Under Health Minister Dr Aaron Motsoaledi’s watch government has made generally good HIV policy over the last decade. Treatment guidelines kept up with international best practice, newer medicines with fewer side effects have been introduced, and the malicious compliance of the last years of the Mbeki presidency was replaced with real political will and commitment to ensure people get the treatment they need, at least at national level.
But, while HIV and some aspects of TB policy has been good, there have been important failures in other areas. Below we highlight five important government policies or plans that have been stalled, are out of date, or simply never got off the ground. We recognise that National Health Insurance constitutes a major area of policy uncertainty, but we will not discuss that in this article.
These five health-related policy areas are not only areas that we hope will receive higher priority in the new administration, they are also areas in which we urge government to communicate its plans more clearly and more timeously.
- Human Resources for Health Strategy
People, or human resources if you will, are critical to the functioning of the public healthcare system. We need to have enough nurses, doctors, pharmacy assistants, managers and so on where they are needed most. This involves ensuring that enough people are being trained, but also ensuring that there are jobs and careers for these people in which they receive enough support. To make all this happen we need an over-arching plan or strategy.
Government’s key human resources strategy document for healthcare in South Africa is the HRH strategy for the Healthcare Sector 2012/2013-2016/2017 – in other words, it expired around two years ago. When we recently contacted the Department of Health to ask for the HRH plan, this outdated plan is what they sent us. They did point out that work is underway on a new plan, but did not say when it would be finished.
- Community Healthcare Worker policy
Community healthcare workers play an important part in the provision of primary healthcare services. Particularly in South Africa, where people with HIV or tuberculosis often only go to clinics or hospitals when they are very sick, CHWs can help get people into care earlier. This benefits both the individuals who are linked to care, but also helps prevent further transmission of HIV or TB.
Over the last decade provinces have gone about the employment of CHWs in very different ways. Salaries or stipends differ widely, required qualifications have differed, many provinces essentially outsourced the employment of CHWs to NGOs, training and job functions were not standardised across provinces, in one instance over 3 000 CHWs were dismissed without warning.
The need for a single, coherent national policy was recognised as far back as 2010 when the Health Minister and MECs went to Brazil and returned with a vision of a wide-reaching CHW cadre integrated into the health care system. Between 2011 and 2018, policy development and implementation moved at a glacial pace until the Policy Framework and Strategy for Ward Based Primary Healthcare Outreach Team 2018/19 – 2023/24 was published.
We now finally have the policy but adaptation to local needs and implementation is up to provinces. It should be made a top priority as new provincial administrations come into power. While having the right policies in place is essential, implementing policies is often another matter altogether.
- Policy on Occupational Health for Health Workers in Respect of TB and HIV
Healthcare workers are at a much greater risk of contracting tuberculosis than the general public. It goes without saying that we need to have good policies in place to ensure that as many healthcare workers as possible stay healthy.
By the end of 2016 a policy on “Occupational Health for Health Workers in Respect of TB and HIV” was completed. According to sources involved in the drafting of the policy, the policy was to be released on World TB Day (24 March) 2017. However, more than two years later the policy has still not been published.
- The National Drug Master Plan
The National Drug Master Plan is supposed to guide South Africa’s response to addiction and drug use – everything from tik to injecting heroin. A progressive, evidence-based plan is particularly important given that HIV and hepatitis rates are much higher among injecting drug users.
South Africa’s last National Drug Master Plan covered the period from 2013 to 2017 – in other words, it is now out of date by about two years. In April 2019 cabinet approved an evaluation report of this plan.
When a new plan will be published is not known – although we understand that drafts have been around for well over a year.
- Guidelines for Sexual and Reproductive Health Rights, Contraceptives, Abortion, PrEP and Cervical Cancer
Everyone has a right to reproductive health care services. Exercising that right is beset by difficulties, however, including health workers who refuse to provide abortions, contraception stock outs, the non-availability of pre-exposure prophylaxis outside of a limited number of donor-funded pilot sites, and oncology crises across the country.
A Guideline on Abortion is in its sixth or seventh draft currently and, we understand, has been approved by the technical sub-committee of the National Health Council. When it will be passed by the National Health Council itself and whether it will be implemented is not known. We are also aware of pending draft guidelines relating to SRHR, Contraceptives, PrEP and Cervical Cancer but are uncertain as to the status of these guidelines.
Apart from finalising all the above guidelines and policies, making those guidelines and policies that have been finalised easily accessible online should be a priority.
In addition to all of the above, there are areas in which clear national policies are needed, but where we are not aware of any sufficiently far-reaching policy processes that are underway. So, for example, emergency medical services and planned patient transport services in many provinces appear to be in a constant state of crisis. New EMS regulations came into effect late in 2018 and EMS is often mentioned as a key element of NHI, but beyond that there appears to be very little planning, leadership and public consultation on how to fix our chronic EMS and planned patient transport problems. If NHI is to be part of the solution, then maybe the EMS element of NHI should be fast-tracked and prioritised. Either way, we need publicly available and consultative plans and policies to address urgent crises such as those in EMS.