The Gauteng Department of Social Development has decided to defund more than half of its existing capacity for inpatient drug rehabilitation in the province.
The department funded 571 beds in 13 non-profit organisations in the 2023/24 financial year, but at least five organisations, with 246 of these beds, will not be funded in the 2024/25 financial year.
The five organisations to be defunded – Westview Clinic Empilweni Treatment Centre, Golden Harvest Treatment Centre, Freedom Recovery Centre and Jamela Rehabilitation Centre – have been providing inpatient treatment for several years, but they have not received subsidies since the end of the last financial year.
Organisations GroundUp spoke to said they received letters from the department in the past few weeks informing them that they would not receive funding due to ongoing investigations. But they had not been told why they are under investigation, they said.
Representatives of FSG Africa, a forensic auditing firm appointed by the department, briefly visited some of the centres earlier this year, but the centres received no feedback on the progress or outcome of these investigations.
The auditors spent less than two hours at most of the facilities, asking only a few questions before leaving, the organisations said.
The organisations said they are yet to receive a report on the findings of the investigations. Queries they sent to the department have gone unanswered.
In previous years, the funding process was managed at a regional level, but this financial year it was centralised, cutting out the regional officials who would usually be in direct contact with the organisations. This has caused catastrophic delays.
Several of the organisations have been operating without departmental funding since March, depleting their savings and taking on debt, and having to short-pay staff salaries.
The department’s spokesperson Themba Gadebe confirmed to GroundUp that the organisations are under investigation, but did not provide details on the allegations.
In October 2022, Premier Panyaza Lesufi said treatment for substance abuse disorder was a priority. Yet the department has decided to defund beds in treatment centres without a clear plan to replace the lost capacity.
Gadebe said the department’s state-owned facility in Cullinan, near Pretoria, which has 288 beds, is undergoing renovation to increase its capacity. But he did not provide further details or timelines for completion.
Sedibeng’s only inpatient centres face closure
The only two drug rehabilitation centres with an inpatient programme in the Sedibeng region of Gauteng, with 116 funded beds between them, will be defunded this financial year.
One of these, Freedom Recovery Centre, was funded last year for 52 of its 94 beds (the remainder are for private patients). CEO Derick Matthews says when they received the department’s letter on 23 May “our world came crashing down”. What shocked him most was that there had been no warning that funding would stop.
Freedom Recovery Centre received a visit from the forensic auditors in March, who spent just two hours at the centre. They asked to see vehicles that the centre had supposedly received from the department.
“I was shocked by this request because we have never received vehicles from the department. But the auditor said that, according to their list, we had received vehicles from the department,” said Matthews.
“We are being punished for something. But we don’t even know what our transgression is,” he said.
On Monday, Freedom Recovery Centre began the process of discharging patients who were nearing the end of their treatment plans, as they can no longer afford to care for or feed them.
“We’ve had to take out loans for the past few months because of the delays in finalising service-level agreements and paying subsidies,” said Matthews. The centre has racked up more than R2-million in debt.
“Our staff are entering the third month of working without pay. Eskom is going to cut our electricity some time this week, because we are in arrears, and then we won’t even have water, because we rely on electricity to pump our boreholes. There are no funds left to keep the centre going,” said Matthews.
He said the centre will have no choice but to close completely in the coming weeks.
The other inpatient programme in the Sedibeng region, Jamela Recovery Centre, funded for 64 beds in 2023/24, faces a similar fate. CEO George Sibanda said they were relying on food donations from community members to feed their patients.
“We have been fully funded by the department since 2018 and our services are offered at no cost,” Sibanda said.
“We always had a backlog of patients. Our waiting list is sitting at 60 people so we were relieved when the department informed us that we would be getting additional beds in March this year. But what we don’t understand is how we must now provide a service to those patients if the department is not funding us this year?” said Sibanda.
Jamela also received a visit from the forensic auditors in March.
Despite not receiving any subsidies this financial year, Sibanda said the centre has been operating at full capacity.
“The department continued to refer people to us and we couldn’t turn them away,” he said.
Social workers at the centre have had to use their own money to pay for petrol for the centre’s car, which they use for outreach programmes.
Department spokesperson Themba Gadebe said that the closure of both centres in Sedibeng was not a concern as “the department prefers the placement of individuals within inpatient facilities far from where they reside, to limit the risk of them checking out or being contacted by those within their substance use networks.”
A number of radiation therapy graduates, who must by law complete the Department of Health’s Internship and Community Service Programme in order to practise medicine, say they have been waiting for nearly six months to be placed in hospitals.
They have finished their four-year studies and now need to complete a year-long internship, referred to as Comserve, in order to register and practice as medical professionals. Their primary role is to administer radiation treatment to patients with cancer.
The community service programme is administered by the National Department of Health.
“We are left in limbo, not sure when we will receive a post,” a graduate from the Western Cape, who wished to be anonymous, told GroundUp. He said that they’ve been told since the beginning of the year by Comserve officials that they are engaging with provinces to secure them placements.
He shared correspondence that said he was not yet allocated a position “due to the unavailability of funded posts”.
He said that it was “frustrating” that they are required by law to do Comserve yet the department cannot find them posts.
“We are all stressed out … We still have bills to pay from university. We are squatting with our parents. We were promised we were going to have a job after studying and now we can’t apply for other jobs. Our hands are cut off. We can’t do anything,” he said.
He said he knew of about nine other radiation therapists also waiting for placements.
Another graduate, from KwaZulu-Natal, said the lack of placement risked creating a backlog when next year’s graduates need to do Comserve.
“At the end of the day, our cancer patients are going to suffer … They need us and we have trained specifically to help them,” she said.
The failure to place graduates is happening despite staff shortages in radiation oncology departments in Gauteng.
On 30 April activists from SECTION27, Cancer Alliance and the Treatment Action Campaign (TAC) as well as cancer patients marched to the offices of the Gauteng department of health demanding that millions of rands set aside for radiation treatment be used.
In an open letter addressed to health MEC Nomantu Nkomo-Ralehoko, the organisations provided a backlog list of about 3000 patients awaiting radiation oncology treatment.
Salomé Meyer of the Cancer Alliance says there are radiation oncology staff shortages in Charlotte Maxeke Johannesburg Academic Hospital and Steve Biko Academic Hospital.
Both graduates GroundUp spoke to had applied to Charlotte Maxeke for their Comserve year.
In December 2023, the national department stated that nearly 10 400 Comserve applications were received. Of these just shy of 9400 applicants “were successfully placed, and this includes medical doctors, nurses, pharmacists and other health professionals at health facilities throughout the country”.
National Department of Health spokesperson Foster Mohale sent GroundUp an incoherent and incomplete WhatsApp response. “We only know those who were placed. We can’t tell those who were not placed because we are not sure of their career plans,” he wrote.
Asked about staff shortages, Mohale wrote that the department “prioritises all critical posts using limited budget”.
The Gauteng Department of Health did not respond to our questions about radiology therapist Comserve placements and staff shortages in its hospitals, despite committing to do so and repeated follow-ups.
Post-COVID-19, there has been a notable increase in vaccine fatigue and apathy, influenced significantly by social media.1 Higher trust in social media correlates with increased vaccine hesitancy, driven by the widespread dissemination of vaccine misinformation and conspiracy theories on these platforms.1 This has significantly impacted public perceptions and trust regarding vaccinations.1
Recently, statistics have indicated a notable increase in pertussis cases in South Africa. In December 2022, the National Institute for Communicable Diseases (NICD) reported a total of 408 cases countrywide.2 Most of these cases occurred in children younger than five years old as parents might not return to their healthcare professional to have their children vaccinated after six weeks of age.2
Pertussis is a vaccine-preventable disease
Recent research concluded that immunisation with the pertussis vaccine during pregnancy prevented 65% of pertussis infections through 6 months of age.3 These results indicate that maternal pertussis vaccination protects infants from infection during a period of greatest vulnerability to severe morbidity and mortality.3 The findings support the infant health benefits of recommendations to administer a dose of pertussis vaccine near 28 weeks of gestational age.3
Health authorities in South Africa have emphasised the importance of vaccination to control pertussis outbreaks.4 Immunity following vaccination lasts for approximately 5-6 years, necessitating booster doses.4 Episodic increases in pertussis cases occur in vaccinated populations every 3-5 years, making the completion of childhood primary series Tdap (tetanus, diphtheria, and acellular pertussis) vaccine and boosters important for prevention.4 The NICD also recommends vaccination of healthcare workers and pregnant women to reduce transmission to neonates and other vulnerable populations.4
“2024 marks the 50th anniversary of the Expanded Programme on Immunisation (EPI),” says Dr Lourens Terblanche, Vaccines Medical Head at global pharmaceutical company, Sanofi South Africa. “Every country has a national immunisation programme, and vaccines are universally recognised as best practice in terms of efficacy, tolerability, cost impact and successful public health interventions to prevent fatalities and enhance the quality of life. As we celebrate the lifesaving impact of EPI, we also need to strengthen routine immunisation initiatives, especially for pregnant women.”
Effective protection for children with Tdap vaccination
South Africa’s national immunisation schedule provides vaccinations against various diseases free of charge at state clinics, starting from birth, followed by additional doses at set times during a child’s early years.
“It is crucial to prioritise the health and well-being of patients, especially during critical stages such as pregnancy and childhood,” says Terblanche. “We urge all healthcare professionals to encourage pregnant women to receive their vaccinations timeously, and to ensure that their children’s vaccinations are up to date. Proactive efforts can significantly reduce the risk of vaccine-preventable diseases for mothers and children, safeguarding their health and the health of our communities.”
Terblanche reiterates that pertussis has the potential to cause serious and sometimes deadly complications in the paediatric population. “The majority of cases of pertussis occur in infants less than 2-3 months old, and the highest number of deaths are also seen in this age group. The situation is complicated by the fact that vaccinating infants themselves against pertussis can only start from 6 weeks of age, which is why strategies to protect them in this window of vulnerability is so important.”
Sanofi, in partnership with the National Department of Health, is urging healthcare providers throughout South Africa to encourage pregnant women to have the Tdap vaccination. Tdap vaccine Adacel is an integral component of preventive healthcare and is approved for use in individuals aged 10 through 64. This vaccine provides protection against pertussis, tetanus and diphtheria.5
Immunological response and efficacy
Adacel stimulates the immune system to produce antibodies that are specific to the toxins produced by tetanus and diphtheria bacteria, as well as the cells of the Bordetella pertussis bacteria. “This action provides a critical defensive shield against these diseases, with immunity that is significantly more robust and longer-lasting than natural immunity,” says Terblanche.
Adacel is indicated for immunisation during the third trimester of pregnancy to prevent pertussis in infants younger than 2 months of age.5
The first dose of Adacel is administered at least 5 years after the last dose of DTaP or Td.5
Adacel is approved for a repeat vaccination as soon as 8 years after the initial Tdap dose.5
Adacel for tetanus-prone wound management may be administered as early as 5 years after a previous dose of a tetanus toxoid-containing vaccine.5
“Adacel can help a pregnant woman to create antibodies against the bacteria that cause pertussis, and these are passed to her baby before birth,” says Terblanche.
Impact of vaccination on global health
Today, vaccines have an excellent safety record and most “vaccine scares” have been shown to be false alarms.6 However, misguided safety concerns in some countries have led to a fall in vaccination coverage, causing the re-emergence of pertussis and measles.6
Vaccinations significantly reduce disease, disability, death, and health inequities globally:6
Public Health Impact: Vaccination has substantially lowered the incidence of diseases that were once prevalent and often fatal, contributing greatly to global health improvements comparable only to the provision of clean water.6
Economic Benefits: By reducing disease burden, vaccination cuts healthcare costs and promotes economic growth through lower morbidity and mortality rates.6
Global Disease Control: Successful vaccination programs have led to the eradication and control of numerous infectious diseases.6
Herd Immunity and Social Equity: Vaccination not only protects vaccinated individuals but also contributes to broader community health through herd immunity. This indirect protection is especially beneficial in low-income settings where direct vaccine coverage may not be comprehensive.6
Empowerment and Secondary Benefits: Beyond health, vaccination empowers women by enabling better family planning and increases educational and social opportunities through improved child survival rates.6
Reduction of Antibiotic Resistance: By preventing bacterial infections, vaccines reduce the need for antibiotics, thereby helping to slow the development of antibiotic-resistant strains.6
With Adacel, you can help make a difference in pertussis prevention. Let’s protect mothers, children and our communities and ensure everyone has the chance to lead a healthy life by getting vaccinated.
Tdap – tetanus, diphtheria, acellular pertussis
DTaP – diphtheria, tetanus, acellular pertussis
Td – tetanus, diphtheria
References
1. Carrieri V, Guthmuller S, Wübker A. Trust and COVID-19 vaccine hesitancy. Sci Rep. 2023 Jun 7;13(1):9245. doi: 10.1038/s41598-023-35974-z. PMID: 37286569; PMCID: PMC10245358. 2. Whooping Cough Cases Increase Rapidly, Officials Urge Vigilance. Health-e News. [Accessed 22 Apr 24]. Available from: https://health-e.org.za/2023/01/27/whooping-cough-cases-increase-rapidly-officials-urge-vigilance 3. Regan AK, Moore HC, Binks MJ, et al. Maternal Pertussis Vaccination, Infant Immunization, and Risk of Pertussis. Pediatrics. 2023;152(5):e2023062664. 4. Pertussis Preparedness: An update for Physicians, Accident & Emergency practitioners and Laboratorians. National Institute for Communicable Diseases. Centre for Respiratory Diseases And Meningitis. Revised December 2022. [Accessed 22 Apr 24]. Available from: https://www.nicd.ac.za/wp-content/uploads/2022/12/Pertussis-preparedness-and-alert-doc_12-Dec-2022_Final.pdf 5. Pertussis prevention starts here. Sanofi. [Accessed 22 Apr 24]. Available from: https://www.adacelvaccine.com/ 6. Andre FE, Booy R, Bock HL, et al. Vaccination greatly reduces disease, disability, death and inequity worldwide. Bull World Health Organ. 2008 Feb; 86(2): 140–146. Published online 2007 Nov 27. doi: 10.2471/BLT.07.040089.
By month end, South Africa will have a new Minister of Health. Ufrieda Ho asked some academics and activists what qualities that person should have to tackle the key health issues the country faces.
The precise health minister South Africa needs right now may not exist. But the portfolio still demands that the person appointed to this critical position be up to the job.
The appointment, when it happens, will come against a radically shifted political backdrop. Firstly, the elections results of the May 29 point to a coalition government for the first time in 30 years of democracy. The final configurations of a likely government of national unity is still anyone’s guess. And secondly, the National Health Insurance (NHI) bill is now an Act. President Cyril Ramaphosa signed off on the bill just a fortnight before the elections. It means by law, the work on the advancement of NHI must begin even as the contentions and contestations remain as thorny as ever.
Another reason why getting the right person matters is the money that comes with the portfolio. Annual government spending on health is in the region of R270 billion. Most of this spend is currently directed via provincial health departments, but flows under NHI will be nationalised and the NHI Act gives the minister extensive powers over NHI, and indirectly, the NHI fund.
At the same time, problems like entrenched health sector corruption and high levels of medico-legal claims against the state remain acute. Health budgets have been shrinking in real terms over the last decade. Financial shortfalls and shortages of healthcare workers in our health facilities are dire, while health needs enlarge.
Bridging ideological divides
Fatima Hassan, a human rights lawyer and founder of the Health Justice Initiative, says: “Policymaking in a coalition government is going to be so difficult – a Herculean task. And the place where you’re going to feel it most acutely is in health, because we have a dual health system and because NHI is sitting on the table.”
She says the role of minister will call for an astute politician. She says: “It must be someone who can work with different parties as well as constituencies in different sectors to try to bridge a number of these ideological divides.
“Health is a lightning rod for the differences between the different political parties; we saw this in how the parties campaigned for or against NHI,” she says.
Hassan says the worst case scenario will be someone in the position who is a “placeholder minister” who stalls on reforms, is a person more concerned with “calming the markets” and someone who will simply play the political long game waiting it out until the next elections.
“It must be someone who is able to work on creating a fairer system for access to proper healthcare services across the country, not just in specific provinces. They must invest in health infrastructure, invest in human resources for health, and invest in some of the more positive aspects of preparing for national health insurance,” she says. She adds that the person must prioritise fixing the “glaring issues in the NHI Act” to avert looming law suits.
In addition, Hassan says the minister must be someone who can stand up to the bullying of private sector power, including the likes of big pharma, and must be able to show leadership on domestic health issues while also being a strong Global South voice on international platforms to champion global health equity.
‘Health is more than a biomedical response’
Professor Scott Drimie is a researcher at the University of Stellenbosch and director of the Southern African Food Lab. Drimie works on food systems and food security and how these intersect with the social determinants of health.
For Drimie, South Africa’s health minister must be a person with an expansive leadership style; a person who is able to work across government departments and also be awake to the grassroots realities people face. Around 85% of people in South Africa rely on public healthcare.
“The minister must be able to grapple with the lived reality of most poor people and put in place a health system that supports the most vulnerable.
At the same time, that person should be someone who understands that health is more than a biomedical response – health is also issues like food security, sanitation, stable livelihoods and safety,” he says.
Another quality Drimie highlights is that the minister should be open to collaboration and experimentation. He says there has to be a “whole-of-government” approach and a “whole-of-society” approach. The Department of Health cannot achieve its key performance indicators on its own; it needs to collaborate with departments including social development, education and basic education.
“It must also be able to be bold with programmes and work with communities directly as well as with civil society, health advocates and health activists,” he says.
Reform of bureaucracies in the health department must also be something the minister tackles, Drimie says. He says it means appointing effective managers who are not micro-managed or politically influenced. Effective implementers of policies and programme, he says, can be a counterweight to politics.
“Politicians can come with very short-term, very narrow party politics,” says Drimie. But, he adds, enduring and relevant health programmes survive beyond political tenure and are more likely to achieve positive health outcomes.
Put people first and ‘show humility’
For activist Anele Yawa, who is secretary general of the Treatment Action Campaign, we need someone who puts people first. He says the minister must serve the interests of people and show humility for the office.
“The minister must not be someone who pushes his or her agenda. A minister is appointed; he or she did not submit a CV to us. So a minister must understand that there will be times when we as citizens and civil society will disagree with them. It’s because we will continue to speak truth to power, we will continue to hold them accountable; whatever the new coalitions will look like,” he says.
“Our ministers must not be arrogant and think it’s because we hate them. We will disagree and we will fight because it is an effort to make sure that things are done the right way and we can bring health services to the majority – it’s that person who is working class, black and is a woman,” says Yawa.
He says it means a strong minister must be one who maintains an open-door policy; who arrives at community meetings in person; take calls personally and engages.
Yawa says it’s also critical that the seventh administration is one that works cohesively. “We voted on the 29 May for a contractual agreement with government; not a fashion show. It means that we don’t just need a good health minister, we need a good administration that delivers on water and sanitation, on education and on social development, and so on.”
Motivate and inspire
Professor Lucy Gilson is head of health policy and systems division in the School of Public Health at the University of Cape Town. Her top qualities for a good minister also centre on people skills. She says the health minister in South Africa must be an inspiring leader.
“The person must be able to motivate health workers and managers to be the best public servants they can be.
“The person must also inspire the public to trust in the public health sector,” Gilson says.
The new health minister must have strategic management skills, she says. These will be necessary to navigate the complexity of power and interests in a coalition government and to figure out how the NHI will take shape.
In the end, she says the person in the post should have patience and persistence. She adds: “Bringing change to the health system is a collective and sustained effort over time. The minister must be able to strengthen capacity, assemble coalitions and networks of learning, experience and mutual accountability.”
Dr Kenneth Jacobs entered Parliament as an ANC MP in 2019, and two years later was elected chairperson of the Portfolio Committee on Health. (Photo: Parliament)
By Biénne Huisman
The chairperson of the National Assembly’s Portfolio Committee on Health Dr Kenneth Jacobs played a pivotal role in deliberations on the National Health Insurance Bill. Spotlight’s Biénne Huisman asked Jacobs about some criticisms of NHI and about his plans for life after Parliament.
Back in Cape Town, Jacobs tells Spotlight the NHI signing was the culmination of his own work dating back fifteen years. He says he started working on public health projects relating to universal health coverage and the NHI in 2009, as a consultant to the National Department of Health.
For him, at the heart of the bill lies fairness.
“We should be able to provide all of the people of South Africa the opportunity to access quality healthcare,” he says.
Jacobs entered Parliament as an ANC MP in 2019, and two years later was elected chairperson of the Portfolio Committee on Health after his predecessor, Dr Sibongiseni Dhlomo, became the Deputy Minister of Health. Committee chairpersons are elected by and from among the members of each committee, meaning the majority party in Parliament has the most influence in selecting chairpersons.
As chairperson, a large part of Jacobs’ job was to hold the country’s executive and the National Department of Health to account on behalf of South Africa’s citizens.
Amongst other tasks, he played a pivotal role in overseeing public deliberations around the NHI Bill, which included 338 891 written submission and presentations by 133 organisations. These included political parties, trade unions, medical aid schemes, health technology organisations, the South African Medical Association, and university departments.
“It is never in the history that the committee had such an engagement by the public,” says Jacobs. “So I’ve been very blessed and fortunate to go to Parliament in the final process of the NHI Bill.”
‘Disheartening’ criticism
Both before and after its signing into law, NHI has been deeply divisive, with several political parties and other role players threatening litigation. One line of criticism is that, while many people and organisations made submissions to the committee chaired by Jacobs, the final bill did not changed substantially from what it was prior to the public hearings.
Interviewed on the topic, Business Leadership South Africa CEO Busi Mavuso, said government rushed populist policy through Parliament – an electioneering ploy – as the significant public input into the Bill and its socioeconomic ramifications had not been considered.
Jacobs voices his frustration at such criticism of the NHI public participation process, saying it is “disheartening”, adding that criticism are doled out by South Africans who are “in better financial positions”.
He explains the process of collating so much information: “Well, firstly it’s driven by the chairperson [him]… We appointed a team through Parliamentary processes, who looked at the submissions, and interpreted the submissions using computerised systems. It’s thematic – what are the themes, really? These are developed into reports; the reports on all the public hearings, those reports are all available.”
He adds: “So people who want to write and say all these negative things, they really should go and access these documents and see what the submissions were.”
‘It’s attractive to make people insecure’
Another aspect of NHI over which many have expressed concern is the potential for corruption, particularly in light of massive healthcare corruption during the height of the COVID-19 pandemic and more recent alleged corruption at Tembisa Hospital in Gauteng. Here criticism ranges from a simple distrust in government to run such funds, to more nuanced criticisms of aspects of the bill that critics say increases the risk of corruption – such as the Minister of Health’s expansive powers and accountability to cabinet rather than to Parliament.
In an interview following the signing of the bill, DA Chief Whip who was also a health portfolio committee member, Siviwe Gwarube, said: “The NHI will not address the underlying issues in our healthcare system; it is financially unfeasible, an election gimmick, and will burden South Africans with increased taxes.” She added: “The potential for corruption is staggering, and the flawed parliamentary process further erodes public trust…”
When asked about fears that money might disappear from centralised NHI coffers – to be governed by a board appointed by the minister of health – and accountability to prevent such, Jacobs says: “I think that people are putting the cart before the horse. You must remember this will be an entity [with tender procedures], and then who is supposed to appoint them [board members] in any case? Somebody has to have the responsibility. Why can that not be the minister, for example. But remember that it will be a transparent process, the same as the appointment, I think, as what we do with the appointment of judges.”
The NHI fund will be a schedule 3A entity, similar to, among others, the Road Accident Fund, the National Lotteries Commission, the National Laboratory Service, the Office of Health Standards Compliance, the Competition Commission, and the Council for Medical Schemes.
Jacobs says checks will be provided by the country’s forensic investigation agency, the Special Investigating Unit (SIU). “And there are many ways to put checks and balances into place,” he says, “we talk [in the bill] about the interventions which can be made, or the investigations which can be made by the SIU and other law enforcement agencies”.
Shortly after taking over as health committee chairperson, Jacobs told Spotlight that rooting out corruption in the health sector was a priority. At the time, he stressed the importance of safety nets for whistle-blowers, and of establishing systems to enforce accountability. Around the time of his appointment in 2021, whistle-blower Babita Deokaran was murdered for exposing R1 billion worth of allegedly irregular tenders issued at the Tembisa Hospital in Gauteng.
Asked about these particular earlier priorities, Jacobs responds: “I have no answer on that, I don’t think I want to talk about corruption now…” Upon reflection, he adds: “Of course corruption is important. Losses to the fiscal is important; people doing wrong is important. People need to be brought to book, be held accountable for doing wrong…”
Later on in the interview, when the issue of corruption comes up again, he says that corruption has decreased in South Africa: “I think we’ve advanced quite a bit from the time when corruption was more rife. I think nowadays you hardly hear about these things and it’s because unprecedented intensive programmes were put in place to address these issues of corruption and fraud. I really think what they [critics] are doing is fear-mongering, telling people that you need to be frightened, and I’m going to say again, those who are telling others to feel frightened, are in a better financial position. So it’s attractive to make people insecure.”
Money for NHI?
Another common argument against implementing NHI is that it is not affordable. Government’s spending on health has declined in real terms for much of the last decade and the South African economy is struggling by most measures.
Asked about crippling budget cuts in the health sector as it stands, and questions around the NHI’s affordability, Jacobs says South Africa has insufficient central funds because of unemployment, and that South Africa needs more jobs and more workers to increase its tax-base.
“My personal view is that we need to understand why there’s a budget problem,” he says. “So where is government supposed to get money? Who are supposed to contribute? Those who are employed. And look at our employment rate – is it government’s responsibility? No, the emphasis is wrong. It is businesses’ responsibility.
“When people have employment they can contribute to the coffer… and I’m going to keep on saying, the narrative is in the wrong place. We need to say to South Africans: ‘don’t all of us have a responsibility?’ Those who have the economy in their hands and those who don’t have the economy in their hands, all of the responsibility to drive our country forward.”
How to drive South African healthcare forward, remains contested. Several organisations representing healthcare workers, such as the South African Medical Association, do not support the NHI Act in its current form. Others, including the South African Medical Association Trade Union, welcome it.
Meanwhile, Jacobs expresses empathy for his clinician colleagues: “As a medical doctor, I have absolute respect for all of my colleagues. I would like you to write it; I understand the conditions under which our medical and or health personnel have to function. And I don’t think that National Health Insurance be a negative thing for healthcare professionals.”
‘Why should there be people who profit from the ill health of other people?’
Another concern in some quarters is that NHI will over time squeeze out medical aid schemes and leave people with no alternative to health services provided through NHI. This because, according to Section 33 of the NHI Act, medical schemes will not be allowed to cover services that are already covered by the NHI fund.
Asked about the future of medical aid schemes in South Africa, Jacobs says: “What is the medical aid system? It’s a profit driven system by people who are in business. Is it correct that there are people who make profit off the lives of people, and the health of people? I don’t think that is correct.” (Note: Medical schemes are non-profit entities while medical scheme administrators are for-profit.)
He adds: “What is wrong with having one single system, in which everybody has access to the same healthcare? Why do we need to keep exclusionary rights for some people, based on them having a better income than others? I think that’s the bottom-line on the answer of the medical aid. Whether medical aid will stop functioning or not. I think that’s not the question to ask. The question is why should there be people who profit from the ill health of other people?”
‘From policy to practice’
Going forward, given that he won’t be returning to Parliament, Jacobs hopes to resume doing public health consulting work for the National Department of Health.
“I have a project which is very dear to me,” he says. “I want to start an institute for health governance, and it’s called, ‘from policy to practice’. It’s on health governance, universal health coverage… and will be instrumental in influencing dialogue. So, I can’t wait to stay active in the health sector, but not being restricted in that I’m no longer a member of Parliament, not feeling that there’s some sort of conflict.”
Jacobs will now move from the Acacia Park Parliamentary Village on Cape Town’s northern fringes back to his family home in Wellington.
Jacobs says that they will soon have seven public health doctors in his family – that is, when his son completes medical school at Stellenbosch University. His daughter recently finished medical school and is contracted as a doctor at a clinic in Khayelitsha.
Originally from Gqeberha, Jacobs holds a Bachelor of Medicine and Bachelor of Surgery degree from Stellenbosch University where he also obtained a Master of Medicine degree in family medicine. He went on to get a Master of Science degree in sports medicine from the University of Pretoria. In earlier years, he served as a physician to the Stormers and Springbok rugby teams.
In the previous interview with Spotlight, Jacobs relayed how his formative years were tough. His family were forcibly evicted from sea-facing South End, in what was then Port Elizabeth, and moved to Gelvandale, in the city’s northern suburbs. His father worked in a shoe factory, but lost his job when Jacobs was in grade 10.
“South End was like Port Elizabeth’s District Six,” said Jacobs, in the earlier interview. “So yes, honestly, that was something that had a huge impact on me. I decided then that I would not allow somebody to suppress or oppress me and I think it is probably why I just kept on studying and improving.”
At 65 years old, Jacobs exudes ambition and enthusiasm. Wrapping up, he quotes an Afrikaans aphorism: “Die mens wik maar God beskik” (Humanity proposes, God disposes).
President Cyril Ramaphosa at signing ceremony of the NHI Bill at the Union Buildings in Pretoria.
Speech by Cyril Ramaphosa, article from Spotlight
President Cyril Ramaphosa yesterday signed into law the National Health Insurance (NHI) Bill, which is the ANC-led government’s plan for universal health coverage, just 14 days before the country heads to the polls.
The NHI aims to unify the country’s fragmented health system, Ramaphosa said at the signing ceremony at the Union Buildings in Pretoria on Wednesday.
However, he also noted that processes are yet to be established and that the Act’s implementation will be incremental rather than a massive overnight overhaul.
Here are 8 noteworthy quotes from the President’s speech:
“[T]he NHI is a commitment to eradicating the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect”.
“[T]he NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention”.
“The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.”
“The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.”
“The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.”
“The NHI is an important instrument to tackle poverty. The rising cost of health care makes families poorer. By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.”
“Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.”
“The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.”
Here is Ramaphosa’s full prepared speech:
REMARKS BY PRESIDENT CYRIL RAMAPOSA ON THE SIGNING OF THE NATIONAL HEALTH INSURANCE (NHI) BILL, UNION BUILDINGS, TSHWANE, 15 MAY 2024
Minister of Health, Dr Joe Phaahla, MECs of Health, Senior Officials, Representatives of the health fraternity, Representatives of civil society, Representatives of labour, Members of Parliament’s Portfolio and Select Committees, Public representatives, Members of the media, Distinguished Guests, Ladies and Gentlemen,
We are gathered here today to witness the signing into law of the National Health Insurance Bill, a pivotal moment in the transformation of our country.
It is a milestone in South Africa’s ongoing quest for a more just society.
This transformational health care initiative gives further effect to our constitutional commitment to progressively realise access to health care services for all its citizens.
At its essence, the NHI is a commitment to eradicate the stark inequalities that have long determined who receives adequate healthcare and who suffers from neglect.
By putting in place a system that ensures equal access to health care regardless of a person’s social and economic circumstances, the NHI takes a bold stride towards a society where no individual must bear an untenable financial burden while seeking medical attention.
This vision is not just about social justice. It is also about efficiency and quality.
The provision of health care in this country is currently fragmented, unsustainable and unacceptable.
The public sector serves a large majority of the population, but faces budget constraints. The private sector serves a fraction of society at a far higher cost without a proportional improvement in health outcomes.
Addressing this imbalance requires a radical reimagining of resource allocation and a steadfast commitment to universal healthcare, a commitment we made to the United Nations.
The real challenge in implementing the NHI lies not in the lack of funds, but in the misallocation of resources that currently favours the private health sector at the expense of public health needs.
The NHI Bill presents an innovative approach to funding universal healthcare based on social solidarity.
It proposes a comprehensive strategy that combines various financial resources, including both additional funding and reallocating funds already in the health system.
This approach ensures contributions from a broader spectrum of society, emphasising the shared responsibility and mutual benefits envisioned by the NHI.
The financial hurdles facing the NHI can be navigated with careful planning, strategic resource allocation and a steadfast commitment to achieving equity.
The NHI carries the potential to transform the healthcare landscape, making the dream of quality, accessible care a reality for all its citizens.
The NHI Fund will procure services from public and private service providers to ensure all South Africans have access to quality health care.
The NHI recognises the respective strengths and capabilities of the public and private health care systems. It aims to ensure that they complement and reinforce each other.
Through more effective collaboration between the public and private sectors, we can ensure that the whole is greater than the sum of its parts.
The effective implementation of the NHI depends on the collective will of the South African people.
We all need to embrace a future where healthcare is a shared national treasure, reflective of the dignity and value we accord to every South African life.
Preparations for the implementation of NHI necessarily require a focused drive to improve the quality of health care.
We have already begun implementing a national quality improvement plan in public and private health care facilities, and are now seeing vast improvement.
In signing this Bill, we are signalling our determination to advance the constitutional right to access health care as articulated in Section 27 of the Constitution.
The passage of the Bill sets the foundation for ending a parallel inequitable health system where those without means are relegated to poor health care.
Under the NHI, access to quality care will be determined by need not by ability to pay. This will produce better health outcomes and prevent avoidable deaths.
The NHI is an important instrument to tackle poverty.
The rising cost of health care makes families poorer.
By contrast, health care provided through the NHI frees up resources in poor families for other essential needs.
The NHI will make health care in the country as a whole more affordable.
The way health care services will be paid for is meant to contain comprehensive health care costs and to ensure the available resources are more efficiently used.
Through the NHI, we plan to improve the effectiveness of health care provision by requiring all health facilities to achieve minimum quality health standards and be accredited.
Following the signing of this Bill, we will be establishing the systems and putting in place the necessary governance structures to implement the NHI based on the primary health care approach.
The implementation of the NHI will be done in a phased approach, with key milestones in each phase, rather than an overnight event.
There has been much debate about this Bill. Some people have expressed concern. Many others have expressed support.
What we need to remember is that South Africa is a constitutional democracy.
The Parliament that adopted this legislation was democratically-elected and its Members carried an electoral mandate to establish a National Health Insurance.
South Africa is also a country governed by the rule of law in which no person may be unduly deprived of their rights.
We are a country that has been built on dialogue and partnership, on working together to overcome differences in pursuit of a better life for all its people.
The NHI is an opportunity to make a break with the inequality and inefficiency that has long characterised our approach to the health of the South African people.
Let us work together, in a spirit of cooperation and solidarity, to make the NHI work.
Disappointment as President prepares to sign flawed bill
The announcement that President Cyril Ramaphosa will sign the National Health Insurance (NHI) Bill into law this week without seeking much-needed revisions is disappointing, although not unexpected, according to the Health Funders Association (HFA).
“The HFA has been preparing for this day, despite our strong belief that a more collaborative approach between the public and private sectors is essential for achieving Universal Health Coverage [UHC] in a timely and effective manner,” says Craig Comrie, HFA Chairperson.
“We are deeply disappointed that the opportunity to review certain flawed sections of the NHI Bill has been missed, as the HFA sees enormous potential for leveraging the strengths of both public and private healthcare to expand access to quality care for all South Africans.
“Throughout the NHI Bill’s development process, the association submitted recommendations centred on collaboration and maximising the sustainability of healthcare provision through the use of a multi-funding model to build the South African healthcare system,” he says.
“Even with the President signing the NHI Bill into law on Wednesday, there will be no immediate impact on medical scheme benefits and contributions, nor any tax changes. The HFA is well prepared to defend the rights of medical scheme members and all South Africans to choose privately funded healthcare, where necessary.
“Our focus, as always, is on protecting and expanding access to quality healthcare for all South Africans. As we await the finer details of the President’s signing, we wish to assure all South Africans that we are ready for this next step,” Comrie says.
“The HFA will continue monitoring developments closely and share updates as necessary. Our goal remains the same: a healthcare system that works for all South Africans, and we will take all necessary actions to support that goal.”
After what was an insightful and collaborative meeting of the minds of healthcare professionals and experts at the 2024 BHF Annual Conference, the final day concluded by providing crucial insights into regulatory reforms shaping the future of healthcare in South Africa, as well as the legalities surrounding the controversial NHI Bill.
Facilitated by Nomo Khumalo, BHF Director and Head of Solutions at MMI Health, part one of the discussion comprised the key regulatory responses essential for building a resilient health system capable of navigating beyond current barriers.
Among the notable delegates participating in the discussion were Vincent Tlala, Registrar and CEO of the South African Pharmacy Council; Dr Magome Masike, Registrar of the Health Professions Council of South Africa; Dr Thandi S Mabeba, Chairperson of the Council for Medical Schemes; Dr Mark Blecher, Chief Director of Health and Social Development at the National Treasury; Yoliswa Makhasi, Director General of DPSA; and Dr Sandile Buthelezi, Director-General of the National Department of Health.
Their expertise across the healthcare regulatory sector added invaluable insights into the state of the sector, where they explored the current policy landscape, analysed the intent of reforms versus the realities, and discussed necessary changes for policymakers to ensure healthcare sustainability.
While all dignitaries note the need for Universal Health Coverage (UHC) to bridge the gap in access to healthcare in South Africa, Dr Sandile Buthelezi, acknowledged the complexity of implementing the NHI and the need for a phased approach. To this end, Buthelezi cited that significant work is required to establish the fund, develop regulations, and set up administrative structures.
“Apart from this, optimising healthcare delivery requires prioritising resource utilisation through proper management and spending, and addressing managerial issues to utilise available resources effectively,” suggests Buthelezi.
“Regulatory reforms are essential for advancing healthcare, encompassing standardised data collection, quality enhancement, and informed policy evolution. Moreover, the integration of digital health strategies is paramount, leveraging technology to bolster comprehensive health information systems and elevate healthcare delivery.”
Amidst the discussions, a common thread resonated among all dignitaries: the vital importance of collaboration. Here, Buthelezi stressed the necessity for stakeholders within the healthcare sector to unite in pursuit of shared goals, emphasising the need to improve health outcomes and effectively tackle challenges through collaborative efforts.
Following this, the conversation swung to the legalities of the impending NHI Bill in a session chaired by Michelle Beneke of Michelle Beneke Attorneys Inc, and featured industry experts Neil Kirby, Director at Werksmans Attorneys, and David Geral, Partner at Bowmans.
The conversation focused on the several facets of the implementation of the Bill, including its constitutionality, lack of government response to engagement efforts, and the broader regulatory challenges facing the healthcare industry.
According to Kirby, Werksman Attorneys, as legal representatives of BHF, have closely monitored the evolution of the NHI Bill, thoroughly scrutinising its alignment with South Africa’s constitutional principles.
“Regrettably, the implementation process hasn’t yielded a bill that adequately addresses our constitutional concerns. Despite incremental progress and assurances of future adjustments, the current iteration falls short of meeting the constitutional litmus test.
“As stakeholders directly impacted by the bill’s implications, we cannot afford to overlook constitutional shortcomings. Our obligation demands rigorous adherence to constitutional standards, ensuring that any legislation enacted upholds the rights and principles enshrined in our constitution,” he says.
To this end, Geral adds that the Bill introduces significant changes to the healthcare system, which may potentially affect tax policy and revenue sources.
In closing the conference, Dr Katlego Mothudi, Managing Director at BHF, emphasised the success of the conference in addressing industry challenges while promoting sustainability across the healthcare sector.
“As we conclude this enlightening conference, we reflect on the breadth of topics covered, from disease burden to the transformative potential of digitisation and AI in healthcare. Our discussions underscored the necessity of embracing change, combating fraud, and fostering regional collaboration.
“With a firm focus on healthcare reform, particularly the intricacies of the NHI Bill, our gathering has propelled us toward a future marked by innovation, resilience, sustainability and collective action. In the words of Edgar Tan – we can have what we need if we use what we have,” he concludes.
Professor Bob Mash. (Photo: Division of Family Medicine and Primary Care, Stellenbosch University)
By Bob Mash for Spotlight
To drum up support as South Africans head to the polls, President Cyril Ramaphosa reportedly vowed to “end the apartheid that remains in healthcare” when he hit the campaign trail. Professor Bob Mash has three health reforms on his wishlist for the incoming administration to prioritise.
South Africa is battling a quadruple burden of disease that includes HIV and tuberculosis (TB), non-communicable diseases such as diabetes, hypertension and mental health problems, challenges with maternal and child health, as well as substantial trauma from interpersonal violence and road traffic accidents.
At least 80% of the population is dependent on public sector health services. However, currently, we are in a state of austerity, with substantial cuts to the health budget that undermine years of work to improve the quality and coverage of health services.
In this context, what health reforms can be recommended?
In 2008, the World Health Organization (WHO) told us that we need primary healthcare “now more than ever” and recommended four health reforms. Universal health coverage has become a mantra for governments and implies that everyone should have easy access to quality primary care without any significant financial barriers. They also recommended that services should move away from a focus on a few priority diseases (such as HIV) and selected health programmes (such as immunisations). Rather, services should be integrated and built around the needs of people, across the life course, and in a comprehensive approach that spans health promotion, disease prevention, treatment, rehabilitation, and palliative care.
The WHO also recommended that integrated primary care be combined with essential public health functions. In other words, we don’t just worry about the people who enter the doors of the clinic but think about the health needs of all the people living in the catchment area. Finally, they recommended transformation of the leadership in health to make it more collaborative and to dialogue on policy with multiple stakeholders.
In South Africa, our last set of reforms were known as primary healthcare re-engineering. This led to the establishment of specialist clinical teams in each district to improve maternal and child healthcare, the establishment of teams of community health workers to extend the work of the clinic into the community and a focus on better health services – like health screenings and HPV vaccinations – at primary and secondary schools.
Of course, the other major policy reform that is still on the table is the introduction of national health insurance (NHI) to improve health equity and universal health coverage.
Going forward, three areas need urgent reform and attention.
More family physicians
Firstly, notwithstanding the 2030 Human Resources for Health Strategy, South Africa does not really have a comprehensive policy on the human resources for health that are needed. Thinking on primary healthcare and district hospitals has been particularly flawed in relation to family physicians. South Africa created a new medical speciality of family medicine in 2008 which has led to the training of family physicians in all nine medical schools. These are doctors who spend four years of additional training to be specialists in family medicine and to work in primary healthcare and district hospitals.
Family physicians are known to improve the quality of primary and district hospital care. They bring expertise closer to the community, capacitate the whole clinical team, improve quality, patient safety and reduce litigation. Adding a family physician to the clinical team is a cost-effective intervention. Despite this, only one province has really gone to scale with the employment of family physicians. This is a wasted opportunity and a low-hanging fruit in terms of reform.
The South African Academy of Family Physicians has a medium-term goal of one family physician at every community health centre, every district hospital and subdistrict (without a health centre). To achieve this, we need provinces to incrementally create posts over the next 10 years and to support an increase in the number of training opportunities.
Community-orientated primary care
As previously mentioned, we have introduced community health worker (CHW) teams into primary healthcare across the country. Unfortunately, many of these teams are dysfunctional due, for example, to an absence of supportive supervision, lack of resources or poor collaboration with the local primary care facility. Often, they are regarded as just extensions of the facility-based services and expected to perform tasks allocated by the clinic nurses.
The presence of these community health worker teams is, however, a huge opportunity to introduce community-orientated primary care (COPC). This model of primary care makes the switch to a focus on the health needs of the whole population served. Introducing COPC requires commitment to nine essential principles for organising primary healthcare.
Firstly, there must be a clear delineation of the community served and CHWs given responsibility for designated households (typically 250 households per CHW). Facility-based and community-based health care workers must operate as one multidisciplinary team and offer a comprehensive approach as described earlier. The team must make a careful analysis of the health needs in their community and also the resources available (government, non-government and private, health and social services) to address these needs.
At this local level, the team should prioritise the health needs in a participatory process with community and other stakeholders, and develop interventions tailored to their community. This process requires a commitment to community and stakeholder engagement. It also requires data to provide information on the health needs and this can come from households, facilities, and other sources. Finally, the service should be built around the needs of people and ensure that equity is improved.
The implementation of CHWs across the country needs to be reframed within a clearer policy on COPC. One province has already published its intention to make COPC the model of care and other provinces have examples of best practice.
Honing in on diabetes, hypertension, and mental health care
The final area that needs reform with more resources and attention is non-communicable diseases – particularly diabetes, hypertension, and mental healthcare. Historically, we have focused on the challenges of HIV and TB in service delivery, research, and donor funding. We have also been mindful of the need to improve maternal and child health.
Diabetes is now the leading cause of death in women in South Africa. Hypertension, heart disease and stroke are together the largest cause of deaths across all causes. Mental health, substance abuse and psychosocial problems may not cause death, but are a huge cause of morbidity and illness.
There is a danger of inequity by disease, and we need to ensure that we allocate resources commensurate to the problem of non-communicable diseases. In particular, we need to ensure that we have patient education and counselling that empowers people for lifestyle change, self-management and better mental health. Interventions are also needed in communities and the population to make healthier choices (on problem-solving, physical activity, healthy eating, tobacco smoking, alcohol and substance use) the easier choice.
Improving people’s health and healthcare is essential for sustainable development in South Africa. As the country heads to the polls, the incoming government would do well to keep this in mind. Such reforms will lead to higher quality primary healthcare and help pave the way for the proposed national health insurance.
*Mash is the Executive and Divisional Head of the Department of Family and Emergency Medicine in the Faculty of Medicine and Health Sciences at Stellenbosch University. The views expressed are those of the author and do not necessarily reflect those of Stellenbosch University.
Activists and cancer patients marched to the offices of the Gauteng department of health on Tuesday demanding that millions of rands allocated for radiation treatment for cancer patients be used.
SECTION27, Cancer Alliance and Treatment Action Campaign (TAC) called for the department to use R784-million set aside by the provincial treasury in March 2023 to outsource radiation treatment. They say not a single patient has received treatment through this intervention a year later.
In an open letter to health MEC Nomantu Nkomo-Ralehoko last week, Khanyisa Mapipa from SECTION27, Salomé Meyer from the Cancer Alliance and Ngqabutho Mpofu from TAC said that in March 2022, Cancer Alliance had compiled a detailed list of approximately 3000 patients who were awaiting radiation oncology treatment.
They said there were shortages of staff in the two radiation oncology centres in Gauteng, Steve Biko Academic Hospital and Charlotte Maxeke Johannesburg Academic Hospital. Charlotte Maxeke Hospital had only two operational machines compared to seven in 2020. Tenders for new equipment had been delayed and the backlog of patients was increasing, they said.
As a result, SECTION27 and Cancer Alliance had asked the provincial treasury to set aside R784-million to outsource radiation treatment. The money had been allocated in March 2023, but a year later, no service provider had been appointed.
“It has actually been four years since the matter was brought to the Department of Health,” said Mapipa on Tuesday. She said cancer patients were not getting the treatment they needed.
“We as Cancer Alliance and SECTION27 ran to Gauteng Treasury to ask them to allocate these funds. Gauteng Treasury responded and they gave this money, but this money is still sitting.”
Thato Moncho, who was diagnosed with breast cancer in September 2020, is one of the patients on the waiting list. She said she had faced many delays in her treatment. “I’ve had three recurrences of cancer and I need to have radiation six weeks after my surgery, which they failed to give me. I have pleaded with the MEC of Health and the Chief Executive Officer at Charlotte Maxeke to speed up the process so I can get my radiation but they failed.”
“I’m pleading: help us so we can get radiation to live a normal life with our family.”
Gauteng Department of Health spokesperson Motalatale Modiba said the department had received the memorandum and would respond to it. He acknowledged that there had been delays which he said were caused by tender processes.
“It is in our interest to ensure that we get to address the backlog of those that require treatment, and the department will formally respond to the concerns that have been raised.” He said a tender had been awarded.
“In May the process to treat patients will start in both hospitals.”
“The respective heads of oncology in Charlotte Maxeke and Steve Biko hospitals are busy with that process of onboarding.”
