A healthcare system in crisis: The long road ahead

A healthcare system in crisis: The long road ahead
A Speech by Sibongile Tshabalala, TAC National Chairperson, 11 June 2019, SA AIDS Conference Opening Plenary, Durban

Greetings comrades!

I would like to take this moment to acknowledge the Deputy President, DD Mabuza; the Health Minister, Dr. Zweli Mkhize; the Premier of KwaZulu Natal, Sihle Zikalala; MECs for health; the organisers of the SA AIDS Conference; the media; delegates; and importantly, people living with HIV who managed to make it to the conference. We also acknowledge those who could not make it as a result of many factors such as the high cost of conference fees and  the need to work in order to feed their families, amongst others.

Comrades, the ninth SA AIDS Conference occurs during a critical juncture in South Africa’s history.

We meet at a time when AIDS denialism is beginning to recede in the nation’s collective psyche.

A time where South Africa has the world’s largest HIV treatment programme.

And let me pause here to acknowledge the tremendous work of former Minister of Health Dr. Aaron Motsoaledi in building the HIV treatment programme.

But we also meet at a time where corruption is rampant.

While the disgraceful details of state capture are being exposed in commissions of inquiry – much corruption in our provincial departments of health goes unreported and unprosecuted.

Comrades, we are being trampled down into the dirt by the co-epidemics of corruption and mismanagement.

These are the co-epidemics behind the Life Esidimeni tragedy, behind the disgraceful cancer crisis here in KZN, and the looting of the HIV Conditional Grant to pay Buthelezi EMS in the NorthWest.

Honourable Deputy President and Minister of Health, if you have any doubts of the scale of the crisis, I urge you to study the reports of the Office of Health Standards Compliance.

Let me focus on one symptom of these co-epidemics. Stockouts.

Comrades and friends, as some of you know, the Treatment Action Campaign turned 20 in December last year. As one of the foremost social movements in the country, we have been monitoring drug availability in health facilities for much of those two decades.

According to PEPFAR data, in 2018, around 750 thousand people were initiated on treatment but only around 400 thousand additional patients were retained by the last quarter of the year.

What happened to the other 350 thousand people?

Through our ongoing monitoring campaign, which recently focused on the Free State and Gauteng provinces, PLHIV sector members found that many facilities still undergo drug shortages, or worse, stockouts.

As part of the Stop Stockouts Project, 673 facilities were monitored by members of the PLHIV sector and other comrades within the past two months. We found that of the health care facilities monitored, 109 facilities in the two provinces had drug stockouts of Dumiva, a key antiretroviral. 106 overall did not have injectable contraceptives. When our publication Spotlight travelled to the Northern Cape, they found many facilities with no stock of basic medical supplies such as bandages, plasters and intravenous drips.

It is heartbreaking that as we stand here today in 2019, some of the same issues from a decade ago still plague us.

We cannot run away from the fact that the health system that you are inheriting, Honorable Minister, is one that is in dire need of resuscitation.

Often we have stockouts simply because our healthcare system is in such a terrible state that medicines pile up in depots while clinic shelves are empty.

When the problem is with the supplier, it takes months for the news to filter through to clinics and for the department to provide advice on alternatives – as has just been the case.

Honourable Minister, patients are being turned away. Patients are being told to go pay R900 for Dumiva at private clinics.

Stockouts is one thing. But there are also long queues, often demoralized healthcare workers, a lack of confidentiality. These are all symptoms of the mediocrity and dysfunction in our healthcare system.

We do not accept this.

We do not accept that the price we have to pay for accessing healthcare services is to give up our dignity.

So what do we ask?

We as the Treatment Action Campaign, the PLHIV sector and public health care users call for the urgent prioritization of health care through an access to healthcare ‘bailout’ starting with the  during the October budget review.  In real terms our health budgets have been falling while the need for healthcare services has grown. In simple terms, we need money so that we can employ more healthcare workers.

We urge government to root out corruption in our provincial healthcare systems and to ensure only appropriately qualified persons are appointed in these departments. We will hold you responsible if the co-epidemics of corruption and mismanagement are not dealt with.

We urge the new national and provincial administrations to prioritise the welcome back campaign, in order to trace people who are missing and link them back to care and treatment.

Our HIV response is already beginning to unravel.

In order to get it back on track, we have to transform our healthcare system into a place that affirms human dignity rather that degrades it.

Comrades, Deputy President, Minister, Premier, MECs, we are not anti-government.

But please understand that we are a membership-based organizations andour responsibility is to our members and to the poor.

We are guided by this responsibility and by the Constitution of South Africa and the right to access healthcare and the right to dignity.

We will work with government in instances where it is in the best interest of our members and of the poor to do so.

But we will also hold you accountable to the highest standards.

Our lives, our dignity, is not negotiable.

Amandla!

I thank you!

Why SA’s medicines regulator should consider affordability

By Tendai Mafuma and Nomatter Ndebele

Before any medicine can be sold in South Africa, it has to be approved by the South African Health Products Regulatory Authority (SAHPRA), who certify that the medicine is safe, of good quality and is effective. Unless the medicine has gone through these processes, it cannot be on the shelves for sale. In exceptional circumstances, SAHPRA may permit access to unregistered medicines. This exception is permitted by section 21 of the Medicines and Related Substances Act, 101 of 1965 through a process that is commonly referred to as “a section 21 application”.

Section 21 applications are typically used to access an unregistered medicine in circumstances where there is no version of that medicine that has been registered in South Africa. An example of this could be where registration of the medicine is pending but there is a need to urgently access that medicine in order to save lives. This was the case during the height of the HIV/AIDS pandemic, when organisations such as the Treatment Action Campaign used section 21 applications to get access to fluconazole for the treatment of HIV-related opportunistic infections. This provision may also often be relied on where a patient has sufficiently justified why they cannot use the registered product, for example if a patient can show that the unregistered alternative is not only superior in terms of safety and quality standards but will also have superior therapeutic effect on their health.

One of the questions that comes up regularly is whether the fact that a registered medicine is excessively priced is sufficient justification for seeking section 21 access to an unregistered alternative. Over the past decade, individual patients have sought access to unregistered medicines on the basis that the alternatives registered in South Africa are excessively priced, and therefore inaccessible. SAHPRA has routinely declined authorisation of the applications on the basis that cost is not a factor to be considered. Put simply, according to SAHPRA, if there is a registered medicine in South Africa, that would be effective for the diagnosed condition, you cannot request access to an unregistered alternative solely on the basis that you cannot afford the registered medicine. This means that if patients cannot somehow find money for the registered treatment, they will not access any treatment.

People with chronic health conditions such as cancer are particularly affected by this. We use cancer as an example because due to the astronomical costs of cancer medicines, very few patients are able to gather the money required for new cancer medicines.

Take for instance Hayley Stols who was diagnosed with stage 4 malignant metastatic myeloma. Her oncologist recommended treatment with Opdivo, a drug that was not registered in South Africa. At the time, there was a registered drug, Pembrolizumab which would have cost R1,8 million per year. Opdivo, on the other hand, would have cost R770 000 per year if purchased from the Netherlands. Whichever option Hayley chose, it would have had to be self-funded as neither medicine was covered by her medical aid scheme. It is difficult to imagine anyone in South Africa who has R1,8 million per year for one course of treatment. R770 000 is still a lot of money, but it is significantly less than R1,8 million.

Hayley made two section 21 applications to SAHPRA to request permission to access Opdivo. In both applications, she clearly stated that the reason for this request was that Opdivo was more affordable. Both applications were rejected.

There are a few exceptional cases where SAHPRA has approved section 21 applications on the basis of cost, for example applications by MSF for access to the TB medicine linezolid, but the fact is most of these applications are rejected. Patient advocacy groups have been trying to engage SAHPRA on this issue with little success.

In the past, SAHPRA has argued that the law does not empower it to make decisions based on cost and that its only mandate is to consider the “safety, quality, and therapeutic efficacy” of medications. This, in our view cannot be the only consideration.

Firstly, the Constitution doesn’t only guarantee the right to access to health care services, it also requires the State to take reasonable measures, within available resources, to achieve progressive realisation of the right. It also places an obligation on organs of state such as SAHPRA, to respect, protect, promote and fulfil fundamental rights. Moreover, the Constitution states that legislation must be given an interpretation that promotes the spirit, purport and objects of the Bill of Rights. This means that laws must be interpreted in a manner that will allow the enjoyment of rights to the fullest possible extent. As an organ of state responsible for ensuring that consumers have access to safe, quality and effective medicines, SAHPRA’s interpretation of the law should not be one that effectively hinders access to healthcare.

It also means that SAHPRA must develop and implement policies that do not undermine access to medicines. At the most basic level, access to medicines refers to the ability of all persons to receive the medicines necessary for the treatment of any condition affecting them. It entails physical, informational and economic access (i.e. affordability). This interpretation of access to medicines has been laid out by the courts. If SAHPRA does not concern itself with practical concerns about whether patients can afford medicines, that is tantamount to a failure of its duty to respect, protect, promote and fulfil the constitutional right to have access to medicines.

Considering affordability does not mean that SAHPRA must turn a blind eye to considerations of safety, quality and efficacy. Neither will it open the flood gates of section 21 applications as patients seek access to unregistered medicines even where the price difference is marginal. Rather, it requires an acknowledgement that there can be no access if the medicines are priced excessively and beyond the means of those who need them.

SAHPRA recently published a guideline aimed at ensuring that section 21 applications are received, processed effectively and consistently, and decided timeously. Despite SAHPRA already having dealt with several section 21 applications based solely on cost, the guideline makes no mention of how the entity intends to resolve such applications. Given the constitutional obligations, we think that it is about time SAHPRA begins to concern itself with matters of affordability of medicines. Failing to do so would be a failure to ensure access to medicines and a violation of the right to access health care services.

ARV stockouts putting lives at risk, says SSP

By Anso Thom and Marcus Low

LATEST NEWS! Updated circular on Lamivudine can be seen here

Stockouts of several critical medicines have been reported at healthcare facilities in five provinces, according to a statement from the Stop Stockouts Project (SSP). This includes stockouts of the antiretroviral (ARV) combination of Abacavir and Lamivudine and of various oral and injectable contraceptives. The Abacavir and Lamivudine combination is prescribed in the public sector to tens of thousands of patients who have become resistant to first line ARVs.

Following up on initial reports from users of the public healthcare system, Treatment Action Campaign (TAC) members are currently visiting healthcare facilities in the Free State and Gauteng to assess the situation. They are reporting stockouts of ARVs, paracetamol, flu medication, contraceptives, some antibiotics and HIV test kits. The TAC, together with various other civil society organisations, is a member of the SSP.

National Department of Health Director-General Precious Matsoso said they had sent technical teams to work with the TAC in an effort to identify affected facilities and patients. She said a circular was being prepared and will be sent to doctors with guidance on how to switch patients to alternative drugs.

The SSP says that several stockouts have been unresolved since the second half of 2018 and “the situation has now escalated into a crisis”.

They warned that scores of lives are at risk.

SSP’s Kopano Klaas said they had received stockout reports of second-line ARVs from the Free State, Gauteng, Mpumalanga, Limpopo and KwaZulu-Natal.

A list of stockouts supplied by the Treatment Action Campaign in the Free State reveals that since March there has been stockouts of the Abacavir/Lamivudine combination in at least 15 health facilities.

In the Mangaung Metro district it includes Mafane, Thaba-Nchu, Freedom Square, Bloemspruit and Gabriel Dichabe.

In the Lejweleputswa district the TAC reported stockouts at Rheederspark, Bophelong, Tshepong, Welkom, Leratong, Phomolong, Boithusong and Welkom.

In the Thabo Mofutsanyane districts stockouts were reported at Intabzwe and Qholaqhwe. The stockouts at Qholaghwe were understood to be mainly due to a break-in at the clinic.

Information from a TAC visit to Gabriel Dichabe Clinic in Bloemfontein suggests that there has been a breakdown between the provincial depot, the pharmacy, the clinic and patients. In cases where the clinic does not have stock, patients are given scripts so that they can purchase medicines at private pharmacies. The Medicines Price Registry lists a price of R921 for a month’s supply of the Abacavir and Lamivudine combination – likely out of reach for most public sector patients.

SSP also said that there had been repeated stockouts of injectables and oral contraceptives. Klaas said according to their information only one company was contracted to supply the oral contraceptive and because they were given very short notice they have been unable to keep up with the demand. Klaas also claimed that alternative companies were not interested in supplying the contraceptives as they were paid late or not at all.

The only alternative, an implantable device, is ineffective in women on ARV regimens containing Efavirenz, contained in most first line combinations provided in the public healthcare system.

“The SSP reports in to District, Provincial and National Departments of Health staff on a daily basis, but they seem to know as much or as little as we do. Surely someone needs to account to the scores of patients, who are travelling long distances to collect their medication, having to take a day off work to do so, only to be turned away when they get there?” Klaas said.

Deputy Director General in the NDOH Dr Anban Pillay said that there was a shortage of  Lamivudine globally and that the pharmaceutical company Mylan was unable to supply full order quantities.

He said they had secured a section 21 approval so that they can get stock from another source. Pillay advised facilities to manage the shortage by providing lesser quantities than usual for each patient.

On the contraceptives, Pillay said there should be no stockout but a shortage of the injectable nuristerate. “This is due to the only supplier Bayer being unable to produce sufficient quantities relative to demand. SA is one of a few countries using nuristerate,” he said.

Note: Spotlight is published by SECTION27 and the TAC – both of which are members of the SSP. Spotlight is editorially independent and a member of the Press Council.

Regulatory barriers to life-saving and affordable HCV medicines can be overcome

Hepatitis C (HCV) is a viral infection of the liver that is transmitted through blood. HCV can be spread through blood transfusions, organ donations, needle stick injuries, injecting drug use and other blood exposures. The vast majority of people with untreated HCV will develop chronic hepatitis C infection, which can lead to serious and life-threatening liver conditions including liver damage, cirrhosis and cancer. The prevalence of HCV in South Africa is unknown due to inadequate screening. While prevalence in the overall population is believed to be low (under 1%), screening initiatives have indicated higher prevalence in certain populations. For example, a recent screening initiative in Cape Town showed an HCV prevalence of 3.4% in HIV-positive men and 5.6% in HIV-positive men who have sex with men. This was confirmed in another study. In addition, a viraemic prevalence of 50% has been demonstrated in people who inject drugs (PWID).

Until relatively recently, the gold standard of HCV treatment globally consisted of the medicines pegylated interferon and ribavirin. This regimen required patients to withstand lengthy treatment with difficult side effects and inadequate cure rates. The introduction of a new generation of direct-acting antivirals (DAAs) from 2013 onwards has been heralded as a “game-changer” for HCV. The new drugs which can be taken orally, have significantly shorter treatment lengths (generally 12 weeks), fewer side effects and cure rates of over 95%.

While new generation DAAs provide significant and game-changing benefits to patients, the high costs charged for patented DAAs has been a considerable barrier to their use and scale-up globally. However, patents should not be a barrier to use in South Africa, where voluntary licenses allow for generic versions of key DAAs to be marketed. Bilateral licenses between the pharmaceutical company Gilead and generic companies allow for the use of generic sofosbuvir on its own and in combination with ledipasvir or velpatasvir. Medicine Patent Pool (MPP) licenses also allow for use of generic daclatasvir and glecaprevir/pibrentasvir. (All of these are considered important DAAs for the treatment of HCV – which typically requires two or more DAAs).

Yet, despite the fact that there are licenses in place allowing for generic sale and use in the country, no generic versions of these new generation DAAs have so far been registered in South Africa. The lack of registered products has required patients and doctors to use alternative pathways to access these life-saving treatments in the country.

Groote Schuur hepatologists Professor Mark Sonderup and Professor Wendy Spearman have previously described the difficult journey faced by one of their patients in accessing affordable DAAs in South Africa. The patient described as a businessman in the import and export business learnt about the life-saving benefits of HCV DAAs sofosbuvir and daclatasvir and started exploring options to import the unregistered medicines in South Africa. However, he soon learnt that the pharmaceutical companies holding patents on sofosbuvir and daclatasvir were charging astronomical prices for the drugs. Unable to afford the cost of patented drugs, the South African businessman flew to China and bought sofosbuvir and daclatasvir’s active pharmaceutical ingredients, which he dispersed into empty capsules for his personal use. He later contacted Sonderup and Spearman to inform them of what he had done in the hope that it could help other patients. Sonderup and his colleagues advised the patient that they could not engage in any activities that contravened South Africa’s laws to bring unregistered products into the country and highlighted the potential dangers of developing one’s own drugs from active pharmaceutical ingredients, including the inability of the patient to ensure that what he bought was not mixed with toxic chemicals, or that it was properly formulated to ensure that it is safe and effective.

On testing the patient, Sonderup and Spearman found that while the patient’s attempt at self-treatment initially lowered his HCV viral load, it did not cure his disease. Together the clinicians and patient explored ways to legally import quality approved sofosbuvir and daclatasvir into the country. Their efforts opened up an important pathway for people living in South Africa to access new, life-saving HCV drugs. The clinicians found that while patented medicines remained unaffordable to the vast majority of people living in the country, generic HCV medicines had started entering the global market at substantially reduced prices – due to a combination of strategies to overcome patent barriers in the global South, including patent oppositions and challenges, voluntary and compulsory licensing.

Using Section 21 authorisations granted by the South African Health Products Regulatory Authority (SAHPRA), Sonderup and his colleagues began legally importing unregistered generic DAAs to South Africa for HCV treatment in patients. Section 21 authorisations refers to section 21 of South Africa’s Medicines Act, a section that contains provisions that provide for the importation of medicines that are not registered in South Africa. To date, more than 200 patients have been treated with DAAs imported with Section 21 authorisations.

Generic products that have been imported into the country using this regulatory pathway include generic sofosbuvir, sofosbuvir/ledipasvir, sofosbuvir/velpatasvir and daclatasvir. However, the pending registrations of Gilead’s patented sofosbuvir, sofosbuvir/ledipasvir and sofosbuvir/velpatasvir threatens to extinguish this important access pathway for sofosbuvir and sofosbuvir combination products. This is because Section 21 importation is often not allowed once there is a registered product on the market in South Africa, even if the product is unaffordable.

Something similar to this recently happened in South Africa following the registration of the patented cancer medicine lenalidomide, which is used to treat multiple myeloma. Prior to the 2016 registration of the pharmaceutical company Celgene’s patented lenalidomide in South Africa, multiple myeloma patients were able to access generic lenalidomide from India at around R4,000 per month (including importation costs) through Section 21 authorisations. After the registration of the patented product these authorisations were refused, leaving patients to pay over R70,000 per month for the same treatment they previously imported for a fraction of the price. With pro-bono legal support, the Cancer Alliance has been able to assist previously treated patients in challenging the refusal of their Section 21 re-authorisations to access further generic lenalidomide treatment. However no new patients have been authorised, so all new patients must now pay the exorbitant prices for the registered patented product – or forgo this treatment.

Similarly to the lenalidomide case, the pending local registration of patented sofosbuvir products threatens to end Section 21 authorisation for use of generic sofosbuvir products in the country. The exorbitant prices likely to be charged by patent holders will block treatment access for most new patients that could benefit from this treatment. Yet, unlike for lenalidomide, there are voluntary licenses in place that allow for the sale and use of generic sofosbuvir products in South Africa as soon as they receive registration by SAHPRA. Unfortunately, experience shows that SAHPRA registrations are often extremely slow – and regulatory delays could thus interrupt access to generic sofosbuvir products in the country for years after the registration of patented products.

SAHPRA has however committed to clearing the backlog of applications that contributes to regulatory delays. In order to do this, the regulatory body will need to employ new strategies to speed up medicine regulation including through use of so-called “reliance pathways” that allow for SAHPRA to better utilise and rely on resources and decision making of other stringent regulatory authorities (such as the US Food and Drug Administration and European Medicines Agency) and the World Health Organization (WHO) in informing domestic decisions.

One of these reliance pathways is the WHO’s collaborative procedures for accelerated registration of medicines that have undergone regulatory review and received prequalification by the WHO. Through the collaborative procedures national medicine regulatory authorities can access regulatory evaluations and related information for medicines that have been prequalified as safe and effective by the WHO. Countries that use this process must commit to reaching national decisions within 90 days of receiving regulatory data from the WHO. This procedure has already been used to register generic sofosbuvir in Botswana, Zambia, Malawi, Zimbabwe, Ukraine and Thailand.

While South Africa has agreed to participate with the WHO’s collaborative procedures for accelerated medicine registration, to date it has not used these procedures to register a single medicine locally. Sofosbuvir offers an important ‘test case’ that South Africa can use to test these procedures as a reliance mechanism to speed up domestic registration of medicines – while simultaneously securing access to life-saving generic sofosbuvir.

Health advocates and the Department of Health should encourage generic companies whose sofosbuvir products have WHO prequalification (Mylan, Hetero and Cipla) to file for domestic registration as soon as Gilead’s sofosbuvir is registered and call on SAHPRA to use WHO collaborative procedures to accelerate rapid domestic registration. This procedure can also be used to secure access to generic sofosbuvir/velpatasvir and sofosbuvir/ledipasvir as soon as generic products under review by the WHO receive prequalification.

In addition to using WHO registration pathways, SAHPRA must develop new pathways for registering generic products when originator products are not yet registered in the country. Originator products may not be registered due to a lack of interest of originator companies in registering and marketing their products in South Africa – or delays by SAHPRA in registering originator applications.

Generic companies that have filed for registration of generic products that do not have a domestically registered originator have previously been told by SAHPRA that they need to provide their own clinical data. SAHPRA’s requirement for generic companies to submit their own clinical data effectively blocks generic companies from entering the market – as it is generally not financially feasible or ethically possible for generic companies to repeat clinical trials for their products. When originator products are registered, generic producers are able to rely on originator’s clinical trial data and must simply demonstrate bioequivalence with the originator product for registration – meaning that the two products are the same for all intents and purposes.

Previous experiences with SAHPRA have disincentivised generic producers of HCV DAAs from seeking registration in the country when originator products are not registered. To overcome this challenge, SAHPRA must create regulatory pathways for generic companies to enter the market when originator products are unregistered. Again, SAHPRA could utilise “reliance pathways” to access unredacted regulatory data and assessments from other stringent regulatory authorities with which it is aligned and has confidentiality agreements that have already registered relevant originators. Registration of generic daclatasvir could provide an important test case for use of this reliance pathway – despite licenses in place allowing for generic daclatasvir sale in South Africa since 2015, the originator producer Bristol-Myers Squibb has not filed for registration or indicated that it will seek domestic registration in South Africa.

While Section 21 authorisations currently provide an important access pathway to generic daclatasvir and sofosbuvir products in South Africa, the cumbersome nature of these procedures prevents broad access for all patients that could benefit from these medicines. However, despite their limitations, Section 21 procedures (which are currently under review) remain vital to securing access to unregistered products and should be expanded to explicitly allow for importation of unregistered generic products when the costs of registered originator products are prohibitive. There is precedent for this reform, as SAHPRA (when under the banner of the MCC) has previously authorised the importation of unregistered generic fluconazole and linezolid, used to treat HIV and TB respectively, on affordability grounds when patented products registered in the country were unaffordable. Section 21 approvals may also be used to allow for bulk importation of stock on other public health grounds, such as to address shortages of registered products.

As South Africa moves to adopt a viral hepatitis treatment policy, the registration of generic versions of key medicines (including sofosbuvir, sofosbuvir combination products and daclatasvir) will be critical to enabling an effective HCV response in the country. Regulatory barriers and delays have prevented the registration of affordable generic versions of key HCV medicines to date – and important access pathways secured through Section 21 authorisations are under threat. Through employing new reliance pathways, SAHPRA can begin to register key generic products. Health advocates and the Department of Health have an important role to play in highlighting the need for and encouraging SAHPRA to urgently use these pathways.

 

 

Donor shift threatens adherence clubs in the Free State

Mosamaria’s Connie Motsoeng addressing an adherence club at Pelonomi Hospital in Bloemfontein Photo by Khothatso Mokone

A shift in donor funding for HIV has endangered the continued existence of successful and effective antiretroviral adherence clubs in the Free State.

The Mosamaria project, an NGO-run adherence club project based in Mangaung, has in the last five years reached 25 000 people through 21 health facilities and achieved a 98% patient retention rate. The clubs operated on a R4 million a year budget, which translates into about R161 per patient, per year.

These gains are in danger of being reversed as donor support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) shifts to other programmes.

Right to Care (a large national NGO), which for five years has been a primary recipient of money from the GFATM, has been distributing funds to Mosamaria. The GFATM distributes funds to a series of so-called primary recipients in South Africa, who then distribute it to specific projects.  Right to Care is no longer a principal recipient of GFATM funds and none of the new primary recipients will be stepping in to fund the Mosamaria Project. The key reason for this appears to be that South Africa’s country coordination mechanism (CCM – a committee that submits funding applications on behalf of the country) decided last year that no further application to the GFATM to support community adherence clubs would be undertaken. The CCM is administered by the South African National AIDS Council (SANAC).

Mosamaria’s funding for adherence clubs came to an end on 30 March 2019.

As a result, the Mosamaria project is in the process of being shifted to the Free State health department, a risky move in a province with a poor track record when it comes to health and more especially HIV.

That adherence clubs are part of the solution to South Africa’s HIV epidemic is now widely accepted. The clubs have been a model of successful HIV management since they were first piloted by MSF (Medicins Sans Frontieres) in Khayalitsha in the Western Cape in 2007. By filtering stable HIV positive patients into the clubs it helped patients receive their medicines on a fixed schedule and helped them save time by avoiding regular long hospital or clinic queues. Peer support is also a key part of adherence clubs.

As a result of successful pilot projects, adherence clubs as a model was adopted, along with CCMDD (Centralised Chronic Medicine Dispensing and Distribution) and Fast Lane dispensary services as part of the National Department of Health’s ARV adherence policy.

What clients say

Patients’ adherence club logbooks Photo by Khothatso Mokone

Bloemfontein local Margaret Baratang is one of the Mosamaria patients at Pelonomi Hospital in Bloemfontein. On the morning of her last club meeting with the Mosamaria team, Baratang was angry and deeply anxious.

“These people [Mosamaria facilitators] treat us nicely. I’ve been coming to the club for three years. Every time I’m here 30 minutes then I can go. Now if we must go back to the hospital queue and we will have to wait for two or three hours, I’m telling you,” she says.

She talks as she shuffles up the rows of seats. The queue moves fast. In her hand is her club booklet. It’s covered in decorative wrapping paper. Most of the patients have done the same – they are a support group after all. The foil wraps, the prints of flowers and butterflies represent their care and respect for a club model that’s come to represent service and significance in their lives.

Others in the queue with Baratang include a man who works as a driver. He’s juggling car keys and says he is irritated. His HIV status is his private business and the club model respected this he says, by allowing him to arrive every second month, have a basic medical screening, receive his medicines and still arrive at work on time. Now he will have to explain to his employer and colleagues why he has to take a whole morning off every second month to be at the hospital.

Another patient, Boitumelo Mokeane, launched a petition to the Free State MEC for Health. In representing “concerned people living with HIV”, she said in her petition that patients deserve access to quality healthcare. She raised fears that the Mosamaria facilitators’ expertise would be lost and that CHWs would not be able to cope. Over time Mokeane also said people would default because collecting medicines would become too much of a hassle.

“We don’t want the situation where we have to start from scratch in adjusting with new people and new systems,” she says.

Mosamaria workers host one of their final adherence club meetings. Photo by Khothatso Mokone.

CHWs assigned to take over

With the absorption of the project into the Free State Department of Health, community healthcare workers (CHWs) have been assigned to take over the running of the clubs. Mosamaria facilitators spent the last few weeks while they were still employed, training the CHWs. It was a scramble against time as the Free State’s Chief Director of district health service and health programmes only sent out an internal memo on 6 February. It was a memo to the three affected districts of Fezile Dabi, Mangaung Metro and Xhariep to identify two CHWs per facility to be trained to run adherence clubs. It was also only in February that the Department met with NGOs for a “transitioning meeting”. This was less than two months before Mosamaria was scheduled to wrap up its operations.

Thapelo Mabule, Mosamaria’s outgoing programme manager for the adherence clubs, says often CHWs didn’t show up for training sessions in those weeks.

“CHWs are being paid a stipend by the department of health, not salaries so maybe they don’t care enough to come for training. The clubs as we know them will collapse the minute we hand them over,” he says.

His seems a realistic assessment, because without the structure, that includes salaried facilitators trained in record keeping, monitoring and evaluation and managing patient loads and communicating with the pharmacy for filling pre-packing scripts, the club model has a slim chance of succeeding.

Free State Department of Health spokesperson Mondli Mvambi however, is confident there will be few disruptions. He says: “The transitioning of Mosamaria will not negatively influence the patients as the clubs will continue using the principles outlined in the National Adherence Guideline Standard Operating Procedure. When the project was started the Free State Department of Health was aware that funding was only for a limited period of time, hence the province has worked on a transitioning plan for when funding comes to an end.”

He adds that in addition to the two CHWs assigned to each club, each facility will have a nurse and an operational manager for continued implementation of the clubs and other differentiated care interventions.

“Patients trusted us”

Mosamaria’s Connie Motsoeng Photo by Khothatso Mokone

For Connie Motsoeng, a Mosamaria club facilitator, walking away is tough. She says: “We are losing something that we love. Patients trusted us and now we worry that they will suffer without properly run clubs.”

She’s also worried because she has a baby on the way – her second child. She’s one of 39 facilitators and administrators who are now jobless as their posts were funded through Right to Care funding.

According to Mabule, communication with Right to Care has been minimal. Mosamaria were notified that their funding would be discontinued in mid-October last year and they had a close-out meeting with Right to Care in Johannesburg, but not much else has been communicated.

According to Right to Care discussions with Mosamaria were initiated in October 2018 to indicate that the funding will come to an end in March 2019. “Representation to the CCM were undertaken to indicate that adherence clubs will require continued support.  The Department of Health indicated that transition plans would be made,” Right to Care said in response to questions from Spotlight. Going forward, Right to Care will provide adherence club services in Ehlanzeni and Thabo Mofutsanyane districts in the Free State with support from the United States government.

By the beginning of December Mosamaria fired off hopeful funding proposals to new Global Fund South African principal recipients and also notified the provincial department of health of the situation.

Trudie Harrison, a Mosamaria co-ordinator, says one local principal recipient didn’t respond, another told them to wait till February to submit proposals. A month after that they were told HIV adherence clubs would not be funded.

“Five months is not enough time to close out a project like this. We did assume that one of the other local principal recipients would continue funding the clubs because they have proven to work so well.

“We are a small organisation but instead of being in the field, we end up spending more time writing proposals, stuck in meetings and following up with would-be funders,” says Harrison.

She adds: “International donors do not consult sufficiently, if at all, with the people who are actually implementing programmes in communities. We just get told by principal recipients ‘the Global Fund has decided …’ without any reasons why this has happened.

Government’s responsibility

Lynne Wilkinson, a differentiated service delivery consultant with the International AIDS Society, says closing out plans need to be properly and effectively managed so there is seamless transfer and patients are not put at risk or under any anxiety over the future of their care.

Wilkinson, who was involved with MSF’s first clubs launched in the Western Cape (that now are run by the Western Cape Department of Health), says it remains government’s responsibility to ensure that adherence club models are not compromised, even as outside funders’ priorities shift.

“The national adherence policy guidelines are in place to ensure that stable patients can access their medication as easily as possible throughout the cycle of lifelong treatment,” Wilkinson says.

She adds too that it’s adherence clubs that have over time proven to be the cheapest most effective model of keeping patients on treatment. She says: “The government’s target is to get another two million people on ARV treatment by 2020, it means we need to use every resource we have. So when an organisation like Mosamaria has successfully built up clubs that have proven to be successful and cost effective, they should be supported and funded, not allowed to fall away.”

South African National Aids Council (SANAC) CEO Dr Sandile Buthelezi drives home the point that donor funding is finite. He says: “Principal recipients [like Right to Care] are aware that their funding is for three years. It is therefore imperative that sustainability plans and transition plans are part and parcel of the application, and the Oversight Committee of the Country Co-ordinating Mechanism ensures that these plans are followed and implemented. In addition, the main reason for the Department of Health to always be part of principal recipients is to ensure that this transition takes place.”

He says SANAC, through its Resource Mobilisation Committee, will canvas for more domestic and donor funding to ensure that ARV adherence is implemented and that South Africa continues to wean itself off foreign donor funding.

AIDS2018: Reduction in price of bedaquiline welcome, but is it enough?

This week the price of bedaquiline in the public sector in South Africa was cut in half. What does this mean for the increased uptake of this critically important TB drug across the world?

This week at the International AIDS Conference South Africa’s Minister of Health Dr Aaron Motsoaledi announced that the South African government had negotiated a much-reduced price for the multi-drug resistant tuberculosis (MDR-TB) drug bedaquiline.

Bedaquiline is something of a break-through drug being one of only two new TB drugs approved in the last half-a-century. The South African government recently announced that bedaquiline will replace kanamycin injections in the country’s standard treatment for MDR-TB. This decision has been widely welcomed given the serious side-effects, such as irreversible hearing-loss, related to the painful injections. It is expected that the World Health Organization and other high-TB-burden countries will follow South Africa’s lead.

The new price announced by Minister Motsoaledi is $400 (around R5400) for a six-month treatment course. This is down from a price of $750 according to Motsoaledi. The figure quoted to Spotlight by the Department of Health last month was $820. Either way, the South African government has managed to negotiate a price drop of around 50%. For this they deserve credit.

More good news is that the new price will also be available to countries purchasing bedaquiline through the Global Drug Facility and to countries that benefited from the soon-to-end bedaquiline donation programme. It is now up to these countries to update their MDR-TB treatment guidelines and to ensure that all people who can benefit from the drug has access to it. So far, uptake of bedaquiline outside of South Africa has been depressingly poor and many people are still being exposed to hearing-loss causing injections of doubtful efficacy.

And yet, even the $400 price is far from ideal. Researchers from the University of Liverpool have estimated that bedaquline could be produced and sold at a profit for under $100. The researchers did however assume much larger volumes than current demand – so that price might not be realistic right away. It is with this in mind that activists recently demanded that bedaquiline should be priced no higher than $200 for a six-month course. Whether this demand played a role in the price-cut is not known.

For some perspective, a year’s supply of first line antiretrovirals costs the South African government about $100. Six months of drug susceptible TB treatment (a full course) costs less than $30. It should also be kept in mind that bedaquiline is just one of multiple drugs used for MDR-TB and the entire MDR-TB drug regimen will thus cost much more than $400.

It seems likely that for bedaquline to become available to all people who need it across the world the price will have to be dropped further. Then said, this week’s price-cuts is a firm step in the right direction. It is now up to countries to start scaling up use of this drug and over time to negotiate further price cuts.

Low is both an editor of Spotlight and a member of the Global TB Community Advisory Board, one of the organisations that demanded a reduction in the price of bedaquiline. The views expressed in this article are his own.

AIDS2018: Time to make AIDS political again

By Anele Yawa

Two years ago, we welcomed the world to the International AIDS Conference

Anele Yawa at the Durban2016 march

in Durban, South Africa. At a march of ten thousand people we held up banners proclaiming that 20 million people still need treatment. At that conference we said to the world that AIDS is not over – and indeed, the misguided rhetoric about the end of AIDS have now given way to more sober, more realistic assessments. The reality is that we are still in the thick of it.

In South Africa, as in many other countries, the first phase of the global AIDS response was a fight for policy. It was a fight for the idea that governments have a responsibility to do whatever they need to do to get HIV treatment to the people who need it. In our country it involved various court cases and a fight against AIDS denialism. Around the world it required a massive effort by activists, researchers, diplomats, progressive business persons and willing governments. Our shared success is something to be celebrated.

That said, the victories of this first phase of our struggle against HIV has to be won again and again. We cannot take the recognition of the human rights of all people for granted nor can we take the affordability of medicines for granted. As we hear reports of plans to shut down UNAIDS without any public consultation, we can’t take even United Nations support for granted. As we know too well, we can’t take continued political will or funding from our governments for the AIDS response for granted either. All this work from the first phase of the AIDS response must continue and we must support each other in it.

Almost everyone agrees today that we need to provide prevention, treatment and care to all who need it. The wide adoption of the 90-90-90 targets are testimony to that consensus. We have reached a point in the AIDS response where the question is not so much what to do, but rather how to actually get it done given the state of our healthcare systems.

We now know that policy victories and innovative technical interventions can only take us so far. In South Africa, and in many other countries, the AIDS response has come up against a wall. This wall is the widespread dysfunction in our healthcare systems. It doesn’t matter how good our donor-written policies are if they are never implemented. It is no use if we have medicines in depots, but the medicines never reach the people in the clinics. Beautiful guidelines for treatment and care mean little if we refuse to employ healthcare workers to actually provide the treatment and care.

As TAC we we are very clear: Our struggle against HIV is now in a new phase, a phase where our fundamental struggle is against dysfunction, mismanagement and corruption in our public healthcare system.

This new phase of our struggle is, in its way, much harder than the struggles against AIDS denialism and profiteering pharmaceutical companies. There are fewer victories to be had in laws or in policies. The problems we face are much more diffuse and harder to influence. Meetings in board rooms in Geneva, New York or Amsterdam matter less in this phase of our struggle, while community meetings in Lusikisiki and Khayelitsha matter more and more.

As TAC we have in recent years attempted to create accountability across the public healthcare system in South Africa. Our 200 branches spread across the country have each adopted a clinic – where our members, all users of the public healthcare system, both monitor and provide support where possible. Where issues persist, we escalate them to district or provincial level, and if needs be to the National Department of Health. Let me be clear, the more we monitor, and the more systematically we monitor, the more disturbed we get about the near collapse of our public healthcare system.

Our recent monitoring reports on seven of South Africa’s nine provinces paint a very bleak picture. In these and in our previous reports, it has become clear that TB infection control measures are grossly deficient in many facilities – turning many clinic waiting areas into likely transmission areas. Our diagnosis of widespread dysfunction in public sector facilities is confirmed by devastating reports from the Office of Health Standards Compliance (a statutory health inspection body that reports to parliament).

The crisis in many of our public facilities does not come from nowhere. Over the last decade, on the watch of former President Jacob Zuma, corruption has flourished in South Africa and the public service has been systematically hollowed out. This has directly impacted the healthcare system and the AIDS response.

It is worth recounting some details. Recently in emerged that millions ear-marked for HIV in the North West province was looted to pay overinflated prices to a controversial ambulance company that is now the subject of police investigations. This is while over 200 000 HIV treatment eligible people in that province are not yet on treatment.

In the same province strikes resulted in the shutdown of the public healthcare system, a shutdown that meant medicines distribution had stopped completely for weeks on end. Some shared treatment with others, others paid high prices in private pharmacies, many simply defaulted. These strikes, and a similarly disruptive strike at a Gauteng hospital, suggest that more healthcare workers are now prepared to strike in ways that place patients at risk. It tells us that the ethos of public service has dangerously eroded.

Of course, there are still many good people trying to do their best within a failing system. The tragedy though is that there is so little help for them. While some politicians come when there is a strike or a protest, they generally show little interest in fixing the underlying problems plaguing the system. Indeed, many officials in provincial departments of health have been appointed for political reasons or with corrupt motives and have neither the inclination or the ability to start turning the system around. And even with Jacob Zuma gone, the balance of powers in the ANC is such that many corrupt and underperforming persons remain firmly in place.

Part of why Cyril Ramaphosa is now President of South Africa is a deal he made with David Mabuza, the former Premier of Mpumalanga province and now Deputy President of South Africa. Mabuza has generally been associated with some of the more unsavoury characters in the ruling party and on his watch Mpumlanga politics was mired in alleged corruption. As Deputy President Mabuza is also now the new head of the South African National AIDS Council, a body already ridden in controversy over the way it removed its former CEO and its failure to deal decisively with conflicts of interest. While Premier in Mpumlanga and chairing that province’s provincial AIDS council, Mabuza failed completely to address that province’s severe HIV crisis, not to mention the general corruption of that province’s government.

That Mabuza is now making some of the right noises on HIV and TB is of course welcome and we will hold him to his words. That our government has finally approved a progressive new policy on patents and medicines 17 years after the Doha Declaration is also welcome. That our Department of Health has shown urgency in introducing new medicines such as bedaquiline for MDR-TB and dolutegravir for HIV is to be applauded.

But, as Minister Aaron Motsoaledi recently admitted, South Africa’s healthcare system is in crisis. From our national department he has tried to stop the crisis, but in South Africa the healthcare system is run by provinces and Motsoaledi has been powerless to get the provinces into line. The underlying reality is that inside the borders of South Africa, our internationally popular Minister is severely hamstrung by his lack of political power.

Ultimately, as with all the issues we faced in the first phase of our struggle, the second phase is also fundamentally political. And as we have to address the patronage networks within our ruling party in South Africa, we call on our international allies to address the distorted values of the current United States administration and to seek out again the international solidarity that made our movement as successful as it once was.

As the world gathers in Amsterdam for the 22nd International AIDS Conference, my appeal to you is to once again make AIDS political. Just like the gag rule and Global Fund withdrawal is political, the failure in my country to act against corrupt individuals is political. The potential shutdown of UNAIDS and the mishandling of sexual harassment at the agency is political. In recent years we have too often played nice with our elected leaders and as a result they have come to believe that AIDS is almost over. We must once again take the gloves off and make AIDS political. We have elected our leaders, we demand that they deliver the AIDS response and the healthcare systems we need.

Anele Yawa is the General Secretary of the Treatment Action Campaign. The TAC is a South African membership-based organisation that advocates for the rights and interests of people living with and affected by HIV and TB.

NHI Bill: Welcome but flawed

By David Sanders & Louis Reynolds, People’s Health Movement South Africa

The People’s Health Movement South Africa (PHM-SA) welcomes the National Health Insurance (NHI) Bill in that it confirms Universal Health Coverage (UHC) through a single payer system as the platform for the delivery of health care. The goal of UHC is to realise the right to comprehensive health care of good quality for everyone on the basis of need, while ensuring that no one experiences financial hardship in accessing the care they need.  Comprehensive care includes promotive, preventative, curative, rehabilitative and palliative health services regardless of people’s socio-economic or health status.  The NHI should be funded through a solidarity mechanism where there is a cross-subsidy from the rich to the poor via taxation.

Although we are supportive of the principles that underpin the NHI, PHM has several reservations about whether the Bill can deliver UHC. More broadly, we remain deeply concerned about government’s ability to steer this ambitious project in the context of South Africa’s deep-seated and multi-pronged health crisis.

Administration of the NHI Fund

The Bill makes clear that the NHI Fund will be overseen by a Board of ten persons appointed or approved by the Minister. It will be the only purchaser of health services from accredited providers – public and private – and will ensure equity and efficiency in health care. A unitary system with the National Health Insurance Fund (NHIF) as the single purchaser of services allows for strategic purchasing of those services that are necessary to reach defined health goals. .

A justifiable concern, expressed by a number of analysts and based on experience of state-owned enterprises, is the potential that exists for this enormous fund to be looted.

Services free at the point of use will be provided to permanent residents while documented refugees and asylum seekers will be eligible for free emergency services, care for conditions of public health importance (presumably TB, HIV and other infectious diseases) and services for paediatric and maternal conditions.

Services not reimbursed by the fund (i.e. not part of the defined ‘package’) can be paid for through medical schemes or out-of-pocket. All users are required to be registered with a primary care provider (presumably a clinic, health centre or general practitioner) and will have to attend such a provider before being eligible for specialist care.

Services provided under NHI

The details of what services are to be funded (the benefit package) are not provided. It is hoped that the benefits package will be identical for all users of NHI-funded providers. However, the Government Gazette of July 2017 titled ‘NHI Implementation: Institutions, bodies and commissions that must be established’ describes the proposed funding arrangements for five different groups: the unemployed, the informal sector (such as taxi industry; hawkers, domestic workers), those in formal sector employment (bigger business), those in formal sector employment (small and medium size business), civil servants (including SOEs, Intelligence Agencies, Defence, Police Service). This is a concern, since it implies that there will be different packages for different groups. Although this arrangement is said to be ‘transitional’, experience from other countries shows that it is very difficult to change such benefits packages once they have been in place for any length of time. It is likely that the poorest and sickest in our country will receive the most limited package of services. If this occurs it will increase already existing inequality.

A ‘Benefits Advisory Committee’ will decide what the content of these packages will be. This important body has representation from all medical schools, provinces, private hospitals, medical schemes and the World Health Organisation (WHO) but none from civil society or labour. This will be supported by a Health Benefits Pricing Committee which also has only technocrats.

There is no room in these committees for meaningful public participation. This will bias their work and decisions towards hospital-centred specialist care and a narrow biomedical approach. It is essential to include civil society and labour on these committees.

Their proceedings should also be open and transparent, and accountable to the Minister and Parliament. In particular, they must be accountable for the reasonableness of their choices of the benefits they include in the package. The reasoning behind their choices should be open to public scrutiny, including the evidence upon which they are based and how they apply in local contexts.

Only the Stakeholder Advisory Committee, a large body that merely advises the Minister, has representation from indigenous practitioners, NGOs and civil society, although they are greatly outnumbered by representatives from professional and statutory bodies.

How will NHI purchase services?

Purchasing of services is intended to be devolved to provincial and district level hospitals and at sub-district level to contracting units for primary health care. District Health Management Offices are intended to play a coordinating role.

Justifiable concern has been expressed about whether these sub-district and district entities will have the capacity to undertake such detailed and complex activities. The mechanisms for payment of accredited service providers are vague in the Bill and it is strongly rumoured that medical schemes may be enrolled to perform this function. PHM-SA is concerned that the greater likelihood of urban and private providers being accredited than public and (especially) rural providers, holds the danger of aggravating already existing urban/rural inequity. For example, the great majority of medical specialists and therapists of various kinds are overwhelmingly located in large metros, especially in Gauteng and Western Cape. This effectively means that public tax money will be used to fund a service that will likely cater preferentially for the better-off living in urban areas.

Transitional arrangements

The Bill specifies transitional arrangements that consist of three phases extending to 2026. The current second phase will focus on establishing institutions that will form the basis for the Fund, as well as on interim purchasing of personal health care services. Phase 3, from 2022 to 2026, will establish the necessary structures and be guided by two committees – the National Tertiary Health Services Committee and the National Governing Body on Training and Development. These will be responsible for a Human Resources for Health (HRH) development plan.

PHM has two concerns about these arrangements: Firstly, an HRH plan is required urgently to ensure the development of a robust public health sector, especially at district level and below, so that the NHI can operate effectively and efficiently in formerly underserved areas. Secondly, given their unimpressive record to date in transforming health sciences education and training, it is unlikely that these structures, whose composition has been proposed to include mainly hospital-based clinicians and educators, will implement an appropriate HRH plan.

The Ministerial Advisory Committee on Health Care Benefits will be a precursor to the Benefits Advisory Committee which will advise the Minister on priority setting. Although the composition of this structure is not specified in the Bill, the 2017 gazette discussed above proposed a composition in which senior government officials and medical scheme representatives predominated. This structure too creates a concern that the emphasis will be on facility-based clinical medicine and that primary and community-level care will be marginalized, as will prevention activities.

The context: the national health crisis

While the crisis in the public health sector is front-line news today, the private sector is in a crisis of its own — a crisis of growing medical scheme unaffordability,  shrinking benefits and static or declining  membership.

The roots of the crisis lie in the systematic underdevelopment and structural inequality enforced by apartheid. Its more immediate cause is the neoliberal Growth, Employment and Redistribution (GEAR) macroeconomic policy adopted by the ANC-led government in 1996.  GEAR follows the free market fundamentalist mantra of public sector austerity, privatisation of public services and goods, trade deregulation and low corporate tax. It is failing in all 3 of its components: growth is poor, unemployment rampant, and we remain one of the most unequal countries in the world.

More than 2 decades of austerity, combined with a deepening culture of corruption, have aggravated both facets of the national health crisis. Firstly, the state has failed to address inequity in access to the social determinants of health (SDH) such as sufficient quality food, water, sanitation etc through poor service delivery and growing unemployment and income inequality, thus aggravating the burden of disease. Secondly, the tight financial constraints imposed on the public health sector by austerity, together with a growing and increasingly pervasive culture of corruption, has led to loss of posts and skills, deteriorating infrastructure, and demoralisation of staff at all levels of the system. The fact that rigid austerity was forced on the public sector in the face of the burgeoning and badly-managed HIV-AIDS pandemic of the 1990s made it all the more devastating.

Strengthening the public health sector

Before the public health sector can participate in the NHI it will need to be strengthened substantially, especially in terms of its physical infrastructure, human resource base and their skills, especially in leadership and governance. These imperatives will require strong political will and significant funds. Government has little option but to provide such funding, since the current health crisis is untenable. Although the upfront financial commitment will be large, the returns on investment are potentially even greater – as a result of savings on long-term health care, improved economic productivity of a healthier workforce, and the multiplier effect in the economy of having a larger number of employed people, especially rural women.

Financing the NHI

The Bill says very little about possible sources of funding for the NHIF, but there are no real options other than through taxation and an end to austerity budgets. PHMSA believes that progressive income tax — a surcharge added to the normal income tax at an increasing percentage — would be the best option. The principle that those who can afford it pay more, while those who need more health care receive more care, also builds social solidarity. The retrogressive recent increase in VAT adds to the tax burden of poor and working class people and exacerbates inequity in access to the social determinants of health through increased prices on some essential commodities.

There is no doubt that increases in revenue from tax are necessary to strengthen the public sector and finance the NHI. This may be difficult politically, but we believe there is room for such increases. Forslund notes that, because tax brackets have increased faster than inflation, the tax burden on the middle class and the rich has decreased substantially over the past decades. He points out that if the government had merely kept personal income tax stable since 2005/06 – by raising tax brackets strictly at the rate of inflation – personal income tax would have added more than R150 billion to the present budget. This would have made financing the NHI easier even before raising additional tax.

The alternative to tax is to borrow, which means eventually paying more and more government income towards debt servicing and away from delivering services.

Corruption

It is also essential to root out corruption. Corruption weakens the state, delegitimises taxation, destroys public services, and ruins the social fabric. Corruption thrives in dark spaces where the public and private sectors meet. Forslund argues that “as long as the public sector isn’t strong enough to provide basic services, but relies on “partnerships” and tenders, corruption will remain rampant”.

Conclusion

There have been many responses to the NHI Bill, most of them negative, many containing uncomfortable truths about the state of the health system and the extreme difficulty of fixing it. But this strengthens the case for the NHI and an equitable health system based on UHC and the principles of Primary Health Care. The state, at present, does not have the capacity to deliver it. Nor can the corporate private sector, as is shown by abundant empirical evidence in the public health literature. This places a major responsibility on civil society to give the state critical support and mobilise the public around health. It underpins PHMSA’s campaign for a “People’s NHI”.

The People’s Health Movement South Africa calls upon all citizens of South Africa and civil society to unite behind a People’s NHI to ensure that the principles of the Right to Health, Universality and Social Solidarity are adhered to throughout the implementation process. 

To join the People’s NHI Campaign, please do one of the following:

  • Dial *134*1994*333# (it’s free)
  • SMS ‘NHI’ to 31660 (standard cost SMS)
  • Visit http://bit.ly/2r22Tnl
  • Or send a PCM to 066 040 9017

Contact Person: AnneleenDeKeukelaere@secretariat@phm-sa.org

 

 

8 key findings from new district health report

The Health Systems Trust last week published the latest edition of the District Health Barometer (DHB). The DHB provides a wealth of district, provincial and national level data on a wide variety of indicators. Below we have picked out eight interesting national-level findings. You can access the DHB 2016/2017 report and an associated data file by clicking here.

1. In 2016 only an estimated 72.8% of people in South Africa with diagnosed TB were started on TB treatment. The rate was slightly lower at 68% for people with TB resistant to rifampicin (one of the standard first line medicines to treat TB). The fact that around 27% of people with diagnosed TB do not start treatment timeously puts the health of these people at risk and makes it more likely that they will transmit TB in their communities.

2. According to current treatment guidelines almost all patients with both HIV and TB should be receiving antiretroviral therapy (ART). According to the DHB only 28% of people in this group received ART in 2011 (partly due to different treatment guidelines at the time). This number climbed rapidly to 90.8% in 2015 and then dropped to 88.3% in 2016. We do not know whether this drop from 2015 to 2016 is real or whether it is due to a statistical or reporting error.

3. According to the DHB the annual death rate for people with drug-resistant TB (DR-TB) is around 23%. The rate of loss to follow up is around 17% and only around 50.5% of people with DR-TB are successfully treated.

4. There has been a steady rise in the number of male condoms distributed in recent years – growing from 15.7 per male over 15 in 2011 to 47.5 in 2016.

5. The percentage of total life years lost due to non-communicable diseases (NCDs) in South Africa has risen over the last four years from 34.5% to 38.2%. This provides further evidence of the growing threat of NCDs to people living in South Africa and to the country’s healthcare system and economy.

6. In 2016/2017 only 82.3% of infants received all the required immunisations in the first year of life. This was a substantial drop from the previous two years – something the report ascribes to both vaccine shortages and poor distribution.

“During 2016/17, immunisation coverage nationally was 82.3%, almost 10 percentage points lower than the national target of  92.0%. This  was a 6.9 percentage  point  reduction  from  the  immunisation  coverage  of  89.2%  reported  in   2015/16 and lowest during the last five years. Between 2012/13 and 2014/15 there has been a general upward trend, with  immunisation  coverage  increasing  from 83.6% in 2012/13 to 89.8% in 2014/15.  The  rate  then declined slightly between 2014/15 and 2015/16 but showed a huge drop in 2016/17. The main reasons that contributed to this decline were: the global  shortage of Hexavalent that lasted approximately nine months and was resolved at a national level in October 2016; in some  provinces and/or districts the available stock was distributed equally to different areas without considering the demands  and population targets, thus painting an extremely heterogeneous picture of coverage.” – DHB

7. In 2016 there was 18 119 stillbirths in South Africa. While there is a downward trend over the last three years, the DHB also reports a downward trend in live births – which suggests that the decrease in still births is at least in part due to a reduction in the overall birth rate.

8. According to the DHB the period from 2014/2015 to 2016/2017 has seen steady reductions in the following three child-health-related indicators: Diarrhoea deaths under five years (1 514 to 886), pneumonia deaths under five years (1 411 to 1 003), and severe acute malnutrition death under five years (1 851 to 1 188). While the trend is encouraging, it is nevertheless unacceptable that over a thousand children in South Africa died of severe acute malnutrition in 2016/2017.

Steps to consider when proving PrEP in higher-education institutions

By Thuthukile Mbatha, SECTION27

1 October is set to become a memorable day in some higher-education institutions. It marks the day in 2017 that Pre-Exposure Prophylaxis (PrEP) was first rolled out at select campus health clinics as a new, highly effective HIV-prevention method. PrEP is an ARV drug combination taken to prevent infection by HIV-negative people who are at a greater risk of acquiring HIV. The two drugs in the only registered PrEP pill in South Africa are tenofovir and emptricitabine – also known under the brandname Truvada.

The provision of PrEP in South Africa occurs through various sites, these include the national health system, demonstration projects, large scale implementation initiatives (i.e. Dreams project) and the private sector. The Department of Health (NDoH) has identified seven higher education institutions that will form part of the above sites in rolling out PrEP to young people.

These institutions are the University of Free State, the University of Venda, Rhodes University, Nelson Mandela University, the University of Zululand, the University of Limpopo and Vaal University. Not all of them began rolling out PrEP on the set date; however, all these institutions were selected because they met the criteria set by the National Department of Health to assess their state of readiness to provide primary healthcare services to students.

A number of factors must be considered when determining whether an institution is fit for PrEP roll-out. These include staffing, qualification of nurses, dispensing licences and adequate storage, to name a few. The seven institutions currently providing PrEP are already dispensing antiretroviral treatment (ART) to students living with HIV, as well as other primary healthcare services, which was another prerequisite for PrEP provision. Many institutions do not offer this service for the reasons listed above, among others.

It is important for professional nurses to have a primary healthcare qualification, and also to acquire a dispensing licence. This enables them to deliver primary healthcare services, including ART and PrEP initiation. The provision of such services is usually supported by the District Department of Health office. Only the institutions that pass the assessment are considered as PrEP roll-out sites. In the institutions listed above, extensive training of clinic health personnel and peer educators was done to ensure readiness for PrEP provision and demand creation in these institutions. However, students have not yet been properly engaged, as the roll-out was introduced at what was a very busy time for students, who were preparing for exams. These institutions aim to intensify their demand-creation campaigns in the new year.

Most institutions fund the operation of their own campus health clinics; however, the Department of Health supplies them with family-planning and STI medicines. “We had to sign a memorandum of understanding with the Department of Health in order for them to supply us with PrEP,” said a health professional at one of the institutions.

“We do not have a set target number of students to provide PrEP to – every student who comes to our clinic and requests it is given it, after doing an HIV test and establishing that the student is HIV-negative,” she added.

The seven higher-education institutions that have started rolling out PrEP are an addition to the 17 demonstration sites providing PrEP that were established from June 2016. These demonstration sites include clinics for sex workers and for men who have sex with men (MSM). South Africa’s approach to PrEP roll out is focusing on targeting these ‘key population’ groups. For groups of people considered to be key populations, see www.avert.org/professionals/hiv-social-issues/key-affected-populations

Truvada (or any other tenofovir-based regimen) as PrEP is still not included in the South African Essential Drugs List (EDL). Its inclusion in the EDL would bring down the costs of PrEP, which would make it cheaper for the National Department of Health to provide sustainably to people who need it.

It is also important to note that the state of readiness for PrEP varies from institution to institution. Institutions such as the Technical and Vocational Education Training (TVET) colleges do not have campus health clinics, therefore they rely on off-campus clinics for sexual and reproductive healthcare services. The future roll-out plans should also consider such cases. A proper audit of all campus and off-campus clinics is required, so that all the issues may be addressed before the scale-up of PrEP roll-out.

Moreover, for PrEP roll-out to be effective, the inclusion of Student Representative Councils is very important, because of the power of influence they possess. It is critical to have student involvement in the entire process, to ensure a more positive uptake.