#Vote4Health: Healthcare after the elections

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

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

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

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

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

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

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

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

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

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

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

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

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

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


#Vote4Health: Lusikisiki push for condoms in schools

By Biénne Huisman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Spotlight’s Vote4Health

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

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

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

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

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


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

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

Article by Biénne Huisman

Photographs by Halden Krog

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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