One of the most damaging aspects of our public discourse on National Health Insurance (NHI) is the mistaken notion in some quarters that the only two options are NHI and the status quo. PHOTO: Rosetta Msimango/Spotlight
By Marcus Low for Spotlight
One of the most damaging aspects of our public discourse on National Health Insurance (NHI) is the mistaken notion that the only two options are NHI and the status quo. Often implicitly, sometimes explicitly, defenders of NHI suggest that any argument against NHI is one for maintaining the current system. Since the current system doesn’t work very well for most people, this line of argument gets some purchase, even though it is based on a false premise.
In his book “Which country has the world’s best health care?”, oncologist and bioethicist Ezekiel Emanuel outlines the key features of healthcare systems in 11 different countries. Two things that stand out are that health systems differ substantially between countries and that most systems are the relatively messy products of complex histories and political and other compromises. This latter point about the path-dependency of healthcare systems is an important point we will return to.
Many varieties
South Africa’s proposed NHI system is sometimes clumped together with systems in other countries such as Canada, the United Kingdom, and Thailand. At times this is fair, at times it skims over important differences.
For example, NHI will be a single-payer system, which is to say, the NHI fund will be responsible for almost all purchasing of healthcare services in the country. In some respects, Canada has a similar system, except that rather than one system for the whole country, they in effect have 13 single-payer systems for each of their provinces and territories. Even Thailand, at times referred to as an example of NHI, technically has three funds rather than one, although it resembles South Africa’s NHI plans in several other respects. In principle, a large single-payer should be able to negotiate better deals than several smaller payers, but on the other hand, having Canada-style provincial funds would be more closely aligned with South Africa’s current governance arrangements and in some provinces, like the Western Cape, chances are people would have more trust in a fund run by the province than in one run nationally.
Another thing that quickly becomes apparent when looking at the variety of healthcare systems out there, is that a simplistic dichotomy between NHI and private healthcare is a false one. Countries like the Netherlands and Germany have achieved excellent health outcomes with systems that are neither NHI-style systems nor examples of the private sector running riot. Though the details are significantly more complicated than this, you can think of the Netherlands and Germany roughly as having many strictly regulated medical schemes (called sickness funds in Germany) with scheme/fund membership being compulsory (with some exceptions). The German system is progressive in that people with higher incomes contribute more than people with lower incomes – an important difference from South Africa’s medical schemes.
Funds in the Netherlands are also not primarily funded directly, as with our medical schemes, but receive funding from a central fund via a risk adjustment process. Both the German and Dutch systems have significant social solidarity built-in in the way it institutionalises the cross-subsidising of the poor by the wealthy.
In South Africa, such a system could, for example, be implemented by dramatically tightening up the regulation of medical schemes, putting in place a progressive mechanism for cross-subsidisation between schemes, making scheme membership compulsory for those who can afford it, and, over time, using tax revenue to pay for scheme membership for the unemployed (although this last element, like NHI, does come with a big question mark on affordability. Those with long enough memories might remember that a system roughly along such lines was on the cards in South Africa around the turn of the century. (see for example the Taylor report of 2002 and this interesting paper.)
Getting to there from here
One striking thing about NHI in South Africa is that for all the column inches, submissions to Parliament, and oral hearings across the country and in Parliament, hardly anyone seems to have shifted their positions in the last decade and there has been very little serious consideration of alternative paths to universal healthcare.
Photo by Hush Naidoo on Unsplash
One reason for this is the sense that the design choices behind the NHI Bill were essentially decided on by a relatively small group of people in the National Health Department and the African National Congress (ANC) around 10 or 15 or so years ago. What followed since then often felt like an attempt at co-opting rather than meaningful engagement. This was particularly apparent in the way some members of the Portfolio Committee on Health continuously pushed people on whether they are for or against NHI, rather than engaging with the substance of people’s submissions. Though the boxes for public engagement were ticked, the reality was often a parody of what such engagement is meant to be.
We could have gone a different route. It would have been entirely feasible to have a process for NHI akin to the much more meaningful set of engagements we had for the Competition Commission’s Health Market Inquiry into the private healthcare sector. In that case, people could make submissions, be heard by the panel, and crucially, one never got the sense that the outcome was preordained. Such a process may in some respects have given government officials and members of Parliament a few more headaches, but it would also have built trust and understanding of the technical issues, and for major reforms like NHI trust and public understanding is half the battle.
The draft regulations were gazetted in January and consumers had until 21 July to comment. These regulations, among other things, propose the mandatory use of new and bolder warning labels on unhealthy food which include items high in salt, sugar, saturated fats and items containing artificial sweeteners.
Community Media Trust (CMT) is a not-for-profit company, mainly focused on health and human rights and has partnered with the Healthy Living Alliance (HEALA), a coalition of organisations focused on nutrition.
In February, CMT and HEALA staged a flash mob as part of the “Less Sugar, More Life” campaign in Cape Town ahead of the Finance Minister’s Budget Speech, advocating for an increase in the sugary drinks tax. They were disappointed by the announcement that the tax would be frozen for two years.
Following a massive media campaign on the draft regulations, CMT and HEALA successfully collected thousands of submissions.
CMT’s co-director Lucilla Blankenberg said the warning labels had been tested with audiences and researchers. If you’re a diabetic shopping for food and there was a clear warning label saying, ‘high in sugar’, the consumer won’t have to spend time trying to work it out because the message is simple.
The proposed warning labels are black and white triangles and would clearly indicate when food is high in sugar, salt and fat or contains artificial sweeteners.
“The reason the food industry is fighting back is because if food has a warning label, it cannot be marketed directly to children. Which means cartoons and animation that will attract children cannot be used to market a food item that has a warning label. If a pack has a warning label they can’t make any health claims whatsoever,” said Blankenberg.
“We won’t see the results immediately, but it will happen over time, especially for the children. With warning labels, it will be easier for parents to avoid buying certain food,” said Blankenberg.
HEALA’s communications manager Zukiswa Zimela said conversations proposing front of pack warning labels started in 2016.
Zimela said research for the campaign was initially done by the University of Western Cape to determine which foods qualify to have front of pack warning labels. She said the research gave more insight into what consumers thought of the current information on packaging as well as what the new warnings should look like.
“We started the campaign in May and went to eight provinces, mainly to educate and inform communities about the importance of front of pack warning labels and the food they were eating,” said Zimela. She said they found that many consumers agreed that they did not understand the nutritional information on food packaging.
She said the food industry had used scare tactics like saying warning labels would cause job losses which was “completely untrue”.
“This is not something new, warning labels have been done in other countries like Chile, Mexico, Peru and Columbia and there has been no evidence that jobs have been lost because of it. This is just undermining the government’s plan to get people to eat better.”
Zimela said HEALA will be monitoring the responses to the regulations. “Should the regulations be implemented, we need to make sure that they are not watered down or seen as useless.”
Sugar industry warns against “demonising sugar”
The South African Sugar Association (SASA) told GroundUp it had also submitted comments on the draft regulations, and that the front of pack warning labelling system was of particular concern to the industry.
SASA executive director, Trix Trikam, said: “The objective of this system is to encourage the reduction of energy/calorie intake, saturated fat and salt to prevent obesity and non-communicable diseases.
“It is well known and there is evidence that sugar is not the sole contributor of kilojoules to the diet and should therefore not be singled out in a regrettable out-of-context manner,” he said.
He said the warning labels should not be done in a sensationalist or alarmist manner “which seeks to demonise sugar” because that would have “a significant adverse impact on the sugar industry”.
Trikman suggested that the warning labels should instead reflect the calories in a food product. “SASA is also not convinced that the perceived cut-off values for sugar is evidence-based. A possible solution to that would be to use the perceived cut-off values based on percentage of energy value and not the amount of sugar per volume of product,” said Trikam.
“The draft regulations make it mandatory for a warning symbol to be placed on the front of pack labels for foods that exceed a perceived cut-off value for sugar. In order to avoid the warning symbol for sugar, food manufacturers will seek to find ways of removing sugar from their products. This will lead to a decrease in the demand for sugar and will ultimately negatively impact the livelihoods of those dependent on the sugar industry in the deeply rural areas of KwaZulu-Natal and Mpumalanga.”
Trikam said SASA is concerned about the obesity rates in South Africa but added that the solutions should be evidence-based.
Disclosure: GroundUp was once a project of, and still has a close relationship with, Community Media Trust.
Staff, including nurses, at RK Khan Hospital in Chatsworth, Durban, picketed on Wednesday over poor working conditions at the facility. Photo: Tsoanelo Sefoloko
Nurses, administration staff and general workers brought parts of RK Khan Hospital in Chatsworth, Durban, to a standstill for about an hour on Wednesday. They protested outside the hospital to highlight what they say are poor working conditions.
Protesting nurses say they are forced to perform cleaning duties in addition to patient care because the hospital has not employed enough cleaners. Other workers complained of staff shortages in the administration and general units.
Workers say they met with the management in February. Union leaders had asked the facility to commit to resolving their complaints.
Nurse Zizakele Ndlovu said they were told by the union leaders that working conditions would improve. But nothing changed, she said.
“The conditions we work under at the hospital are not good. We end up having to work more hours, and we don’t get paid for overtime. Sometimes I even work as a clerk,” she said.
“The department treats us as if we don’t know our job, and we don’t deserve what we are asking for. We lost many workers to Covid; some retired and others resigned. Those vacancies have not been filled. Even at top management there are lots of vacancies and this leads to poor service.”
Chairperson at the hospital of the National Education, Health and Allied and Workers’ Union (NEHAWU) David Mpongose said they had engaged management and had been promised that the situation would improve.
“Our bosses are arrogant. They really don’t take us seriously. Each time they make empty promises, so we decided to protest for the provincial government to assist us,” said Mpongose.
Xolani Mnguni, a cleaner, said he earned R7800 per month under the hospital’s previous contractor, but now only earns R3000 under the current contractor. He also said he has to do jobs other than cleaning.
Hospital CEO Linda Sobekwa accepted the workers’ memorandum and signed it on behalf of the provincial health department. She promised to ensure that the department responded within ten days as requested.
Agiza Hlongwane, spokesperson for the KwaZulu-Natal Department of Health, said officials would consider the workers’ demands and respond to them.
According to a 27-page ‘factsheet’ purportedly produced by the Department of Health and the Presidency, the National Health Insurance (NHI) scheme would be funded through a payroll tax and additional personal income taxes. There are however better ways to go about this, according to a number of experts who weighed in on the topic.
Professor Alex van den Heever said that the payroll tax plan is misguided, according to Daily Investor. In the same vein as Unemployment Insurance Fund (UIF) payment, both employers and employees would make contributions to a payroll tax.
But Van den Heever criticised this, saying that those who suggested this do not have the qualifications to make financial comments such as NHI funding.
“They talk of introducing payroll taxes. You don’t introduce payroll taxes for a general government allocation,” he explained. “Payroll taxes are for contributory systems where you get a specific benefit or entitlement for what you contribute.”
The term “payroll taxes” in relation to funding NHI does not make sense, he said. Discussions on raising taxes and a new payroll tax shows that the government does not know how to fund the NHI.
He called them an “incredibly naïve set of fiscal proposals that you cannot even consider implementing,” and that they were “incoherent from a public finance perspective.” Introducing them as is would be politically suicidal: the tax base is already overburdened, and raising taxes beyond a certain point results in a reduction in taxes actually collected.
“It is very dangerous to overstress your tax bases. We are hitting the limit on the amount you can fund the government and the public health system from taxes.”
Huge tax increases needed to fund NHI
Van der Heever’s viewpoint is shared by Connie Mulder, Solidarity Research Institute head and Ryan Noach, Discovery Health CEO.
Mulder said trying to fund NHI through additional taxes is unfeasible because of the tremendous amount of money needed.
Mulder said that the massive additional taxation would “crush South Africa’s economic outlook.”
It is naive for the Department of Health to assume that medical aid contributions will be funnelled into a national health insurance scheme, said Noach. The NHI scheme would force South African taxpayers to pay much higher taxes but cut their healthcare entitlement by 72%, and would provoke a tax revolt.
South Africa has a unique situation where a very small tax base of 5.5 million people funds nearly all government expenditures, accounting for 80% of public healthcare funding, he said. Notably, their after-tax disposable income is used to pay medical aid and private healthcare.
The single-funder model described in the NHI Bill would not be able to achieve the government’s goal of equitable access to healthcare, Noach told Daily Investor. This is a model which Discovery Health does not endorse, calling it not only “risky and inefficient” but also not likely to be equitable because “cross-subsidies cannot be properly managed”.
He reiterated earlier comments where he said that the NHI Bill would have no immediate impact on medical schemes, but once it is fully implemented (with “implemented” remaining undefined), medical aid schemes would only be allowed to offer what is not covered under the NHI – at the discretion of the Health Minister. This would make NHI a single monopolistic funder for the NHI package of services, which he had said in an earlier interview with Newzroom Afrika was without a parallel anywhere in the world.
Even though implementation is a decade away, this is going to drive off health sector investment, Noach said.
Noach recommended a multi-fund framework, which he described as “not only less risky and faster to implement, but also ensures that cross-subsidies are managed to ensure that social solidarity is achieved”.
Collaboration between the private and public sectors is the only way financial integrity and sustainability is achievable, something which has been built on the successful COVID-19 partnerships.
NHI ‘charade’ – but Obamacare offers an alternative
Business Leadership South Africa CEO Busi Mavuso has a similar view – and didn’t mince her words. According to Mavuso, NHI as currently envisaged, was a “charade” without any thought to funding, according to Moneyweb. One that would leave all South Africans worse off, and recommends instead a private-public partnership.
She also pointed to the public–private partnership behind South Africa’s COVID-19 response. The two entities sourced resources, rolled out vaccines and funded other interventions.
“It was a clear demonstration that national health outcomes are achieved faster and more efficiently when government and business work together, drawing on their respective strengths,” she said.
“With the right incentives, the private sector can complement government efforts, speed up the investment needed and reduce costs to the state and users.”
One viable alternative to the NHI’s single buyer model was the US’ Affordable Care Act (aka Obamacare) in the US, wherein health insurers provide minimum cover, with the state subsidising those below a certain level. Insurers are however able to compete to offer coverage.
One other disadvantage of South Africa effectively ending the private sector was that it would discourage internationally mobile businesspeople from working in the country.
In a study conducted across 80 countries, researchers found that unprocessed red meat and whole grains can be included or left out of a healthy diet. Published in the European Heart Journal, the findings showed that diets emphasising fruit, vegetables, dairy (mainly whole-fat), nuts, legumes and fish were linked with a lower risk of cardiovascular disease (CVD) and premature death in all world regions. The addition of unprocessed red meat or whole grains had little impact on outcomes.
“Low-fat foods have taken centre stage with the public, food industry and policymakers, with nutrition labels focused on reducing fat and saturated fat,” said study author Dr Andrew Mente of the Population Health Research Institute, McMaster University, Hamilton, Canada. “Our findings suggest that the priority should be increasing protective foods such as nuts (often avoided as too energy dense), fish and dairy, rather than restricting dairy (especially whole-fat) to very low amounts. Our results show that up to two servings a day of dairy, mainly whole-fat, can be included in a healthy diet. This is in keeping with modern nutrition science showing that dairy, particularly whole-fat, may protect against high blood pressure and metabolic syndrome.”
The study examined the relationships between a new diet score and health outcomes in a global population. A healthy diet score was created based on six foods that have each been linked with longevity. The PURE diet included 2-3 servings of fruit per day, 2-3 servings of vegetables per day, 3-4 servings of legumes per week, 7 servings of nuts per week, 2-3 servings of fish per week, and 14 servings of dairy products (mainly whole fat but not including butter or whipped cream) per week. A score of 1 (healthy) was assigned for intake above the median in the group and a score of 0 (unhealthy) for intake at or below the median, for a total of 0 to 6. Dr Mente explained: “Participants in the top 50% of the population – an achievable level – on each of the six food components attained the maximum diet score of six.”
Associations of the score with mortality, myocardial infarction, stroke and total CVD (including fatal CVD and non-fatal myocardial infarction, stroke and heart failure) were tested in the PURE study which included 147 642 people from the general population in 21 countries. The analyses were adjusted for factors that could influence the relationships such as age, sex, waist-to-hip ratio, education level, income, urban or rural location, physical activity, smoking status, diabetes, use of statins or high blood pressure medications, and total energy intake.
The average diet score was 2.95. During a median follow-up of 9.3 years, there were 15 707 deaths and 40 764 cardiovascular events. Compared with the least healthy diet (score of 1 or less), the healthiest diet (score of 5 or more) was linked with a 30% lower risk of death, 18% lower likelihood of CVD, 14% lower risk of myocardial infarction and 19% lower risk of stroke. Associations between the healthy diet score and outcomes were confirmed in five independent studies including a total of 96 955 patients with CVD in 70 countries.
Dr Mente said: “This was by far the most diverse study of nutrition and health outcomes in the world and the only one with sufficient representation from high-, middle- and low-income countries. The connection between the PURE diet and health outcomes was found in generally healthy people, patients with CVD, patients with diabetes, and across economies.”
“The associations were strongest in areas with the poorest quality diet, including South Asia, China and Africa, where calorie intake was low and dominated by refined carbohydrates. This suggests that a large proportion of deaths and CVD in adults around the world may be due to undernutrition, that is, low intakes of energy and protective foods, rather than overnutrition. This challenges current beliefs,” said Professor Salim Yusuf, senior author and principal investigator of PURE.
In an accompanying editorial, Dr Dariush Mozaffarian of the Friedman School of Nutrition Science and Policy, Tufts University, USA, stated: “The new results in PURE, in combination with prior reports, call for a re-evaluation of unrelenting guidelines to avoid whole-fat dairy products. Investigations such as the one by Mente and colleagues remind us of the continuing and devastating rise in diet-related chronic diseases globally, and of the power of protective foods to help address these burdens. It is time for national nutrition guidelines, private sector innovations, government tax policy and agricultural incentives, food procurement policies, labelling and other regulatory priorities, and food-based healthcare interventions to catch up to the science. Millions of lives depend on it.”
June is Men’s Health Month and while the focus is mostly on men’s attitudes about their health, it is also worth reflecting on the health sector’s attitudes toward men.
We hear many stereotypes about men and health, but how many of those are actually true?
A few years ago representatives of The Mpilo Project spoke to more than 2 000 men in KwaZulu-Natal and Mpumalanga to understand why many find it hard to engage with HIV testing and treatment. We uncovered several myths and misperceptions in the process.
One common myth is that men are stubborn and apathetic about HIV – that they aren’t listening and don’t care. While many men may indeed wear a mask of indifference, HIV leaves many of them feeling paralysed by fear and anxiety. This is why we need a health service delivery approach rooted in encouragement and reassurance, not scolding and pressure.
Another common misconception is that men are mainly just workers who need practical solutions like convenient clinic hours and quick service. The reality is that men are complex human beings who face social and emotional barriers as well as practical ones. We need solutions that address both practical and psychosocial barriers.
There is also a view that sources of support are available and that men just fail to access them, perhaps because “they don’t really want support”. In fact, many men are hungry for support but see no sources that feel safe or relatable. They experience counselling as scripted, one-directional, overly technical, and often judgmental. The key is to give men the right sources of support and to speak empathetically to their individual issues and concerns.
Finally, there is a view that healthcare providers are helping men by taking proactive approaches like provider-initiated testing and tracking-tracing. But these often leave men feeling hunted and ambushed by the health system. We need proactive approaches that leave men feeling like they still have control over their own lives and decisions and help them develop their own internal motivation to start and stay on treatment.
These and other misconceptions can lead healthcare providers to conclude that men are simply difficult if not impossible to reach. But once we understand their barriers, that picture changes dramatically.
The 11th SA AIDS Conference concluded last week and in one of the plenary sessions we had the opportunity to respond to the question: “Strategies for reaching men—are we seeing a return on investment?”
The short answer is yes!
Since 2017, the percentage of men with HIV in South Africa who know their status has increased from 78% to 94%, nearly on par with women. We can attribute that in part to approaches like HIV self-testing that have made it quick, easy, and private for men to learn their status.
We’ve also seen good progress on viral suppression, which has increased from 82% to 93%, again comparable to the rate among women – proof that men on treatment are fully capable of being adherent.
Yet only 70% of men who know they have HIV are currently on treatment – hardly any increase at all from 68% in 2017.
Given the progress we’ve seen in men testing for HIV and achieving viral suppression, the persistent gap in men on treatment suggests that something is wrong – not with men but with the HIV treatment services and support we are offering them.
The good news
The good news is that we know much more than we did a few years ago about what works. Here are three examples.
The MINA campaign aims to reach men with “the new HIV story” by featuring stories from real men living a healthy, happy life with HIV on social media, television, radio, billboards, etc. The campaign also helps men feel more welcome in the clinic, using signage and materials to send the signal to men that “this is your space too”. MINA-supported districts and facilities have seen strong growth in testing and linkage, as well as modest improvement in retention in care.
The Coach Mpilo model employs men who are thriving with HIV as coaches of men at risk of non-initiation or disengagement. Coaches provide a safe, relatable source of support and serve as living proof that HIV is not the end of the road. Piloted in 2020 and currently implemented in 18 districts, the model is achieving 97% linkage to care and 94% retention.
The B-OK bead bottles are a simple visual tool for helping people to understand the benefits of HIV treatment and viral suppression and, more importantly, to build the motivation to start and stay on treatment. Red beads are HIV; black beads are healthy cells. A mixed bottle represents most people upon diagnosis. A red bottle represents the virus multiplying uncontrolled in the absence of treatment. A black bottle with one red bead represents viral suppression achieved through treatment adherence. In an evaluation of the tool, understanding of how HIV treatment works increased from 12.5% to 92.5%.
Men are not indifferent about their health and they are not inherently poor health-seekers. If many of them are avoiding healthcare services, let’s consider that it may be because they are not getting what they need from these services.
We have seen that men do engage when we in the public health sector meet them where they are rather than where we want them to be; when we speak to their needs and priorities rather than ours; when we give them the right sources of support rather than one-size-fits-all, and when we help them build understanding and motivation rather than simply instructing.
When we invest, we see returns. Let’s keep investing in scaling what works.
*Malone is the Project Director of The Mpilo Project, PSI.
A massive and much-anticipated phase 3 trial of an experimental tuberculosis (TB) vaccine is set to proceed after funding for it has been secured from two large philanthropies. Wellcome and the Bill & Melinda Gates Foundation (BMGF) Wednesday announced they’d be investing a combined $550 million into the trial – around $150 million from Wellcome and the remaining from the Bill & Melinda Gates Medical Research Institute, a nonprofit subsidiary of the BMGF.
The vaccine, called M72/AS01E or just M72, made headlines in September 2018 when it was found to offer 54% protection against pulmonary TB disease in a phase 2B trial. That trial, of around 3 300 people, was conducted in South Africa, Zambia, and Kenya. Final results from that study were published in the New England Journal of Medicine in 2019 – efficacy in these final results was down to around 50%.
Medicines and vaccines are typically only brought to market once safety and efficacy have been confirmed in a large phase 3 trial. In this case, the phase 3 trial is set to have around eight times as many participants as the phase 2B trial.
26 000 study participants
“Conducted in collaboration with an international consortium of TB clinical investigators, the trial will enrol approximately 26 000 people, including people living with HIV and without TB infection, at more than 50 trial sites in Africa and Southeast Asia,” Wellcome and BMGF said in a statement announcing the trial.
They said the trial will “assess the candidate vaccine’s efficacy at preventing progression from latent TB infection to pulmonary TB”. In an online media conference on Wednesday Trevor Mundel, President for Global Health at BMGF, clarified that while most study participants will be people with latent TB infection, 4 000 people without TB infection would also be recruited. This is because establishing evidence of the vaccine’s safety in people without latent TB infection will be important if the vaccine is to be rolled out in areas with high background rates of TB without first having to test everyone for latent infection. “You’d want to be comfortable with vaccinating everyone in the community,” he said, “So we need to have that safety data in the uninfected as well in order to be able to have that usage, which will be the easiest way to use the vaccine at the end of the day.”
Mundel said that the study is scheduled to start early in 2024 and that it is expected to last for four to six years. Exactly how long the study will take will depend largely on how long it takes for 150 study participants to develop active TB – the number required for the study to have sufficient statistical power. By comparison, recruitment for the phase 2B trial started in 2014 and the first findings from that study were published in 2018.
According to the statement, additional details about the trial design and participants will be announced in the coming months.
Given that the phase 2B trial was partially conducted in South Africa and the country has substantial TB clinical trial capacity, it is almost certain that some of the 50 trial sites will be in South Africa – although know specific trial sites have yet been announced.
As pointed out in the statement, the only TB vaccine in use today, bacille Calmette-Guerin (BCG), was first given to people in 1921. It helps protect babies and young children against severe systemic forms of TB but offers limited protection against pulmonary TB among adolescents and adults. If the findings from the phase 3 trial of M72 are positive, m72 will become the first new TB vaccine in over a hundred years to be proven safe and effective.
According to the most recent figures from the World Health Organization (WHO), around 304 000 people fell ill with TB in South Africa in 2021. While TB rates are declining, they are declining relatively slowly and according to the most recent WHO World TB Report, a major technological breakthrough such as a new vaccine will be needed if ambitious TB control targets are to be met.
Announcement welcomed
“We’ve waited a long time for this study, so are happy to see the Bill & Melinda Gates Foundation and Wellcome taking up this important task,” said Patrick Agbassi, chair of the Global TB Community Advisory Board, in a comment included in the Wellcome/BMGF statement. “The question now becomes how we can enroll 26 000 people most quickly and ensure that all populations at risk of TB will ultimately be able to benefit from access to what could be the first new TB vaccine in over 100 years. A robust community engagement programme will be key, as will taking on studying this vaccine in younger adolescents, pregnant women, people with prior history of TB, and other key groups often underrepresented or left out entirely of TB trials and the benefits of scientific progress.”
Mark Harrington, executive director of New York-based advocacy organisation Treatment Action Group (TAG) said, “TAG welcomes this historic investment in TB vaccine development by Wellcome and the Bill & Melinda Gates Foundation. A Phase III clinical trial of the M72/AS01E TB vaccine candidate is a long-awaited milestone. We hope this funding commitment sparks governments and other funders to substantially increase investments in the TB vaccine pipeline, which contains a number of promising candidates in addition to M72/AS01E but faces a dire financial shortfall.”
“This Phase III trial,” Harrington said, “will take several years to complete. We encourage the Gates Foundation, Wellcome, GSK, country governments, and other partners to use this time to lay the groundwork for eventual vaccine adoption by ensuring the availability, affordability, and acceptability of M72/AS01E should it prove safe and effective.”
Initial development of M72 was driven by the pharmaceutical company GSK with support from several governments, philanthropies, and research organisations. The vaccine contains the M72 recombinant fusion protein, which the Wellcome/BMGF statement explains is derived from two Mycobacterium tuberculosis antigens (Mtb32A and Mtb39A) combined with the GSK proprietary Adjuvant System AS01E. According to the statement, GSK will continue to provide the adjuvant for the vaccine’s further development and potential launch.
NOTES: (1) The BMGF is mentioned in this article. Spotlight receives funding from the BMGF, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council. (2) A representative of the Global TB Community Advisory Board is quoted in this article. Spotlight editor Marcus Low was previously a member of the Global TB Community Advisory Board.
A number of service providers have voluntarily ended their contracts with the Gauteng Department of Health to provide food to hospitals. In response, Gauteng Health is looking at a multi-vendor approach to tackle the problem which it blames on vendors being unable to fulfil their orders.
Meanwhile, Gauteng continues to battle with surgical and cancer treatment backlogs. R784 million has been allocated to this end, with a portion allocated to cancer treatment services, some of which will be outsourced to the private sector and some of which is going to new radiotherapy equipment.
This year has seen a number of Gauteng hospitals battling to secure their food supplies. Responding to SA parliamentary questions, Gauteng Health MEC Nomantu Nkomo-Ralehoko wrote that 26 out of 34 Gauteng public hospitals have been affected by food shortages.
“The shortages were mostly due to suppliers not being paid, contracts expiring, or companies not delivering. It was so bad for two hospitals, Bronkhorstspruit and Lenasia South, they had to borrow food from other hospitals!” said DA Shadow MEC for Health, Jack Bloom, who posed the questions.
Hospitals have being going through long stretches of not being able to provide full meals: at George Mukhari Hospital, chicken, fish and frozen vegetables were unavailable for four months, and there was no milk from February to May. The petty cash budgets are woefully insufficient to cover the gap: Kalafong hospital can only spend R2000 a day, not nearly enough to feed its 700 patients, reports SA People.
According to News24, Gauteeng Health spokesperson, Motalatale Modiba, said that the main problem was down to vendors struggling to fulfil their orders on time.
Currently, Gauteng health is running a tender to outsource oncology services for the Charlotte Maxeke and Steve Biko hospitals. The outsourcing programme should be able to ensure that patients who are currently awaiting treatment in the public sector will be able to access private sector treatment instead.
In their announcement, Gauteng Health stated: “We recognise the urgency of the situation and want to assure the public that we are committed to handling the outsourcing of radiation oncology sources diligently and are nearing implementation.”
The open tendering process will last 14 days, and is divided into categories for oncology specialists, treatment services and radiation planning services.
The department has already procured 4 Llinac machines, and has recently closed a tender for a Brachytherapy, and have advertised a tender for another Linac machine for Charlotte Maxeke. Ongoing investigations by Spotlight have also revealed that the oncology procurement process is lagging behind. The GDoH aims to have the first treatments under the outsourcing programme to start in August 2023.
Amid skyrocketing youth unemployment, healthcare, a vast sector which touches all of our lives at some point, seems a sensible space for young people to set their sights on for opportunities. From clinical sciences to pharmacy, there is a myriad of careers in the healthcare ecosystem, but there are also factors preventing this potential from being unleashed, writes Bada Pharasi, CEO of The Innovative Pharmaceutical Association South Africa (IPASA).
A career in health has long been seen as a symbol of success in South Africa. The no-nonsense nurses in our communities, the hard-working doctors and the knowledgeable pharmacists have long represented those who had “made it”.
For many of us, these were the lucky ones who had found a career path that was both rewarding and respected. This has also been the way that South Africans view the myriad of the less visible jobs in healthcare (lab technicians, pharmacist assistants, dieticians, the list is endless).
Bada Pharasi, Chief Executive Officer of IPASA
As South Africa grapples with the highest unemployment rate1 in the world, with youth unemployment being the biggest concern (currently at more than 60%2), it’s not difficult to see why the healthcare system with its vast range of careers would present a solution. Careers in health not only benefit young people looking for a start in life, but they also build South Africa’s capacity to provide care for millions who desperately need it.
As young people search for the stepping stones to long, rewarding careers, many will be advised by well-intentioned family and friends to seek a future in healthcare. And it’s not bad advice.
As a sector that can generate employment opportunities at both ends of the value chain – from highly skilled specialists in technology and research to those who operate in palliative or frail care environments2 – the recent effects of the Covid-19 pandemic underscored the essential value and role that healthcare workers play in bolstering South Africa’s socio-economic and overall health resilience.
Human resource gaps in healthcare are clear
In 2020, the Hospital Association of South Africa suggested that there was a shortage of between 26 000 and 62 000 professional nurses and this shortage is expected to increase to between 305 000 and 340 000 by 2030 as the country’s population continues to grow. Alarmingly, estimates suggest that only 26 ,000 will be trained by then3.
South Africa also has less than one doctor per 1000 patients4. In a country with serious disease burdens, the situation is far from ideal.
The need for long-term planning
A challenge often cited when posts are frozen in healthcare is funding. While there are undoubtedly funding constraints in the healthcare system, it seems unlikely that the addition of funds will solve the challenge. It’s worth rethinking the way the human resources pipeline in South Africa is structured and where the bottlenecks lie.
South Africa’s history of inequality, which is deeply entrenched in the country’s healthcare system, has created the twin challenge of a shortage of skills and inadequate capacity to manage and distribute those skills to where they’re most needed. There are also policy bottlenecks that can hinder progress.
For instance, while complementing the qualification with some kind of work experience and community service spent in the public sector is an applaudable initiative, it becomes counterproductive when there aren’t enough posts in the public sector to place people coming out of training institutions. This, in turn, limits the number of professionals who can qualify, adding incrementally to the shortage of personnel every year.
Similarly, the cap on the number of personnel that the Nursing Council can accredit per year may limit the number of posts needed, but it doesn’t help address the shortage of nurses in South Africa.
The burden of disease in South Africa, coupled with the uneven spread of healthcare facilities means that it’s also a singularly challenging environment to work in. This means that retention policies, and initiatives that prioritise the well-being of healthcare workers are also important considerations.
It’s worth noting that over the past few decades, there have been a number of well-considered human resources strategies for the healthcare system in South Africa5. Unfortunately, these have suffered from inadequate implementation. This long-term planning and implementation is critical.
Ultimately, it means ensuring that we’re able to encourage young people to take up these worthy careers with the guarantee that once they qualify, their skills will be put to good use.
As the National Department of Health prepares to move South Africa toward the National Health Insurance scheme, the question of staffing becomes even more critical. It’s going to call for long-term strategies that will need to be implemented over generations.
South African scientists – notably, the team headed by Professor Tulio de Oliveira – were thrown into the global spotlight through their pivotal role in detecting and monitoring the emergence of new variants of SARS-CoV-2 – the Beta variant in 2020 and Omicron in 2021. De Oliveira is now at the University of Stellenbosch, but for much of the pandemic headed the KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP).
The country’s advanced genomic sequencing capabilities and proactive surveillance efforts allowed for the early identification of the variants and the discoveries played a crucial role in alerting the global scientific community to the potential for viral mutations and the need for enhanced monitoring.
Now, scientists worldwide believe it is critical to continue investing in genomics to support disease control in public health in South Africa and the broader continent.
What is genomics?
The World Health Organization (WHO) defines genomic surveillance as “the process of constantly monitoring pathogens and analysing their genetic similarities and differences”. It is done through a method known as whole genome sequencing, which determines the entire genetic makeup of specific organisms or cell types. This method is also able to detect changes in areas of genomes, which can help scientists to establish how specific diseases form. The results of genomic sequencing can also be used in diagnosing and treating diseases.
Genomic sequencing enables scientists to read the DNA and RNA of pathogens and understand what they are and how they spread between people – and to develop vaccines and other measures to deal with them.
The US Centers for Disease Control (CDC) explains, “All organisms (bacteria, vegetable, mammal) have a unique genetic code, or genome that is composed of nucleotide bases (A, T, C, and G). If you know the sequence of the bases in an organism, you have identified its unique DNA fingerprint or pattern. Determining the order of bases is called sequencing. Whole genome sequencing is a laboratory procedure that determines the order of bases in the genome of an organism in one process.
“Scientists conduct whole genome sequencing by following these four main steps:
DNA shearing: Scientists begin by using molecular scissors to cut the DNA, which is composed of millions of bases (A’s, C’s, T’s, and G’s), into pieces that are small enough for the sequencing machine to read.
DNA barcoding: Scientists add small pieces of DNA tags, or bar codes, to identify which piece of sheared DNA belongs to which bacteria. This is similar to how a bar code identifies a product at a grocery store.
DNA sequencing: The bar-coded DNA from multiple bacteria is combined and put in a DNA sequencer. The sequencer identifies the A’s, C’s, T’s, and G’s, or bases, that make up each bacterial sequence. The sequencer uses the bar code to keep track of which bases belong to which bacteria.
Data analysis: Scientists use computer analysis tools to compare sequences from multiple bacteria and identify differences. The number of differences can tell the scientists how closely related the bacteria are, and how likely it is that they are part of the same outbreak…”
Time to expand
At a recent conference held at Stellenbosch University’s new state-of-the-art Biomedical Medical Research Institute, de Oliveira stressed that African and other experts should now build on their success in COVID-19 genomics to expand to other pathogens such as influenza, H5N1, and climate-amplified pathogens.
John Sillitoe, the Director of the Genomic Surveillance Unit at the Wellcome Sanger Institute in the United Kingdom, agreed.
“It is important now to focus on endemic diseases so we can improve our understanding and control of endemic diseases. We should also be looking at TB, particularly with the increased prevalence in drug resistance and reduced response to drugs. For other African countries, malaria should be a key focus area. We know that drug resistance now is spreading into Africa from South East Asia and understanding the right combination of drugs to use is something that is easily identifiable through genomic surveillance.”
But surveillance is also about being ready for the next pandemic.
“There’s that classic line that, ‘diseases take no notice of national borders’,” Sillitoe said in an interview. “So, it is really important that we can get as wide a picture of surveillance as possible to identify something new emerging as soon as possible.”
Marco Salemi, Professor of Experimental Pathology at the Department of Pathology, Immunology, and Laboratory Medicine at the University of Florida College of Medicine, said Africa and the world need to be “proactive, rather than reactive” in the battle against future epidemics. He said the world is currently focused on monitoring the COVID-19 pandemic. “But we forget this is this huge reservoir of pathogens out there which we know so little about and which can become more and more of a threat, especially because of climate change – so we need to understand more about all these pathogens in the wild, in animals, and their potential to jump to humans, especially with the rate of globalisation on the planet … Events of zoonotic transmissions will become more and more frequent. We need to face it.”
Building capacity
De Oliveira is of the view that Africa could, in the next few years, potentially, “leapfrog over the rest of the world” in genomic surveillance, thanks to its success in COVID-19 genomics and its experience in using genomics to monitor other pathogens over the past 20 years.
We won’t be starting from scratch.
The use of genomics in infectious diseases started in the mid-eighties during the HIV epidemic, when scientists realised HIV was a complex virus that existed in many different sub-types. Scientists around the world started using genomic tools to sequence the HIV virus, track its origin, and trace the way the virus disseminated.
Genomics has, however, changed dramatically since the 1980s.
“There have been many attempts… to use genomics for public health purposes, but the key factor that was always missing was the ability to generate DNA sequencing in real-time,” said Salemi. “Real-time means there is an epidemic, with cases happening today – and we need to generate sequences within one or two days and then to analyse the genomic data and then to have actionable information that can be immediately transmitted to the public health authorities so that they can act within a few days.”
“Now the technological and computational limitations of the past few years have been overcome, and, as was clearly shown during the COVID-19 pandemic, we have machines that can generate literally thousands of sequences, like coronavirus sequences, in less than one day, or even within a few hours. At the same time, we have high-performance computer clusters, and super calculators that are capable of analysing this data in a very short time,” he said.
These technical advances would, of course, be of little value without people to use them and develop them further.
“Investment has been made on the continent in infectious disease surveillance and genomics surveillance specifically, and so we have lots of experts on the continent who know a lot about infectious diseases and how viruses work, and why it’s important to look at the genomics to trace when there is going to be a new outbreak,” says Professor Zané Lombard, Principal Medical Scientist in the Division of Human Genetics at the University of the Witwatersrand. “South Africa’s role during COVID-19 showcased what can happen quickly and effectively for public health interventions if you have the right experts with the right platform and expertise and infrastructure in place to do that kind of surveillance.”
De Oliveira and his team have worked closely with the Africa Centres for Disease Control and Prevention (Africa CDC) to scale genomic surveillance on the continent and have actively collaborated with other African countries to share expertise, resources, and genetic data in a bid to foster a continent-wide approach to genomic surveillance.
They have also helped set up large genomics facilities in Zimbabwe, Mozambique, and Botswana.
The Africa CDC, through its Pathogen Genomics Initiative (Africa PGI), has, for the past few years, been building a continent-wide genomic disease surveillance network. In 2019, when the PGI started its work, only seven of the African Union’s 55 member states had public health institutions with the equipment and staff to do genetic sequencing. Today, 31 African nations are able to do genetic sequencing for surveillance of COVID, malaria, cholera, Ebola, and other diseases.
De Oliveira said the continent’s experience in genomic surveillance of pathogens in Africa evolved to “unheard-of” levels during COVID. “We’ve been trying to advance genomic surveillance in Africa for the past two decades, and when the pandemic came, we had the right expertise to deal with viruses and respiratory pathogens such as tuberculosis, so we were able to pivot for SARS-CoV-2. In the end, South Africa and Africa became an example to follow for the whole world.
“All the investments we have made in genomic surveillance for COVID can now be leveraged and advanced to other areas of genomics in Africa… including for rare diseases, for cancer diagnostics, and human genomics. Finally, we have the tools and the equipment, as well as the support, to do advanced genomics in Africa, as we have dreamt of doing for the last twenty years.”
What it means in practical terms
Asked what it means, practically, to build capacity for genomics research, Lombard said one aspect is the establishment of strong laboratories. “Historically, if infrastructure was not available locally, researchers would partner with international labs and send their samples to have their sequencing done there. The problem with that was that expertise in using [that] technique was not being built locally,” she said. “It is really important to train the right people who know how to do the laboratory experiments but also to interpret the data correctly.
“It’s not only about building the infrastructure in the labs but also about training the individuals and making sure there are job opportunities locally for them,” she said.
Turning to the machines used in genomics, Lombard said, “The most popular machine these days is called a next-generation sequencer. These can read the whole DNA sequence of a virus.”
Salemi added, “Some of these sequencers are very large and some are even little portable boxes. Some can sequence thousands of samples at a time, while others are capable of sequencing a few dozen samples at a time. The samples, depending on the virus (or pathogen) being tested for, are taken from blood samples, nasal swabs, or sputum from patients, from faeces, urine, or from the skin.
“The BMRI (at Stellenbosch University) – which has the largest sample storage capacity in the southern hemisphere – can store five million samples at minus 80 degrees. If someone wants to build a lab that includes top-of-the-line computational capacity, it will cost anything from $40 million (over 700 million), but to start a small operation to do a few hundred sequences of a virus every week, $100 000 to $200 000 (roughly R17 million to R34 million) is enough, which has been done in many different African countries during the pandemic.”
Training is key
While all the scientists interviewed agreed that laboratories are important in building capacity for genomics research, they stressed that what is really needed is to train more individuals.
“More people need to be trained in genomics but also in bioinformatics, which is a really important component of this work. The technology component is becoming very smart and automated, but the data being generated is becoming more and more complex, with bigger data sets. Dealing with these,” Lombard said, “requires special data analysis skills and bioinformatics skills. The field of bioinformatics will need investment so that we can deal with the deluge of data that will come out.”
She said South African and other African universities are taking this skills need seriously, with many initiatives to offer undergraduate and post-graduate training programmes in these areas.
Salami agreed. “The most important part of building capacity is the human training. I find it naïve and sad when I hear politicians talking about building top-of-the-line laboratories, when, what they really need to do is to start building human capacity. Africa is an amazing reservoir (from which to build these skills) because 50 percent of the continent [are] people who are less than 30 years old. There are about 27 excellent laboratories all over Africa. We need to start creating a strong next generation of scientists.”
In support of this, de Oliveira is trying to raise 100 million dollars to implement real-time genomic research to enable the African continent to respond to new epidemics.
He said during COVID, the Network for Genomics Surveillance was founded and funded by the Department of Science and Innovation and the South African Medical Research Council (SAMRC). This funding was until 2021.
The Centre for Epidemic Response and Innovation, which is led by de Oliveira and forms part of the BMRI, is funded by the Africa CDC, the WHO, the Rockefeller Foundation, and the Elma Foundation. These funders support the work in South Africa and in other African countries, as well as the SA government. The BMRI was mostly funded by Stellenbosch University to the effect of R900 million, while the Department of Higher Education provided about R300 million. CERI occupies one floor of the BMRI.
In de Oliveira’s words, “This truly is the genome era for Africa.”
