my experience, if you don’t have a pharmacist, nothing gets done properly,” she said.
Her solutions? Compliance with the “comprehensive and robust” evidence-based standard treatment guidelines, access to an updated and well-maintained cell phone-based application that gives everybody access to the latest information and medicine changes – and more attendance by all healthcare professionals of webinars held after every medicine’s committee meeting, plus clinicians regularly reading drug update bulletins to keep up with new medicines.
By Prelisha Singh, Partner, Martin Versfeld, Partner and Alexandra Rees, Senior Associate, Webber Wentzel
Robust contestation on how to best fulfil the fundamental rights of South Africans complements and strengthens our constitutional democracy. Recent debate has centred on the effective realisation of the right to access healthcare, which the state is required progressively to realise for all South Africans, irrespective of their background and income.
The right to access healthcare came into sharp focus on 15 May 2024, when President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law, prompting the initiation of constitutional challenges by concerned stakeholders. The most recent of these was filed on 1 October 2024 in the North Gauteng High Court, Pretoria by the South African Private Practitioners Forum (SAPPF), represented by Webber Wentzel.
According to the government, the NHI Act is intended to generate efficiency, affordability and quality for the benefit of South Africa’s healthcare sector.
An assessment of South Africa’s current healthcare landscape shows a stark difference between private and public healthcare. The country has a high quality, effective private healthcare offering. However, it is currently inaccessible to the many South Africans who cannot afford private care or medical aid payments. Public healthcare, on the other hand, is understaffed, poorly managed and plagued by maladministration and limited facilities.
The NHI Act has been positioned as the vehicle to address this disparity and a desire to take steps towards achieving universal healthcare in South Africa. But a closer reading of the Act highlights numerous problems with its content and implementation design. The absence of clarity, detail or guidance contained in the Act makes it impossible to assess how the Act will actually be implemented (or, by extension, what the effects of this implementation will be).
This is particularly concerning given that years have passed since the economic assessments, on which the Act was based, were undertaken. Also problematic is the apparent lack of consideration given by the government to submissions made by affected stakeholders during multiple rounds of constitutionally required public participation.
SAPPF underscores these deficits in seeking both to have the President’s decision to assent to the Act reviewed and set aside, and the Act itself declared unconstitutional.
President Ramaphosa was obliged, in terms of sections 79 and 84(2)(a) to (c) of the Constitution, not to assent to the Act in its current form. Section 79 requires the President to refer back to Parliament any bill that he or she believes may lack constitutionality. In this case, it is difficult to conceive how the President, or any reasonable person in the President’s position could not have had doubts regarding the constitutionality of the NHI Bill. The decision by the President to sign unconstitutional legislation into law, instead of referring it back to Parliament for correction, is also irrational.
The President’s duty properly to have referred the NHI Bill back to Parliament is affirmed by the fact that the President is enjoined, by section 7(2) of the Constitution, to respect, protect, promote and fulfil the rights contained in the Bill of Rights.
SAPPF’s application demonstrates that the NHI Act, in its current form, infringes upon the rights to access healthcare services, to practice a trade, and to own property. Patients, including those using private healthcare, will be forced to use a public healthcare system that currently fails to meet its key constituents’ needs. Practitioners’ rights to freedom of trade and profession will be infringed upon, and the property rights of medical schemes, practitioners, and financial providers will be unjustifiably limited.
On its current text, the Act could make South Africa the only open and democratic jurisdiction worldwide to impose a national health system that excludes by legislation private healthcare cover for those services offered by the state – notwithstanding the level or quality of case.
Concerns regarding the rights infringements in the NHI Act are exacerbated by its lack of clarity and the fact that crucial aspects of its implementation are relegated to regulations, with no clear guidance provided in the Act itself.
For example, section 49 provides that the NHI will be funded by money appropriated by Parliament, from the general tax revenue, payroll tax, and surcharge to personal tax. However, this stance does not reconcile with section 2, which provides that the NHI will be funded through ‘mandatory prepayment’, a compulsory payment for health services in accordance with income level. Crucially, the extent of the benefits covered by the NHI’s funding mechanism and its rate of reimbursement, which impact affordability and the provision of quality healthcare, remain unknown.
The Act is, at best, a skeleton framework, seemingly assented to in haste. It is conceptually vague to the extent that the rights it seeks to promote will, in fact, be infringed if implemented. This renders the Act irrational, in addition to its other constitutional defects.
The NHI Act represents a radical shift of unprecedented magnitude in the South African health care landscape. This should be – and is required to be – underpinned by meaningful public participation, up-to-date socio-economic impact assessments and affordability analyses and final provisions that provide a clear and workable framework for implementation.
It is not sufficient for these vital issues to be addressed after the fact. Further engagements with stakeholders and the solicitation of proposals by the government cannot be used to splint broken laws. Collaborative engagement, including the solicitation of inputs for meaningful consideration, should take place during the law-making process, not after its conclusion.
A shift of the magnitude proposed by the Act, absent compliance with the structures of the law-making process and adherence by the state to constitutional standards, including rights protections, would be detrimental to the entire healthcare sector – public and private – and not in the best interests of patients and practitioners.
Notwithstanding the legal contestation surrounding the Act, it and the laudable goals underlying it can also be a watershed. The achievement of universal health coverage is an opportunity for the different stakeholders in South Africa’s healthcare system to meaningfully collaborate and inform well-supported, factually informed, rational and genuinely progressive legislative steps by the state.
Given the questions surrounding the Act and the evident need it seeks to address, the space exists for healthcare stakeholders to align around shared goals and values. They can leverage their available resources to design a healthcare system that serves all of South Africa’s people fairly and equitably, using the significant existing resources invested in the country’s healthcare sector.
Bada Pharasi, CEO of The Innovative Pharmaceutical Association of South Africa (IPASA)
Imagine a healthcare system which ensures that every patient’s voice helps shape their treatment, where barriers to life-saving care are dismantled, and where innovation is driven by meaningful collaboration. In South Africa, this vision is no longer a distant aspiration; it’s an urgent mission to create a system that truly serves its people, writes Bada Pharasi, CEO of the Innovative Pharmaceutical Association of South Africa.
South Africa’s healthcare system stands at a critical crossroads. Despite remarkable medical advancements, countless patients remain on the sidelines, hindered by financial, regulatory, and logistical barriers. Today, there’s an opportunity to reshape this reality by building a patient-centred healthcare model that expands access, amplifies patient voices, and creates strategic partnerships.
Empowering patient voices
In a truly inclusive healthcare system, patients aren’t just recipients of care; they are active contributors. By integrating patient perspectives into decision-making, healthcare becomes more responsive to those it serves.
Through collaborations with patient advocacy groups, educational campaigns, and year-round initiatives, there’s a growing movement to create an environment in which patients feel heard and empowered to influence the care they receive. While events such as World Patient Safety Day help highlight the importance of prioritising patient needs, the goal is to make this a constant focus, not just an annual observance.
Key prerequisites for achieving this are efficient regulatory frameworks, impactful public-private partnerships, rare disease management, and a true commitment to innovation.
Streamlined regulatory partnerships
Timely access to groundbreaking treatments depends on efficient regulatory frameworks. Collaborating closely with regulatory authorities such as the South African Health Products Regulatory Authority (SAHPRA) is pivotal in expediting access to new therapies.
Such partnerships ensure that treatments meet rigorous safety standards while streamlining approval processes so that life-changing therapies reach patients without unnecessary delays. Maintaining high standards for post-market safety also strengthens public trust and reinforces the resilience of the healthcare system.
Public-private partnerships: Catalysts for innovation
Expanding access to quality healthcare in South Africa demands strong public-private partnerships (PPPs) that leverage both public resources and private sector innovation.
Collaborative efforts with the Department of Health and other key stakeholders maximise impact by ensuring that resources are effectively allocated and that patients benefit from the latest treatments. These alliances are vital for achieving universal health coverage (UHC) under the National Health Insurance (NHI) framework, helping to ensure that equitable, high-quality healthcare becomes a reality for all.
Closing gaps in rare disease management
For patients with rare diseases, access to treatment is often riddled with obstacles, from limited therapies and high costs to a lack of awareness. Multi-stakeholder collaborations, including advisory boards initiated by organisations such as Rare Diseases South Africa, bring together patients, healthcare professionals, and industry experts to advocate for better support and access to treatments.
This prioritisation of open communication and patient-centred outcomes offers hope to rare disease patients who, through these partnerships, gain better access to essential treatments and the support they deserve.
Breaking down barriers to innovation
The drive for a more accessible healthcare system also requires addressing policy barriers. Streamlined processes, simpler registration pathways for new drugs, and patient-centred reimbursement policies ensure that patients receive the right treatment at the right time.
Working alongside policymakers, healthcare providers, and civil society, a concerted effort is being made to create a system in which innovation and equity go hand-in-hand to provide better outcomes and quality of life for all South Africans.
Shaping the future of healthcare
The future of South Africa’s healthcare lies in a system that prioritises patients, breaks down barriers, and capitalises on partnerships to make innovation accessible.
The call to action is clear: build a healthcare ecosystem that is dynamic, inclusive, and adaptable to ensure that every South African has access to the care they need. By promoting patient voices and ensuring collaboration across sectors, we can transform South Africa’s healthcare system to be more responsive, resilient, and equitable – a system that truly serves its people.
Rates of HIV and Hepatitis C are “extremely high” among people who inject illicit drugs, according to new research by TB HIV Care. The organisation tested over 1200 injecting drug users in Tshwane, eThekwini, Mashishing and Mbombela (formerly Nelspruit).
In Tshwane 72% tested positive for HIV and nearly 90% had antibodies for hepatitis C virus (HCV), which could indicate past or present infection.
HCV is a blood-borne virus which damages the liver. When left undiagnosed it can be fatal, though it’s usually curable if treated.
Less than half of those who tested positive for HIV in Tshwane were aware of their HIV status. As such they would not have been on treatment and could have been spreading the virus without knowing.
Survey Site
HIV Prevalence among people who inject drugs
Antibodies for Hepatitis C among people who inject drugs
Share of HIV positive people who knew their status
eThekwini
49%
75%
76%
Mashishing
45%
41%
77%
Mbombela
30%
91%
64%
Tshwane
72%
89%
48%
Results of the TB HIV Care survey of four cities.
People who inject drugs (such as heroin) are at a higher risk of contracting HIV and HCV when needles are shared – something which happens because drug users don’t have easy access to new ones.
This has long been a problem in South Africa and appears to be getting worse. Research conducted in eThekwini in 2013 found that 17% of injecting drug users were HIV-positive. According to the new research, a decade later the figure has nearly tripled to 49%.
Professor Harry Hausler, CEO of TB HIV Care and a former technical advisor to the National Department of Health on TB/HIV, believes the main reason for this “massive” uptick in blood-borne diseases among drug users is “the limited access to needle and syringe programs” in the country.
Government ignored its own solution
Research shows overwhelmingly that providing clean needles to drug users reduces the spread of HIV, not only by removing the need to share injecting equipment but often because needle programs offer other services such as health education and condoms.
A large review published in 2017 identified 133 academic studies on needle and syringe programs (commonly known as NSP). The results were “supportive of the effectiveness of NSP in reducing HIV transmission among [people who inject drugs], as well as in reducing HCV infection, although the latter to a lesser extent”.
Yet despite these formal policy commitments, there is virtually no public funding for such interventions.
A person discards used needles in a specialised bin provided by TB HIV Care at a mobile clinic in Wynberg, Cape Town.
One exception is the Pretoria-based Community Oriented Substance Use Program, sponsored by the Tshwane Municipality. It has been left to non-profit groups, such as TB HIV Care, to provide these services. According to Hausler, the organisation currently provides clean needles to nearly 10 000 injecting drug users in Cape Town, Nelson Mandela Bay, eThekwini, Tshwane and Mbombela.
Users access needles from drop-in centres as well as mobile clinics – usually vans that get driven on set days to areas where injecting users congregate. Users discard their old needles in specialised bins provided by TB HIV Care. They will then receive a pack, which includes clean needles, alcohol swabs and sterile water.
Nurses are present at the mobile clinics so users can also get tested for HIV and HCV. They also offer ordinary medical services, such as cleaning and bandaging wounds.
Mobile clinics are also manned by psychosocial and human rights workers, and peer educators (people who were beneficiaries but now work for TB HIV Care) from whom users can get counselling or report abuses.
“We’re not just a needle provision organisation”, says Loraine Moses, who oversees quality standards for the program. “We’re a health services organisation”. Users have to register with peers and get health counselling and education before getting their needles, she says.
Beneficiaries have access to various amenities at TB HIV Care’s drop-in centres, including showers, lounging areas and washing machines.
Anthony (surname withheld), previously a heroin user for 15 years, who now volunteers for TB HIV Care, spoke to GroundUp at a drop-in centre in Cape Town.
“In the beginning, I started experimenting with friends in school [but] after my mother passed away, I found that there are those properties in [heroin] that calm you and numb pain, so that’s when I started to delve [into the drug] more.”
After ending up on the street and becoming “a slave to that drug”, he increasingly wanted to get sober. Fetching needles from a TB HIV Care site, he began speaking with one of the peers. The person told him about TB HIV Care’s opioid agonist program, which helps users to quit or reduce their heroin intake.
Opioid agonists are drugs which block heroin withdrawal. Methadone is the most widely known. Numerous clinical trials show that initiatives which offer methadone to heroin users over an extended period are more effective than rehab programs that force users to quit cold turkey.
Hausler says that TB HIV Care currently provides methadone to over 1100 people. Along with the medicine, they receive counselling and are assisted with finding shelter, and in some cases to reintegrate with their families.
Anthony says he’s been taking methadone since June last year. The program also helped him link up with a shelter and get an ID document so that he could find work.
“Being a client at TB HIV Care has helped me a lot to reintegrate back into society,” he says. “Being on the street, you lose a lot of yourself”.
A notice board at the TB HIV Care drop-in centre in central Cape Town.
Law enforcement continues to confiscate needles
Local governments have assisted TB HIV Care with some of its services. The City of Cape Town provides the HIV tests for use at mobile clinics, according to Hausler.
And yet, not only has the government failed to directly fund the sterile needle programs but in some cases it appears to work against them.
Research carried out by TB HIV Care shows that users frequently have their injecting equipment confiscated by law enforcement officers.
In Tshwane and eThekwini more than half of all people surveyed said that the authorities had seized or destroyed their needles at least once in the previous six months.
Outcome
Mashishing
Mbombela
eThekwini
Tshwane
No
57%
76%
31%
36%
Yes, In the last 6 months
18%
20%
64%
54%
Yes, but not in the last 6 months
25%
4%
5%
10%
Results of survey question: Have you ever had your needles and syringes confiscated or destroyed by a police officer/law enforcement? Source: TB HIV Care
“What’s very frustrating is that there are two arms of government,” says Hausler. “There’s health and then there’s police. And police are confiscating needles and syringes that we’ve been providing to clients – [even though what we’re doing] is a clearly endorsed health intervention.”
Hausler notes that in some cases the organisation has “really good alliances with local police”, but in other cases it is a constant battle.
“There needs to be better mainstreaming of education of officials across all government departments on the … HIV and TB response [plans],” says Hausler. “If people were really sensitised, we would not run up against as many obstacles.”
Asked for comment, Gauteng SAPS spokesperson Lieutenant Colonel Mavela Masondo told GroundUp that “possession of needles is not a criminal offence. Therefore, we cannot arrest a person [for] possession of needles, and neither can we confiscate needles”.
Note: The full report by TB HIV Care, which received assistance from the United States CDC, is not yet publicly available. A 16 page summary of some of the findings can be found here.
Professor Harry Hausler, CEO of TB HIV Care, at his office in Cape Town.
To see National Health Insurance primarily as the setting up of a state-run medical aid scheme risks underplaying its massive potential to restructure how public healthcare services are organised and funded, and with that, its potential to boost the delivery of primary healthcare services in South Africa, argues Russell Rensburg.
It has been 30 years since South Africa emerged from centuries long racial suppression and state-sponsored apartheid and took her place among the community of sovereign, democratic nations. In 1996, we adopted the final Constitution, in which we committed to addressing the injustices of the past and building a society based on social justice and human dignity. That promise is carried through in the Bill of Rights, which under Section 27 includes the right to healthcare, food, and social assistance. The right to access healthcare services, like many socio-economic rights, is subject to the state taking reasonable legislative and other measures within available resources to progressively realise the right.
Pursuant to this, the National Health Act, which provides the framework for a structured uniform health system within the country, was adopted in 2003. The Act assigns the minister of health the obligation to ensure the provision of essential health services, which must include primary healthcare services. But, to date, no health minister has published regulations that define the exact scope of essential health services, nor has a framework been offered for the development of a defined package of care to be provided within the resources available.
The result is that, despite significant investments in public funded healthcare, the system and the services it provides has largely been shaped by existing infrastructure inequity. Put differently, health investments have typically gone where the infrastructure exists, rather than being guided by providing a defined package of primary healthcare services in all the places where it is most needed.
In the near term, the health system faces several immediate challenges. Per capita spending is declining. Spending is biased towards hospitals, with 42% of the national health budget spent on central and provincial hospitals. Another problem is that health service planning and budgets do not sufficiently account for our changing demographic profile – life expectancy has increased and we have a growing population of young people.
The National Health Insurance (NHI) Act is an attempt to address this through the establishment of the national health insurance fund, which initially will be the only purchaser of public sector healthcare services. Broadly, the NHI aims to pool funds to provide access to good quality, affordable healthcare services for all South Africans and certain foreign nationals, based on their health needs and irrespective of their socio-economic status.
This shift marks a substantial change from the existing setup, where 85% of the national health budget is allocated at the provincial level. In South Africa, the share provinces get of the national budget is largely determined by the equitable share formula. The health component of the formula includes a number of variables to account for healthcare need, including premature mortality (as a proxy for unmet need ), multi index deprivation (to account for social determinants of health such as poverty ), income, housing, and measures of sparsity (to account for rurality). But the biggest driver of funding is historical utilisation, which shapes resource allocation at the provincial level. The result is that the funding is overly focused on providing care under the existing systems, rather than progressively expanding access to healthcare, and boosting access to primary care in particular.
In short, NHI represents a major shift away from this paradigm by which provinces receive healthcare funds via the equitable share and based on historic spending.
How it will work
Under NHI, the public sector will budget according to level of care, initially prioritising the district health system through the establishment of district health management offices. These offices will support contracting units for primary care, which will comprise a district hospital, community health centres , primary healthcare clinics, and ward based outreach teams as well as provisions for integrated practice comprising GPs, pharmacists, dentists, and rehab professionals (occupational health, physiotherapy, and speech therapy). The district health management offices will be responsible for the achievement of health outcomes in districts.
In theory, this will allow for healthcare priorities to be shaped at the district level and for services to be more responsive to the healthcare needs of communities. For example, a district like OR Tambo could prioritise more resources towards addressing maternal mortality by expanding ante-natal services or developing responses to address the health access gaps for older people in rural areas. In urban districts, like the City of Johannesburg, it could prioritise expanding access to reproductive health services by contracting in private health providers who are better placed to respond to the needs of working women. Ultimately, such a shift to a more responsive and more localised health system could also help increase uptake of TB and HIV prevention and treatment services across the board.
How to get the ball rolling
Reorientating our health system towards primary healthcare will be a difficult and time-consuming process, given the complex nature of health systems. But, there are things we can do right away to get things moving. We don’t have to wait for full implementation of NHI.
The current District Health Programme Grant can be expanded to enable provinces to increase primary healthcare services. The grant currently focuses on resourcing the country’s response to HIV, which seems to have reached a plateau with fewer people initiated on treatment. Contracting in private providers using this grant could improve service accessibility for testing, reproductive health services and routine healthcare for the working poor. Indeed, contracting in non-state healthcare providers, such as healthcare NGOs, pharmacies, and GPs, can significantly improve the patient experience and help build the public trust that is needed for NHI. As we repurpose the District Health Programme Grant, we can also start building the systems we will need for the district health management offices envisaged under NHI, thus helping to ease the transition when it comes.
The biggest immediate opportunity however lies in improving the accessibility and acceptability of district health services for the working poor. A study by the Bureau of Market Research at UNISA estimated that around 75% of working people in South Africa earn less than R6 000 a month. The current structure of publicly funded primary healthcare services do not respond to their routine needs, which include accessing family planning, seeing a GP when ill, a dentist to address oral health issues or access to rehab services. Apart from meeting the needs of these people, expanding service points, particularly in urban areas, can also improve disease surveillance through increased testing, and increased uptake of HIV prevention and treatment services.
There are more areas where we can make progress now that will ease the transition to NHI. For example, the current National Tertiary Services Grant, with an allocation of R15 billion, can be used to support a deep dive into what services our hospitals offer, what resources they are allocated and why, and how all of that lines up with the health need in our districts. The data isn’t currently there to really know whether we are getting value for money from our public hospitals. As with primary care, we need to get a clearer understanding of the need and start re-engineering the system so that we are in a better position to meet that need as we start implementing NHI.
Ultimately then, it is limiting to think of NHI exclusively as the establishment of a state-run medical aid scheme – as it is often portrayed in the media. A public discourse dominated by debates over the future of medical schemes risks obscuring the substantial potential NHI offers for improving and restructuring how public health services are organised and funded. The reality is that with NHI, we have an opportunity to shift the focus of our healthcare system toward primary healthcare and in the process to make our health system much more efficient and equitable. It is imperative that we do whatever is needed to deliver on that potential.
*Rensburg is Director of the Rural Health Advocacy Project.
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.
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.
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.”
The Department of Health has missed another deadline to provide nurses at public hospitals and clinics with uniforms by 1 September. Instead, a once-off allowance of R3 307 will be paid to nurses by 30 November to buy their own uniforms.
The Democratic Nursing Organisation of South Africa (DENOSA) says its 84 000 members “can hardly afford to get one set of uniforms” with that allowance.
Since 2005, nurses have received an annual allowance to buy their uniforms. In terms of a new agreement signed in March 2023, the department committed to providing uniforms directly to nurses, instead of the allowance of R2,600.
According to the bargaining council agreement, nurses were to receive seven sets of uniforms over two years. The uniform set includes a dress, or a skirt and a top (blouse or shirt), or a pair of trousers and a top (blouse or shirt). Accessories include a brown belt, brown shoes, a maroon jacket and a maroon jersey.
The agreement required the department to supply nurses with four sets of uniforms, one pair of shoes and one jersey in the first year, and three sets of uniforms, one belt, and one jacket in the second year.
However, as the 1 October 2023 deadline approached, the department said it was facing difficulties with the procurement process. In a last-minute bargaining council meeting in September 2023, the department informed nurses’ unions that it would not meet the 1 October 2023 deadline. Instead, it said, the supply of uniforms would be postponed until 1 September 2024 and a temporary allowance would again be paid meanwhile. Uniforms were to be procured through tenders in each province.
But in response to concerns expressed by DENOSA at a meeting in June 2024, the department acknowledged that it was battling with suppliers and would not meet the new deadline either.
Department spokesperson Foster Mohale said there were delays in procurement in some provinces and this was “receiving the urgent attention it deserves”.
He said the department had proposed a new plan and a new deadline of 1 September 2025.
Meanwhile, he said, nurses would be paid a once-off uniform allowance of R3307.60 by 30 November 2024. But DENOSA says this is “too little to buy uniforms”.
“With that amount, a nurse can hardly afford to get one set of uniforms. For a nurse to buy a proper uniform for the whole week, they need between R8500 and R14 000,” the union said in a statement.
Mohale said the uniforms will be supplied in line with the Preferential Procurement Policy Framework Act which stipulates that goods ordered by state institutions must contain a minimum of local content. The policy was first introduced in 2011 in a bid to protect South African industry and jobs.
But DENOSA said a centralised procurement system, similar to those used for police and army uniforms would be more effective than provincial procurement.
“The issue of quality is extremely concerning to us…This is going to open up the whole process to corruption which we have warned against, but it looks like the department has closed its ears on that matter,” DENOSA spokesperson Sibongiseni Delihlazo said.
With South Africa’s healthcare system facing a myriad challenges, experts at a health conference have put forward a range of practical solutions to address some of the country’s pressing issues. Ufrieda Ho rounds up some of the proposed solutions to improve patient care, including the use of public-private partnerships.
Closing the inequality gap and making trusted healthcare services accessible to the majority will require a whole systems overhaul. This was the underlying message of speakers at the recent Hospital Association of South Africa Conference who tackled the question of pragmatic steps to address the divides and failings of the country’s healthcare system. They put forward a range of solutions, models and case studies while highlighting the looming crises as more people fall through the cracks.
Around 15% of people in South Africa are members of private medical aid schemes, leaving 85% of people in the country largely reliant on a severely strained public healthcare system (though some do pay out-of-pocket to visit private sector doctors). As reported in Business Day, an argument was made at the conference for making medical scheme membership compulsory for everyone in formal employment, a move it is estimated could triple the number of people with medical scheme coverage and result in a 25% reduction in medical scheme premiums.
Delegates at the conference also heard that an integrated and coordinated whole systems approach is necessary. Speakers stressed that implementable interventions and innovations must kick in with urgency. Some argued that more political will is required, along with greater corporate commitment if effective public-private partnerships are to be established. Such partnerships was a key theme of the conference.
A kidney care example
Dr Chevon Clark, chief executive of National Renal Care, a private renal therapy provider, outlined the stark reality of an enlarging public health crisis as more people face kidney dysfunction.
“Globally, 850 million people have chronic kidney disease, acute kidney injury or are on renal replacement therapy. This signals a significant public health issue. This is twice the number of individuals estimated to have diabetes, and is 20 times higher than the number of individuals affected by HIV/AIDS.
“There has also been a 29.3% increase in reported chronic kidney disease over the last three decades. Not only is this increase deeply concerning, but so is the ability of our healthcare system to manage and treat individuals impacted by chronic kidney disease,” said Clark.
Last week marked Kidney Awareness week in South Africa. Against this backdrop, Clark said South Africa falls behind other middle income countries in having enough nephrologists and nephrology nurses for their populations. There is a combined 147 facilities for treatment and care in the public and private sectors – a shortfall, she said.
Clark said smarter public-private partnership initiatives are needed. She added these need to be focused on stronger stakeholder engagement, innovative funding mechanisms, advocacy and refining weak policy frameworks.
She presented a case study of National Renal Care (a private company) partnering with the Western Cape Department of Health and Wellness to set up a dialysis clinic at the Vredenburg Provincial Hospital. The hospital services a rural community. Before the unit was opened, patients had to travel long distances to access care in Cape Town. The inflow of patients from outside Cape Town also added to congestion at its facilities.
A benefit of the partnership, she said, is that they have been able to introduce newer technologies. Clark said they have a system that enables online and remote monitoring of patients. Patients’ records can be updated continuously and are maintained digitally. Clark said that patients have also been enrolled on a mobile app making patients “active partners in their healthcare and to drive compliance for better outcomes”.
Tele-health to track diabetes patients
Dr Atiya Mosam, a public health consultant and founder of Mayibuye Health, highlighted the importance of getting the basics right. She presented a case study of a public-private partnership in which a ‘tele-health doctor’ called diabetes patients from the Hanover Park Clinic daily for two weeks to monitor their glucose levels, adjust their medication when needed, and offer health advice.
Mosam said 74% of the patients contacted had to have their medication adjusted, indicating the need for this kind of immediate monitoring and treatment management. Mosam added that the intervention saw improvements in patients’ conditions and improvements in patients staying in targeted ranges for their glucose readings.
She added: “One man articulated that he had a new lease on life, attested to by his family. They said before the intervention, he was really very grumpy. Very interesting for us too was that many patients articulated that by having this contact with the ‘tele-health doctor’, they felt that the government cared for them.”
Cancer care
One area where efforts at a public-private partnership appears to have failed is cancer care in Gauteng. As widely reported, the Gauteng Department of Health set aside R784m early in 2023 for radiation oncology services, which would have included the outsourcing of some services to the private sector. That outsourcing hasn’t yet happened and the Cancer Alliance has since taken the department to court over the ongoing cancer treatment backlogs.
Health activist Mark Heywood, speaking at the conference on behalf of The Cancer Alliance, mentioned the ongoing litigation and said a hearing has been scheduled for 21 November.
Heywood drew parallels between HIV and cancer to illustrate how the fight for cancer treatment looks set to evolve, but also where wins could be achieved.
He said: “Cancer treatment and cancer medicines, like HIV medicines two decades ago, is inordinately expensive. It means that whilst cancer can be cured for the vast majority of people it is unaffordable and inaccessible. For the vast majority of people in our country, a cancer diagnosis is often a diagnosis that indicates a vastly shortened lifespan and the beginning of a journey to severe illness, very often indignity and death, and that is not how it should be.”
Heywood said government had an obligation to follow the constitutional framework to ensure access to cancer treatment as a basic health right. He also said private healthcare providers had to do better.
“There have been complaints of discrimination by medical schemes of only partial coverage of the costs and needs of care. This leaves people unable to complete treatment. There are allegations of overcharging by hospitals and specialists. There’s also a lack of collaboration between the private and the public sector, a lack of monitoring and a lack of a determination of healthcare outcomes when it comes to cancer,” he said.
But Heywood said the long – but ultimately successful – fight for access to treatment for HIV positive people in the country held important lessons that could be applied to cancer.
“What we learned with HIV was that with political will and with resource mobilisation, it is possible to dramatically alter the landscape of care and to tip the balance towards greater equality and social justice in healthcare,” he said.
“The question remains for the Hospital Association of South Africa and private health providers – what can you do to make cancer care more affordable, more accessible, and to build on public private partnerships to take them to scale to reach a greater number of people in a shorter period of time?,” Heywood said.
