Strike terrifies mental health patients in North West

A group of workers staged a strike at Witrand psychiatric hospital in Potchefstroom trashing several sections in the facility and terrifying mental health patients.
A source told Spotlight that the strike started yesterday and that patients, some who have been at the institution for 20 years and know no other home, were traumatised by the violent behaviour from some protestors.
Information shared with Spotlight claimed that among others the kitchen was trashed and food strewn all over the floor, offices were damaged with furniture overturned and files thrown on the floor and corridors in the hospital were strewn with overturned furniture, litter and other objects.
Sources said that the hospital gate had been blocked by Nehawu protestors and that doctors and visitors were denied entry to see patients.
Spotlight understands that hospital staff and patients trapped inside were panicking and that the police had to be called.
National Health Education & Allied Workers Union secretary in North West Patrick Makhafane confirmed that their members had “withdrawn their labour”, but denied that they were responsible for the damage to property and upsetting patients.
However, when questioned further he said that workers had been “provoked” for a long time and that they could not be blamed for reacting.
He said they had been “harassed for many years” and their “anger had reached a maximum point”.
He blamed the hospital CEO Naledi Mocwaledi and accused her of harassing and targeting Nehawu members. He said the last straw was when two shop stewards were suspended by management, but did not disclose what the charges were.
Makhafane said the strike was called off after the MEC met with workers at the hospital.
Tebogo Lekgethwane, Spokesperson for the North West Department of Health, confirmed that the MEC today met with the striking workers to hear there concerns and that the strike was called off after the meeting. He said that details of the agreement would be shared in a media statement to be released later in the day. According to Lekgethwane there will be another meeting with workers at the facility on Monday.

Will the President cure the health system?

The corridors and floors of Tuynhuys are so shiny you almost want to wear sunglasses. Smiling workers bustle around in the fancy mansion, presumably making sure the engine of government’s highest office is purring along. Almost 800 kilometres away the corridors and floors of Keimoes Hospital in the Northern Cape are so dirty and grimy you fear contracting a disease. There are almost no staff in this sad, hot building, an ill patient moans alone in his bare room, two nurses (the hospital’s only health workers) valiantly trying to get through the waiting patients with few drugs and less medical supplies.

One country, two worlds.

Last week a motley crew of government officials, health lobbyists and others working in the health sector gathered at the President’s Cape Town office, assumingly to hear how we will address problems in Keimoes, the Northern Cape and every other corner of South Africa where healthcare is in code Red.

The invitation to Tuynhuys offered a hint that the outcome of this briefing would be some concrete plans, some detail on next steps: “The President will report on the proposed solutions that the nine Summit commissions developed to enhance healthcare efficiency”.

But first a few steps back to October 19 and 20 last year when most of the who’s who in South Africa’s health sector, past and present, descended on a monster-sized conference venue adjacent to OR Tambo International Airport.

Bureaucrats, activists, politicians, doctors, nurses, health workers, researchers, scientists and academics poured over the sick health system and spoke and spoke for two days in what many believed was a genuine effort to save South Africa’s terminally ill health system.

Christmas came, there was a lot of backroom lobbying, but no real signs that there was agreement that a medicine had been found for the ill patient.

The much-awaited Presidential Health Summit compact – based on the outcomes –  that was supposed to be released by December 10, was delayed. It remains delayed.

Fast forward to last week where the President was due to perform the launch of the Presidential Health Summit report at a media briefing at Tuynhuys in Cape Town.

A few journalists gathered in the media room, but were soon outnumbered by men and women in business suits, some good people but with an unhealthy sprinkling of individuals who have been freeloading off the health system’s challenges by selling themselves as consultants or representatives of one or other stakeholder.

The first hiccup was the none arrival of the President. In October last year Ramaphosa also failed to arrive at his own summit, but he had done so on doctor’s order as he battled a nasty respiratory infection.

This time we were told the President had landed at 4am from the African Union meeting in Addis Ababa (the true story was possibly more linked to Eskom which turned the Monday blue with Stage 4 load shedding).

Enter Health Minister Dr Aaron Motsoaledi who read the President’s speech, joined on his right by a group of people seated on gold-coloured chairs and who were introduced as those representing various key stakeholders in the crafting of the President-led plan, the leaders of the various commissions.

Sadly the report and the various speakers did very little to deliver on the promise of “proposed solutions that the nine Summit commissions developed to enhance healthcare efficiency”. The report reads like minutes of the two-day meeting with the “Way Forward” chapter already outdated as the compact is yet to be signed.

Some speakers rambled on about rather being on the train than being left at the station, others rambled on about first having to meet before being able to say how they would contribute meaningfully while others just blew hot air.

The President’s statement released after the launch offered some glimmers of hope: “The Presidential Health Summit 2018 gave us an opportunity to examine our national health system as a patient in its own right and to arrive at a diagnosis that would allow us to intervene and return this system to good health.” Okay, so at least an admission that we had a sick patient.

The President’s speech spoke about the need to prioritise the filling of critical vacant posts so that staff shortages in key areas of the health system can be stabilized, the need for provinces to prioritise their financial resource allocations in a manner that will ensure that the delivery of quality health care, the need to review and  develop sustainable financing model to address urgent financial resource requirements and the need to look at a centralised procurement system with standardised procurement systems and a processes to deal with corruption, economy of skills and scale. Imagine what would happen in Keimoes if this was operationalised.

Was there enough in the President’s statement to offer us a way forward, to hold those in power accountable? Do we have a plan that will help us to hold them accountable, to nudge and push and make sure they deliver and work faster and with more urgency?.

Not yet, but time will tell. South Africa is notorious for saying the right things on paper, writing policies that hit all the right notes, but our Achilles heel has always been implementation and even if there is an attempt at some implementation, holding those with the power to account will be the challenge.

The Presidential Health Summit report released last week is not the desperately needed road map, it is not the plan that will take us forward. It is one of many, many building blocks, a part-recording of an important meeting that took place.

And then there is of course National Health Insurance which is already a pre-election playball, but is not moving forwards, backwards or sideways. If those in the driving seats do not tread carefully, we will one day look back and know we missed a crucial opportunity to truly create a health system for all and not one that simply suited the short-term political objectives at the time.

Asked for an update on the progress of the NHI Bill (which was discussed at the cabinet meeting on January 30) Motsoaledi said, “When everything is done and dusted, and the bill is going to parliament we will make an announcement. You just have to be very, very patient.”

So, in short, last week’s “launch” felt like nothing more than ticking a box, releasing a “report” that does not offer the urgent way forward or a road map. It had the feel of a pseudo-consultation with well-selected yes-persons to nod through what has already been decided behind closed doors along gleaming corridors. It appears that for now those in Keimoes and the rest of the country will have to be very, very patient.

This is an illness we have as a country, we convene summits, we appoint task teams, we create war rooms, we write and launch glossy reports and hold press conferences saying all kinds of things, but very rarely does it make a difference.

For now, the reality for Keimoes will remain critical nurse and doctor shortages, drug stockouts, almost no ambulances, dirty floors, long queues, stockouts of basic medical supplies and rampant corruption. For now we have to wait and hope the good people, who have the best interests of our country at heart will find the solutions, the medicine to heal this sick patient.

For an hour and a bit Tuynhuys felt a little like a time warp amid clinking glasses and fresh sandwiches while at the coal face the picture is the polar opposite. The time for window dressing is over, it is time to revive this patient, apply the plasters, administer the drugs and bring in the “doctors” who know how to save this very sick patient. This means having actual consultations with a variety of experts where you actually listen, rather than simply trying to get agreement on what you have already decided is the way forward. Our economy, our well-being, the lives of millions depend on this.




Four healthcare priorities for South Africa’s budget

By Russell Rensburg, Rural Health Advocacy Project

The president in his recent “state of no action” address outlined five major areas that in his approximation articulates the road that lies ahead. The priority given to the restructuring of the country’s security services notwithstanding, there was one particular priority that stood out and that was the rebuilding of the capability of the state to address the needs of the people. It was tacit acceptance that without a supportive state we will not be able to deliver on our promise as a nation.

The tabling of the national budget this afternoon will give us a sense of the extent of our fiscal crisis. How will we achieve the difficult task of addressing the risks posed by the potential collapse of ESKOM which requires in excess of R200 billion just to meet its immediate needs. With over R400 billion in state guaranties the ESKOM bailout is a fait accompli.

The bigger question posed to the minister is how will we mitigate the impact of the looted purse on the millions of South Africans who rely on the state to meet their most basic rights. None more than the millions of people living in rural areas particularly those in former Bantustans, whose long walk to freedom is far from over.

As the Rural Health Advocacy Project, we call on the minister to respond to the crisis in our health system by.

Fixing the way we fund healthcare

The National Health Insurance (NHI) bill, though imperfect, provides an important framework through which to implement the reforms needed to fix our broken health system. Its success will depend on a strong publicly funded health system. We can begin this reform by consolidating the more than R220 Billion spent on health into a single financing stream managed by an independent National Health Fund.

Addressing our Human Resource Crisis

The advertising of over 5 500 critical health posts in December was an important first step but it cannot end there. The National Department of Health estimates that there are more than 40 000 vacancies across all nine provinces. Despite this, between 2002  and 2010 less than 40% of health professionals trained were retained in the public healthcare system. RHAP reported in 2016 how provincial departments delayed or failed to fill vacancies merely to save costs without any consideration of the resulting impact on quality of care. To effectively address the Human Resources for Health crisis we need a comprehensive assessment of where our health workers are. Using this assessment, we can begin to develop a plan that ensures that our available resources are distributed in an equitable manner prioritising those most in need of care.

Strengthening Primary Health Care

Since the dawn of our democracy we have invested heavily in improving access to healthcare services and currently there are 4 000 primary healthcare centres scattered across the country. In the recently published district health barometer budget analysts from National Treasury reported two interesting findings. The first was that despite the talk of a system in crisis primary health care expenditure has actually gone up.  Similarly, the percentage of patients without referrals also trended downwards suggesting that people were accessing care at the appropriate level. On further inspection, the rise in primary healthcare expenditure is actually a result of fewer people visiting primary health care clinics despite an increasing burden of disease. Which begs the question, if the people are not going to clinics or district hospitals, are they delaying health seeking because they have lost trust in the system? District management in one deep rural district report to us that they are operating with vacancy rates of up to 80%.

Prioritising Rural

The challenges in the health system are amplified in Rural districts plagued by inadequate staffing levels, inconsistent availability of medicines and poor physical infrastructure – despite the fact that rural communities often bear a greater burden of disease. Women in rural districts are 30% more likely to die from complications related to pregnancy. While we have almost eliminated mother to child transmission of HIV we continue to struggle with under 5 mortality including malnutrition. Rural populations account for close to 38% of the population of which more than 50% are below the age of 35. Failure to prioritise rural populations for the delivery of good quality health can no longer be acceptable.

So, dear minister, lets reflect on the goal of our ongoing struggle, as expressed in the preamble of our Constitution, above all else to “Improve the quality of life of all citizens and free the potential of each person”.

Let’s hope the budget you present today is a step towards realising that ambition.










UN Committee finds austerity measures implemented in SA “may further worsen inequalities”

The United Nations Committee on Economic, Social and Cultural Rights has called for more inclusive economic policies and a review of fiscal policy to enable government to meet its Constitutional and international human rights obligations. But is Tito Mboweni willing to take a tip based on international law? Sadly, it seems unlikely by Mark Heywood.

It is a cruel quirk of history that 1948, the year when DF Malan and his cronies began ushering in a system of legalised racism in South Africa, was the same year the United Nations adopted the Universal Declaration of Human Rights. The UDHR was a forward-looking document that imagined a world order where all human beings were regarded as being “born equal in dignity and rights.”  Apartheid, by contrast, was a system that built walls, rather than broke them down and which looked backwards to the heydays of colonialism – where white was right and freedom a privilege.

Not surprisingly, on that auspicious December day in Paris, South Africa was one of the few governments to abstain from voting for the UDHR.

Seventy years later on December 10th 2018, South Africa joined the world in celebrating the 70th anniversary of the UDHR. In his speech from Constitution Hill President Ramaphosa pointed out that:

“This historic declaration, this manifestation of humanity’s common conscience, significantly influenced the development of South Africa’s constitutional order …”adding that “whether it is access to land or the provision of basic services, we have to give expression to the rights of our people as entrenched in our Bill of Rights.”

Ramaphosa was right to tip his hat to the UDHR. One of the first fruits of our democracy was to tie South Africa back into a world of globally recognised human rights and international human rights law. Being part of this international community was an affirmation of our common humanity. In a sense, the UDHR had taken our ancient philosophy of Ubuntu, which recognizes the interdependence of people and communities, and embedded it on a global stage.

This was why in 1996 when we nailed down our aspirations to a tangible and enforceable Constitution (which Nelson Mandela deliberately signed on International Human Rights Day) we tied our destiny to a revolutionary idea: that when it comes to matters as universal as human rights there exists a set of laws even higher than our own, those of the Covenants of the United Nations (UN).

This is why the Constitution requires that when Courts interpret the Bill of Rights they “must consider international law” (s39(1)(b). It’s also why the Constitution recognizes that an international agreement becomes binding “after it has been approved by the National Assembly and the NCOP.”

One such agreement is the International Covenant on Economic, Social and Cultural Rights (International Covenant) which Parliament took a (belated) resolution to ratify in January 2015.

In October 2018, in fulfillment of our duty to report on progress with implementation of the ICESCR, a high-level government delegation, led by Deputy Minister of Justice and Constitutional Development John Jeffrey, travelled to Geneva, to participate in a review of our laws and practices against the rights and duties established by the International Covenant. In their wake was a collection of social justice organisations, armed with more than two dozen ‘shadow reports’ sans the gloss that governments always put on their own stories.

Sadly, unlike glitzy events such as the World Economic Forum in Davos, the hearings garnered, no media interest, despite the release of statements by organisations that participated.

Yet what happened in Geneva was arguably of much greater significance.

Both government and civil society delegations engaged in a robust interrogation from the UN’s Committee on Economic, Social and Cultural Rights (UN Committee). The government told how its efforts were generally improving the conditions of the poorest in our country. Civil society offered up hard statistics on everything from rising unemployment to the collapse of public health care and education systems as well as telling human tales describing how austerity policies were actually worsening the conditions of the poor.

The committee, which is made up of 18 experts elected by UN members, had to make its assessment based on these conflicting reports and on 12 October it issued what it termed politely its ‘concluding observations’.

Unfortunately, the media missed the significance of this too. Maybe news needs a pop star or a former President to get attention, or maybe human rights just aren’t newsworthy to the ‘mainstream’ media…

The CESCR welcomed the “constructive dialogue” as well as the input from civil society and the SA Human Rights Commission. However, without wasting words, it then made recommendations under 32 different sub-headings. Many of its findings are explosive. For example, commenting on the state’s duty to allocate the ‘maximum of its available resources’ to socio-economic rights (a duty we have ratified, remember), it said that while it: “welcomes the efforts pursued since the end of apartheid, the persistence of such inequalities signals that the model of economic development pursued by [South Africa] remains insufficiently inclusive.”

It went on, noting:

“The State party’s fiscal policy, particularly relating to personal and corporate income taxes, capital gains and transaction taxes, inheritance tax, and property tax, do not enable it to mobilize the resources needed to reduce such inequalities.”

The committee therefore recommended that South Africa “review its fiscal policy” and “re-examine its growth model in order to move towards a more inclusive growth pathway.”

On the vexed matter of the ‘Austerity Measures’ currently being implemented by our government, it suggested an approach not dissimilar to that which our Constitutional Court has taken when presented with disputes over the government’s past failures to fulfill rights to housing and access to health care services. It “reminded the State party: “that, where austerity measures are unavoidable, they should be temporary, covering only the period of the crisis; necessary and proportionate; not result in discrimination and increased inequalities; and ensure that the rights of disadvantaged and marginalized individuals and groups are not disproportionately affected (all of which we are failing to do – my comment). The Committee recommends that the State party:

(a)    Increase the level of funding in social security, health and education;

(b)    Task the Department of Planning, Monitoring and Evaluation with ensuring that public policies are directed towards the realization of the rights of the Covenant;

(c)     Ensure the Standing Committee on Public Accounts in the national parliament (and its equivalents in provincial parliaments) take such rights into consideration in assessing the budgetary choices of the national and provincial governments respectively.

In terms of the ICESCR, the government is expected to respond to these recommendations as well as to “disseminate them widely at all levels of society, including at national, provincial and municipal levels, in particular among parliamentarians, public officials and judicial authorities …” One doubts that that has happened – has it, Deputy Minister Jeffrey?

Now, as the public braces itself for another round of austerity measures, the Minister of Finance, Tito Mboweni and the Cabinet must be reminded that the unholy trinity of Standard and Poor’s, Moody’s and Fitch – are not the only supra-national power whose hunger they have to satisfy.

Before Tito dismisses my tip and titters at the naivety of the organisations gathered under the umbrella of the Budget Justice Coalition, let me say that reasonable people recognise that our government has a nigh impossible task of balancing its books and meeting needs that have been denied over hundreds of years. This is made harder by gross corruption, state capture and corporate greed. Nonetheless, that difficulty aside, in balancing the books, our state cannot escape the fact that protecting human rights is one big rule of law we signed up to – for reasons given by President Ramaphosa.

My tip for Tito would be to acknowledge the UN’s recommendations and tell the nation that they will be seriously considered. When it comes to the Parliamentary debate on the budget, our MPs should do the same. Yet, my bet is that the UN’s findings will not get a mention in the budget. One can only conclude then that when it comes to our economic policy, the human rights treaties ratified by Parliament are considered less important than the dictates of international finance and local capital.

This is not just bad for the people of South Africa, it is bad multilateralism and the idea of binding international norms and standards based on human rights.

So, whilst it was fitting that President Ramaphosa paid tribute to the UDHR, the hypocrisy does makes one wonder whether the nice words are more pomp than purpose – a mere lip-service to liberation from indignity and desperate poverty.

For these reasons the ordinary man and woman in the street who would benefit most from a government that respected universal human rights standards might be forgiven for thinking that the United Nations is just another elite club. They could be forgiven too for seeing multilateral forums, be they the European Union or the UN, as nothing more than bloated bureaucracies that organize elite gatherings. But what we should not forgive ourselves for is adopting policies that by failing the poor assist the global turn towards nationalism and populism.

Once we had a dream! Turn back Tito: South Africa still has the moral authority to set a different example for the world. But it starts with how we govern our own house and who we take our orders from.



Presidential Health Summit report released

Late last year several hundred people who work or have connections with the health sector gathered in Johannesburg under the banner of the “Presidential Health Summit”. Yesterday Health Minister Dr Aaron Motsoaledi released a report which “contains the output of the deliberations of the first Presidential Health Summit held in Boksburg on 19 and 20 October”.

Read the President Cyril Ramaphosa’s speech here Speech on the launch of the Health Summit Report (which was read by Motsoaledi). The full report can be read here Presidential Health Summit 2018 Report

Spotlight will publish an opinion piece by the end of this week.






Make the health system, not health politics, a priority in this SONA

South Africa has been “on the brink” of major health system change for almost a decade. National Health Insurance (NHI) has been the buzz-phrase for  years, but somehow it is still one of the most elusive policies of our time and  it is made less tangible with each iteration of the policy.

So where are we now? We are nowhere.

A leaked revision of the NHI Bill late last year included sweeping changes to the version published for public comment, albeit not, apparently, in response to those comments. We remain in the dark about the status of the Bill currently. Task teams have worked on aspects of health system reform in reports that have never been made public. The Competition Commission has spent R196 million on a Market Inquiry into Private Health Care which has made significant preliminary findings and recommendations but has now been stalled until the new financial year due to a lack of political will to find the funds for it to finish the job with urgency.

One of the things that characterizes the South African Health care system, is a lack of political will. Politicians pay lip service to the idea of universal health care, a universal health care that only exists in boardrooms and on power point presentations. On the ground however, universal health care is but a term that blasts out of radios and televisions, but by no means has it translated into tangible change that will better people’s access to healthcare.

At this very moment, there are hundreds of health care users who have been queuing outside healthcare facilities since 4am, there are people who have been turned away without their medication due to stock outs, there are people who have spent their pension money hiring private cars to get their loved ones to hospital. These are the experiences of the masses who have no other option but to go and try their luck in the primary health care system. The people who have battled for years to get attention, are still battling today. These people are not just statistics, they are our mothers, grandmothers, aunts, cousins, and fathers. They are real people who are too often reduced to statistics.

The health care crisis is not just a numbers game. People are losing their lives every single day while we fixate on the passage of an NHI Bill that says little about quality and instead focusses on the creation of a Fund and various opaque structures at national, district and sub-district level.

These delays and obfuscation on the side of government are even more devastating in the context of a health system in crisis. A system in which only 5 of the 696 health facilities assessed by the Office of Health Standards Compliance according to its minimum standards in fact comply with those standards. A system in which private health care users are being pushed into state care through ever increasing costs and unknown quality.

Health financing is a vital component of health system improvement, but the creation of a Fund does not itself improve the health system. Think about the funds that are made available, where does that money go? The government tells us that millions are being pumped into this and to that, but due to high levels of corruption very few people will reap the benefits of those millions.

We cannot afford to stop at only a few incremental interventions and the passing of a Bill. As the Cape Town streets are cleared for tonight’s State of the Nation Address we need much more ambitious and serious action to fix the health system.

We must proceed in the knowledge that quality health care services can improve learning in schools, revive rural economies and save billions of Rands now spent in treating preventable diseases.

We need to expand the investment in human resources for health and establish mechanisms to manage and retain the people in the system. We need to audit and repair infrastructure, strengthen governance and management systems, and develop and implement a plan for the regularisation of healthcare  appointments (uninfluenced by party political structures and patronage). We need to capacitate and better resource health committees and hospital boards to begin to exercise governance functions within health facilities and strengthen the capacity and resourcing of the Office for Health Standards Compliance to ensure that it is able to fulfil its mandate effectively.

There are structures that exist and can be improved upon in order for us to realise universal health care for all. The government cannot work in isolation, as it seems to be doing with NHI. It is not the people in boardrooms who will drive health reform, it is the health practitioners working in facilities. It Is civil society who will provide the required research and expertise.

Access to Universal Health Care will never be achieved in isolation. There must be much more openness and accountability. Government must show real willpower to move forward, not on its own or through lip-service consultations, but in a real and meaningful compact with civil society. On that foundation we need President Ramaphosa to show leadership. On that foundation we can start the urgent work of fixing our healthcare system.

Stevenson is head of health at SECTION27.

Ndebele is a communications officer at SECTION27 where she is responsible for health-related communications.

Spotlight is published by SECTION27 and the Treatment Action Campaign, but is editorially independent and is a member of the South African Press Council.


Ailing Nation – The things SONA Won’t Say About the Health Crisis

Tonight when President Cyril Ramaphosa delivers his second state of the nation address (SONA) he will say very little about the actual health of the nation. In fact, if past SONA’s are anything to go by, health gets a few paragraphs three quarters of the way through the speech, usually sandwiched between education and crime. Although Ramaphosa says he has prioritised the health crisis he is unlikely to acknowledge the impact of our individual health on the state of the nation’s health as a whole. Yet health affects our morale, our psychology, our productivity, our educational outcomes and employment prospects, our patterns of expenditure as individuals. It’s one of the government’s biggest budget items.

If health is central to our being. It ought to be central to the nation’s being – not an after-thought.

So be warned, the President will not tell us about:

The continued extremely high levels of illness and death due to Tuberculosis (TB), where there are an estimated 300,000 cases and 80,000 deaths a year, despite the fact that TB disease has been curable since the 1950s.

The 8,000 babies who die each year during or shortly after birth, mostly due to preventable causes that are linked to health system failures.

Or the malnutrition that faces up to 30% of children, often followed by obesity in adolescence and adulthood, due to paths of deprivation cut by childhood hunger.

The President will probably not tell us about:

The exploding cancer epidemic and how many people are dying because cancer medicines cost so much and public sector oncologists are almost extinct.

The crisis in mental health care services that continues after Life Esidimeni; or the largely untreated epidemic of depression that was made evident last year in the deaths of respected figures like Professor Bongani Mayosi and Hip Hop Pantsula – as well as an estimated 14 other males who die of suicide daily.

The unquenched HIV epidemic, that still causes 89,000 deaths a years and 270,000 new infections –  which is now under new management of his Deputy President David Mabuza, a man with a track record of disinterest and failure on HIV when he was Premier in Mpumalanga.

Neither will he make us aware of the world-beating levels of trauma caused by alcohol, gun violence and car accidents – and what this costs our nation.

Sadly when it comes to our health there is no good story to tell. More worryingly there is little evidence of a plan. Although President Ramaphosa promised a ‘new dawn’ to be ushered in by a system of National Health Insurance (NHI) that is still stalled, the public health system remains shrouded in darkness. Consequently, it will not be convenient for the President to quantify:

The quantum of corruption in the health sector; or how ambulance services or medical equipment supplies can be as profitable for corrupt tenderpreneurs as Bosasa.

The numbers of publicly trained doctors and nurses who drain out of the public health sector, into the private sector, to Canada and Australia.

The unacceptable levels of medicine stockouts, or equipment shortages.

The profiteering that is taking place in parts of the private health sector or the preliminary findings of the Health Market Inquiry, which has now been shelved for the next few months due to a lack of money – itself a sign of limited political commitment to fixing the health system.

Instead, the President will probably spend those few precious lines heralding the promise of a controversial Bill on NHI which address none of the crises above, and which has created division and despair at the very moment when we need unity.

I record this woeful diagnosis not because I wish to detract from the importance of the many initiatives the President’s SONA will announce, or to deny the superhuman effort that is being made by some in government, including the President, to root out corruption and rebuild a capable state. I do so because health is vital to our national well-being and the AIDS denialism of an early President continues to have a deadly legacy.

Health, as well as being a symptom of the inequality we inherited from our past, is also a cause of inequality in our future. Therefore, how we tackle inequality must be a measure of the state of our nation.

President Ramaphosa undoubtedly will remark on the fact that 2019 marks the 25th year of our democracy. But as the ANC’s chief negotiator he knows that our new South Africa was founded with a constitutionally entrenched promise of equality and a system of social justice.

Health was one of the rights singled out in section 27 of our Constitution’s Bill of Rights because of the liberation movement’s recognition of its importance. The Constitution says it is a right that must be realised “diligently and without delay” (s237) by a government in which “people’s needs must be responded to.” (s195)

It is the President job to “uphold, defend and respect the Constitution” – that is the whole Constitution, not just the parts that will make the wealthy feel secure.

The crisis in our nation’s health arises from an unconstitutional state of affairs; it is not preordained, it is not even a legacy of apartheid because there is much we could have done to improve it. It arose from bad governance, corruption and planning that doesn’t take account of human rights or equity. It points to a Health department in denial about the crisis or incapacitated about what to do about it.

The annual SONA should therefore offer strategies to realise rights as much as it will set out strategies to improve its economy. We reject the argument though that investment in fixing health must wait for improvements in the economy.

Health should be considered as crucial to productivity as a stable electricity supply; the efficiency of our public hospitals is as important as that of our State Owned Enterprises. Not having a plan for the estimated R80-billion in that has accrued in medico-legal claims due to state failure is a drain on our health system as much as Eskom’s debt is a drain on our economy.

President Ramaphosa, responding only to the ills of the economy – and not giving equal treatment to the ills of the people – is like emergency services rushing to the scene of an accident and then tinkering with the crashed car while the patient bleeds to death on the road side. You need the person to be healthy to drive the car. By investing in the person you might just be able to kick start the car.

If only they could learn to look at things differently, government planners would see that meeting their constitutional duty to ensure “everyone has access to healthcare services” might be a means of creating jobs and saving billions of rands by preventing costly illnesses.

Or, is that a dawn too far?

Provinces make progress with AIDS plans

All nine of South Africa’s provinces have finalised their NSP provincial implementation plans, according to the South African National AIDS Council (SANAC). These nine implementation plans are meant to guide implementation of South Africa’s National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022.

In total, 46 out of 52 districts in the country have finalised their district implementation plans. The six that are missing are from the Western Cape, where district implementation plans will not be implemented due to the fact that the province does not have district AIDS councils – but similar structures called Multi-Sectoral Action Teams (MSATs).

Of the nine provincial plans we managed to find only the Limpopo plan online. After contacting provincial AIDS councils we managed to get hold of a total of six of the nine plans – with the Eastern Cape, North West, and Northern Cape not sending us their plans after multiple requests – although provincial AIDS council representatives in the Northern Cape did indicate that a print copy could be collected in Kimberley. (Future Spotlight articles will engage with the content of the plans)

SANAC says they view provincial implementation plans as public documents that should be freely available. “however the provinces and the districts have custody of these plans,” SANAC told Spotlight. “A new SANAC website is currently being developed and provinces/districts will be encouraged to share formatted and designed documents for upload. At a provincial and district level, we encourage AIDS councils to print and distribute the documents.”

Six of nine provincial councils chaired by premiers

According to SANAC all provincial AIDS councils are chaired by the Premiers except for Gauteng, Western Cape and the Eastern Cape. “The Premier in North West is currently leading the reestablishment of the PCA in the province and wants the council re-established by 28 February 2019,” SANAC told Spotlight.

Activists have argued that provincial AIDS councils should be chaired by premiers so as to ensure high-level political buy-in into the AIDS response and to ensure the AIDS response involves not only the provincial department of health. “Provincial AIDS Councils have a huge role to play in coordinating the HIV response and from national to local level they have not been successful in doing this. Their functionality signifies a crisis as they are mostly measured by the number of meetings held instead of the production of fundamental plans and or commitments agreed on at meetings that will improve the response,” says Vuyokazi Gonyela, of the Treatment Action Campaign and SECTION27.

“The directive from the previous Deputy President, Cyril Ramaphosa, to the Premiers that requires the full resourcing of AIDS Councils has not been implemented to the same level across all provinces”, SANAC told Spotlight. “This hampers their capacity to function adequately, including the development and monitoring and evaluation of implementation of the PIPs and DIPs and the capacity building and inclusion of civil society sectors in subnational AIDS council structures.”

Capacity to draft good plans

One of the criticisms previously made in Spotlight of the NSP was that it does not provide enough guidance on how the plan is to be implemented. Spotlight understands that the process of developing provincial implementation plans has been difficult and slow. Various factors may have contributed to this, including a lack of political prioritisation, a lack of capacity in provincial AIDS councils, and a lack of funding.

SANAC did however step in to provide assistance to provinces. As SANAC explains: “A national steering committee was established to guide and review the draft multi-sectoral provincial and district implementation plans. This committee provided guidance and oversight, review and alignment roles in terms of their development. In addition a project management team was established within SANAC to provide technical assistance to provinces and districts by supporting the writing, facilitating workshops and calculating targets for the M&E plans.”

The NSP steering committee was comprised of a multi-sectoral team that included key donor representatives from PEPFAR and the Gates Foundation, explains SANAC. UNAIDS and the World Health Organization were also part of the NSP steering committee. Some funds were made available by donors for technical assistance to provinces and districts and some costing support currently for Mpumalanga.

We asked SANAC whether there were any common problems or difficulties in the development of specifically district implementation plans, since districts are often where the least data is available and the least planning capacity is in place. SANAC identified the following five issues:

  1. Availability of data for baselines was often a challenge – as information is not collected routinely or in the required disaggregation (especially for NSP goals 3,4,5).
  2. In addition, information on private sector and community responses was difficult to know/access if constituencies were not part of the AIDS council structures.
  3. Developing plans and targets at sub-national level which may have different targets from existing APPs (annual performance plans) was a challenge to overcome with government departments as it meant some activities in the PIPs and MDIPS would be included without having committed funding for implementation.
  4. Participation of civil society was correlated to the strength of the civil society leadership within the provincial aids council and their influence and role in the provincial steering committee.
  5. The contribution of NGOs to the achievement of targets is not always fully reflected

Municipal involvement

In one of its many aspirational undertakings, the NSP commits that “Steps will be taken to ensure that  municipal mayoral committees work together alongside  civil society and the private sector to institutionalise an inter-and multi-sectoral approach.” We asked SANAC to describe what steps have been taken in this regard.

SANAC explained that in partnership with SALGA and through the support of UNAIDS and IAPAC, they are implementing a fast track programme, which focuses on fast tracking local responses to HIV and TB, as well as strengthening local leadership for the local AIDS response. “19 high HIV/TB burden municipalities were identified and have also been assisted to identify their own fast track priorities. The municipalities are currently being supported to develop response plans linked to the PIPs and MDIPs.”

“During the December 2018 conference of the South African Local Government Association (SALGA) Members Assembly – which is the highest decision making body at SALGA – all mayors attending signed a Pledge to lead, institutionalise and support the AIDS response in their districts and local municipalities,” SANAC told Spotlight.

The above responses were sent to Spotlight by Kanya Ndaki on behalf of SANAC.


South Africa urgently needs an antiretroviral pregnancy registry

South Africa will roll out a new antiretroviral medicine called dolutegravir in the public sector later this year. One reason for caution about dolutegravir are reports from Botswana that suggests it may cause serious birth defects if women take the drug in the early stages of pregnancy. As previously argued in Spotlight “Women of childbearing age have the right to make an informed decision on whether they want to use dolutegravir or not – and alongside that they have the right to be provided with access to a range of contraceptive options and termination of pregnancy services”. It is likely that this approach will be endorsed by the committee that decides South Africa’s HIV treatment guidelines.

However, the question of dolutegravir’s safety in pregnancy remains an open one, and we owe it to patients to answer this question as quickly as possible. It is important to understand that this critical question cannot be answered in a test-tube or in an animal laboratory. It can only be answered if some women fall pregnant while taking the drug, something that is sure to happen if women of childbearing potential choose to take the drug, regardless of their contraceptive choices. It is therefore incumbent upon researchers and policy makers to ensure that we answer questions about dolutegravir’s safety as quickly as possible and with the minimum number of pregnancies. If we don’t, and dolutegravir is confirmed to cause birth abnormalities, we will have allowed too many foetuses to be exposed to this risk. On the other hand, if we can establish that there is no increased risk, we will miss the chance to quickly reassure patients of its safety.

The solution is a registry of women falling pregnant while taking antiretroviral therapy. This means that as soon as pregnancy is confirmed in a woman taking ART, and before any assessment of the baby has been made, her details are recorded in a register. She is then followed-up until the end of the pregnancy, and regardless of the outcome, an assessment is made of whether or not the baby had a birth abnormality. It is only by taking this rigorous approach that we can be sure that any birth abnormalities are indeed related to ARVs and not a chance finding.

To date, South Africa has an appalling record with regard to pregnancy registries. There is no national registry and only 2 provinces have made attempts to create one. There is a registry in KZN based on women receiving medicines of interest as part of their routine clinical care.. In addition, the Western Cape has a Pregnancy Exposure Registry-Birth Outcomes Surveillance programme. This is is based on routinely collected data which is notoriously unreliable as there are often inaccuracies and gaps in the data compared to when a dedicated registry is used. Neither registry has thus far published a peer-reviewed paper which is open to scrutiny. Therefore, after more than a decade of the widespread use of antiretrovirals in South Africa, we still have a huge gap in knowledge about the safety of drugs in pregnancy.

This is a terrible omission and patients have every right to deserve better.

Many remember the confusion and distress caused by the possible link between another antiretroviral medicine called efavirenz and birth defects. Efavirenz is currently part of the three-drug combination given to almost all public sector patients newly diagnosed with HIV.   In the case of efavirenz it took many years to resolve an issue that could have been solved in a very short period of time if there had been an active registry in South Africa. We must not repeat these mistakes with dolutegravir.

There are a number of well-functioning pregnancy registries around the world, notably the ‘Antiretroviral Pregnancy Registry‘ (APR) which is based in the United States, but accepts reports from any country. The scientific conduct and analysis of the registry data are overseen by an independent advisory committee consisting of members from the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the academic sector. A review of the data from January 1989 to July 2018 found 20,064 prospective registry reports with birth outcomes. So far, the registry has provided reassuring data that does not suggest that any anti-retroviral causes birth defects.

Rather than ‘re-invent the wheel’ it would be straightforward for South Africa to join forces with this well-funded and professional endeavour by registering as many sites as possible with the APR and prospectively reporting all women who fall pregnant while taking ARVs, including dolutegravir. It has taken 29 years for the APR to accumulate 20,000 reports; with 1 million births per year in South Africa and around 30% of pregnant women being on ART, we could collect that same number in a matter of months and with minimal effort.

With the dolutegravir roll-out around the corner, the time is now ripe for patients and activists to demand a prospective pregnancy registry for the whole of South Africa. Whether it is a new endeavour or piggy-backs on international efforts is a matter for debate, but it is the only way we can answer the question of dolutegravir’s safety with the minimum number of women being exposed to the drug. It’s the least that patients deserve.

Dr Tom Boyles is a Senior Research Clinician at the Wits Reproductive Health and HIV Institute.

Opinion: The devastating cost of the North West strikes

There aren’t bodies to count or graves to mourn over, but the North West health sector strikes last year did claim its share of victims and did set in motion a ripple effect of tragedies.

They are tragedies that tell the story of how a strike turned not just violent but vicious, and how it was allowed to rage out of control till it reached a terrible turning point – one where everyone is a loser.

The headlines and photos of mayhem from a year ago may be old news now, but people who need health services to deliver are still counting the costs. Doctors and medical staff are adamant the strike did lead to deaths or at the very least severely compromised patients’ healthcare.

Senior personnel at the Tshepong Hospital in Klerksdorp, Prof Ebrahim Variava and Dr Alistair Calver, kept an informal list from the weeks when the strikes hit their hospital hardest in that first quarter of last year.

On the list are the dozens of patients who were unable to receive their medicines because people were prevented from entering the hospital during the strikes. Some patients had to be discharged prematurely because there were not enough nurses to attend to them. Others were redirected to nearby hospitals – their fate remains unknown. Some patients never returned to have their surgical procedures and the hospital has not been able to track them.

“We could have a worse scenario on our hands than the Life Esidemeni tragedy,” says Calver.

Variava and Calver are among the 73 doctors who felt compelled to write an open letter of concern that was published in various publications in April 2018. Taking a stand publicly was a turning point. It was an acknowledgement that doctors had become direct targets – more casualties of the strike.

At Tshepong doctors were barred from getting to their patients. They were verbally abused, harassed, pushed and shoved as they tried to treat patients at the hospital.

As the strike deepened last year, striking workers from Nehawu were joined by those from Saftu (South African Federation of Trade Unions). At around the same time there were general service delivery riots calling for the axing of then Premier Supra Mahumapelo and other North West government officials. Thugs piggybacked on the chaos of labour action and the political dissent with looting and rioting, adding to the perfect storm of mayhem that marked that first part of 2018 in the province.

It was the thugs who surrounded vehicles headed to the hospitals and clinics. They tried to extort money from doctors by demanding R20 from each driver to pass on the roads that they had barricaded with burning tyres and large rocks.

Variava recounts being racially abused when he tried to appeal to strikers to allow doctors to attend to patients. Instead what was believed to be Nehawu members made pejorative comments about his surname, asking “If he had Gupta links” before shouting him down from being allowed to address strikers who had gathered in a hall inside the hospital.

Community service doctor Hanrie van Niekerk from Tshepong Hospital remembers at the height of the North West province strikes the lengths non-striking staff went to in order to get to patients. Some arrived before 6am before the strikers stirred, others arrived incognito and at one point doctors tried to get access to the hospital via helicopter. Their plans were thwarted when striking staff piled furniture, dustbins and other objects onto the helipad.

“I remember a young woman in casualty who was a resus case. It was just me, two intern doctors and general ward nurses. The senior doctors couldn’t get into the hospital and the general ward nurses didn’t know what to do in casualty. I had to get advice and instructions by phone, we could have lost our patient,” she says.

Young doctors like Van Niekerk stand to be casualties too. They are the ones the country needs to retain in the public healthcare system. Many, already frustrated with the lack of resources and support for their jobs, feel they don’t need the added stress of being targets during strikes. While Van Niekerk says she has no intention of leaving the public sector, she admits she felt threatened on many occasions during the strikes. She refused to stay away from her patients though, forcing her anxious husband to insist on driving her to and from the hospital every day during the strikes.

“Even in a war a hospital is not a target, but in the North West the strikers were in the wards and in the theatres trying to force us and patients out,” she says. Damage to infrastructure and loss of resources also count as casualties.

Variava and Calver, like many other doctors and nurses, do believe in the right to strike, also in many of the demands their striking colleagues made. Variava says it’s wrong that they have been ignored for the longest time. But hospitals, clinics and other healthcare facilities and non-striking staff cannot be reduced to pawns.

They say what’s needed are for new service level agreements to be negotiated with unions. Variava also calls for a Human Rights Commission inquiry into the extent of deaths and casualties as a direct and indirect consequence of the strikes in the North West province.

He says there must be consequences for those who vandalise property, threaten people, incite violence and those who use labour action as cover for criminal activity that includes extortion, looting, robbery and assault. To date no one has been arrested and prosecuted for these criminal acts.

In the aftermath of the strikes bitterness lingers. Broken relationships are a casualty too. It was patently obvious at a Unisa College of Law Biotechnology and Medical Law Flagship discussion group held at the end of October. The event was titled “The right to strike in the public healthcare sector: South Africa’s healthcare battlefield” – ‘battlefield’ not being hyperbole.

The expert panel included lawyer Suemeya Hanif from ENSAfrica, Professor Ames Dhai, director of the Steve Biko Centre for Bioethics at the University of Witwatersrand, Sibongile Tshabalala, national chairperson of Treatment Action Campaign (TAC) and Professor Chris Lundgren, anaesthesiologist and bioethicist from the Faculty of Health Sciences at the University of Witwatersrand.

The panel condemned the violence from the strikes, recalling incidents like clean linen being deliberately strewn outside laundries, garbage bins being tipped inside hospital lobbies and doctors being assaulted, harassed and robbed as they were walking to their cars. It wasn’t just the North West hospitals either, but also Charlotte Maxeke and Baragwanath Hospital in Gauteng.

The Unisa gathering was aimed at sharpening the focus on the legal framework that is in place for labour disputes. It should be adhered to, not disregarded as more casualties get chalked up.

Both Lundgren and Tshabalala said they believed that the real toll on patients and staff is still to be revealed.

The panellists called for new rules of engagement with unions, also for shifting the “battlefield” away from hospital and healthcare facilities.

It was one nurse’s comment from the floor during that day’s discussion that showed just how deeply the fault lines and failings in healthcare run. The man who identified himself as a nurse and a Nehawu member said: “Patients are not my first priority; they are ‘a’ priority. There are some of us who refused to take the nurse’s pledge because this is just a job for us.”

This nurse too is a casualty as a person who sees a profession of caring and healing as little more than a pay cheque. He is a casualty stuck in the cycle of endless fighting for fairer pay, improved work conditions and better career opportunities.

Organised labour is also a casualty, winning only Pyrrhic victories and increasingly losing public sympathy and support as the legitimacy of strikes grows fuzzier. What “victories” labour has had in the North West has come at the cost of others’ wellbeing and rights. Nehawu leadership’s worn excuses of “distancing themselves” from rogue members of their organisation doesn’t cut it anymore. They knew what was happening and their response to it was feeble and mealy-mouthed. Nehawu spokesperson Khaya Xaba’s failure to respond to questions sent to him by Spotlight also show contempt for the media and disrespect for the public who deserve answers and open communication.

Nehawu’s reputation is a casualty and so is that of police officers who stood by as acts of violence and criminality took place before their eyes during the strikes. The same goes for the Provincial Department of Health as a whole and for health minister Aaron Motsoaledi. Motsoaledi acted too slowly in the North West, leaving many to question if he was simply letting politics play out as the ANC faced its own internal struggles over the messy ousting of the then premier. It added more barbs to the thorny narrative that outlying, rural areas are relegated lower down government’s priority list.

The North West is still under administration, as it has been since May last year. The strikes proved to be the straw that broke the camel’s back, turning government structures and departments into casualties – casualties unable to serve the citizens of the province even at the basic level of services provided prior to the strikes.

The strikes cemented in place a web of failings – sticky, tangled and toxic. Right at the centre of this web of tragedy is the patients and their families. The ultimate casualties are the mothers who rock babies with brain damage to sleep in their arms knowing their children would have been born fine if there had been functioning operating theatres where they could have delivered their babies.

It’s the people who died at home not able to face thugs who had barricaded hospital gates or those who were forced to leave hospital too soon and later died of complications. It’s the people who grapple with the anxiety of knowing they face new medical challenges having defaulted on treatment they could not access on time. It’s the patients in the North West who today still will wait an extra hour or two in a queue or be told to come back next month as backlogs are worked through.

They’ll likely be told the standard excuse now: “It’s because of the strikes from last year”.