NSP Review COMMENT
It is a curable disease. It is a treatable disease. Yet, it has managed to devastate health systems and communities for centuries. When HIV arrived, this wily disease made a storming comeback and now kills young people in their prime, condemns old people to a painful death and maims and disables the young. Archbishop Desmond Tutu, a TB survivor and activist for most of his life, continues to speak out on the need to tackle this disease: “TB is the child of poverty but also its parent and provider. If we are to do something about AIDS, then we have to do something about TB. If we are to do something about TB, we are going to have to do something about AIDS. As we have overcome apartheid, so we shall defeat TB and HIV/AIDS, these ungodly twin killers.”
NSP Review did offer the National Department of Health space in this issue to share their plans and progress on TB. They had not responded at the time of going to press. A document which was shared after the deadline included no detail or facts.
It is not an exaggeration to describe South Africa’s Minister of Health Dr Aaron Motsoaledi as the darling of the international tuberculosis world. He has been outspoken about the problem of TB, he oversaw the rapid rollout of the GeneXpert TB diagnostic test platform in South Africa, and he heads the Stop TB Partnership. There can be little doubt that he will receive standing ovations at the Union World Lung Conference in Cape Town this December. And, for his leadership on TB, this will certainly be deserved.
But when it comes to the implementation of TB programmes there is another side to South Africa’s story – a less flattering side that the international community rarely hears about. And, when the international community does happen to hear about it, people often choose to overlook it. ‘Managing health systems is a domestic matter’ is the thinking. Yet, as a civil society group working in South Africa, we do not have that luxury.
As Ebola has reminded us, the state of public health systems should be as much a matter of international concern and support as individual diseases like TB or HIV.
The Minister says all the right things about ending TB. He is ambitious. He is part of the ambitious setting of targets to end the global scourge of TB. He is a man fully ready and armed to take on the world’s oldest mass killer of human beings. However, when it comes to addressing the dysfunction in provincial healthcare systems Dr Motsoaledi tells us that his hands are tied and that he can do very little about it. Effectively this means he becomes powerless to turn around the healthcare systems that are supposed to deliver on the bold targets on TB, HIV and other diseases.
To make all this more concrete, consider the Free State province. The South African Health Review recently reported that the Free State lost a quarter of its public sector doctors from 2014 to 2015. It is not rocket science to understand that you cannot beat TB, or any other epidemic, if you are bleeding doctors at such an alarming rate. Yet, the loss of doctors in the Free State was not unpredictable and nor were its underlying causes unknown.
When Dr Motsoaledi took office in 2009 he would have had two reports on the Free State healthcare system to draw on – one by the South African Human Rights Commission published in 2007 and one by the Integrated Support Team. The latter was commissioned by his predecessor Barbara Hogan. He would also have been aware of the headline-making antiretroviral moratorium in the province that left many HIV-positive people who needed treatment without it.
In recent years the Treatment Action Campaign (TAC) has repeatedly raised the dysfunction in the province’s healthcare system directly with the Minister and through the South African National AIDS Council. We also raised it with his political heads when we met with African National Congress General Secretary Gwede Mantashe and his deputy Jessie Duarte. In 2014 the provincial Treasury took over the finances of the provincial Department of Health. The South African Medical Association and the opposition Democratic Alliance also made their concerns known. In January 2015 whistle-blower doctors sent a call-for-help letter to the Minister and published an open letter on the GroundUp News website. Through all these attempts at engagement and calls for help, all six plus years of them, Dr Motsoaledi has been unable to prevent the situation in the Free State from deteriorating to the point where we now have to deal with the extraordinary exodus of doctors from the public sector in the province.
The man entrusted with the public healthcare system in the Free State is Dr Benny Malakoane – the MEC for Health. Malakoane is currently facing multiple charges of fraud and corruption. Quite apart from the corruption cloud that continues to hang over his head, Malakoane has consistently refused to engage with civil society. He is widely blamed for the culture of fear and victimisation in the province.
Yet, Minister Motsoaledi has effectively been prevented from taking any steps to get Malakoane suspended or removed from his position. Despite the increasingly dire state of the Free State healthcare system the Minister has also not said a word in criticism of Malakoane in public. A bit of context is important here. Malakoane is a close ally of the Free State Premier Ace Magashule. This means that Malakoane is politically very well connected. Magashule has for some time ruled the Free State province like his personal fiefdom. More recently he has been associated with an increasingly powerful lobby group within the ANC referred to as the ‘Premier League’ – made up of a group of Premiers of similarly dysfunctional provinces. Men who also attract allegations of corruption and patronage.
Minister Motsoaledi is politically very experienced. He is, no doubt, also smart enough to know that his political career could come to a premature end should he attempt to take a hard line with MEC Malakoane or any other underperforming, but politically well-connected, MECs for health. After all, the ANC still has a practice of deploying loyal cadres to plum positions in government even if they are not suited for them.
One thus assumes that Dr Motsoaledi has concluded that he can do more good by not rocking the boat and staying in the position of Minister of Health than he could by rocking the boat and potentially losing his job. Of course, the result of such an approach is that people like MEC Malakoane remain firmly entrenched and that provincial healthcare systems like that in the Free State stumble from crisis to crisis.
All of which does not mean that Minister Motsoaledi and his team at the National Department of Health do not work extremely hard, and do not show tremendous commitment in stopping TB. In fact, they work extra-hard to make up for some consequences of the severe dysfunction across provinces. So for example, the National Department of Health (NDOH) has in recent years had its hands full in dealing with chronic medicines stockouts across the country. An estimated 80 percent of these stockouts are a result of poor supply chain management in provinces rather than actual supply shortages. One could fairly assume that, had only qualified and committed MECs for health and heads of departments been appointed, provinces would be better managed and the NDOH would not have to step in so often to sort things out.
The failure to rid the health system of the likes of Malakoane (and there remain many of them as CEOs of hospitals or running provincial health departments) leads to a stale-mate for which people dependent on the public healthcare system pay the ultimate price. Often their lives. This is not trivial. The doctors who have left the public sector in the Free State in the last year were in a very real way let down by the ANC and our government’s failure to deal with this political dynamic. Their patients were also let down. The committed whistle-blower doctors who called for help and who wanted to keep serving the public in the Free State were let down. So, too, our members in the Free State, and other provinces, were let down.
We have few illusions about our current politics in South Africa. In this sense our healthcare system, as with our government and public service more broadly, has been crippled by the internal politics and patronage networks of the ruling ANC. By failing to address this underlying problem, the ANC and government are condemning a visionary and passionate Minister to failure. This is why the TAC is calling for the cabinet and the ANC to place the Constitution and the right “of everyone to have access to healthcare services” above party interests and to give Ministers full power over non-performing MECs. Health may be a concurrent jurisdiction in South Africa (that means that it is a duty split between national and provincial governments), but ultimately the Constitution makes the Minister responsible to ensure and maintain national standards. He should be empowered to deliver on this responsibility.
Ultimately we all want our public healthcare system to succeed for all of us. We want only qualified and committed people to be appointed to positions of power and influence in our healthcare system. We want to ensure that all the many committed healthcare workers in our country have decent working conditions and that they are supported rather than hindered by the organisational infrastructure around them.
This is not too much to ask. But we won’t ever get to this point by turning a blind eye to our abrasive politics.
It will require tremendous political will and bravery to knock our public healthcare system into shape in the places where it is most broken.
Unfortunately though, the required political will is clearly lacking both in the ANC and in government more broadly. For as long as this remains the case, Minister Motsoaledi will struggle to deliver the progress our healthcare system so desperately needs – including ending TB.