NHLS crisis draws blood

The 2014 South African HIV Clinicians Society conference was plastered with a guerrilla sticker campaign: ‘Saving the NHLS = saving lives’.

The National Health Laboratory Service – a national asset at the heart of the country’s healthcare system – is in critical condition.

It’s in debt to the tune of R5-billion, owes suppliers hundreds of millions of rands, is leaking skilled staff, and many of the employees who remain are demoralised.

The ongoing financial crisis has severely impacted the NHLS’s capacity to deliver the necessary services, leaving the future of laboratory testing in South Africa in jeopardy, and a leadership void, amid perceptions that the embattled CEO Sagie Pillay is marking time until his contract expires in November.

This grim picture was sketched by health experts who work closely with the Service and three senior people inside the NHLS itself, who spoke to NSP Review on condition of anonymity.‘We’ve never had a test not come out, but we’ve hit the wall,’said a senior staff member, adding that he was on the verge of walking out.

So, what’s gone wrong for the country’s network of laboratories? According to some NHLS detractors, fi mismanagement is the problem; others believe the fault lies with a dysfunctional Board. Yet others say it’s because two provinces aren’t paying for services rendered. According to the Health Minister, Dr Aaron Motsoaledi, it’s the chaotic and glitch-riddled billing system; but some blame an‘interfering Minister’.
Health experts say that whatever led to the mess, the implications are‘horrifying’– and must be resolved urgently and permanently.

‘Without the NHLS the country’s health system cannot function,’says SECTION27’s Executive Director Mark Heywood. ‘The NHLS is responsible for most HIV and TB tests in the public health system and plays a critical role in screening for cervical cancer. HIV/AIDS and TB treatment depend on accurate and timely tests. Without the NHLS, TB, HIV and cancer patients won’t have access to diagnostic testing, which means they won’t be properly treated. The implications are serious: Without lab tests, there can be no other services.’

‘Yes,’agrees Professor Francois Venter from the Wits Reproductive Health and HIV Institute,‘the NHLS has been lurching from crisis to crisis for four years. It’s nothing short of a monumental stuff up.’

The crisis reached a tipping point in September and Minister Motsoaledi stepped in to announce a process of reforms to save the NHLS.

But,‘The way this was reported made me angry,’said one insider,‘because it makes it sound as if the NHLS is to blame for being in debt, which is not the case.’

According to Professor Venter, the NHLS is being held hostage by KwaZulu-Natal and Gauteng, which owe the lab billions of rands. The National Health Department allocates funds to each province from which they are meant to pay the NHLS for services.

Earlier this year Dr Motsoaledi said faults in the Service’s billing system were to blame for its financial woes. One of his reforms is to bypass the provinces and pay the NHLS a global lump sum directly from the Treasury. Another is to create a National Public Health Institute to monitor disease and respond to outbreaks. It would include the National Institute for Communicable Diseases, the National Institute for Occupational Health, and the National Cancer Registry, which is currently run by the NHLS, as well as two new institutes – the National Institute for Non-Communicable Diseases and the National Institute for Injury and Violence Prevention.

The Minister has also said that the cost of training pathologists and technicians, which is another one of the Service’s tasks, would become the responsibility of the Department of Education.

Dr Motsoaledi’s reforms are a case of‘too little, too late’, said the source.‘The problem is, we’ve lost so many staff. In the last year 30 pathologists have left – and we already had fewer than we needed. We’ve lost all their years of experience. They are leaving through sheer frustration. We’ve also lost 30 percent of our technologists. People with 10 years’experience are being replaced by people fresh out of [college].’

A second highly-placed source at the NHLS echoed these sentiments, saying the Service employed 7 200 people two years ago and is now down to fewer than 6 000.‘It’s the best who are going – either being lapped up by the private sector or leaving the country.’

‘We’re on a treadmill and managers are using “austerity measures” to block everything – like going to conferences. Labs have been forced to consolidate, which means the smaller labs are being swallowed up. Lab managers have to beg for gloves and struggle to get stock. Staff members also wait anxiously each month to see if they have been paid.’

Dr Francesca Conradie, President of the Southern African HIV Clinicians Society, said it was worrying that technicians and technologists were leaving.‘Laboratory testing is a labour-intensive technical service – we train them up and we want them to stay with us. If they don’t, we’ll see a decline in quality,’she warned.

She described the NHLS as an innovative laboratory network that uses technology – like the highly celebrated GeneXpert programme, which diagnoses active TB throughout South Africa – to link all systems to a single, central database collection.‘This means that every test can be accessed by health professionals from all over the country so we can see trends and get information, for example, about drug-resistant TB. Because of this the NHLS is one of our best health assets.’

According to Dr Conradie, South Africa’s ability to deliver outstanding HIV care is dependent on laboratory testing.‘For TB and HIV, laboratory investigations are needed to initiate and monitor therapy. About 10 or 15 years ago we took a wise decision to have a viral load supported programme; we can’t afford to let that fall down because of administrative issues.’

She said the collapse of the NHLS would have devastating implications for people who can’t afford private lab tests – about 80 percent of patients in the country.‘Without the NHLS, health care will grind to a halt. This is a service that belongs to South Africa – it must be sorted out urgently.’

Meanwhile, our source said that despite the ongoing crisis, the Service’s quality hadn’t dropped‘yet’, but warned that this would happen when unpaid suppliers shut down their services. ‘We collect from every clinic at least once a day. We rely on private people to go to clinics in remote places and if they don’t get paid the logistics chain breaks – and the system collapses.’

A third source confi med this, describing the situation as dire. ‘Hundreds of millions of rands are owed to suppliers. The big suppliers can afford a delay, but if the smaller creditors don’t get paid they will go under. Each month the finance people balance who they are going to pay.’

Another insider observed that because the NHLS is state- owned it is the last to be paid.‘Of course, we can’t stop services to the provinces because that would mean punishing patients,’he said.

That nearly happened in March when Sagie Pillay sent a memo to staff announcing the suspension of services to Gauteng and KwaZulu-Natal (see‘History of the Crisis’). At the time, SECTION27 and the Treatment Action Campaign said suspending laboratory services would make a mockery of South Africa’s flagship HIV/AIDS and TB programmes.

Due to fear of victimisation nobody working at the NHLS were prepared to go on the record. Numerous attempts to speak to senior Department of Health officials and several attempts to get responses to a set of specific quesitons were unsuccessful.

The memo stated,‘The organisation has been under severe pressure due to the fact that both Gauteng and KwaZulu-Natal provinces have not paid their bills. This increasing pressure of non-payment has resulted in the NHLS not being able to meet a number of its own financial commitments … (The) NHLS has made several attempts to explore all options available to ensure payment is received from these provinces, without success.’

Pillay’s threat to suspend services apparently infuriated the Minister, and has led to speculation that he is being frozen out of the Service. One source said that Pillay has been made the scapegoat.‘He hasn’t been a bad CEO. When he came in fi e years ago he gave the HIV and TB programmes a much-needed kick in the backside. He may not be the greatest manager, but he cares about the patient – and that’s king. He has fallen out of favour with the Minister and his fi e-year contract, which expires in November, is not being renewed.’

NSP Review contacted Pillay who said it would be‘awkward’ for him to comment and referred queries to the Department of Health. He did say, though, that he thought the Minister’s reform process was a positive development but needed to be implemented urgently.

Then, of course, there is the matter of the R5-billion debt.‘It’s all very well getting paid directly from the Treasury but what will happen to the accrued debt?’asked the source.‘The NHLS is finacially bankrupt and no company in the world can function with a R5-billion debt.’

According to the third source, the NHLS Board, which is meant to be an independent entity, has been deeply dysfunctional.

‘The Board has a lot to answer for,’he said, an opinion with which Professor Venter concurred, saying the Minister needs to be held accountable for the situation‘being allowed to escalate’.

‘The question that needs to be asked is why the NHLS – one of the country’s most valuable services, an institution of excellence that has global best practices – is coming apart at the seams? Why would provinces not pay? It just makes no sense,’says Mark Heywood.

One source said Gauteng is cash-strapped and can’t pay, while KZN has had an inexplicable‘guttural hatred’of the NHLS since 2010.‘The only thing I can think of is that people with a stake in private labs have a vested interest in crashing the NHLS so they can benefi ,’said Heywood.‘I’ve heard mutterings that KZN wants to pull out of the NHLS and go private. However, the operating model of NHLS cannot survive if KZN pulls out. If the NHLS collapses, it will be a national disaster.’But the source said there are no‘ifs’about it.‘The NHLS has already collapsed,’he said.‘It has already crumbled.’