Once again, concerns are being raised over the implementation of the proposed National Health Insurance (NHI) scheme. This time, it is over the future of private healthcare and medical aid under the contentious Section 33 of the Bill.
Many previous discussions have focused on the NHI’s affordability, accountability, the potential mass flight of healthcare professionals from the country, and even whether NHI is even possible to achieve given South Africa’s challenges.
In a new healthcare stakeholder opinion report [PDF] published by Section 27 and the Concentric Alliance on Monday, 20 June, it is noted that private healthcare is a major contributor to the economy. May public and private sector respondents believe it could play a significant role in achieving health reform thanks to its resources and capacity.
However, Section 33 of the NHI Bill states that medical schemes may only provide “cover that constitutes complementary or top-up cover and that does not overlap with the personal health care service benefits purchased by the National Health Insurance Fund on behalf of users”.
This basically means medical schemes which are not gap cover will no longer operate – something which does not sit well with the private sector respondents in the report, who argue that even in countries with the best developed public health systems, private healthcare funders still exist.
A carrot vs stick approach
An academic respondent suggested incentivising people into switching to a public healthcare funder, rather than removing private healthcare funding. A private sector respondent also suggested the idea of competition with private funders as a means to improve the NHI’s efficiency. Indeed, it may even be necessary the NHI to function well.
The report makes note of Section 33 of the NHI Bill becoming “something of a hill to die on”. The report says that “During the six-a-side engagements between Business Unity and the National Department of Health, urgent discussions on NHI were nearly derailed by demands that Section 33 be re-opened for discussion and one respondent in the NDOH stating that the Bill was now before parliament. This respondent stated that they would rather see this point litigated, than back down. The current approach to this draft provision has the potential to undermine the implementation of the NHI and delay urgent reform to the health system.”
In a perspective piece published in the New England Journal of Medicine, authors find a parallel between the tactics used in the ‘tobacco wars’ and vaccination efforts. In a seeming repeat of history, anti-vaccination groups are using the same tactics the tobacco industry used to defend their products and undermine trust in science, but the successful anti-tobacco campaign holds important lessons for turning the tide against misinformation and normalising vaccination.
In late 2020 when the first COVID vaccines became available, the authors note that surveys indicated that about a third of US adults were keen to be vaccinated, 15% expressed strong resistance to vaccination (a proportion that has stayed fairly constant), and the remainder didn’t harbour strong ideological resistance. Now, about 27% of US adults now remain unvaccinated – and reaching this remainder is an important public health challenge.
The authors believe that the ‘tobacco wars’ can provide perspective. The tobacco industry fuelled preventable deaths by glamourising smoking, with almost 50% of US adults smoking cigarettes in the 1960s.
The current rate of about 12.5% is the result of decades of public health efforts make tobacco use less socially acceptable. The first US Surgeon General’s report on smoking and health in 1964 was attacked by the tobacco industry. It was only until C. Everett Koop’s overwhelming report in 1986 that cemented tobacco use as a major preventable cause of cancer and death and highlighted the dangers of second-hand smoking.
Koop and others were vilified by the tobacco industry, which mounted a sustained campaign that cast doubts on the science, publicised misinformation, emphasised tobacco’s economic importance, and warned against restricting individual freedom. Industry leaders directly lied about knowing that nicotine was addictive and the lethal dangers of tobacco use. Indeed, from the 1920s to 1950s, in response to growing health concerns, the tobacco industry had actively courted doctors and influenced medical journals, widely reporting positive findings of studies that were deeply flawed. This may have only played into the hands of antivaxxers, creating a historical example of distrust in the medical system.
While the focus of the debate was initially on smoking as an individual choice, two 1981 studies on nonsmoking wives of smokers vs nonsmokers revealed the dangers of secondhand smoke and shifted the discourse.
The US Congress has never enacted a federal smoking ban, but did grant the FDA limited authority to regulate tobacco in 2009, enabling restrictions on youth sales.
However, the broad-based effort from all levels of society that were important, discouraging smoking in public settings. This was supplemented by messaging from celebrities, taxation, and even a 1998 legal battle against the tobacco industry.
Efforts undertaken by the antivaccination movement, which is hardly new but is thriving during the COVID pandemic, bear many similarities to strategies used during the tobacco wars. Although not driven by a single industry but a collection of celebrities and social media groups, it sows mistrust in science and promotes conspiracy theories. Misinformation tactics are used that are strikingly similar to the tobacco industry’s, and this time Dr Antony Fauci is vilified instead of Koop.
There are big differences between tobacco control and vaccination; such as taking a long time for smoking interventions to reduce chronic diseases, whereas vaccinations usually reduce hospitalisations and severe illness within days or weeks.
The authors believe that success against antivaccination movement can draw on the tobacco wars’ lessons, illustrating COVID’s harm and the power of vaccines. Getting vaccinated and boosted should be the accepted social norm during a pandemic, they stress.
Drawing on similar efforts for anti-tobacco campaigns, vaccination campaigns using real patients in ICU who express regret over not being vaccinated. Unvaccinated people often assume they can be cared for if they get sick, so messages could also be included from healthcare works talking about the strain of the pandemic.
“There is an opportunity to mount a serious effort to provide accurate vaccination information using the same media channels on which people currently consume misinformation,” they wrote.
They also consider vaccine mandates which make being vaccinated a social norm such as wearing a seatbelt, and other regulations at the community and business level may be more effective.
They note that personal physicians play a key role, being the best way to transmit health information. But many people at risk of remaining unvaccinated have had negative experiences with health care, compounded by doctors spreading misinformation.
The authors note that the dangers of tobacco use were known to public health practitioners for years, but it took a well-funded concerted effort that emphasised the impact on others to achieve a change in behaviour. This is something that needs to be repeated for vaccinations.
“Freedom of choice remains; people can still smoke cigarettes and decline vaccinations. But the roadmap drawn by tobacco-control efforts shows that the public mindset can be tilted toward public health and social good. With vaccination, this work shouldn’t take decades; it needs to begin immediately.”
By Dr Hlombe Makuluma, Clinical Risk Management at EthiQal and JP Ellis, Senior Legal and Claims Manager at EthiQal Medical Risk Protection, a division of Constantia Insurance.
South Africa’s medicolegal problems are well documented. Our healthcare system is vulnerable, with many healthcare workers working under stressful conditions, not to mention the uncertainty in relation to the implementation of National Health Insurance and the adverse consequences of the pandemic.
A public healthcare system which is overburdened and under-resourced finds itself confronted with litigation daily with the result that it has accumulated contingent liabilities (ie, the projected cost of payments for medical litigation claims) in the billions. Whereas in the private sector the burden of professional indemnity insurance cover for certain high-risk specialities has resulted in many private practitioners limiting their scope of practice or reconsidering the viability of continuing to practise. Since many private hospitals are self-insured for medico-legal claims up to a certain level, the price for their litigation defence is ultimately brought back to the consumer. To make matters worse, the South African civil justice system is renowned for its delays, inefficiencies, and the unnecessarily high cost of litigation. All these things make up the perfect recipe for a very lucrative industry which rewards many role-players, who have no hesitation in taking advantage of a vulnerable medicolegal system.
The South African Law Reform Commission (SALRC) was requested by the Ministers of Health and Justice to review the current system and to offer proposals. The SALRC has published their discussion paper 154 in November 2021 on their recommendations based on preliminary research, five years after the publication of their initial working paper on Project 141: Medico-legal Claims. While we should all be happy that progress has been made the real question is whether there is real appetite to improve our system or whether this is all a knee-jerk reaction?
There is an urgent need for meaningful reform. Patients who suffer harm because of negligence by healthcare providers require reasonable compensation quickly, and healthcare providers should be sufficiently protected from abuse and unmeritorious claims. Sadly, our medicolegal system does not adequately provide for this.
The burden of clinical negligence litigation is great as it often takes many years to finalise cases – whether in the form of a resolution or judgment – and the cost of litigation is exorbitant. Overall, the SALRC has taken great care in considering the rights of claimants and the burden of compensation on the State by thoroughly researching the medico-legal landscape in South Africa. Reform is generally classified into three areas, namely reforms that limit access to our courts, reforms that influence court processes, and reforms that limit the amount of compensation awarded.
They have offered recommendations which they believe will make the most difference. Most notably:
Reforms that limit access to our courts
Mediation has been encouraged as a first step to deal with medico-legal disputes before litigation. Most stakeholders appear to have no serious objections to mediation, especially because Uniform Rule 41A was introduced a few years ago, which requires a plaintiff or applicant who initiates litigation proceedings to file a certificate indicating whether they agree to the referral of the matter to mediation and, if not, to state the reasons for that refusal.
A certificate of merit affidavit should be filed on behalf of an accredited and suitably qualified medical practitioner to avoid frivolous, meritless, fraudulent or abandoned claims. This essentially opens the door for a successful defendant to claim the costs of litigation against those parties, and possibly their attorneys, who engage in irresponsible litigation.
A plaintiff is barred from proceeding with a claim after a period of inaction after issuing summons, with the possibility of having the period extended by the court but only on good cause shown. Either our Court rules or Practice manuals should be amended to ensure that once legal action is taken the matter must be finalised within a specified period, depending on the nature and extent of the litigation.
Adopting an administrative compensation system for smaller medical negligence claims.
Introducing a pre-action protocol system for larger medical negligence claims.
Reforms that influence court processes
There seems to be a consensus in the legal fraternity that the rules relating to the way in which experts are used should be reconsidered. The recommendation from the SALRC is that opposing parties to litigation should use joint expert witnesses, and when necessary, a panel of three joint expert witnesses from the discipline concerned, for technical medical evidence. The use of joint experts should be encouraged but naturally there will be situations where it is inappropriate, and a panel of three experts will only increase the costs unnecessarily. Rather the two main areas of concern which ought to be addressed is the accreditation and accountability of expert witnesses for the purposes of court proceedings and the desirability of sanctions for inappropriate or unethical conduct by expert witnesses.
The Superior Courts Act and the Uniform Rules of Court should be amended to provide for the appointment of specialist assessors to assist judges in complex medical negligence matters, rather than the establishment of specialist medical courts. Although the use of specialist assessors will be helpful this won’t necessarily address the issue that a generalist court will misapply the law, confuse rather than clarify the issues, and inadvertently encourage additional litigation rather than a specialist court.
Civil procedures be amended to substantially improve pre-trial procedures, as well as case management to expedite and simplify the finalisation of litigation.
Reforms that limit the amount of compensation awarded
Compensation to be awarded in the form of a structured settlement, with part of the compensation paid in a lump sum, part of the compensation paid as periodic payments, and part of the compensation provided as ‘payments in kind’ by means of the delivery of services – allowing a combination of these methods and determining the ratio of one aspect in comparison to another aspect by considering the circumstances of each case. This ‘payment in kind’ element is arguably the most controversial, given the parlous state of much of South Africa’s public healthcare system.
Periodic payments in the nature of an annuity be awarded for future maintenance, loss of earnings and the portion of future medical care, treatment, rehabilitation and therapy that the state cannot provide.
The underlying principle for the calculation of future loss of income be changed to a structured method based on the average national income or the average income of the area where the claimant lives.
It may be necessary to cap any damages other than special damages such as constitutional damages and general damages (non-pecuniary damages).
It should be possible to adjust periodic payments in exceptional circumstances.
Except for a few controversial recommendations, most will probably carry widespread support from various stakeholders. But the reality is that this is not enough. As the saying goes ‘the proof is in the pudding’. How exactly these recommendations will translate into independent pieces of legislation, amendments to existing legislation, adjustments to Court rules and practices are largely uncertain.
Whether their recommendations will carry through into positive and meaningful change is dependent on the ‘Powers that Be’. At this stage, there are indications that tend to suggest that the SALRC is under political pressure to now finalise this investigation and are more concerned with adopting recommendations which will relieve the most burden on the public sector rather than taking this opportunity to adopt a holistic approach to strengthening the entire South African medico-legal system, which is obviously preferable.
For example, there has been much criticism levelled at the SALRC for their exclusive focus on reform to the public sector. In their own words “(t)he proposals focus mainly on measures to alleviate the financial burden of medico-legal claims against the state on the fiscus, and to provide for alternative procedures for the speedy resolution of medical negligence claims against the state”. What is clear from the proposals offered in chapter 9 of Discussion Paper 154 is that efforts to reform the system can only realistically be done through a process of collaboration between the private and public healthcare system. According to them this was deliberate since the request for the current investigation was initiated at the insistence of the Ministries of Health and Justice. It would be preferable if law reform was not a knee-jerk reaction to the financial burden medical malpractice claims present for the State. Although the public sector exposure is, for various reasons, much greater financially: if not similar, the same risks exist for the private healthcare industry. Many medical malpractice claims and significant awards continue to plague the private sector. Therefore, it would be ideal if law reform was universally applied because there is no reason why the SALRC’s investigation should not include specific law reform initiatives that are helpful to the challenges presented to the private sector. Patients, health establishments and medical practitioners, whether in the private or public sector, are equally deserving of the constitutional imperative of equality before the law and “the right to equal protection and benefit of the law”.
What remains to be seen is how the recommendations in the final report will be implemented. The state has an exceptionally poor track record in following the corrective measures contained in the Public Protector reports, the South African Human Rights Commission reports, the Auditor-General audit reports, the Office of Health Standards Compliance reports, the Presidential Health Summit 2018 Compact and other existing government-initiated reports, plans and studies.
So whereto from here? Only time will tell. The investigative work of the SALRC is ongoing and it will no doubt take some time before we receive a final report. The real issue confronted by the SALRC is that there are a variety of different competing interests in the healthcare ecosystem, and it will be difficult to provide a holistic set of recommendations that will please everyone.
Acknowledging the good work done by SALRC the final report should adopt a balanced approach, one which prioritises interests of the state versus the poor and most vulnerable. Deciding how to compensate someone for harm suffered due to medical negligence is a thorny and complicated question. There is a difficult balancing act here. On the one hand, people have a right to be given fair compensation. On the other hand, the state has only limited funds and there is an understandable impulse to limit how much of those funds go toward compensation payments.
Of course, those mechanisms of compensation must not be unfair and punitive. The work of the SALRC is difficult, necessary, and very important to the sustainability of our healthcare system. The SALRC has noted the contribution of an ailing healthcare system to the significant medicolegal burden the country is facing. Factors contributing to poor healthcare service delivery by the State include maladministration, mismanagement and fraud, number of qualified healthcare workers and access to drugs, technologies and emergency transport.
Unfortunately, legislation and other reforms cannot fix the healthcare system or improve the standards of healthcare. But, overall, care must be taken to ensure that the final recommendations are well balanced and will pass constitutional muster.
19 May 2022: Healthcare – Cape Town, South Africa: The healthcare system in South Africa and on the continent is beset with structural challenges and skewed political priorities that hamper the attainment of universal healthcare coverage, therefore a fundamental overhaul of the healthcare system and renewed political will is required to improve citizen’s access to quality healthcare services.
Connected virtually, South Africa’s Minister of Health, Dr Joe Phaahla invited the private sector to submit recommended solutions to strengthen the country’s healthcare systems, emphasising the need for a collaborative approach to transform healthcare.
Dr Phaahla conceded that the health system in the country was already weak before the outbreak of COVID and inequality in access to reliable health services is inextricably linked to the economic and social inequality that our country is facing.
The Minister added, “The country’s healthcare system should be restructured to focus more on preventative services rather than the current curative approach.”
“The socio-economic inequality is perpetuated further by our own health services, which are highly heavily commodified. Our two-tiered healthcare system with one being driven by the private sector for a few who can afford it and the other by the public sector being provided for the majority of the population does not bode well for the future prospects of the country. This system is unsustainable and if we are going to talk about a change in strengthening the health system, we cannot avoid talking about the need to accelerate the creation of a more equitable health system.”
He acknowledged that the passing of the NHI Bill will not in itself be a silver bullet in the transformation of our health system, however, will lay a good foundation for the country to timely start to fundamentally transform our health system towards equity.
Speaking about the relationship between politics and healthcare, Professor Patrick Lumumba, former Director of the Kenya Anti-Corruption Commission, said, “Politics is at the very heart of the provision of sound healthcare systems.”
He challenged some of the perceptions around the delivery of national healthcare insurance across Africa, asking governments and the private sector to closely examine suitable healthcare solutions that will consider the continent’s current different types of conflicts.
He highlighted that considerations should be made in the best interest of the continent’s populations when making the decision on an approach to be taken for the continent’s healthcare needs, bearing in mind what is affordable to the different countries across the continent, especially given that the continent’s entire GDP is less than that of Italy, which has just under 60 million people.
“The continent is currently under different types of conflict at various intensities, and these conflicts are in turn undermining the provision of healthcare,” said Prof Lumumba.
He noted that in Africa, there is a lack of political will to spend more on healthcare despite the commitments made at Abuja, Nigeria, in 2001 to invest a minimum of 15% of their national budget in healthcare.
“Politicians are rich in making promises. The evidence we have in different countries is that universal health care as promised by politicians and as desired by the population is not easily achievable,” he said.
He cautioned against the temptation to compare the healthcare system in Africa with that of developed countries, citing a lower tax base and GDP in Africa to fund a healthcare system that services a substantially larger population.
“The entire GDP of Africa is slightly over two trillion US dollars, which is smaller than the GDP of Spain, which has a population of no more than 50 million people, it is critical that the private and public sectors; and politicians work together to come up with a system that is going to be beneficial to the majority of Africa’s people,” said Professor Lumumba.
He said the envisaged economic revival of Africa cannot be sustained if the continent’s healthcare needs are not adequately addressed.
“If the continent of Africa is to enjoy the perceived economic growth that is expected, then the population must be healthy. Healthcare is about creating healthcare systems that are also able to retain the skills that are required for Africa’s emerging or growing economies. There is also a clear need for collaboration in the delivery of health services,” said Lumumba.
Dr Millicent Hlatshwayo Chairperson of the Government Employees Medical Scheme (GEMS) reiterated the need for the private healthcare sector to play a meaningful role towards shaping the proposed healthcare funding model to ensure its sustainability.
She acknowledged that the healthcare sector is faced with several systemic challenges, and this is reflected in our international rankings; where South Africa ranks 49th out of 89 countries on the 2022 Global Healthcare Index. Though South Africa is the highest-ranked African country in this index, it has been rated below its peers in BRICS such as China and India, which are rated 40th and 44th respectively.
Dr Hlatshwayo said, “Proposed reforms such as the implementation of the NHI can help to facilitate better cooperation between the public and private sectors. We cannot afford to be passive observers in these deliberations, because our failure to act on these opportunities will be an indictment on the industry.”
Dr Hlatshwayo said from its inception, GEMS has been aligned with the transformation of the healthcare industry and supportive of the principles of universal health coverage.
She said universal health coverage can only be achieved if we get the basics in place, namely qualified staff, equipment and technology, infrastructure and working systems.
The Eastern Cape Department of Health has served more than 200 paramedics with letters of intention to dismiss them for embarking on a strike.
Long-standing problems with access to ambulances in parts of the Eastern Cape have worsened over the last three weeks as paramedics have stopped work in Buffalo City Municipality, Amahlathi and Raymond Mhlaba Local Municipality. The paramedics are demanding fully equipped ambulances, with valid licence discs, and cellphones.
They want electrocardiography (ECG ) monitors, batteries, spine boards, blankets, head blocks, cervical collars, and baby cribs.
The workers are members of the National Education, Health and Allied Workers’ Union (NEHAWU) which maintains that the paramedics are not on strike but are exercising their right to safety at work. The paramedics come to work everyday in full uniform and wait at their work places until their shifts are over.
One of the workers, who has been a paramedic for six years, told GroundUp: “The service we offer to the public is very poor. Our ambulances have no equipment. There are no machines to check diabetes and high blood pressure. Our radios don’t function because we work in deep rural areas where there is a network problem. We use our cellphones to respond to the calls and communicate with our control room.”
“These issues have been raised for many years with the department but it has always been empty promises. If we transport a patient in an ambulance which is not fully equipped the department shifts the blame on us if something wrong happens to the patient. We are not on strike, because we come daily to work.”
“The Department is threatening to fire us but it’s fully aware that it is failing its workers and patients.”
When GroundUp visited Fort Beaufort Provincial Hospital on Tuesday, we found patients being transported in private vehicles.
Thando Ntsume from Hillside dropped a patient in casualty with his private vehicle. “I could see that she was in severe pain and battling to breathe. Her family had been calling for an ambulance since the morning but it never arrived.”
“I know from my own experience that there are no ambulances available in this hospital. Three months ago I was stabbed and admitted to this hospital. Doctors transferred me to Cecilia Makiwane Hospital but they told me I should find my own transport because ambulances are not available. My brother had to take me with his car to East London.”
Patients outside the Fort Beaufort Provincial Hospital casualty department complain about the lack of ambulances. Photo: Mkhuseli Sizani
Mihlali Matshoba says the ambulance crisis has been going on for a long time. “On 7 October I gave birth at home because ambulances are not available here in Fort Beaufort. Sometimes they are hours late or we are told there is only one ambulance operating.”
Nolly Oliphant had to borrow money to put fuel in her car to take her son to Cecilia Makiwane Hospital after he injured his hand.
“I drove with him to Fort Beaufort Provincial Hospital. The doctors treated him and told me that I should take him with my own transport to Cecilia Makiwane Hospital. “I had to borrow R1,200 for fuel because ambulances are not available.”
“The strike has been devastating,” said one of the Fort Beaufort doctors. “We had to ventilate a patient in Fort Beaufort for over 24 hours because of the strike. Eventually we managed to get a private ambulance to come. The hospitals have been using their bakkies to transport patients.”
Regional NEHAWU coordinator Mzamane Mgwantashe says the workers are not on strike. “Over 200 workers are coming everyday to work. But they cannot perform their duties because ambulances are faulty and not fully equipped. In February, ambulances were fully equipped by the Department in order to obtain service compliance certificates. The same day after the assessment was done the equipment was stripped by the Department. We don’t know why that was done and we don’t know where that equipment was taken.”
He said workers had been told cellphones had been bought for them, but they had never received them. “Instead the Department bought ‘push-to-talk’ devices without consulting the workers.”
Mkhululi Ndamase, spokesperson for Health MEC Nomakhosazana Meth, confirmed the notices to dismiss over 200 workers who had embarked on an unprotected strike. He said the department had addressed the issues raised by the union.
“All vehicles are licensed annually and a certificate of fitness is issued before a vehicle is put on the road. We are in agreement that if a vehicle does not carry the valid licence and/or the certificate of fitness displayed, it should not be used. There are more than enough vehicles in the pool even while vehicles may be grounded whilst being repaired. The rough terrain of our predominantly rural areas and high volume usage does make them vulnerable to breakdowns.”
He said the vehicles were replaced every 300,000 km.
On the issue of cellphones, he said the department had issued “push-to-talk devices” earlier this year and most paramedics had accepted them. Responding to the complaint about equipment being put in the ambulances just to get licence approval, Ndamase said this was being investigated.
“None of these issues are considered valid reasons to suspend services to the communities we serve.”
The department was using private ambulances to respond to emergency calls, which was costly. Two of these ambulances had been stoned, he said.
Ndamase said a rule of no work no pay would apply.
The US Supreme Court has voted to strike down the landmark Roe v Wade decision which constitutionally protects abortion rights, according to an initial draft majority opinion leaked by news outlet POLITICO. This comes at a time when abortion rights are being challenged in a number of US states, and such a ruling would cause abortion to become immediately illegal in 22 US states.
In 2019, there were 630 000 reported abortions in the US in 2019, according to the US Centers for Disease Control, an 18% decrease compared with 2010. Women in their 20s accounted for 57% of abortions in 2019. Abortions are highest among black American women, with a rate of 27 per 1000 for ages 15–44.
The Roe v Wade decision in 1973 gave women in the US an absolute right to an abortion in the first three months of pregnancy, and limited rights in the second trimester.
In 1992, in Planned Parenthood v Casey, it was ruled that states could not place an “undue burden” on women seeking abortions before a foetus could survive outside the womb, at about 24 weeks.
The draft opinion written by Justice Samuel Alito completely refutes the 1973 decision which guaranteed constitutional protections of abortion rights in the US, and also a subsequent 1992 decision – Planned Parenthood v. Casey – that largely maintained the right. “Roe was egregiously wrong from the start,” Justice Alito wrote.
“We hold that Roe and Casey must be overruled,” he writes in the document, labelled as the “Opinion of the Court.” “It is time to heed the Constitution and return the issue of abortion to the people’s elected representatives.”
In the past, deliberations on controversial cases have been fluid, with justices occasionally changing their votes as draft opinions circulate. This represents a rare breach of Supreme Court secrecy and tradition around its deliberations. The final, binding decision, is expected to be published in two months. Currently, five Republican appointees including Justice Alito have voted in favour of repealing Roe and Casey, while the three Democrat appointees are dissenting. It is not known how the last member, Chief Justice John Roberts, will vote.
The ruling as it currently stands would end the 49 year old US constitutional protection of abortion rights, instead allowing each US state to restrict or ban abortions outright.
POLITICO notes that public disclosure of a draft decision is unprecedented in the court’s modern history. Some observers had predicted that the conservative majority would have chipped away at abortion rights without overturning it.
The draft shows that the court is seeking to reject Roe’s logic and legal protections. “The inescapable conclusion is that a right to abortion is not deeply rooted in the Nation’s history and traditions,” Justice Alito wrote, declaring that one Roe’s central tenets, the “viability” distinction between foetuses not capable of surviving outside the uterus and those which can, “makes no sense.”
Justice Alito also described doctors and nurses who terminate pregnancies as “abortionists”, instead of the more neutral term “abortion providers” used by Chief Justice Roberts.
More than two years since the start of the COVID pandemic. President Cyril Ramaphosa on Monday evening (4 April) announced the repeal of South Africa’s national state of disaster. A transition to new regulations to manage the pandemic will take place in coming weeks.
However, the end of the state of emergency had already been extended, a decision met with much criticism. Its end had long been called for, including experts such as Professor Shabir Madhi of Wits University.
Speaking about the extension in January, Prof Madhi told the Daily Maverick that the state of disaster regulations “have done very little when it comes to protecting people from being infected, because, had it had any impact, we wouldn’t have had 70% of the population infected with the virus at least once since the start of the pandemic.”
In the announcement, President Ramaphosa said the state of disaster and associated lockdown restrictions had been needed to properly deal with the COVID pandemic.
The state of disaster also allowed the establishment of the COVID TERs scheme, the R350 social relief of distress grant, the extension of driving licences and other necessary changes.
President Ramaphosa stated that the state of disaster and its powers were always ‘temporary and limited’, with the country now entering a new phase in the pandemic. While SARS-CoV-2 continues to circulate in the country, experience had already shown early in the fourth wave that the Omicron variant has decoupled COVID infection from rates of hospitalisation or deaths.
“Going forward, the pandemic will be managed in terms of the National Health Act. The draft Health Regulations have been published for public comment. Once the period for public comment closes on the 16th of April 2022 and the comments have been considered, the new regulations will be finalised and promulgated.
“Since the requirements for the National State of Disaster to be declared in terms of the Disaster Management Act are no longer met, Cabinet has decided to terminate the National State of Disaster with effect from midnight tonight.”
President Ramaphosa said certain provisional regulations will remain in place for a further 30 days to ensure a smooth handover to the new regulations under the National Health Act.
The transitional measure which will automatically lapse after 30 days include:
Wearing face masks must continue to be worn in an indoor public space.
Gatherings will continue to be restricted in size. Indoor and outdoor venues can accept 50% of capacity subject to vaccination or a COVID test. Gatherings of 1000 people indoors and 2000 people outdoors are permitted for the unvaccinated.
Travellers entering South Africa will need to show proof of vaccination or proof of a negative test.
The R350 SRD grant will remain in place, with the Department of Social Development finalising separate regulations allowing it to continue.
The grace period for driving licence extensions remain in place.
All other regulations fall away from midnight and the COVID alert levels will no longer apply, President Ramaphosa said. The no-fault vaccination compensation scheme will also continue operating.
The prospect of an exodus of doctors and other key healthcare personnel from South Africa ahead of the planned introduction of the National Health Insurance (NHI) scheme has prompted concern among healthcare stakeholders.
In addition to the loss of skilled healthcare professionals, there is also a growing concern that the country could lose valuable training skills as professionals look to leave.
Thirteen years on from its inception, the NHI continues to suffer from the same criticisms. A May 2021 research paper [PDF} found that South Africa’s per capita spending on public healthcare was higher than even wealthier developing countries, yet it ranked near the bottom for measures of healthcare outcomes.
An informal poll on the QuickNews website in March showed that 81% of respondents had at least considered emigrating due to the planned introduction of NHI.
Professional associations are also warning of an exodus with the start of NHI. The South African Medical Association (SAMA) has said that its members cannot support the NHI in its current form.
This stems from a deep-rooted lack of confidence in the capacity of government and its financial ability to ensure the service is successful, the association said. Other concerns that members have raised include only providing emergency treatment to refugees and illegal immigrants, as well as their children.
SAMA conducted a survey which showed that up to 38% of its members plan to emigrate from South Africa due to the planned introduction of the NHI.
6% of members said that they plan to emigrate for other reasons, while 17% of doctors said that they were unsure about leaving the country. Many doctors have said that the aim should rather be to get the public sector to a state where it can appeal to private sector patients.
They added that there should be engagement with private doctors to provide additional services funded by the state. The group also called for a proper pilot of the proposed systems and payment mechanisms.
The Department of Health noted these concerns in a parliamentary briefing this week, noting that skilled personnel will be needed for the NHI to work. It added that this was not limited to healthcare professionals, but that general skilled human resources will be central to the health system going forward.
It added that the complex interactions between training, registration compliance and employment can all be greatly improved.
“This is a big ship that will need to be turned, but the framework is in place,” said acting director-general of health Dr Nicholas Crisp. “We have heard the threats that there will be an exodus of personnel if the NHI is implemented and a brain drain.”
The department is actively responding to this, he said, with a framework in place to ensure the country retains the necessary skills. A ‘Human Resources for Health strategy’ before was already under development before the start of the COVID pandemic, he added.
This framework sets out a multi-work implementation plan, but it requires money and investment in the health workforce to ensure the country is ready for universal health coverage, Dr Crisp said.
“Every health professional has a place in the National Health Insurance – whether you choose to work in the public portion of the delivery system or the private portion of that delivery system.
“We do not think there needs to be a threat on anybody, or their viability, or their role to be played.”
On Sunday 13 March, the World Health Organization released a statement condemning recent attacks on hospitals and other healthcare facilities in Ukraine, which it called “horrific”. It also called for an immediate end of all such attacks, which are killing and injuring both patients and health care workers, as well as threatening vital health services.
“To attack the most vulnerable – babies, children, pregnant women, and those already suffering from illness and disease, and health workers risking their own lives to save lives – is an act of unconscionable cruelty,” the organisation said.
WHO’s Surveillance System for Attacks on Health Care (SSA) has documented 31 attacks on health care since the outset of the war that started with the Russian invasion on 24 February, now in its third week. These include 24 incidents of damage to or destruction of health care facilities, and five cases of ambulances.
In one incident, a maternity hospital was hit by a Russian air strike, causing three deaths including a child.
There have been 12 deaths and 34 injuries as a result of these attacks, and impaired access to and availability of essential health services, the WHO stated. Since attacks are ongoing, this is expected to continue.
The organisation also stresses that such attacks also directly impact the needs of vulnerable groups, and the health care needs of pregnant women, new mothers, younger children and older people inside Ukraine are rising even as violence curtails health care access.
“For example, more than 4,300 births have occurred in Ukraine since the start of war and 80 000 Ukrainian women are expected to give birth in next three months. Oxygen and medical supplies, including for the management of pregnancy complications, are running dangerously low,” the WHO statement read. WHO warned that Ukraine’s health care system is “clearly under significant strain” and a collapse would be a “catastrophe”. It stresses that “every effort must be made” to prevent this.
“International humanitarian and human rights law must be upheld, and the protection of civilians must be our top priority.
They call for international humanitarian and human rights laws to be upheld, with the protection of civilians as a top priority. Aid and health care workers must be able to continue and strengthen service delivery, and health services should be provided at border crossing, to provide prompt care and referral for children and pregnant people. Care should be unimpeded, with access to civilians in all areas of the conflict, and health care and services should be protected from attacks.
WHO stated that, in the wake of COVID’s huge strain, “such attacks have the potential to be even more devastating for the civilian population.” As such, it called for an urgent ceasefire.
“Finally, we call for an immediate ceasefire, which includes unhindered access so that people in need can access humanitarian assistance. A peaceful resolution to end the war in Ukraine is possible.”
Hydroxychloroquine and ivermectin, two COVID treatments that have been shown to be ineffective for those purposes, were more heavily prescribed in the second half of 2020 in parts of the US that voted for the Republican party, according to a new research letter published in JAMA Internal Medicine.
“We’d all like to think of the health care system as basically non-partisan, but the COVID pandemic may have started to chip away at this assumption,” said lead author Michael Barnett, assistant professor of health policy and management.
The study compared prescription rates for hydroxychloroquine and ivermectin with rates for two control medications, methotrexate sodium and albendazole, which are similar drugs but have not been proposed as COVID treatments. Comparing different US counties, researchers looked at deidentified medical claims data from January 2019 through December 2020 from roughly 18.5 million adults as well as census and voting data.
Overall, hydroxychloroquine prescribing volume from June through December 2020 was roughly double what it had been in the previous year, while the volume of ivermectin prescriptions was seven-fold higher in December 2020 than the previous year. In 2019, prescribing of hydroxychloroquine and ivermectin did not differ according to county Republican vote share. However, that changed in 2020.
After June 2020 – coinciding with when the US Food and Drug Administration revoked emergency use authorisation for hydroxychloroquine – prescribing volume for the drug was significantly higher in counties with the highest Republican vote share as compared to counties with the lowest vote share.
As for ivermectin, prescribing volume was significantly higher in the highest versus lowest Republican vote share counties in December 2020 a 964% increase on the overall prescribing volume in 2019. The spike lined up with with a number of key events, such as the mid-November 2020 release of a now-retracted manuscript claiming that the drug was highly effective against COVID, and a widely publicised US Senate hearing in early December that included testimony from a doctor promoting ivermectin as a COVID treatment.
Neither of the control drugs had differences in overall prescribing volume or in prescribing by county Republican vote share.
The authors concluded that the prescribing of hydroxychloroquine and ivermectin may have been influenced by physician or patient political affiliation. “This is the first evidence, to our knowledge, of such a political divide for a basic clinical decision like infection treatment or prevention,” said Barnett.