The South African Medical Association (SAMA) issued a statement stating that they reject the current form of the National Health Insurance (NHI) Bill, with a major objection being that the mere establishment of the NHI fund does not embody the Constitutional principle of universal health coverage (UHC).
The NHI Bill is designed to provide one pool of healthcare funding to all South Africans and long term residents.
They state that the NHI Bill was developed without regard to expert concerns and opinions, especially on key issues such as Contracting Units for Primary Healthcare (CUPS), Benefit Packages and Reimbursement Models.
Given the mismanagement of COVID funds by the government and state-owned entities, there is further concern over its ability to regulate the R500bn fund.
SAMA spokesperson Dr Mvuyisi Mzukwa said: “Misappropriation of funds in various state-owned entities casts doubt on government’s ability to handle the health care budgets responsibly. The public, alongside healthcare stakeholders, cannot simply entrust their lives to a government with an established history of financial mismanagement.”
SAMA contends that while the UHC is intended to improve the health and livelihoods of all South African citizens, the Bill as it stands will set the healthcare system up for failure.
“SAMA believes that a robust approach to health systems strengthening is indispensable, as it would rectify the current deficiencies and overcome the challenges posed by the NHI,” the statement concludes. “This approach seeks to enhance the efficiency, effectiveness, and resilience of the healthcare system, ensuring the delivery of optimal care to all individuals. Governance within the healthcare sector must be strengthened, with transparency and accountability at its core. Effective management of funds and meticulous budget allocation is imperative to rebuild trust and demonstrate responsible stewardship of public resources.”
South Africa’s long-awaited new National Mental Health Policy Framework and Strategic Plan 2023 – 2030 has been published. The policy framework was presented at the SA mental health conference this week. PHOTO: DOH/Twitter
But even though there has been a gap from 2020 to 2023, speaking to Spotlight at the conference, Minister of Health Dr Joe Phaahla said that it doesn’t mean there was a gap in terms of updating. “Every either three or five years, we revise the policy. So, it is not that there has been a gap. There has been a policy, which has been guiding,” he said.
“But as things change, and in each cycle of the strategy and planning, we have a particular timeframe so that we can evaluate. And so now we have evaluated, and that’s why we are adding [additional things], as we learned from the previous implementation.”
Phaahla said that gaps in the country’s mental health services are not because of a lack of policy and plans but due to implementation issues and sometimes the shortage of resources and psychiatrists.
“If you look at the area of psychiatrists, it is just the two-tier system of our health service, which makes it very difficult because what psychiatrists can earn providing the services to more of the insured patients – it is something we can’t really match with the public sector salaries generally,” he said. Phaahla said that psychiatrists, who mostly work in the private sector, were typically trained at public-sector teaching hospitals. “But once they’re qualified, they stay for one year or so, then they are attracted by better income,” he told Spotlight.
According to Phaahla, to deal with the shortage of psychiatrists in provinces such as the Northern Cape where there are only three psychiatrists, the department plans to contract psychiatrists from other provinces. “We can have part-time psychiatrists, maybe take some from Gauteng where the majority are and in Western Cape and contract them to provide services in Northern Cape. Even if it’s on a weekly rotation,” he said.
Concerns over delays
While several mental health experts have welcomed the new policy framework and agree with Phaahla about the importance of implementation, they are not happy about the delays.
“We’re now sitting in 2023, three years late,” said Cassey Chambers of the South African Depression and Anxiety Group (SADAG). What that means, she said, is that civil society did not have a working document with which to engage government at provincial or district level.
Bharti Patel of the South African Mental Health Federation expressed similar concerns. “As the Federation for mental health, we are disappointed that it has taken this long for the policy to be reviewed, given the fact that the initial policy was launched in 2013,” said Patel.
“We had a crisis during that period from 2013 to 2020. We have witnessed mental healthcare users losing their lives during Life Esidimeni. The [Health] ombud report, the South African Human Rights Commission Report, have all given recommendations,” Patel said. Patel argues that those recommendations should have informed policy and implementation more quickly.
Implementation problems
Chambers described the previous strategic policy framework as a “very good document”. Then, she said, the problem came in the implementation. “And I think perhaps this is [why there was a] delay in having an updated document that is now running from 2023 to 2030. It is because the document was good, the policy was good. However, how it was implemented was not happening,” she said.
Speaking to Spotlight, Professor Crick Lund, Co-Director, of the Centre for Global Mental Health at King’s College London, explained that there are a number of factors that create implementation challenges. “The one is ignorance on the part of senior decision-makers about mental health, ignorance about the scale of the problem, and ignorance about the fact that something can be done about it,” he said.
According to Lund, the new policy framework has stronger implementation monitoring mechanisms and implementation can be tracked in a much clearer way over time.
For the new policy framework to work better than the previous one, Lund believes there is a need to create greater public awareness about mental health and about the mental health policy. He says, “We need to get all the sectors involved working together – the Department of Health, Education, Social Development, the criminal justice system, and also the NGO sector.”
Along similar lines, Patel stressed the importance of getting more government departments involved. “While the policy is developed at the national level, the National Department of Health is responsible for training the provinces and not only the Department of Health; they need to train all government departments within the province who have bought this policy,” she said. “You can’t have the Department of Health alone implement a policy. This is a policy that requires inter-sectoral collaboration so that different departments can also put budgets towards implementation.”
Lund said that there is a lot of common agreement on what the priorities are and a lot of energy going forward. “So I’m hopeful that we can move things forward.”
Budgets and human resources
While there seems to be consensus on the need for more training and getting wider buy-in, there is also a shared awareness that successful implementation will depend on the availability of sufficient funds and human resources.
“We need to see structured action plans in the provinces with budgets allocated so that we can hold the government departments accountable,” said Patel.
Chambers agrees that in order to get implementation of the new policy framework right, we will have to get the budgets right. “You need to allocate a budget in order to help with the implementation plan, especially knowing that our previous policy framework was not implemented. So, we have to overcompensate for that now, which is concerning because this year, the health budget has been reduced. Therefore, meaning that the national mental health budget has been reduced,” she said.
According to the new policy framework, the case for investing in mental health is strong. It states that at a societal level, lost income associated with mental illness far exceeds public sector expenditure on mental healthcare – in other words, it costs South Africa more to not treat mental illness than to treat it. The impact of mental illnesses such as depression and anxiety has been estimated to cost the economy more than US$3.6 billion (R61.2 billion) in lost earnings per year. Certain conditions such as perinatal depression and anxiety have lifelong cost consequences. For example, it is estimated that the lifetime costs of perinatal depression and anxiety in South Africa amount to US$2.8 billion (R47.6 billion) per annual cohort of births.
Chambers also stressed that we are facing shortages of human resources and appropriate facilities. “We don’t have the human resources or the capacity to fulfil that implementation plan and that’s a worry and a concern,” she said.
NHI and provincial plans
According to the new policy framework, mental health will be financed according to the principles adopted for all health financing in South Africa, and people will be protected from the catastrophic financial consequences of mental ill-health.
According to the policy framework, in the financing of the National Health Insurance (NHI) system, mental health services will be given parity with other health conditions, in proportion to the burden of disease and evidence for cost-effective interventions. NHI will specifically include packages of care for mental health, in line with the evidence for the most cost-effective interventions. The policy framework states that private medical aid schemes should be required to provide similar parity between mental health and other health conditions.
“Budget will be allocated to meet targets set for the implementation of the policy and regular discussions will be held with provinces to discuss strategies and monitor progress with implementation. At provincial level, mental health budgets will be reviewed annually to align mental health with national priorities, for each of the areas for action in 2023 and annually thereafter,” the policy framework reads.
The policy also says that all provinces will develop provincial strategic plans for mental health, in keeping with national policy, which outlines specific strategies, targets, timelines, budgets, and indicators in 2023 and annually thereafter, informed by specific unique local challenges.
By Vincent Lali, Chris Gilili, Liezl Human, Tariro Washinyira, Nombulelo Damba-Hendrik, Thamsanqa Mbovane, and Mkhuseli Sizani
“You have shown the power of the people by closing all the hospitals,” National Education Health and Allied Workers’ Union (NEHAWU) Western Cape provincial secretary Baxolise Mali told striking union members on Wednesday. “The employer says people are dying. It is not our responsibility to keep people’s lives.”
Mali was speaking to strikers outside the Khayelitsha District Hospital in Cape Town, as NEHAWU members continued a wage strike which has disrupted hospitals and government offices across the country. The government considers the wage negotiations for 2022 to be settled but NEHAWU and several other unions are still demanding up to 12%.
Police presence outside the hospital had kept protesters away, said hospital CEO David Binza. He said the situation was “better than yesterday”, when “things were bad”.
Binza said services at the hospital had been severely affected by the strike on Monday.
Protesters had prevented people coming in and out of the hospital. Staff had ended up working 24 hours because there were not enough nurses to relieve them, and there was a shortage of nurses in childbirth wards. “Yesterday they prevented night staff from gaining access into the facility. It was mostly doctors that they allowed in. Doctors alone can’t work properly,” he said.
Today things had been better, he said, as the police had arrived early and kept protesters away from the hospital.
Western Cape health spokesperson Mark van der Heever said shift changes at the hospital were being closely monitored after patients in critical condition had to be transferred to other hospitals such as Helderberg, Tygerberg, Mitchells Plain and Karl Bremer.
Striking workers outside Khayelitsha District Hospital on Wednesday. Photo: Vincent Lali
“On Tuesday night, 7 March, protesters disrupted services and blocked staff from entering Khayelitsha District Hospital until 11pm. The ongoing disruption has directly resulted in staff shortages as they are prevented from entering, backlogs building up and other operational challenges.”
He said protests had been reported at Karl Bremer and Tygerberg hospitals, but services had not been disrupted.
Mali said NEHAWU’s intention was to “collapse the provision of government services” to force the government to the negotiating table. “Our tactics involve closing workplaces, to force workers to get out and switch off their computers.”
Home Affairs offices in Khayelitsha were closed. Disappointed, Luthando Tiso said he has been going to Khayelitsha Home Affairs to collect his ID since Monday. “I can’t get a job without an ID,” he said.
In the city centre, the Home Affairs office in Barrack Street and the offices of the Department of Labour were closed and there was a strong police presence.
One man said he had been to the Mitchells Plain Labour Department offices on Monday and Tuesday only to find them closed because of the strike, and had come to Cape Town hoping for help. “I desperately need to claim from the Unemployment Insurance Fund. I lost my job in January. My rent and children’s school fees are already behind,” he said.
Eastern Cape
In the Eastern Cape, Department of Health spokesperson Yonela Dekeda said hospitals were being run by skeleton staff.
“We had an incident early in the morning where striking workers blocked the Cecilia Makiwane Hospital’s entrance in East London. But police were called to remove them.”
Dekeda said unions which were not supporting the strike action had raised concerns that their members were being intimidated and denied access to workplaces.
“We do appreciate responsible shop stewards who have called their members to order, where necessary, and ensured that critical services continue and that our patients receive necessary care,” she said. “However, we take very seriously those employees who intimidate others, and cause services to be affected negatively.
“Appropriate action will be taken in all such instances, and law enforcement agencies are being deployed.”
At Laetitia Bam Day Hospital in KwaNobuhle, Kariega, Eastern Cape deputy secretary of NEHAWU, Busiswa Stokwe told about 100 striking workers: “We know we will be attacked even in the community, accused of not caring for patients. But the same community when you are doing the work of ten people, whilst you are four, would insult you, saying you are lazy. We must put ourselves first.”
A patient who did not want to give his name said he had arrived at 5am to have three teeth removed but had been ordered out by striking workers at 7am. “They came by car and on foot and sang in the corridors. We realized that we should go back home, with aching teeth.”
“We were about ten and have no money to remove teeth at a private doctor, who charges R350 per tooth,” he said.
Gauteng
In Tshwane, striking workers closed down the offices of the Department of Public Service and Administration, shouting and insulting some workers who were inside the offices.
There was a stand-off between the striking workers and police, as the workers closed off Hamilton and Edmond Streets with huge stones and turned cars away. Police moved the workers away.
Phumuzo Malahleni, a registry clerk at the Department of Agriculture, said his R12,000-a-month salary was too low to cope with the soaring cost of living. “As public servants we can’t afford anything. Violence and going to the streets is the only language our government understands.”
NEHAWU Gauteng provincial chairperson Mzikayise Tshontshi told GroundUp that the battle for a wage increase was far from over.
He said NEHAWU had been called to the Public Sector Bargaining Council on Thursday. “Our negotiators will be there, but the rest of us will continue shutting down public services.
“We believe our strike has been resoundingly successful. From Monday to today, the numbers have been growing. Tomorrow we want to intensify the strike,” said Tshontshi.
Addressing the crowd outside the department, Tshontshi called out those who were still at work.
“We are also aware of ‘amagundwane’ (rats). Some are sitting in cosy offices, and then when we win this battle they are going to be first in the queue because they think they deserve what we have fought for. There have always been traitors in every struggle; this is no different.”
At Tembisa hospital, striking workers blocked the entrance with burning tyres and debris while chanting slogans. Calm was later restored.
Free State
Free State health spokesperson Mondli Mvambi said the province had obtained an interdict on Wednesday morning to prevent strikers from disrupting services at hospitals and clinics. “The order does not stop the strike but stops acts of intimidation, violence, disruptions and instigating.”
Mvambi said hospitals hardest hit were National District Hospital, Universitas, Pelonomi and Medical Depot in Bloemfontein. “There were no nurses at work and patient care was seriously compromised.” Mvambi said calm had been restored but services remained strained as nurses were still not at work.
“At Manapo in QwaQwa they are not allowing nurses into the hospital. At Boitumelo in Kroonstad, picketers were singing at the gate but services are said to be continuing. At Pelonomi Hospital, nurses in ICU were forced out by the strikers.”
North West
In the North West, services at least six hospitals were disrupted by the strike: Klerksdorp-Tshepong, Potchefstroom, Taung District, Moses Kotane, Ganyesa District, and Gelukspan. There were pickets outside several other clinics and hospitals.
Mpumalanga
In Mpumalanga, spokesperson Christopher Nobela said that all health facilities had been affected and hospitals were working with skeleton staff in hospitals.
Limpopo
Limpopo health spokesperson Neil Shikwambana said, “We do not have reports of disruptions in any of our facilities so far.”
KwaZulu-Natal
Workers stopped work at Inkosi Albert Luthuli Central Hospital in Durban for several hours on Wednesday morning, singing outside the hospital. Patients were allowed to enter.
NEHAWU branch secretary Sikhumbuzo Gumbi said workers decided to go back to work at midday so they could assist patients. “As workers we decided to protest in the morning then attend to patients around lunchtime.”
Gumbi said the staff would continue protesting in the mornings until the strike ends.
Prince Mthalane, Durban NEHAWU regional secretary, said clinics had been closed in KwaMashu and at Polyclinic workers had burned tyres. Police had been called but workers had talked to them and no-one had been arrested.
“The aim is to have a peaceful strike,” he said.
GroundUp was unable to reach the health department spokespersons in KwaZulu-Natal or the Northern Cape.
Police
“Innocent patients have been caught in the crossfire and inconvenienced by something which has nothing to do with them,” said Department of Health national spokesperson Foster Mohale. He said the Minister of Health had asked the Minister of Police to strengthen the police presence in areas affected by the strike.
“Skeleton staff has also been available to give care to patients who could not be discharged,” said Mohale.
South African Police Union spokesperson Lesiba Thobakgale said the union had joined NEHAWU in the protest. “As SAPU, from today we have served a strike notice and we are joining the other unions,” said Thobakgale.
Striking members of the National Education, Health and Allied Workers Union (NEHAWU) blocked the department of Home Affairs offices in Cape Town on Tuesday. Photo: Thomas Kachere
Patients were turned away from some hospitals as members of the National Education, Health and Allied Workers Union (NEHAWU) and other unions pressed forward with their wage strike, in spite of a court interdict.
Many government offices were closed for several hours.
NEHAWU has approached the Labour Appeal Court to appeal against a decision to enforce the interdict against the strike granted by the Labour Court to the Department of Public Service and Administration.
In Cape Town, police intervened after a scuffle broke out after a member of the public who was queuing for service at the Department of Home Affairs office in Cape Town called protesters names.
The police warned the protesters not to engage in any violence.
Provincial General Secretary of NEHAWU, Baxolise Mali said, “Today we have escalated matters”. He said hospitals including Khayelitsha Day Hospital and Somerset Hospital had closed, and the offices of Home Affairs and Labour were closed. “SASSA offices will close soon for social grants,” he said.
NEHAWU served the department with a notice to strike on 24 February after wage negotiations deadlocked. The department offered a 4.7% increase while unions demanded between 10% and 12%.
Ronald Ruiters had queued at the Home Affairs office in Cape Town for hours for a temporary ID, without getting help, he said. “Yesterday I was here at 4:30am. I am an old man. What about people who are suffering now including sick people in hospitals? There should be a better way of dealing with these issues.”
“Since morning the police were here but they could not control the protesters, nothing is working here.”
Mali said workers were angry at a statement by acting Public Service Minister Thulas Nxesi who had described the strike as reckless.
“The acting minister called people reckless and said they need to go back to work … go back to work on what basis? Come with an offer: we are willing to negotiate.”
“It is reckless for the government to impose salaries on people. It is reckless for the government to expect the people who have been praised during the time of Covid for having to work hard in very difficult conditions to serve our people to get peanuts.”
“The ‘no work no pay’ principle is not a new thing. Let them deduct the money, we are used to poverty. “
Mali said members of the public did not understand. “They stand in long queues because the government is refusing to employ more people to work for Home Affairs, [Department of] Labour and SASSA. Instead they increase the cabinet. Too many deputy ministers and what work do they have to do?”
“What needs to be done is to create employment so that people get served quickly. That is all we are fighting for. We are not going to compromise.”
In Pretoria, striking workers occupied the Department of Labour Head office, singing and shouting at workers inside to come out. They also closed entrances to the offices of the Department of Higher Education and Training, and disrupted traffic on Francis Baard Street.
A striking cleaner at the Department of Labour, Boitumelo Motaung said she earns R6000 a month and supports a family of four people. She says she spends about R1000 on transport from Ga-Rankuwa to Pretoria for work.
“We are suffocating, and we are earning peanuts. I have three kids that are attending school and their father is unemployed. I am taking care of everything and a few days after payday, I am left without a penny and survive off loan sharks. We need government to recognise our value as people. Sometimes I am forced to do the work of three people where I work because they are not employing enough cleaning staff. That is why I am supporting this NEHAWU strike,” said Motaung.
Motaung said she has been working as a cleaner for seven years.
In a statement, DPSA director general Yoliswa Makhasi said work stoppages and pickets by NEHAWU and its members would be contempt of court.
“We will strike until our demands are met”
NEHAWU deputy secretary-general December Mavuso
Spokesperson for the department Moses Mushi said the minister had called on unions to return to the negotiating table.
NEHAWU deputy secretary-general December Mavuso said the strike had expanded. He said the union’s lawyers and government lawyers were in discussion about an appeal to the Labour Appeal Court. “We don’t know when an outcome will be available . In the meantime, our workers are on the picket lines,” said Mavuso. “We will strike until our demands are met”.
Department of Health spokesperson Foster Mohale said the department was working with provincial health authorities and law enforcement agencies to monitor the situation to ensure rapid response and if necessary urgent intervention.
In Fort Beaufort in the Eastern Cape, community health care workers were ordered to stop their services at clinics and hospitals. Striking NEHAWU members blocked the entrance of the Fort Beaufort Provincial Hospital and turned away patients. Top management was allowed to enter but other staff were locked outside the gates.
NEHAWU also shut down several government offices in the Eastern Cape.
Mphakamisi Shooter, regional NEHAWU treasurer, told GroundUp the union had used its resources to put President Cyril Ramaphosa in power. “But now he is failing to give us what we deserve.”
“We have over 5,000 members in this region. Today we made sure that we shut down all government departments in this region until Ramaphosa gives us a decent wage.”
MEC for Health Nomakhosazana Meth condemned the unprotected strike. “We understand that workers have a right to demonstrate but when they do they cannot infringe on the rights of others. We cannot afford to have a situation where the lives of patients and staff not on strike are in danger as a result of the action of those who have embarked on this action.”
She said there were reports of disruptions and acts of intimidation in some areas.
In Makhanda, clinics were closed as were the offices of the departments of Home Affairs, Labour, and Social Development by a group of about 80 protesters.
Madoda Toni, who was part of the protest, said the government cannot continue to pay workers low salaries while prices of food and other items were rising so fast. “We need permanent jobs, decent wage increases, and contract workers should be absorbed to be full time government employees and paid decent salaries,” said Toni.
In Qonce (King Williams Town) it was also reported that SASSA and Home Affairs offices were closed down by the protesters.
In Durban, patients were prevented from entering Prince Mshiyeni Memorial Hospital by NEHAWU members. The protest started about 6am and ended just before lunchtime when workers dispersed and returned to work. By 1pm, everything was back to normal.
Scientific evidence that supports vaping as an additional approach to tackle smoking-related morbidity and mortality is fast growing. The time is ripe for decisionmakers to embrace tobacco harm reduction and to steer away from precautionary principle-based tobacco control policies. This is according to Dr Riccardo Polosa, Founder of the Centre of Excellence for the Acceleration of Harm Reduction (CoEHAR) and Professor of Internal Medicine of the University of Catania, Italy.
Towards the end of 2022, the South African Tobacco Products and Electronic Delivery Systems Control Bill was officially introduced into parliament by the Minister of Health. Now, in the coming months, it will be discussed and possibly amended by a portfolio committee.
With this Bill lumping Electronic Nicotine Delivery Systems (ENDS, i.e. e-cigarettes and vapes) in the same category as smoking, Kurt Yeo, co-founder of consumer advocacy group Vaping Saved My Life (VSML), explains that it is essential for those involved in this process to consider the mounting scientific evidence demonstrating that vaping is far less harmful than tobacco smoking and is an effective way to support smokers seeking less risky alternatives and/or wanting to quit.
Dr Colin Mendelsohn is an Australian academic, researcher and clinician, who has helped smokers quit for over 30 years, says that vaping nicotine is a more effective quitting aid than nicotine replacement products such as patches and gums and is the most popular aid for quitting or reducing smoking globally. “It has the potential to save the lives of hundreds of thousands of South African smokers and prevent untold disease and suffering.”
He adds that vaping has been estimated to cause no more than 5% of the harm from smoking. “While the long-term effects have not yet been established, e-cigarettes are certain to be far less harmful than smoking. Vaping carries only a small fraction of the risk of tobacco smoking and is an effective quitting aid or long-term safer substitute for smoking. Vaping should be easily accessible to help adult smokers to quit deadly cigarettes.”
Dr Polosa highlights that decisionmakers and the public should also beware of many flawed articles scientific and fake news that are propagating ‘findings’ of potential harms, thus feeding the counter-narrative that e-cigarettes are ‘not as safe as promoted’. “Proliferation of poor-quality science and fake news need to be actively contrasted by good quality science and by correct information/education.”
The proof is in the numbers
“Countries which have supported vaping such as the United Kingdom and New Zealand have had accelerated declines in smoking rates,” explains Dr Mendelsohn. “For example, in New Zealand the national adult smoking rate fell by an unprecedented 33% in the two years between 2020 and 2022 after vaping was legalised.”
Illustrating this point further, Dr Polosa says that according to the same national surveys used for reporting smoking prevalence to the World Health Organization (WHO), these countries show faster declines in smoking prevalence compared with neighbouring countries with lower uptake of these alternatives. “In Sweden and Norway, eradication of smoking is now almost a reality with a daily smoking prevalence among Norwegian and Swedish youth close to zero (1% and 3%, respectively). Widespread diffusion of e-cigarettes in New Zealand and the United States is also contributing to the historical acceleration in the downward trend in daily prevalence of smoking among young people (1.3% and 1.9%, respectively).”
Regulation is essential, but the proposed Bill is deeply flawed
When it comes to regulation, Dr Polosa asserts that vaping and smoking are completely different animals. “Smoking kills. Vaping does not.”
Therefore, to regulate vaping in the same way as smoking does not make any sense, says Dr Polosa. “Doing so denies smokers access to much lower risk products. Rather, the South African government should table a risk-proportionate approach where the main regulatory levers are applied differentially.”
“This means that the most stringent and restrictive regulation would be applied to the most harmful products: tobacco cigarettes. Regulation of the smoke-free alternatives would focus on consumer protection (i.e., benefits to the consumer) and control of uptake by adolescents in a way that does not cause significant harm to adult smokers. This would meet the demands of people who cannot or do not wish to quit completely, but with much less cancer, cardiovascular and respiratory disease as a result,” Dr Polosa explains.
Dr Mendelsohn agrees and says that the preferred regulatory model is for nicotine liquids for vaping to be sold as adult consumer products from licensed premises, with strict age verification, like cigarettes and alcohol. “Regulation of e-cigarettes should be proportionate to risk and a light touch approach is more appropriate. A balanced regulatory model is needed which allows adult smokers easy access to regulated vaping products while restricting access to underage users. The current proposals will restrict adult smokers’ access to an effective quitting aid which can save lives and prevent smoking-related illness.”
“A precautionary approach to prevent the use of much less harmful smoke-free products is unjustified in the face of the massive burden of smoked tobacco products, which are widely available. This principle requires policymakers to compare the risks of introducing a product with the risks of delaying its introduction. In the case of vaping, the relatively small risks of harm will be outweighed by the far more substantial harms from delaying access to current smokers,” Dr Mendelsohn explains.
He points out that harsh restrictions on the sale and marketing of electronic cigarettes will have negative unintended consequences and will lead to black market sales of unregulated products to both adults and children. “The public health goal should be to encourage smokers who are unable to quit to switch to vaping, a far safer alternative.”
Yeo concludes by saying: “With the Bill aiming to reduce the incidence of tobacco-related illness, disability and death, regulations should be drawn up based on all available research and case studies to ensure South Africa’s smokers are truly helped.”
By Yanga Nokhepheyi, Marlise Richter, and Fatima Hassan for Spotlight
A frightful piece of information came to light recently. The pharmaceutical giant Pfizer announced its 2022 revenue at $100 billion. This is more than the combined health spending of 108 countries in 2020 according to calculations of The People’s Vaccine Campaign. The Pfizer COVID vaccine, of course, helped the dollars roll in. In fact, some reports suggest that Pfizer charged some countries $130 per dose of vaccine, while it is estimated that it costs less than $2 per dose to make. That equated to a markup of a stupefying 10 000% but we don’t know the full pricing details because the contracts are marked ‘secret’.
Figures like these make one’s eyes water.
In this pandemic, tackling the pharmaceutical sector and the perversities of its pandemic profiteering has been the focus of an international movement of health activists united under the banner of the People Vaccine Campaign. Partly because of severe resistance by governments in the global north and inaction locally, access to timely supplies of affordable and essential COVID vaccines, medicines and diagnostics has not materialised. But the struggle continues not only to tackle these structural barriers to beat COVID and future pandemics but also to help ensure implementation of Universal Health Coverage (UHC) systems. UHC means that everyone would be able to get the quality health services they need and benefit from scientific progress – irrespective of their ability to pay and without having to face financial hardship.
A Herculean task
South Africa, too, has committed to attaining UHC by 2030 as part of a set of promises made on the United Nation’s Sustainable Development Goals. South Africa’s main strategy to attain UHC is to implement a National Health Insurance (NHI) system. Unfortunately, progress has been historically slow, but in the build-up to the 2024 elections, the African National Congress (ANC) Members of Parliament (MPs) are rushing the law reform process despite an acknowledgement even from the health ministry that progress and timelines are hampered by the socio and mainly economic impacts of the pandemic. This includes a fiscus crisis with additional pandemic-related debt, and according to Dr Nicholas Crisp, Deputy Director-General in the health department responsible for NHI, “the NHI could take decades to be implemented at full scale”.
It will require a Herculean task to unify our apartheid-era two-tiered healthcare system, with the right skills, funding base, and transparency in decision-making around health policy and medicine selection. The pandemic has highlighted why all these elements are critical for healthcare for everyone.
We provide a short overview of our research below.
Law reform
Last year, the Portfolio Committee on Health in Parliament deliberated on the ‘NHI Bill’, but there were no significant changes made to it. It needs major revision. Many serious concerns and recommendations from parliamentary submissions by multiple stakeholders have gone unaddressed. The Health Justice Initiative (HJI) has focused on medicine procurement provisions in the Bill and in 2022 raised at least 17 questions that require greater attention before the law is passed. Neglecting to address the public’s submissions is not surprising seeing that ANC MPs serving on the committee were resolute in having the National Assembly adopt the Bill before the ANC Conference in December 2022. However, time ran out before the adoption of the Bill by Parliament, and the Parliamentary process is seemingly going to resume this month.
Stakeholder submissions to Parliament on the Bill (of which there were 64 000 written submissions following Parliament’s call for comment in 2019) and various commentators have warned about the ‘looming disaster’ that the Bill in its current form poses, but they are often divided on the main reasons. A tiny minority resists the principle of unified health systems and Universal Health Care for all (meaning, also for the poor). Many more groups agree that NHI is an ethical necessity but are concerned about South Africa’s disintegrating public health system, energy crisis, high levels of state corruption involving health product procurement, and the in/ability of the Department of Health to actually implement NHI in its current proposed form.
Other groups have rightfully pointed out concerns over conferring too much power on the Minister of Health, inadequate financing models, the feasibility of NHI in SA post-COVID, and the exclusion of specific categories of people from NHI. (For a curated archive of critical submissions, please see here).
Risks to medicine access
Regrettably, the provisions in the Bill on Medicine Selection, Pricing, and Procurement are ambiguous at best, and as the HJI pointed out in 2022, the entire shift of our medicine selection, procurement, and reimbursement system to “NHI reimbursement” has not been adequately thought through, potentially posing a great risk for the future of medicine selection and access in the country for all people. This requires immediate attention at the highest levels of the executive and the legislature too – and likely needs a multi-department and stakeholder technical group to urgently determine the exact trajectory of this planned process.
The World Health Organization has emphasised that UHC programmes will only be successful if there is “affordable access to safe, effective, and quality medicines and health products”. In addition, the COVID pandemic has taught us that timely and fairly priced access to essential diagnostics, therapeutics, and vaccines is key to addressing any public health emergency and improving health outcomes. We cannot safeguard public health without access to medicines – procured fairly, delivered on time, and based on expert and transparent decision-making and approval.
The cost of medicine, as elsewhere in the world where there are national health systems, remains a key concern. The Minister of Health last November in the National Assembly said that the funds for the NHI would be collected through a combination of taxes, including the reallocation of medical scheme credits paid to medical schemes, provincial health budgets to the NHI Funds, and payroll tax.
The financial feasibility of implementing the NHI is still unclear and a huge risk to the fiscus in a post-COVID economy that is dealing with a recession, load shedding, and high unemployment rates.
In late 2022, HJI argued that the Bill does not adequately consider the complexities of medicines access and that our medicines system could be severely jeopardised if poorly drafted sections in the current Bill become law. We said that government should set up a task team to urgently determine the exact trajectory of this planned process.
The Health Department’s recent response to submissions and its own recommendations on amendments to the Bill sadly does not realise the gravity of the threat to the future of medicine selection and access.
17 questions
In HJI’s 2022 analysis of the Bill, we raised 17 key questions that we believe must be addressed by lawmakers in the next version of the Bill and before NHI comes into effect. These include:
What specific measures are envisaged to enable and promote public transparency related to medicine selection, procurement, and contracting processes under the NHI?
How will the price of medicines not included in or covered by the NHI be regulated? And what role will External Reference Pricing (ERP) methodology play in the NHI and beyond?
How will the NHI Fund (e.g., the Office of Health Products Procurement, the NHI Board) negotiate with global pharmaceutical manufacturers and suppliers to procure for government and how will that process be transparent and accountable?
How will the Minister determine that the NHI is ‘fully implemented’, and what will take place in terms of what medical schemes can and cannot offer members during the transition period, and after the (undefined) date?
Has consideration been given to designing a competitive and different single medicine pricing system for SA?
Drawing on our work on medicine access during the HIV and COVID pandemic, we appreciate that there are powerful vested interests located in the multi-trillion-dollar pharmaceutical industry – this is why there is a need for legal safeguards, sound legislation, and independent and transparent institutions to ensure access to affordable medicines for all of us living here.
The pandemic showed that a lack of transparency, autonomy, and information around expert advice can bedevil open government decision-making. Secret procurement contracts for essential vaccines could become the norm even under NHI as they did in COVID, something we are fighting in our courts to open up, later this year.
Figuring out a sound system for a unified medicine access system under NHI is a formidable undertaking that requires a multi-disciplinary task team with experts from various fields, experience, and technical know-how. It is not easy to simply merge two parallel medicine procurement and selection systems. The risk is that the status quo could continue – where the rich and insured access the best medicines at a higher price.
We believe that the principles underpinning NHI for our highly regressive, unequal two-tiered healthcare system are too important for our collective health, well-being, and our Constitutional democracy to have lacklustre legal provisions and worrying gaps on the essential issues of medicine procurement and selection.
As the Bill currently stands, it will strengthen the private healthcare sector’s stranglehold on us and our fiscus. It will leave us at the mercy of advisory committees that bear no duty to be transparent in deciding which medicines you and I will be able to access under NHI.
We can and need to do better.
* Nokhepheyi and Richter are researchers and Hassan the Director of the Health Justice Initiative.
Health activists demonstrating in Cape Town for a rise in the tax on sugary drinks were disappointed by Finance Minister Enoch Godongwana’s announcement in his Budget speech that the tax would be frozen for two years. Godongwana said this was “due to the difficult operating environment for the sugar industry from the impact of flooding and social unrest.”
The tax on sugary drinks was first introduced in 2018 to reduce consumption. The tax is imposed on drinks with more than 4g of sugar per 100ml. Research from the University of the Witwatersrand in 2021 showed that it has been effective in reducing the consumption of sugar-sweetened drinks.
HEALA, a coalition of organisations focused on nutrition, organised a flash mob in the Cape Town city centre ahead of the Finance Minister’s Budget Speech on Wednesday, advocating for an increase in the sugary drinks tax. They want the tax to be increased from 11% to 20%, following the guidance of the World Health Organisation.
The flash mob was part of HEALA’s “Less Sugar, More Life” campaign, and featured school pupils from Cape Town in a dance.
“We don’t even notice how much sugar we are drinking in sugary drinks and it’s harmful to our health. I want other young people to know that it’s dangerous,” said one of the dancers, Enkosi Stofile.
“The announcement by the Finance Minister, coupled with ineffective increases on other health taxes such as alcohol and tobacco, is a direct attack on the lives of millions of people at risk of serious health conditions such as diabetes, cardiovascular diseases and cancer,” said Nzama Mbalati, HEALA’s Programmes Manager.
Mbalati said there was no rationale for the decision to maintain the rate of tax on sugary drinks. “This decision is not in the interest of ordinary people. Instead, it puts profits ahead of people.”
About 10 000 new cases of diabetes are reported in South Africa each month, according to the International Diabetes Federation. Up to 70% of women and 39% of men are obese or overweight. Sugar is a cause of obesity and tooth decay, and is linked to a range of other non-communicable diseases. The national budget for 2023, tabled by Godongwana in parliament today, includes a R200-million reduction in health spending this year.
Before the budget speech, News24 reported that the South African Sugar Association said 6000 jobs could be lost if the tax was increased. SASA also said 9,000 jobs had already been lost since the levy was introduced.
However, in the aftermath of a fraud scandal at Tongaat Hulett, South Africa’s largest sugar producer, in 2018, 5,000 workers were served with retrenchment letters.
Disclosure: Community Media Trust does work for HEALA. GroundUp was once a project of Community Media Trust and still has a close relationship with Community Media Trust.
In October last year, Eastern Cape Health MEC Nomakhosazana Meth announced a three-phase plan to address key challenges with the province’s emergency medical services. PHOTO: Black Star/Spotlight
By Siyabonga Kamnqa for Spotlight
Gogo Nothembile Fanti (76) says she suffers from a heart condition and every time her grandchildren call an ambulance, they are told to wait, but it never arrives. She is one of about 40 patients – mostly older persons – sleeping on the floor and in chairs at All Saints Hospital in Ngcobo in the Eastern Cape during Spotlight’s visit on 30 January. They are all waiting for an ambulance to take them to referral hospitals such as Nelson Mandela Academic Hospital and Bedford Hospital about 60 kilometres away in Mthatha. They come from various villages around Ngcobo.
Fanti, like many other patients, says they are forced to sleep there overnight as the free transport provided by the hospital leaves at the crack of dawn.
“I had to call my neighbour to [bring] me here, otherwise I could have died waiting for the ambulance. They told me that I have to be taken to Mthatha to see a specialist, but having to sleep under these conditions at my age is a terrible experience,” she says.
An old problem
The challenges with patient transport, specifically emergency medical transport in the Eastern Cape, are not new. Spotlight has previously reported on the issue here, here, and here.
In October last year, Eastern Cape Health MEC Nomakosazana Meth in a response to a written question in the provincial legislature by DA MPL Jane Cowley said that there are 84 Emergency Medical Services (EMS) bases in the Eastern Cape – 16 of those are in the Chris Hani District where All Saints Hospital is situated.
Based on the numbers Meth provided, the district also has the highest vacancy rate – 65%. This means of the 796 posts available, there were 518 vacancies for EMS staff at the time of her response in October. Overall, for the whole province, the total posts were 3 269, but 1 202 were vacant at the time.
The province needs 671 ambulances based on its population but has 447 ambulances of which only 200 were rostered, meaning they were in service at the time. In Chris Hani District, they need at least 72 ambulances but only have 62 of which just 38 were rostered and on the road to provide a service.
Staff shortages and ambulances undergoing maintenance are among the reasons why there are not enough ambulances rostered in the province. Not one of the 84 EMS bases in the province complied with the national EMS regulations for personnel numbers.
According to the DA’s provincial health spokesperson, Jane Cowley, there are 150 ambulances at any given time in for repairs. “The average turnaround time for repairs is a shocking 100 days – this is because they use the Government Fleet Management Services, who are owed in excess of R300 million by the [provincial health department] so they really don’t prioritise ambulance repairs.” She says the DA has been calling for the decentralisation of ambulance repairs and the development of public-private partnerships, which the party believes would speed up repair turnaround times dramatically.
Shouldering the burden
Providing some perspective on the impact this has on services and patient lives, a doctor says there are some districts where, at times, there is only one paramedic on duty per shift (the doctor spoke to Spotlight on condition of anonymity given the risks of reprisals from the health department). “When there is a serious call from opposite ends of the district, then you have to wait for the paramedic to deal with the one case, then come to the second. Patients in hospitals are deemed ‘less serious’ than if they are on the roadside. So, patients can wait for hours in a district hospital before being referred to a tertiary hospital. We recently had an elderly man with wet gangrene on his foot who waited in a casualty for two days. Then he died,” the doctor says.
The doctor says they often have a full casualty unit on Saturday nights. At times there may be four patients waiting for a referral. They may have gunshot wounds, been stabbed in the neck, and assaulted with a head injury. The casualty fills up as time passes and the number of patients waiting for referrals now grew by three, while the other four are still waiting in casualty. The three may be all orthopaedic patients. The doctor will ask the nurse about the patients and is told EMS said “no ambulances available”. “Maybe you have the energy to paste this update on the EMS WhatsApp group. Maybe you try to phone someone yourself to escalate this issue. Maybe someone is able to contact the provincial office and request a private ambulance to assist. But by morning, there are still six patients waiting… then one dies. The oncoming team will now have to re-discuss these patients with the new team at the referral centre. The same thing happens day after day… patients miss appointments, have to be re-discussed, get a new date due to the perseverance of the doctors, then maybe miss another date due to EMS not being available… It is extremely exhausting for all concerned,” the doctor says.
According to two paramedics (who also spoke on condition of anonymity), they struggle with inadequate equipment in EMS vehicles. This, coupled with poor road infrastructure, often puts them under enormous pressure, they say. “Cellphone network also disappears during loadshedding and this makes it impossible for patients to reach our services,” says one of the paramedics. “When we eventually arrive at the accident scene or at a sick patient, we are often met with insults from frustrated patients who said they’ve been trying to get hold of an ambulance for hours. Often, they forget about the challenges we face in trying to get to them on time,” he said.
Three-phased plan – yet to be financed
Meth in her parliamentary response last year said, “The[se] frequent transfers of patients put a heavy burden on the emergency medical services as there are no ambulances to do inter-facility transfers and therefore the emergency ambulances are used to transfer patients from hospitals to other hospitals over long distances with no ambulances left for emergency response at community level.” She said this is why there are often poor ambulance response times or no response at all.
In an attempt to address this, the provincial health department is working on a three-phased EMS plan targeting 28 hospitals across districts – among them All Saints.
This plan, however, will need funding to get off the ground.
Explaining the department’s three-phased plan, provincial health spokesperson Yonela Dekeda last week said the department plans to recruit additional personnel as funding becomes available and so did not provide timeframes. She says phase one is aimed at providing a dedicated inter-hospital transfer ambulance on a day-shift basis at the 28 priority hospitals. They aim to appoint 120 new staff members for this.
In phase two, the department wants to appoint an additional 120 personnel to make the day service a twenty-four-hour service and phase three is to extend this to other hospitals and provide them with the personnel needed.
But, says Dekeda, the department will need R27 million and they expect funding only to be made available in the 2023/24 financial year.
Working to address EMS challenges
Meanwhile, she says, the department has been working to address the many challenges facing EMS in the province and there are some improvements. “These include the response rate to priority 1 calls (life-threatening calls). Over the past three quarters – ending December 2022 – the department has been meeting its targets for priority 1 calls by responding within 30 minutes (urban areas) and 60 minutes (rural areas).” She didn’t however specify what percentage of calls met these targets.
According to her, the department has taken a developmental approach to achieve compliance with the national EMS regulations. She says over the next three years there will be continued investments in infrastructure, equipment, staffing, and vehicles to promote compliance with the ideal promulgated in the regulations.
“We have purchased an additional 50 ECG monitors at a cost of R19 million to supplement the equipment in our ambulances as required by the regulations. About R15 million has been allocated to improving the infrastructure at selected EMS stations around the province and an additional allocation is expected in the next financial year to support the strategy,” she says.
In the current financial year, she says, the Engcobo Local Service Area where All Saints Hospital is located was allocated two intermediate life support practitioners.
Dekeda says the department’s priority remains emergency patient care, so the majority of the current resources are still allocated to this.
“We are using our staff interchangeably between planned patient transport and the emergency transport service. One will understand that the planned patient transport works on weekdays (Monday to Friday) while emergency ambulance services are a 7-day operation, 24 hours a day. We are committed to increasing the number of staff on the emergency transport and then developing a separate staff complement for the planned patient transport service.”
Dekeda also says recruiting more staff is coupled with interventions to have the district hospitals offer the appropriate package of services, which will reduce the number of trips transferring patients. She says by employing dedicated teams to manage transfers of patients at the 28 priority hospitals as part of the three-phased plan, the hope is to improve the overall responsiveness of the ambulance fleet.
“We will continue with this recruitment in the next financial year and also focus on the operational staff to assist with the transfers of critical patients. All Saints is one of the district hospitals that will benefit,” she stresses.
“A total mess”
But some Eastern Cape residents remain sceptical.
Responding to the new plans, activist and community leader from Xhora Mouth, Phumzile Msaro says they are tired of empty promises. “This EMS problem is going to be with us for a long time as long as there are still unreliable people at the top. Every day we are faced with challenges as rural dwellers. Just yesterday (09 February), I called an ambulance for an elderly villager from Xhora Mouth who had fits. The assistants at the call centre lied and said the ambulance was on its way but we waited all day, only for the ambulance to arrive at 7 pm after a number of frantic calls throughout the day. The elderly person only managed to arrive and get assistance at Madwaleni Hospital at 9 pm. We keep hearing about all these so-called plans but nothing gets implemented on the ground. It’s a total mess,” he says.
Cowley echoes these sentiments. She says due to ambulance shortages and the severe shortage of EMS personnel, especially advanced life support paramedics, ambulance turnaround times are very slow, particularly in rural areas. “People can wait up to a day for an ambulance and sometimes that is too late. They have many plans but cannot seem to implement them as there is no political will to do so. It’s just a talk shop. In all my extensive oversight visits, the constant and main complaint is the lack of or slow ambulance service.”
On Tuesday 22 November, healthcare workers were among the public sector employees who engaged in a strike action to protest a lack of pay increase. A number of hospitals and clinics across South Africa and particularly Gauteng were affected, the Daily Maverick reports.
Unions had been offered a 3% increase plus an additional R1000, which the negotiating unions refused. Union leaders rejected this, demanding a 10% increase. Inflation is running at 6%, and food prices have risen by 12% from the start of the year to September – largely driven up by the war in Ukraine.
Union leaders say the strikes and protests are driven by wages staying the same over the past few years. Healthcare workers had already been suffering high rates of burnout battling COVID waves. In addition, workers complained of being understaffed, and enduring dire working conditions from lack of equipment, medication and food.
On Tuesday morning, burning tires were placed on Chris Hani Road in Soweto. Striking workers wearing union colours were preventing many vehicles, including ambulances, from entering Chris Hani Baragwanath Hospital. Patients inside were being left unattended.
Sebokeng Hospital in Sedibeng meanwhile was running on a skeleton staff, with doctors and nurses prevented from entering. Emergency services were being diverted to nearby facilities.
Meanwhile, GroundUp reported that patients were being turned away from Mabandla Clinic in the Eastern Cape. In Gqeberha, Motherwell NU8 clinic and the Motherwell Healthcare Centre were both reported to be closed.
On Tuesday afternoon, the Gauteng Department of Health received an interdict against the strikes, preventing striking workers from interfering with access to hospitals, EWN reports. The public healthcare systems in Gauteng and other provinces have already been strained, with recent high-profile protests and resignations over inadequate funding and allegations of corruption.
The Supreme Court of Appeal (SCA) has set aside a controversial supervisory order, granted in April 2021, compelling the South African Health Products Regulatory Authority (SAHPRA) to report back to court every three months on access to ivermectin for use in the treatment of COVID patients.
The court has ruled that there was no evidence to justify the order made by Pretoria High Court Judge Cassim Sardiwalla, that affected parties had not asked for the order, and that they had not been heard before he made it.
The judge had also failed to provide his reasons for making it, the court said.
The issue has its genesis in four applications, one by the African Christian Democratic Party in 2021 against SAHPRA seeking access to ivermectin for the treatment of COVID.
At that time, SAHPRA, which was wary of its use saying there was no reliable research to prove its efficacy, had already put in place its “controlled compassionate use” programme in response to reports of illicit ivermectin-containing products entering the South African market. The programme was stopped in May this year.
In terms of that programme, permission was granted to five importers of unregistered oral solid dosage forms of ivermectin. Health facilities were permitted to hold bulk stock but individual applications were still required. SAPHRA said it would monitor its use.
The ACDP and others approached the court for orders directing SAHPRA to remove restrictions and do “all things necessary to regulate and ensure the manufacture” of ivermectin until such time as clinical evidence demonstrated that it was not effective in the treatment of COVID.
The matter was settled along the same lines as SAHPRA’s programme.
But Judge Sardiwalla, in making the settlement agreement an order of court, also granted a “supervisory order”, putting SAHPRA under his judicial authority in respect of ivermectin.
SAHPRA and the Minister of Health applied for and were granted leave to appeal the order to the SCA.
In heads of argument before the SCA, SAHPRA said its appeal concerned the propriety of the order directing an organ of state to report back to court and be subject to judicial supervision where the dispute had been settled and there was no evidence at all that SAHPRA and the minister would not comply with the settlement agreement.
“It was simply imposed without justification. The order constitutes a grave violation of the Constitution … it violates the rule of law, the right to a fair hearing and the principle of separation of powers,” it argued.
The judge, SAHPRA said, had improperly made findings on matters not in dispute and his written reasons for the supervisory order “do not constitute reasons at all”.
In the SCA ruling, Judge Clive Plaskett said Judge Sardiwalla had suggested to the parties that he “regarded himself as seized of all matters involving ivermectin” and had proposed the supervisory order.
Both SAHPRA and the minister indicated they would oppose this and filed further papers.
While the judge had indicated that he would hear the parties on 6 April 2021, his registrar had informed SAHPRA’s attorney that morning that he had made a decision, he would not hear arguments, and he would send his order to the parties shortly.
No reasons accompanied the order.
SAHPRA and the minister asked for reasons but when these were furnished, they made no mention of the supervisory order or why he granted it.
Judge Plaskett said the first difficulty with the order was that Judge Sardiwalla had not given SAHPRA and the minister a hearing despite knowing that they did not agree to it.
“He agreed to a hearing but inexplicably changed his mind. In these circumstances, an oral hearing was, without doubt, essential.
“Courts decide matters, particularly opposed matters, in open court and the exceptions to this rule are limited.”
Judge Plaskett said the fact that the order had not been applied for by any party required that it be set aside.
He said, further, there was a complete absence of evidence to justify it.
“Important as supervisory orders may be in appropriate cases, the granting of this type of relief must be carefully considered – and justified on the facts – particularly because of its separation of powers implications.
“In this case, not only was there no evidence as to the necessity of a supervisory order but the fact that SAHPRA and the minister had settled the matter and agreed to an order suggests that there was probably no necessity for one.
“Had he allowed the parties to argue the matter, he would have been informed of the separation of powers problem …
“Finally, it strikes me as telling that the reasons he furnished made no mention of the supervisory order – and this despite being pertinently asked to furnish reasons on this very issue,” Judge Plaskett said, upholding the appeal, and setting aside the order.
The ACDP originally opposed SAHPRA’s appeal but shortly before the SCA hearing, it withdrew its opposition on the basis that no cost order would be made against it. The SCA therefore did not order costs.
The ivermectin programme was stopped in May this year.
