#Vote4Health: Healthcare after the elections

While South Africa’s original “weekend special” stayed in place for only a weekend, many provincial departments of health are still over-run with people appointed with little purpose other than to nod through corrupt deals. In as far as there has been a new dawn, it has been mostly at a national level. In provincial departments the Zuma eras never-ending weekend of unfettered corruption still drags on.

It is not only that there are many corrupt persons in provincial departments of health, it is also that these corrupt people have replaced and pushed aside more principled and more competent people. The loss of management capacity, of a capable state if you will, has been one of the most harmful consequences of corruption and the things done to facilitate corruption. In turn, the lack of management capacity together with widespread corruption has contributed to low levels of morale in the public healthcare system.

This loss of management capacity and morale undermines just about any attempt to improve the public healthcare system.

Does May 2019’s national and provincial elections offer any realistic hope for change?

Unfortunately, what is true of our politics more broadly is also true in health – a wholesale cleaning out of corrupt and underperforming persons may be desirable, but it remains unlikely. The internal democracy of the governing party is simply too compromised, both at national level and in provinces. As illustrated in the ANC’s party lists, many people remain untouchable for purely political reasons – see for example Former MECs for Health like Peggy Nkonyeni and Benny Malakoane, both of whom remain on their respective provincial lists.

So far, it seems that the only real evidence of accountability for poor or corrupt stewardship of a provincial healthcare system in the Ramaphosa era is in Gauteng and North West. In Gauteng former MECs for Health Qedani Mahlangu and Brian Hlongwa are not on any of the province’s lists – the prior because of her role in the Life Esidimeni tragedy and the latter because of alleged corruption of over R1bn. In North West there is some limited accountability with HOD Thabo Lekalakala being suspended and MEC Magome Masike being replaced, both following the Mediosa, Buthelezi EMS, and other scandals. Elsewhere, MECs for health who are clearly out of their depth, such as Phophi Ramathuba in Limpopo, have made it back on to their provincial lists and seem set to continue in their roles – as are various heads of health departments, such as David Motau, the HOD on who’s watch the controversial Buthelezi EMS is still flourishing in the Free State.

Much as one might hope the new dawn will reach down to provinces, there is only limited evidence of that happening so far.

Maybe even less likely than a cadre of new principled and committed MECs and HODs taking the reins after May, would be if the ANC loses power in any of the eight provinces where they currently have a majority. It would be fascinating to see how a DA-led coalition would fare if put in charge of the public healthcare system in Gauteng or the Northern Cape. Improvement would of course not be guaranteed, but the inertia and mediocrity in some provinces is so severe, that a fundamental change in political leadership might be exactly the kind of shock the system needs.

To further complicate the picture, South Africa is not only going into an election, but also into a period of major health reforms in the form of National Health Insurance (NHI) – the implementation of which should accelerate under the next administration. For these reforms to have a chance of succeeding in the context sketched above, we will need a Minister of Health who is a serious and strategic anti-corruption campaigner, who is excellent at managing the implementation of large, complex systems and who can draw on and meaningfully involve the substantial healthcare expertise that we have in this country. It would of course also help if the new Minister has the full backing of both the President and the governing party.

Health Minister Dr Aaron Motsoaledi has been outspoken against corruption and deserves credit for his principled stance in the run-up to the ANC’s Nasrec conference. Even so, he has been ineffectual in his attempts to stem the corruption that have flourished in provincial healthcare systems over the last decade. Similarly, on NHI he is broadly in the right and clearly committed to progressive reforms, but whether he is the right person to oversee the actual implementation of NHI is another question. Vital institutions such as the National Health Laboratory Service, the Health Professions Council, and to a lesser extent even the medicines regulator, have all struggled on his watch. Motsoaledi was in many ways the perfect antidote to AIDS denialism and exactly what the country needed in 2009 – as evidenced by the dramatic increase in life-expectancy – but he has not managed to build a robust healthcare system supported by robust institutions, which is arguably the top priority going forward.

The difficulty facing President Ramaphosa is that there are no obvious replacements who would fit the bill. Of the current nine MECs for health none really stand out – and those who do stand out, do so for the wrong reasons. Current KwaZulu-Natal MEC for health Sibongiseni Dhlomo is second on KZN’s province-to-national list, but surely his disastrous handling of that province’s cancer crisis must rule him out. There have been some whispers that current Gauteng MEC for Health Gwen Ramokgopa is being considered, but apart from the fact that she is not on any of the ANC lists, her relative lack of success in her two stints as MEC for health in Gauteng must raise questions about her ability on a bigger stage. Looking wider than the MECs, Zweli Mkhize might bring political clout, but it is unclear whether he’d want the job and his role in the Tara KLamp scandal remains a blotch against his name. The Presidents health advisor, Olive Shisana, will probably be considered, but it is hard to see that working out well given how divisive her involvement in the NHI process has been.

Technically, of course, the President may look outside of the well-connected cadres of the ANC. If he wishes, he could appoint someone from business, civil society, or even from an opposition party. But in our deeply compromised politics, the prospects of excellence winning out against politics is of course not very good.

Not quite as unlikely as improvement through new and better leadership, would be the removal of corrupt persons from the healthcare system by sending them to prison. Not only will this put some of the guilty behind bars, it would signal to all the “specials” out there that the years-long weekend of unfettered corruption is finally coming to an end. For such accountability through the law to become a reality, we will however require major reform of both the Hawks and the National Prosecuting Authority across our provinces, and not just nationally.

In his appointments at the NPA and State-Owned Enterprises, and his use of the Special Investigating Unit there are signs that President Ramaphosa is serious about uprooting corruption. Whether he will be able to see it through, and whether the NPA will start prosecuting politically connected persons, remains to be seen. Ultimately, the future of healthcare, as so much else in South Africa, depends on whether we can win this fight against corruption and for a capable state. Maybe the most important leadership question for healthcare then is not who the next Minister of Health or the next nine Health MECs and HODs are, but for how long after May 2019 Ramaphosa and his allies will survive the corrupt forces in the governing party.


#Vote4Health: Lusikisiki push for condoms in schools

By Biénne Huisman

In Lusikisiki in the Eastern Cape girls as young as 11 years old are falling pregnant and becoming HIV-infected, prompting renewed calls by the Treatment Action Campaign (TAC) that government condoms are distributed at primary schools.

This and other concerns were raised at a TAC workshop on sexual reproductive rights for women at the Cosy Posy Hotel and Conference Centre in Lusikisiki in February. The workshop was attended by girls and women affiliated to the Village Clinic and Goso Forest Clinic, aged 10 years and older.

‘It is apparent that from 11 years old, kids are getting pregnant,’ said Sinolutho Zweni (12), addressing attendees at the workshop. ‘So how about taking condoms to junior schools. They are available at clinics, but these are often so far from schools, with children having to walk miles to get them. It would be so much easier if they were at schools.’

Also raised at the workshop, was youngsters fearing being shouted at by health workers should they go to clinics to fetch condoms.

Meanwhile, in Lusikisiki’s main road lamp posts and just about every other conceivable surface is covered in pamphlets advertising ‘safe abortions’.

Zweni added that teacher absenteeism and a lack in teacher attention was causing young pupils to experiment with sex during school hours: ‘Teachers don’t come to school to teach, the end result is kids engaging in sexual activities in the bathrooms while they should be in class studying. Often teachers are not paying enough attention to learners.’

Speakers at the workshop pointed out that the problem often started at home, saying that many parents were prone to drinking at shebeens – with mothers allegedly often overlooking rape of their daughters for fear of angering male providers.

‘A lot of neighbours have shebeens, so from a young age children are exposed to booze, parents drinking, and bad things like rape,’ said Sinalo Mlakalaka (11), at the workshop. ‘The children feel they are not safe within their own communities. At home, children are not allowed to speak out about rape. Maybe the rapist is the uncle or the stepfather. The mother will keep quiet about it, because “this is the person that is providing for us”.’

Mlakalaka said men must be educated that it is a privilege to have children and to take care of them, while mothers must be supported to protect their children over male elders.

She added that young girls who feel unloved and unsupported at home become vulnerable to preying older men, giving rise to a growing ‘blesser’ culture: ‘As a result of all this the girls go out and get “blessers” – those older men with money and cars – who give them what they want like cellphones in exchange for sex; these girls just want to feel loved and accepted.’

Some parents are even sending their young daughters to be married to older men for money. ‘Something should be done, there must be a plan,’ said Sesethu Vinjwa (20), at the workshop. ‘There was a case at one of the clinics of a 14 year old girl married to a 38 year old man. It is also teachers’ responsibility to see kids do not marry older men.’

TAC’s provincial manager, Noloyiso Ntamenthlo, said that while HIV education and ARVs had become a common way of life for many in Lusikisiki, she was concerned about the younger generation.

‘The problem we are having now are young girls at school and those just coming out of school,’ she said. ‘I am 42 years old, I know much about HIV, but I think there is a gap, we’ve missed to educate the young ones about ARVs. I’m talking around 15 to 24 years old; when they test positive for HIV and they have to start taking ARVs – it is a struggle for them.’

She added: ‘Secondly my worry is the young mothers with HIV who did not get nevirapine, these mothers are wondering when do they tell their children that they are living with HIV? Here at the TAC office, we had a mother come around saying: “My child is doing grade 12 now; I didn’t get nevirapine and he is living with HIV. He is not attaining treatment because I am scared to tell him. Maybe he knows, because he’s in grade 12 and he’s Googling.”’

Ntamenthlo said the TAC recognised a great need to reach out to youngsters at their homes, to focus on educating the area’s new generation.

Department of Basic Education spokesperson Elijah Mhlanga said the issue of distributing condoms at primary school level fell under the department’s national policy on HIV, STIs and TB for learners, which was workshopped last year.

Responding to questions on whether condoms will be made available to learners at primary schools, Mhlanga said: ‘Discreet access to male and female condoms will be available to all learners around the country, and indeed Lusikisiki is a part of that’. However, he did not say by when this would happen.

Spotlight’s Vote4Health

In the run-up to South Africa’s general elections in May 2019 Spotlight will be publishing a series of articles under the banner #Vote4Health.

In this series we will take stock of the state of healthcare services in South Africa 25 years into democracy. We will revisit some of the places and  people we wrote about previously, such as in our 2014 report ‘Death and Dying in the Eastern Cape’, and ask “what has changed?”

We will also contextualise our assessment of the state of healthcare in South Africa within the current healthcare reform processes in the country – most notably National Health Insurance (NHI). Is NHI the answer to the crisis in the public healthcare system, or is NHI just cynical politics? How will NHI change the reality in forgotten places like Lusikisiki and Kakamas? If not NHI, then what is the alternative?

We will study the different proposals political parties have put on the table and assess how well their solutions measure up to our healthcare problems. Our editors will of course provide their views, but as always, we will invite a variety of op-eds from external contributors with a variety of different views.

Ultimately, we are hoping that the #Vote4Health series will play a part in helping people think about what their vote will mean for healthcare in this country. That is about as much as we can do – the rest is up to you.


Note: Spotlight is independent from all political parties and does not campaign for or against any parties. In the interest of healthy public discourse, we will however publish criticism of political parties or their policies where such criticism is fair and reasonable.

#Vote4Health: New hope as Lusikisiki finally gets a new clinic

Article by Biénne Huisman

Photographs by Halden Krog

In Lusikisiki, in the OR Tambo District of the Eastern Cape, the so-called Village Clinic had become emblematic of a faltering health system, in a rural area fraught with chronic illness and early death due to rapidly-spreading HIV and tuberculosis. Now, following years of activism and litigation that started in 2013, a new state-of-the-art incarnation of the clinic is finally poised for official opening on April 3.

Lusikisiki, formerly the capital of Eastern Pondoland, consists of a bustling commercial centre and roughly 40 villages scattered across a 60-kilometre radius flanking the sea. The area is a significant health strategy node in that from 2002 to 2005 it served as South Africa’s first rural antiretroviral rollout base, a programme spearheaded by international nongovernmental organisation Médecins Sans Frontières (MSF), (Doctors Without Borders). It was also decreed one of South Africa’s 10 National Health Insurance pilot sites in 2012.

Eastern Cape department of health spokesperson Lwandile Sicwetsha did not respond to calls or messages from Spotlight requesting information on the new Village Clinic.

However, national department of health spokesperson Popo Maja confirmed that President Cyril Ramaphosa will headline the facility’s April inauguration, with health minister Dr Aaron Motsoaledi also in attendance.

Failed attempts to engage with Eastern Cape health officials is perhaps not surprising.

In May 2013 the Treatment Action Campaign (TAC) filed a lawsuit against the Eastern Cape’s health department for failing to address dire conditions at Village Clinic, then housed in two tents and a rickety park home on a muddy plot without electricity, and with just one pit latrine on a steep embankment. At the time, witnesses noted how one of the clinic’s nurses broke an arm climbing up to the toilet.

In their 2013 court papers, the TAC listed Motsoaledi as a respondent. In his response Motsoaledi agreed that circumstances at the clinic were unacceptable –sidelining the provincial health department to arrange for the erection of a temporary structure to house the clinic, while tabling plans for an entirely new building. This is the facility finally set to launch next month, after more than five years of setbacks and delays.

In February, Spotlight visited Lusikisiki’s new Village Clinic, which sprawls impressively across a quiet block set back from the town’s teeming main road. The premises already opened its doors to patients in September last year.

The clinic sits behind ample parking and a high fence, with a gentle sloping ramp for wheelchair access. At its entrance, two security guards smile in greeting, pointing towards reception.

Inside, along the first corridor, doors are marked: dental surgery, oral hygienist room, emergency room, and manager’s office, along with three consulting rooms and a counselling room. The consulting rooms are fitted with brand new examination beds, with step access, wall-mounted examining lights, and electronic blood monitoring equipment; on desks there are boxes of hypodermic needles and Vitamin B injections.

In the corridor, two teenage boys in school uniform are waiting to pick up medicine during their school break. ‘We came here for an injection for my friend, you see he has the scabies disease,’ says one boy. ‘We waited 30 minutes to get the injection. This is not bad; at the old clinic it would have taken much longer, we would have had to sit in the sun all day. It got very hot waiting at that clinic, it was very hectic actually.’ His friend attests: ’Yes this is way better.’ Ambling away, he adds: ’So we’re going to the pharmacy now, to get the medication the nurse wrote down.’

Indeed, inside the complex is a dispensary, where a pharmacist in a white coat serves patients one by one from behind a glass pane.

In front of the dispensary is a waiting area, with 82 people – many with babies huddled to their chests – seated in rows on metal benches. To the side in a playroom, parents are watching hip-high toddlers waddling over artificial grass; a man is tilting yoghurt into an infant’s mouth.

Sitting in the waiting area is 25-year-old Nkani Sinelizwi from New Rest location, about a kilometre from the clinic. He pulls up his trouser leg to show a bandaged ankle; he was bitten by a dog the previous Friday, and is waiting for his second tetanus shot. ‘For the first injection I waited 20 minutes, this is a big improvement on the service we had before,’ says Sinelizwi. He is a psychology student interested in mental disorders. ‘People here struggle to differentiate between mental disorders and witchcraft,’ he says. ‘I want to help teach them to differentiate.’

Overhead, the ceiling is high and the air remarkably cool, given the stifling heat outside.

There is a low hum of voices, punctuated by a baby’s shrieks from the maternity section on the building’s far side.

In a consulting room adjacent to the maternity section, nursing assistant Princess Dlakavu is seeing patients. A resident of the Dubana AA location – near the Lusikisiki prison – she is 58 years old and has worked at the Village Clinic for about twenty years, she says.

Dlakavu’s eyes are bright as she points at the equipment around her.

‘Yes at the previous clinic there were challenges. There was no space, but we tried. There were high statistics, HIV, a lot of patients. But now we have many, many consulting rooms.’ She pauses to count: ‘Fourteen consulting rooms in total, yes that’s a lot. Then there is the dental facility, the emergency room, the maternity ward, and the section for chronic illnesses; that’s for our diabetic, hypertensive, and psychological patients, and people who need ARVs, people with TB.’

Dlakavu worked at the Village Clinic when MSF doctor Hermann Reuter brought ARV medication there – and to 11 other clinics around Lusikisiki – in partnership with the Eastern Cape Department of Health. In his book Three Letter Plague, Jonny Steinberg notes that when MSF arrived in Lusikisiki in 2002, one in three pregnant women tested positive for HIV. Reuter’s driving passion was to destigmatise HIV testing and treatment.

Dlakavu recalls: ‘He [Reuter] educated people about the ARVs very well; he taught us about the support groups, that people must be free to tell each other that they are sick, and that they must be free to talk about the side-effects.’

She says that after MSF left in 2005, clinics in the area continued with the programme.

Today, talk on the street is that ARVs are readily available.

Outside the Village Clinic, a 29-year-old woman looks relaxed while speaking to Spotlight. She says many of her generation have realised that ARVs bring about quality of life.

‘Now the most people are taking ARVs,’ she says. ’In the past, if I was going to pick up ARVs, and I saw someone I knew, I would hide myself. Because I would not want them to know my status, that is if I’m HIV positive. But now, most of the people are just going to get their medicine.’

She adds that waiting time to pick up treatment is minimal: ‘When you pick up ARVs there are no queues. You just take out your card – a medical card that shows what you are having – and you give it to the person that’s helping you, and you get your treatment and you go home. Unless it’s your first time, then it’s going to take a little bit more time.’

At the TAC offices flanking Lusikisiki’s Magistrates Court, the TAC’s long-time provincial manager, Noloyiso Ntamenthlo, agrees that ARVs are today widely accessible in the region. However, Ntamenthlo voices concern over the unavailability of other medicines required to treat HIV-related symptoms: ’The challenge is the unavailability of other drugs. I mean, say for example I’m living with HIV and I have shingles; if I’m living with HIV and I have diarrhoea. So in our clinics we are struggling to access these essential medicines; especially in the OR Tambo region, here in Lusikisiki. I was presenting this problem to the MEC [Eastern Cape health MEC Helen Sauls-August] saying that we are struggling. The MEC then said they are doing renovations at the depot in Mthatha, and that everything’s upside down. My point is, what was their plan? You can’t just renovate without considering that people are going to suffer without this medicine, it’s very difficult.’

In addition, Ntamenthlo notes that other clinics in the area are in desperate need of upgrades, notably the one in Flagstaff, 42 kilometres from Lusikisiki’s town centre along the winding R61. ‘The Flagstaff Clinic is incomplete,’ she says. ‘The clinic is operating from the old post office container. At the clinic, when the sisters want a urine sample, the patients and the pregnant women have to go outside to the grass to pee, and then return with the urine. So there are those difficulties.’

Another challenge is the attitudes of clinic staff. Sometimes they treat patients known to them ahead of others who have waited longer; or they insult patients. ‘There are the insults from nurses and staff supposed to help you: ‘You are smelly, go wash your body.’ Maybe that person is sick or staying at home alone and there is no one to assist with cleaning,’ says Ntamenthlo.

Regarding the new Village Clinic, Ntamenthlo is raising questions over the medical staff required to operate the facility.

‘It’s a beautiful building, the TAC and SECTION27 fought hard for this clinic, I am very happy about it,’ she says. ‘But my problem for that clinic is the issue of human resources. I’m scared the Department of Health does not have a human resource plan, and that is the disaster. They are saying it is the biggest clinic in the province, so where is the staff?’

Meanwhile, at his refreshment table next to the new Village Clinic, Lwazi Deyi, of Palmerton village, 10 kilometres away, reports a drop in business. ’I had a shop at the old clinic on the other side as well,’ says Deyi. ’Business was better that side, because people stood outside in the sun and rain waiting for hours, so they would buy my products while waiting. But yes, I decided to follow the new clinic to this side.’

Underneath a blue umbrella his wares are on display: apples, bananas, vetkoek, and chilli sausages.

‘I am selling healthy things, as you can see,’ he says. ‘I look after the patients and want them to get well soon. These are my people, I don’t want them to be sick or to die. I am very happy about the new building.’

All in all, in the days leading up to its official opening, the new Village Clinic is shrouded in an atmosphere of optimism. On the faces of most of those walking its corridors and precincts, looks of cautious wonder; a glow of pride and dignity.

Note: Huisman is a writer and freelance journalist. She was commissioned by Spotlight to write this article. While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence — independence that the editors guard jealously. Spotlight is a member of the South African Press Council.


AIDS2018: Humans in the Age of HIV-There’s no one influencing me anymore

By Nomatter Ndebele

Gloria. Pic by Joyrene Kramer

Gloria lives in Vrededorp, Johannesburg with her partner and her 2-year-old son. She has been on drugs since 2013. Gloria started with Marajuana and then graduated onto harder drugs. She currently smokes Crystal Meth, which Is available in her neighborhood for R50 a hit (less than U$4).

“I used to smoke rocks (Crack cocaine), but it’s very expensive, so I settled for crystal meth, from one bag, I get twenty pulls,” she explains.

Like most people who inject drugs (PWID) Gloria is unemployed and depends on doing odd jobs around the community so she can make some money to feed her habit. “I do people’s laundry or even clean people’s houses to make some money.”

Gloria’s son is perfectly healthy. When Gloria discovered that she was pregnant she decided to quit smoking as she knew it wouldn’t be healthy for the child. When her son was born, Gloria went back to smoking Crystal Meth.

She refuses to smoke in front of her son, when she needs to take a hit, she ensures that her son is outside or otherwise preoccupied. “It’s just not right for my son to see this, and I don’t ever want him to see,” she says. Before she takes a hit in front of us, she asks someone to take her son out of the room.

While Crystal Meth is her drug of choice, she has changed the manner in which she takes it, before she would inject it, but now she has resigned herself to just smoking it.

“When I was spiking, I realized that I was becoming much slower, like my brain was slow, I was slow to respond to things and I didn’t like that.” So far, that is the only bad experience she has had with drugs.

When asked what message she would like to share with the youth, Gloria does not skip a beat. She immediately says “I want to tell the youth not to do drugs, its bad, you cause yourself and your family problems and you’ll end up on the streets.”

When her son was born, Gloria broke away from her group of friends. She felt as though the group was pressuring her into doing more drugs. “I left them, I feel lonely sometimes, but its better like this, there’s no one influencing me anymore.”

Gloria has not thought about quitting at all, for now she is content to smoke her Crystal Meth and go about her life as she does.

This article is part of a Spotlight special series on people who form part of so-called key populations.



AIDS2018: Humans in the age of HIV-It’s the living that can hurt you

By Nomatter Ndebele

Marthinus Barnard. Pic by Joyrene Kramer

There are an estimated 75000 people living in South Africa who inject drugs. According to local NGO, Jab Smart, 1653 of these users, are located within Sub-region F in Johannesburg. Sub-region F covers the Johannesburg CBD, Braamfontein, Rossetenville, Mayfair, Hillbrow and Yeoville. 42-yeard-old, Marthinus Barnard, is just one of them.

It is a bitterly cold morning in Vrededorp, Johannesburg. Marthinus walks ahead of us with a limp that came back a few days ago, after stealing a municipal bin for his friend. We move silently and steadily along, until he turns around with a cheeky smile, opens his arms and announces “welcome to my office”.

His office is one of Johannesburg’s oldest cemeteries, the Brixton Cemetery which is adjacent to Vrededorp. We weave in and out of tombstones, trying to find a spot to settle. Eventually we come to an area that has many horizontal tombstones. Here, the trees part just enough to allow the struggling  sunlight to illuminate a piece of a broken tombstone that reads “Moeder” (A formal Afrikaans reference to Mother).

“My mother told me, dead people can’t do anything, it’s the living that can hurt you,” says Marthinus.

He settles on an abandoned piece of a tombstone and turns his striking blue eyes to mine, ask me anything,” he invites.

“Thinus” has spent more than half his life on drugs. Pic by Joyrene Kramer

Marthinus, who goes by  “Thinus” has spent more than half his life on drugs. He has come a long way since he first smoked marijuana, with a group of school friends in an attempt to beat his depression.  In these twenty years, this once handsome blue eyed boy has lost all his front teeth, his skin is patchy, he is covered in grime as washing himself is no longer a priority. His wrists are decorated with thin lines acquired from self-harm, and his arms are covered in tattoo’s, some from boyhood and others from prison stints.

Thinus spends five to six hours in his “office” every day. In this space, he has had countless “hits” and a track record of 400 clients during the time he was a sex worker. Thinus no longer engages in sex work, he does odd jobs where he can to make enough money to support his habit. Fortunately or unfortunately, Thinus quips.

A bag of heroin costs anything between R18 and R40. (around $1.20 to $3)

A bag of heroin in Vrededorp typically contains about 3% heroine, and is mixed with rat poison, ant poison and antiretrovirals.  The crook of Thinus’ left arm is decorated with a red rash, that’s the “Rattex” (rat poison) he says matter-of-factly. The high from this heroin lasts three to four hours, before Thinus needs his next fix. He goes through six or seven bags every day.

Key populations?

The term key populations draws a blank from Thinus. Despite knowing all there is to know about the history of Vrededorp. It seems this is one term he doesn’t know about.

Although he no longer engages in sex work, Thinus is still an in injecting drug user, and is at high risk of contracting HIV. He admits having been ignorant about HIV in the early days. “I always used to tell people that there was no such thing, that if you just cleaned the needles nicely, you wouldn’t catch it, what a mistake that was,” he says while letting out a belly laugh.

A month ago Thinus learnt that he had tested positive for HIV. He knows for a fact that he contracted the virus through the sharing of needles. “There is only one guy I share needles with, and he is also HIV positive, I’m sure I got it from him.”

A local NGO and mobile clinic called Jab Smart, has started operating in Mayfair which is a few blocks away from Vrederdorp. Jab smart is currently the only organization that provides harm reduction packs (HRP) to People who inject drugs (PWID). The harm reduction packs consist of new needles, alcohol swabs and condoms. These packs are made available to people who inject drugs at least once a week. People simply have to remember when the mobile clinic is coming to the neighborhood, so they can access a HRP.

At the mobile clinic people are encouraged to take HIV tests. This is part of Jab mart’s comprehensive care package. Where they encounter users who are HIV positive, they refer them to a clinic or a doctor to try and get them on treatment as soon as possible. It was through this service that Thinus discovered that he was living with HIV.

Jab Smart is currently the only service assisting injecting drug users  in the area. The programme seeks to ensure that if users cannot quit the habit, they at least continue in a safe manner or that they try to lessen their intake of drugs. The same programme independently provides OST (Opiod substitution therapy) to eligible candidates. OST therapy provides people who inject drugs with monitored dosages of Methadone – which provides relief to the severe drug withdrawal symptoms which could otherwise drive people to again use drugs.

A mobile population

Despite the fact that this service is just a stone’s throw away from Vrededorp (about 7 kilometres), it is an impossible feat for the average drug user to access it.  “We can’t go there every day, it’s easier for us to make up the money to get a hit than to get together the money to travel to Yeoville,” says Thinus.

While Thinus’ problem is that he is  somewhat  immobile, most users face the problem of being too mobile.

Anthony Manion, project manager of Jab Smart, says that the fact that most drug users are mobile provides the programme with great challenges when it comes to monitoring  and supporting users. “Because people move all over the city, sometimes with all their belongings in tow, it is difficult to trace users.” Despite this challenge, Jab smart has managed to retain many of their first time users who receive HRPs.

In the month from May to June Jab smart saw a total of 1 653 new users. In the same month, they had 5 944 people who returned to use the service.  They managed to test 1 086 users for HIV, of which 504 tested positive, but only 112 of them were successfully referred to a clinic or a doctor.

Despite the fact that Thinus was referred to a clinic through this programme, he has not yet gone. “I still feel healthy, but also my life is already fucked up, what is there left to do,” he says.

Thinus has been through Rehabilitation twice and relapsed each time. Despite having had the opportunity to be in a private rehabilitation facility, Thinus was unable to stay away from the drugs. He blames this on the fact that despite getting clean, he came back to the very same environment that fostered his habit for so many years. “If there is nothing to occupy your mind or something for you to do, you’ll go back, there just isn’t enough support for us when we come out from rehab.”

He isn’t lying. The lack of resources and support for people who inject drugs in Vrededorp, is glaringly obvious. The flats are all dark, most have cracked windows and are decorated with crude graffiti. The streets are deserted and there is no life, other than on a few corners where groups of boys loiter around. The community has one soup kitchen, which also operates as a crèche, for smaller children. Other than that, you’d be hard pressed to find a library or a community resource center. Leaving is hardly an option for anyone in Vrededorp.

Apart from Jab Smart, there isn’t any other programme that offers such comprehensive care to users. Even at state hospitals, where people have been specifically trained to work with people who inject drugs, not enough is done to assist this vulnerable key population group. “Often nurses will turn away drug users asking them to return when they are clean”, says Mourbadin. “In most instances, people are turned away from facilities, either because of the way they look, or how they smell.”

The threat of being mistreated or turned away from healthcare facilities has thus become a major deterrent to people looking for care services. This has caused many people who might otherwise have accessed life-saving care, to fall by the wayside. There simply seems to be no way back for people like Thinus.

Six years ago Thinus and his friends were travelling from Krugersdorp to Johannesburg. One moment Thinus was chasing a glass of Vodka with a cocktail of crystal meth, Mandrax and marijuana, the next moment he opened his eyes and a doctor was standing over him in the Intensive Care Unit, telling him that he had flat lined for a minute and 20 seconds. Thinus was clinically dead. “ Doing drugs is never enough, the only way you can win is by dying,”says Thinus.

This article is part of a Spotlight special series on people who form part of so-called key populations.

AIDS2018: Why the conference still matters at this point in the HIV Epidemic

There are many reasons why the end of the AIDS epidemic is not yet in sight and why the International AIDS Conference still matters, writes IAS President Linda-Gail Bekker.

The 22nd International AIDS conference is to be held in Amsterdam this year, as we move through the 37th year of the AIDS epidemic. The first AIDS conference was held in 1985 in Atlanta, United States at a time when the world was still grappling with what this virus is, what its impact might be, and how to even begin helping those affected. The immense strength of the HIV response has meant that in quite a short period of time the HIV/AIDS community has moved leaps and bounds to achieve both treatment and prevention. Some are even suggesting that we are near to the end – however, there are many reasons why the end is not yet in sight and why this conference still matters.

  • The AIDS conference remains an anomaly in the health world, being both the first and one of the only health conferences to cater to the full range of people involved and affected: basic scientists, doctors, programme implementers, social scientists, lawyers, policy makers, activists and the patients themselves. All coming together in one place to hear each other and share their ideas.

This is a manifestation of what the AIDS epidemic has driven home to the world: nothing can be done or achieved without involving everyone, including those who are often isolated, stigmatised, or voiceless. In a slogan this is “nothing about us without us”, but in practise this is what the AIDS conference enables. It works to connect people and form networks across tracks, population groups, and country borders. At every point in the HIV epidemic this has mattered, but potentially now as we face an ever more hostile and nationalist world, this is critical.

  • HIV/AIDS is not over – nor are we fast approaching an end. In terms of new infections, while some generalised epidemics have seen success, infections in key populations such as people who inject drugs and sex workers in Eastern Europe and Central Asia are increasing and in South Africa alone 2000 young women are infected every week. A primary prevention revolution is desperately needed. In terms of mortality, we have also had huge success; however, we now have an aging population of people living with HIV who will need to combat a range of co-morbidities. There is much work still needed to prepare for this.

Ultimately, until we have a vaccine or a cure, until we can reach all marginalised populations affected, until we prevent all new infections and know how to best support those living with HIV, we need to keep this conversation going.

  • We are reaching a new era in the HIV response where considerations need to be made on how to integrate HIV care and prevention programmes with other disease programmes and within a universal healthcare model.

HIV/AIDS has benefited as a favoured child of global health that receives a high level of funding, focus and pooling of global resources. How do we now continue to sustain these gains while also integrating HIV/AIDS with other global health issues? The IAS-Lancet commission (to be released just before the AIDS conference) will aim to tackle these questions and lay out some recommendations. The AIDS conference provides an ideal opportunity to launch this and other new conversations and allow everyone to hit the ground running.

  • The baton needs to be handed to the younger generation.

The AIDS epidemic broke in 1981. Many of the researchers, activists and movers leading the response were there to witness it and thus strategically placed to lead the response. However, as time as passed the baton needs to be handed to the younger generation. We need them to lead, we need their passion and new ideas, and we need them to make it relevant and accessible for generations to come. The AIDS conference with its youth focus, scholarship programmes and inclusive agenda provides the platform to achieve this. The conference coordinating committee includes a youth representative, the global village hosts many youth-lead organisations, and at AIDS 2018 an entire plenary session is to be dedicated to the youth.

The AIDS conference still matters as long as it provides an opportunity for everyone involved and affected by this epidemic to congregate, feel included, get involved and be inspired to move the HIV response forward – because we are not there yet!

  • Professor Linda-Gail Bekker is President of the International AIDS Society and Deputy Director of the Desmond Tutu HIV Centre at the University of Cape Town.


DREAMS and She Conquers

Amy Green, Health-e News

An estimated 2 000 new HIV infections occur in young women and girls every week in South Africa. Two high-profile programmes are aiming to address this crisis. In this joint Spotlight/Health-e News Service special investigation, we go beyond the bells and whistles and ask what difference these programmes are really making.

Roughly 40km outside Durban lies the small town of Molweni. This is where a young woman, Nontokozo Zakwe – now 26 – grew up.

“One of the things I noticed growing up was that gender-based violence (GBV) was the norm,” she says. “And the mentality was: if it happens to you, get over it. If it didn’t kill you, you’re going to be okay.”

The first time ‘it’ happened to Zakwe, she was just 11 years old.

“We had two options on our walk back home from school: the road, or the short cut past the river,” she says. Most days she took the road; but one day, after staying late after school, she decided to use the short cut, because it was getting dark.

“Then this man, he raped me.”

Zakwe survived the attack and made her way home, where she lived with a number of cousins and siblings. Her mother worked in another province, she didn’t know her father at that point, and her grandmother could only afford to come home one weekend a month from her job as a domestic worker on the other side of the country.

“But being from the kind of community I was from, when I got home I decided to sleep. I cried myself to sleep,” she remembers.

A visiting aunt woke Zakwe up that evening, pulled back the covers, noticed blood, and asked the young girl what had happened.

“When I told her, she told me everything was going to be okay. I could tell in her eyes she was sorry for me and wished it hadn’t happened, but that she felt there was nothing she could do except tell me I was going to be okay,” Zakwe says.

“We were forced not to talk about things. Talking that could help us heal. One can imagine, these experiences – experienced by many young girls, around the country – can leave you vulnerable to HIV, teen pregnancy and other problems.”

At the age of 11, not even a teenager yet, Zakwe was expected to overcome the trauma of that violent experience, stay in school, and avoid early pregnancy, without any support – psycho-social, financial or otherwise – jn becoming a successful HIV-negative adult.

2 000 infections a week

It is against this backdrop of the lived experiences of many young women in South Africa that a staggering 2 000 new HIV infections occur in young women and girls every week. Over 70 per cent of new HIV infections in people aged 12 to 24 in sub-Saharan Africa occur in young women and girls, who overwhelmingly bear the burden of the epidemic, according to research done by Professor Ayesha Kharsany from the Centre for the AIDS Programme of Research in South Africa.

In South Africa, one third of young women and girls experience abuse, 60 per cent of young people do not have a matric qualification, and about 70 000 babies annually are born to girls under the age of 18, according to the South African National Department of Health (DoH).

It is being increasingly acknowledged that the contexts in which young women and girls live, which are often patriarchal and violent in nature, need to be addressed in order to make any meaningful impact on reducing new infections, and ultimately ending AIDS as a public health threat to the world.

Treatment and prevention campaigns alone, located in the health department, cannot by themselves address all the systemic drivers that make young women and girls more vulnerable to HIV than their male counterparts: poverty and gender inequality, as well as biological factors. These affect every facet of a girl’s life: her ability to stay in school, choose when to have children, her economic opportunities and the gendered and sexual violence experienced by women that is endemic in South Africa.

It is in this context that a number of initiatives, backed by billions in international aid, have been launched in South Africa. On the face of it, they aim to address the contexts in which young women and girls live in order to help them reach their full potential, including changing long-held perceptions in communities that leave them unsafe from violence and HIV.

It was only two years ago, when Zakwe joined the DREAMS partnership as an ambassador, that she began to receive the psycho-social support she needed 15 years ago.

DREAMS is a global partnership aimed at improving the lives of young women and girls in 10 African countries – with the ultimate aim of reducing the rate of new HIV infections in this group.

Another prevention campaign for young women and girls looking to tackle the societal problems driving their vulnerability to HIV is She Conquers, led by the DoH, launched by then-Deputy President Cyril Ramaphosa, and most famous for the controversy over a number of billboards commissioned under its name in Gauteng.

A grave historical injustice

In his response to the State of the Nation (SONA) debate on Tuesday 20 February, Ramaphosa, the newly-elected president, said:

“Another grave historical injustice that we need to correct is the economic inequality between men and women.

“It is a task that requires both a deliberate bias in economic policy towards the advancement of women and a fundamental shift in almost every aspect of social life.

“One of the programmes where we have sought to integrate various approaches is the ‘She Conquers’ initiative, which aims to empower adolescent girls and young women to reduce HIV infections, tackle gender-based violence, keep girls in school and increase economic opportunities.

“It recognises how patriarchal attitudes, poverty, social pressures, unemployment and lack of adequate health and other services conspire to reduce the prospects of young women – and then involves these women in overcoming these challenges.

“This is one of the ways we are working to build a nation that is prepared to confront the many different ways in which women are subjugated, marginalised and overlooked – a nation that wages a daily struggle against patriarchy, discrimination and intolerance.”

While Ramaphosa’s words are comforting, as they acknowledge the difficult situations in which young women and girls live, as well as the patriarchal nature of our society, one is left to wonder why so little is known about this important initiative, and how it is working to tackle the multitude of obstacles mentioned.

What is DREAMS?

What are She Conquers and DREAMS exactly? What is happening on the ground to improve the lives of South African girls and young women? Are they reaching their intended audience and achieving their aims? And how can systems of power such as patriarchy, entrenched in society for centuries, be tackled by health-led programmes only in place for a few years?

DREAMS is a global partnership, announced in December 2014, between the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare, aimed at reducing new HIV infections in girls and adolescent women by 40 per cent by 2017. But the South African arm of the project started late, and the target has been shifted to 2019.

PEPFAR’s Caroline Schneider told Spotlight/Health-e that to achieve this, the “ultimate goal is to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women” – the tenets the DREAMS name stands for.

Backed by U$385 million [about R4.5 billion], the “ambitious” initiative aims to go “beyond the health sector” to address the social factors that drive young women and girls’ particular vulnerability to HIV, including GBV, poverty, school drop-out, and gender inequality in the form of “economic disadvantage” and “discriminatory cultural norms”.

It was launched in 10 sub-Saharan African countries, with South Africa being allocated U$66 million [about R770 million], when it began operating locally in 2016.

“DREAMS uses multiple evidence-based interventions, including post-violence care, parenting/caregiver programmes, and facilitating access to already available cash transfers and education subsidies,” explained Schneider.

It operates in five districts: eThekwini, uMgungundlovu and uMkhanyakude in KwaZulu-Natal, and Johannesburg and Ekurhuleni in Gauteng, and is facilitated through 20 implementing partners.

What is She Conquers?

Also launched in 2016, She Conquers is a government campaign “aimed to reach adolescent girls and young women aged 15-24 in South Africa who have high rates of HIV as well as teen pregnancies”. Like DREAMS, it aims to do this by looking at the problems in society that make this group particularly vulnerable.

This is according to the DoH’s Dr Yogan Pillay, who said that more than R3 billion has been invested in the programme by three major donors: PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the German Development Bank (KFW).

He added that the campaign is being rolled out in three phases, with the first phase being implemented in the 22 districts with the highest HIV burden, “where the need is the greatest”. Based on what is learned in these areas, the interventions will be rolled out nationally.

The five targets to be achieved in the 22 priority districts for the three-year-long campaign are ambitious:

  1. Decrease new HIV infections in this group by at least 30 per cent, from 90 000 per year to fewer than 60 000 per year;
  2. Decrease teen pregnancies, in particular under-18 deliveries, by at least 30 per cent, from 73 000 to 50 000;
  3. Increase retention of this group in schools by 20 per cent;
  4. Decrease sexual violence and GBV in this group by 10 per cent;
  5. Increase economic opportunities for young people, particularly young women, by increasing youth employment by 10 per cent.

It is unclear whether progress against these targets will be measured and reported in a way that allows the public and independent experts to hold these programmes accountable in a meaningful way.

There is also much confusion in the public domain as to what the campaign is, whether it is a communication and awareness initiative, or if it involves practical interventions; and if it is adequately responding to the needs of girls and young women: the people it aims to benefit.

The confusion extends to how these initiatives are linked.

Health minister Dr Aaron Motsoaledi told Spotlight that “She Conquers became the South African expression of how to implement DREAMS”.

Schneider said the $66 million South African DREAMS funding allocation falls under the She Conquers umbrella, but that the money is not directly funding the local campaign.

“DREAMS is contributing to achieving the objectives of She Conquers. The US PEPFAR programs in the DREAMS focus districts are in line with the She Conquers strategy, and support She Conquers initiatives in those districts. We can’t speak to the overall She Conquers budget, as this is a Government of South Africa initiative,” she said.

Pillay said She Conquers is a “combination of awareness and practical projects”. But many activists have questioned, firstly, if the campaign is adequately raising awareness in a nuanced way that speaks to the myriad societal ills preventing girls and women from staying safe; and secondly, whether the other interventions are reaching those affected.

Billboard controversy

She Conquers has been most visible in its communication campaign – particularly in the controversy surrounding two of the billboards it commissioned.

Social media erupted in September last year when a billboard next to the N1 in Johannesburg was erected with the tagline: ‘Who says girls don’t want to be on top?’ In smaller letters underneath it reads: “Complete your matric, study hard and graduate!”

While the DoH rejected claims that the message contained sexual innuendo and therefore failed to address the context of violence and lack of support in which girls are expected to ‘study hard and graduate’, many on social media felt the message to be insulting.

Sexual and Reproductive Justice Coalition founder Marion Stevens said that instead of trying to address the circumstances in which young women remain vulnerable, this kind of messaging only perpetuates the status quo: expecting girls themselves to rise above their trying circumstances, be resilient, and somehow succeed.

“With the black girl emoji attached to it and the sexual innuendo, it reinforces the harmful tropes of black women as hyper-sexualised, and places the burden on young black women to overcome obstacles that are out of their control. How can a young woman stay in school when she has to choose to buy food for herself and others in the household instead of paying school fees? Girls drop out because of a range of factors, such as food, security and transport,” she said.

In this type of messaging, Stevens said, there is no mention of the challenges affecting their ability to stay in school or protect themselves from HIV.

Nicknaming the campaign #HeDecides, Stevens questioned who is actually responsible for constructing the She Conquers messaging, because the voices of young women themselves have been left out.

Long-standing HIV activist Yvette Raphael was involved in the initial conceptualisation of the She Conquers campaign, and said that the initial “consultations went well”.

“It looked like it was going to be an overarching campaign that would support very successful campaigns on the ground already working with women. But that is not the reality now. I don’t even know what to make of it – it’s very confusing,” she said.

Young women left out?

While the campaign was initially conceived as being youth-led, Raphael said that young women have been left out of campaign decisions on more than one occasion.

“I don’t think enough engaging of the target audience is happening and that’s why we are getting messages that are insulting to young women. Girls want to be on top – which young person would say that, outside of a relationship? Which young person can own that tagline?”

Raphael said that young women were asked to vote on a campaign name, but that name was never used; instead, ‘She Conquers’ was chosen, without an explanation as to why the name chosen by the young women was ignored.

Motsoaledi said a young woman from Limpopo was responsible for the She Conquers name, and suggested it to the DoH through social media.

Raphael said the problem is that “old people are thinking they can think like young women”. “She Conquers can only serve its purpose if it’s led by young people, and comes from them.”

She Conquers has set up a youth advisory committee located within the South African National AIDS Council (SANAC), consisting of nine young woman representatives who were elected at a She Conquers bootcamp.

But members of this committee told Spotlight that they do not have much decision-making power.

The executive secretary for the committee, 23-year-old Koketso Rathumbu, said the committee was not involved in formulating the messaging for the communications campaign, including the controversial billboards.

“The DoH is the one who facilitates and decides on the communication plan; and unfortunately, this was not shared with us, and there no clear reasons as to why – we have made a request,” she said.

While Rathumbu had positive things to say about the campaign – for example, that it is getting people talking about these issues, and is reaching some young women with beneficial interventions – she said that it is failing in other areas.

“We are advocating for the visibility of the campaign, over and above the media campaigns and billboards. We are fighting for more engagement and inclusivity at grassroots level, but it has been a challenge; many people in rural areas, for example, are not being reached.”

She also said that if every stakeholder, including various government departments, were “synchronised”, then “She Conquers would be a success”.

“The biggest challenge we’ve had is getting different departments to play a role, not just Health – for example, the Department of Basic Education to go into schools with the She Conquers plan. What we need and don’t have is a synchronised system that integrates all stakeholders.”

This could be why She Conquers is so confusing to the public, and even to the people involved in it. Conceived of and led by the DoH, so far it has failed to adequately integrate all sectors.

Who is in charge?

The Medical Research Council’s Dr Fareed Abdullah (a former SANAC CEO) said that SANAC – as a body designed to facilitate multi-sectoral collaboration between various government departments, civil society and other stakeholders – should be responsible for the running of the She Conquers campaign. It should also be the seat responsible for the coordination of various partners working on HIV prevention in young women under the She Conquers banner, including the DREAMS partnership and others.

Pillay admitted that She Conquers is “supposed to be a programme that links various initiatives under one banner”, but that “coordination is not an easy thing to do”. While Ramaphosa was deputy president, he asked that SANAC take on this role – indirectly acknowledging that the DoH cannot fulfil the mandate on its own.

But the confusion around the programme continues. While Pillay said that handing over the running of She Conquers to SANAC had been done as early as last year, SANAC spokesperson Kanya Ndaki told Spotlight a different story.

“SANAC is not responsible for the overall running of the She Conquers campaign, but this is something we are working towards. We are hosting a summit on young women and girls in March, and will be bringing all the partners involved to reflect on what has worked, so that we can coordinate the response better,” she said.

Ndaki said that the She Conquers campaign has been led by the DoH, but “we want to change that. We want it to be a multi-sectoral response, and SANAC is best placed to provide that multi-sectoral coordination.”

She added that while locating the running of She Conquers has been discussed on various platforms, it has not been finalised; but it is expected to be at the March summit.

Moreover, according to Schneider, DREAMS and its funding “was intended to spark investment globally in adolescent girls and young women programming, with biomedical, structural, and behavioural interventions, using multi-sectoral approaches”.

But when asked if there has been any domestic investment in She Conquers on top of the international aid, Pillay said no – “just the money we have. We have already made it clear from the beginning, from government, the funding will be a reprioritisation of existing funding,” he said.

But Abdullah made the point that the programme – should any impact it makes be sustained – “cannot only be funded by donors, and the South African Government also needs to make significant investments in this programme”.

Will young women have access to PrEP?

Abdullah also said that “one of the key weaknesses of the programme is the very limited offering of pre-exposure prophylaxis (PrEP)”. PrEP consists of a daily dose of antiretroviral medication to prevent HIV infection, and has been shown to be highly effective if taken as indicated.

The World Health Organisation recommends PrEP for young women in areas where the rate of new HIV infections is high; but according to Abdullah, even though this is “one of the most effective interventions” in existence for HIV prevention, “South Africa has limited PrEP to a few pilot sites”.

This is despite the fact that the latest National Strategic Plan (NSP) for HIV, tuberculosis and sexually transmitted infections makes provision for the implementation of PrEP for populations at a high risk of acquiring HIV.

Abdullah has been critical of the NSP, saying it limits PrEP access. The Plan’s targets are that between 2018 and 2022, there should be just over 104 000 new PrEP users. PrEP will be offered to young women, female sex workers, men who have sex with men, and people who inject drugs.

According to Pillay, through She Conquers, PrEP is slowly being rolled out: it was made available to young women at nine university campuses in October 2017. Only 26 people were initiated on PrEP during the first month; after that, the programme was stalled, because universities were closing for the end-of-year holidays. Those who had started PrEP were given a supply for the holidays.

Since February, two more university campus clinics have begun offering PrEP, bringing the total to 11; but the DoH does not have data on new uptake at these sites for 2018.

Pillay said: “During the next six months, PrEP will be made available at some 20 primary healthcare clinics in the 22 She Conquers priority sub-districts.”

The aim is to offer PrEP to between 5 000 and 8 000 young women over the next year.

There are multiple programmes running under the She Conquers banner that are doing important and effective work. But the success of any HIV-prevention campaign that seeks to solve systemic issues in society such as violence and gender inequality will rely on the successful integration of every actor on every level.

To truly help young women and girls in South Africa, programmes will need to put them and their views, voices and suggestions at the epicentre of decision-making. ‘She’ can only ‘conquer’ when ‘she’ is actively engaged and listened to.

In this context, it is important to remember Ramaphosa’s final words on the epidemic of GBV in South Africa during his SONA response:

“It is a social issue that must engage, involve and mobilise the whole of society.We must be prepared, as government, to acknowledge where we have failed our people. Where we have made mistakes, we will correct them.”

Health4Sale Part 1: North West blows HIV money on controversial private ambulance service

By Marcus Low and Anso Thom, Spotlight

The North West Department of Health blew over R100-million expressly earmarked for HIV health services on two controversial private ambulance companies, it has emerged from correspondence in Spotlight’s possession. Serious red flags are also raised by some of the invoices submitted by one of these companies.

A letter sent by KA Dibodu in May 2016 from the Head of the North West Department of Health’s office to District Chief Directors states that R36-million from the province’s Comprehensive HIV and AIDS Conditional Grant, were to be channelled to two private ambulance companies, Buthelezi EMS and High Care EMS. While the R36-million referred to in the letter relates to the 2016/2017 financial year, the National Department of Health told Spotlight that R93-million in HIV conditional grant funds was transferred to the North West in the 2017/2018 financial year for the line item in question “inter-facility transport”. This brings the total for the two years to a staggering R129-million.

By law the HIV conditional grant can only be spent on HIV-related expenses. Various experts Spotlight spoke to confirmed that inter-facility transfers fall outside the scope of the HIV conditional grant and the spending would thus be unlawful.

“The Division of Revenue Act and grant framework does not allow that a conditional grant should be used for a purpose that is not intended,” says Popo Maja, spokesperson for the National Department of Health. According to Maja the Department has requested that National Treasury investigate the matter. Maja also indicated that steps had been taken by the National Department of Health to ensure that the North West cannot use HIV conditional grant funds for inter-facility transfers in the current (2018/2019) financial year.

Almost half-a-million people (Around 482 000) in the North West are living with HIV (12.5% of the province’s population). The HIV conditional grant is meant to help the roughly 244 000 people in the province already on HIV treatment to stay healthy and on treatment and to get the 238 000 people who still need treatment onto treatment.

Invoices raise red flags

Spotlight has also seen a number of invoices submitted to the North West Department of Health by Buthelezi EMS. Most of these invoices are from Buthelezi EMS CC. But, the Companies and Intellectual Property Commission (CIPC) registration number on these invoices (2013/06/5417/07) is not that of Buthelezi EMS CC, but that of another company called Buthelezi EMS (PTY) LTD. There is a Buthelezi EMS CC registered on the CIPC database, but its registration number is completely different from that on the invoices.

Spotlight has also seen one invoice where the branding on the invoice is not Buthelezi EMS, but B EMS. There is a company called B EMS CC listed on the CIPC database, but its registration number also does not match that on any of the invoices In Spotlight’s possession. The bank account number on the B EMS invoice also differs by one digit from that on other invoices. Some ambulances in North West have been rebranded as B EMS.

The three Buthelezi companies mentioned above are only three of seven Spotlight found with names that are in some way variations of Buthelezi EMS. Mr Thapelo Samuel Buthelezi, the man behind all these companies, failed to answer a question from Spotlight on why he has registered so many companies with similar names.

One clue might be that Buthelezi EMS (PTY) LTD, the company’s whose registration number appears on the service level agreement with the North West Department of Health and the invoices, seems to have had some trouble filing its annual tax returns. According to CIPC records a process of deregistration was started in April 2017 because the company had not filed tax returns since April 2014. With only a few extraordinary exceptions, companies cannot lawfully be awarded tenders or be paid by government without tax clearance certificates. The service level agreement in question was signed in March 2016 when, according to CIPC records, the company could not have had a valid tax clearance certificate. CIPC records show that a week after deregistration was set in motion in April 2017 the company was suddenly taken out of deregistration and reinstated – we do not know whether this is because valid tax returns were finally filed or because of another reason – either way, it would not impact the lawfulness of the initial award of the tender.

CIPC records also reveal an interesting link between Buthelezi EMS and High Care EMS (PTY) LTD – the two companies who between them were awarded the entire North West inter-facility transfer tender with High Care getting Ganyesa District and Buthelezi the rest of the province. Mr Buthelezi, director of the various Buthelezi EMS companies, and Mogale Clifford Mahlo, director of High Care EMS, are listed as co-directors of companies called Vosloorus Ambulance Services CC and VAS Emergency Medical Services (both companies that have been deregistered because of annual return non-compliance).

Two investigations

In February 2018 City Press reported that North West Premier Supra Mahumapelo had authorised a forensic investigation into procurement at the provincial Department of Health.  In addition to the Gupta-linked Mediosa, Mahumapelo’s spokesperson stated that Buthelezi EMS will also form part of the investigation. City Press also reported on alleged overcharging by Buthelezi EMS, something which Mr Buthelezi denies. Additional questions that Spotlight sent to Mr Buthelezi were not answered.

Meanwhile, Buthelezi EMS continues to be paid by the North West Department of Health. Invoices seen by Spotlight show figures in excess of R20 million a month. (The second article in this Health4Sale series will reveal how Buthelezi EMS appears to be overcharging the North West Department of Health and how their service allegedly falls short.)

In addition to the forensic investigation initiated by Mahumapelo, Buthelezi EMS is also being investigated by the Hawks. Spokesperson for the Hawks in the North West Captain Tlangelani Rikhotso confirmed that they were investigating the contract between Buthelezi EMS and the North West health department, but said, “we cannot divulge any more information in relation to the case”.

The North West Department of Health declined to answer any of a long list of questions sent by Spotlight stating only that: “The management of the Department has looked into all the questions posed. The Department has also considered the fact that Buthelezi EMS and a number of other contracts are a subject of investigation by the Hawks as well as a forensic (sic) initiated by the Premier’s Office.  In the light of these developments, the Department feels that the investigations should carry on and a response will then be issued afterwards.” Spotlight allowed the Department additional time to reconsider this position but did not receive comment by the extended deadline.

More in this series:
NorthWest pays double for dubious private ambulance service

Health4Sale: Mpumalanga department of health broke rules for controversial ambulance company

Health4Sale: Motsoaledi asks treasury to investigate Buthelezi EMS

Health4Sale Part 4: Buthelezi EMS running a taxi service, not an ambulance service – Doctors and nurses

Note: While Spotlight is published by SECTION27 and the Treatment Action Campaign, its editors have full editorial independence – independence that the editors guard jealously. Spotlight is a member of the South African Press Council.

10 things to know about TB in South Africa

Tuberculosis (TB) is still a crisis in South Africa. Here are 10 quick facts about the state of TB in South Africa.

  1. Tuberculosis (TB) remains a crisis in South Africa. It is the top cause of death indicated on death reports. There are over 400 000 cases of TB in South Africa every year. TB cases are slowly coming down, but it is not happening nearly fast enough.
  2. One of the biggest problems with TB is that we do not diagnose people fast enough and get them on to treatment fast enough. This is bad for the health of people with TB, but also contributes to the spread of TB in our communities. Two potential solutions are active case finding (ACF) and contact tracing. ACF is when healthcare workers or community healthcare workers go out and look for people with TB. Contact tracing is when we trace the family and/or work contacts of someone with TB and then test them for TB as well. Most experts agree that government must invest more in ACF and contact tracing, but unfortunately government has not shown much ambition in this regard. This lack of ambition is probably because government does not want to employ more people.
  3. Another critical problem in our response to TB is the poor infection control measures in most public spaces. In taxis, or in waiting rooms at clinics, or at Home Affairs offices, often the windows are not opened and all the people present breathe the same air. In addition, many prisons are overcrowded and create ideal conditions for the transmission of TB. Here too, government has not shown much ambition in dealing with the problem.


  1. There are over 20 000 cases of drug-resistant TB (DR TB) in South Africa per
    It appears that the rates of DR TB are going up – something which surely constitutes a public health emergency.

    year at the moment. It appears that the rates of DR TB are going up – something which surely constitutes a public health emergency. DR TB is much more difficult and more expensive to treat than normal TB. There is also evidence suggesting that most people with DR TB did not develop the drug resistance while being treated for normal TB, but were infected with TB that was already drug-resistant.

  2. Until recently, treatment for multiple drug-resistant TB (MDR TB) took two years, and often resulted in severe side effects such as deafness. However, the World Health Organisation recently recommended a new nine-month regimen with fewer side effects for the treatment of MDR TB. South Africa is in the process of introducing this new, shorter regimen.
  3. While the new nine-month MDR TB regimen is an improvement on previous regimens, it still entails a large number of pills and injections, and has is associated with substantial side effects. The good news, however, is that a number of trials are under way to test even shorter regimens that will contain no injections, and hopefully will have even fewer side effects. We should start seeing results from these trials in 2019.


  1. Extensively drug resistant TB (XDR TB) is the most difficult form of TB to treat, and over 70% of people with XDR TB in South Africa die within five years. There is good news, however: an ongoing trial in South Africa called Nix-TB is showing much higher cure rates for XDR TB than we’ve ever seen before. In the Nix-TB trial, people are treated with three drugs: bedaquiline, pretomanid and linezolid.
  2. While bedaquiline and linezolid are already registered and available in South Africa, pretomanid is not yet registered. Pretomanid is not being developed by a pharmaceutical company, but by a non-profit called the TB Alliance. Donors should work with the TB Alliance to make pretomanid available under compassionate-use concessions, so that people in South Africa with XDR TB can access the drug.

Latent TB

  1. People living with HIV are at higher risk of contracting TB. For this reason, people are given isoniazid preventative therapy (IPT) to prevent the development of TB. For years IPT treatment rates in South Africa were very low, but recent figures suggest that many more people are now receiving IPT and being protected against TB.
  2. IPT works well and can be taken for six months or a year, or even longer. It consists of a pill you must take every day. However, there is a new form of TB-preventative therapy called 3HP, which consists of isoniazid and another drug called rifapentine. The 3HP regimen involves taking pills only once a week, for a period of 12 weeks. If ongoing trials of 3HP in South Africa are successful, 3HP will replace IPT at some point in the next five years.