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Good Governance in SA’s Health System is ‘Patchy’ – Experts Unpack Report on How to Fix it

On February 10, 2025February 10, 2025 By ModernMedia

By Elri Voigt

A timely report on governance in South Africa’s healthcare sector released last year identified several serious shortcomings. As the political and administrative wheels again start turning in 2025, we unpack the report and ask if government is paying attention.

The signing of the National Health Insurance (NHI) Bill into law last year, sparked a renewed conversation on how the healthcare sector is governed, making the release of a consensus study on what was needed to achieve good governance and management in the South African healthcare system a few months later particularly timely. Commissioned by the Academy of Science of South Africa (ASSAF), the report was a three-year endeavour led by a panel of experts from multiple fields.

The spark for the project was concerns over the performance of the country’s healthcare system and the Life Esidimeni tragedy in particular, according to the chairperson of the ASSAF report panel Professor Lilian Dudley. The Life Esidimeni tragedy, in which 144 mental healthcare users in Gauteng died due to starvation and neglect, highlighted what the public health medicine specialist described as “not just poor performance but corruption and unethical practices in the health system”.

“There were concerns about the overall governance or oversight and leadership of the health system, and the panel was essentially asked to try and look at some of the challenges, as well as to go over the evidence and make recommendations which could be implemented to address it,” she told Spotlight.

After describing the “magnitude, the spread, and the effects of the governance challenges in the health system” as well as finding examples of where good governance was taking place, the report went on to make eight recommendations on practical strategies to improve the situation. This article focuses on three of these recommendations, so it is by no means exhaustive. The recommendations are interdependent, as is evident from the full report which can be found here.

Good governance is ‘patchy’

Sharon Fonn, Professor of Public Health at the University of the Witwatersrand who also worked on the report, told Spotlight it found that good governance in our healthcare system is “patchy”. She said there were two issues contributing to this: There are some people without the necessary competence and skills or sometimes motivation in key positions, and in some cases dysfunctional or inappropriate systems undermine the best efforts of those who are competent or have the right intentions.

There is no quick fix though. “You need to see this as a 10-year project,” Fonn said. “There’s some political leadership that’s needed, and then there’s some technical interventions that are needed. It’s about having a plan and getting people around the table,” she added.

Foundations for good governance are present but no longer ‘fit-for-purpose’

To contextualise governance within the healthcare system, the report needed to look at the past, according to Dudley. She explained that democratic South Africa “inherited a very flawed, fragmented health system, which was not being governed in order to address the needs of the majority of the population”. Thus, a lot of work had been done after 1994 to set up a unified healthcare system and establish systems and structures to lay foundations for good governance. “But we seem to have lost the plot along the way,” she said.

“One of our key findings was that there were some foundations that were put in place, but they would not be effective as governance structures and were no longer fit for purpose,” Dudley said. “Even though we have some structure, some systems, they are not really supporting and promoting the kind of governance that is needed.” In this regard, Dudley points to key legislation and policies such as the National Health Act (NHA) and the White Paper on Transformation for the Health system.

“The other context within which we are operating is the overall political environment, and health is political at the end of the day with levels of political interference,” Dudley added. “[H]aving the right people, the right competence and the right ethics in place has been a problem because a lot of senior managers in the health system are not necessarily accountable to the people they serve”.

The report stated that a conflict between two pieces of legislation – the Public Finance Management Act (PFMA) and the Public Services Act (PSA) – could be contributing to some of these problems with senior leadership and so-called “cadre deployment” in some provincial health systems. At issue are apparent contradictions and overlaps between the roles of purely political appointments, such as Members of the Executive Committees (MECs) for health, and those of senior officials like heads of health departments.

The PFMA is legislation aimed at regulating the financial management of government and providing for the responsibilities of the persons entrusted with that financial management. According to the report, the Act grants the power and responsibility for financial management, service delivery and human resource management to “accounting officers”, who are either the Head of Department or the Director-General – depending on the level of government being referred to.

By contrast, according to the ASSAF report, the PSA aims to regulate the organisation and administration of the public service, grants Ministers and MECs in the provinces the power of “executive authority” giving them the authority to, among other things, appoint people to government positions.

It is not unusual to have contradictions between pieces of legislation that were developed at different times and by different Ministers or Departments, Dr Andy Gray, a senior lecturer in the Division of Pharmacology at the University of KwaZulu-Natal’s School of Health Sciences, told Spotlight.

He said Section 38 of the PMFA describes the responsibilities of “accounting officers”, which is clearly describing a managerial function. However, every Head of Department is also subject to governance by a minister. The PSA repeats the same definition for an accounting officer as the PMFA but adds an additional definition for an executive authority.

Within the PSA, who the executive officer is depends on the level of government being referred to, for example in relation to “a provincial department or a provincial government component within an Executive Council portfolio”, the executive officer will be the member of the Executive Council responsible for that portfolio.

In the case of a provincial health department, this would mean the MEC for Health is an executive officer, who is granted by this Act all the powers and duties necessary for, among other things, “the recruitment, appointment, performance management, transfer, dismissal and other career incidents of employees of that department”.

“That does appear to contradict the separation between management and governance, so the ASSAF criticism appears to be valid,” Gray said.

Another function of governance that has not been working as it should, according to Dudley, has been the community participation aspect. She said that the NHA has delegated a lot of the power and responsibility for enabling community participation to the provincial governments. And in the cases where provincial governments have created appropriate regulations for the health committees that allow for community participation, it’s still inadequate.

As summarised by the report, the lack of clarity between these three Acts – NHA, PFMA, and PSA – “have contributed to conflicting mandates between politicians and senior managers in the public health sector, across levels of government, and between the health sector and structures for community representation”.

Legislation needs to be refined

To address some of these issues, the report recommended updating legislation and governance structures “to insulate them from vested interests and give them executive rather than merely advisory functions”.

To do so, it called for making accountability structures more effective by amending the conflicts within legislation that weaken or undermine the delegation of governance. This includes, among other steps, aligning the PFMA and the PSA, as well as clarifying and strengthening the way the NHA delegates authority between levels of government, particularly to health districts and health facilities.

The report also proposes taking steps to strengthen community governance structures like clinic committees, hospital boards and other entities. This included, among other things, reforming legislation to ensure “harmonised policies on roles and functions of such structures across all provinces” and extending community participation structures to the private sector. It also called for a common policy defining the “criteria and processes for appointments, role and functions, reimbursement of community committee members for costs, induction, and continuous capacity building”.

Systems are not working

Also hindering good governance, according to Fonn, is dysfunctional systems, such as overly complicated procurement processes and ineffective information systems. She said that whenever a problem arose with procurement, another layer of control was added, making the systems impossible to navigate.

“It must be possible to review it and to work out a more manageable process around procurement. And procurement is particularly important because it’s sort of what keeps things turning over. It’s also the space where vested interests can be exercised,” Fonn said.

Accurate information is another essential component of the health system that overall isn’t working very well, though there are exceptions. Fonn explained that the report found functional information systems in some provinces. Part of what can be done to improve governance, she said, is to take what worked in those instances and try to replicate or adapt it to work in other provinces.

Need functional fit-for-purpose systems

One of the recommendations in the report is to “surround managers and leaders with functional fit-for purpose systems (including human resources, procurement, health information systems) so that they can do their work”.

Part of this was a call to improve procurement processes by simplifying the existing overly complex and sometimes contradictory rules and delegating more of the actual procurement to facilities and district or sub-district managers.

“Overly complex procurement systems are inhibiting decentralisation, as the complexity of existing rules makes it difficult for decentralised managers,” the report stated. “This does not mean that every facility should be issuing its own medicine tenders, but there is no reason why strong sub-district offices or larger facilities should not be ordering supplies off transversal tenders without multiple layers of high-level signoff.”

Some of the suggested reforms include greater development and use of electronic systems like electronic catalogues, stock management systems, ordering systems and e-procurement systems. It also suggested including medical supplies and medical equipment in transversal tenders to achieve economies of scale.

The report also advocated for giving health institutions greater power, where appropriate, over hiring, firing and disciplinary procedures. “Within labour law and labour agreements, space must be made to allow managers to follow agreed procedures without sacrificing the public value mission of the service,” it stated.

Implementing the electronic National Health Information System of South Africa (NHISSA) was also identified by the report as an urgent priority so that patient-linked data can be collected.

Alleged lack of vision and stewardship by the National Department of Health

Another trend observed by the panelists, Fonn said, is an overall lack in a vision of the healthcare system that is being communicated by government – particularly the National Department of Health. She used the example of the NHI, where the government has been, as she described it, “unable to communicate that [NHI] in a way that captures the public imagination and in a way that makes sense to people on the ground who are actually [healthcare] providers”.

“The argument from government is that the NHI Act is simply setting in place the fund, that’s all it’s supposed to do. I understand that…and it’s a legitimate argument. The problem is then that doesn’t tell people what it means,” she added. “It’s that kind of lack of stewardship, lack of communicating a vision.”

Fonn also pointed out an apparent reluctance by the National Department of Health to engage with stakeholders and instead foster a “command-and-control environment”.

Another layer of this issue is that the healthcare system is set up in a way that makes the National Department of Health responsible for steering the system but, according to Fonn, they haven’t done this effectively and have focused on the wrong things.

“The way the South African health system is set up currently is that the National Department [of Health] is responsible for stewarding the system, for making sure that the right legislation exists, the right checks and balances exist, and the right controls exist,” said Fonn.

“I think that at least in part, they haven’t [fulfilled that responsibility]. It’s a complex thing to do so I’m not suggesting it’s easy. But I don’t think they’ve had their eye on the right place,” she said.

“What our report does acknowledge is that there are many good people in the health system who actually want to see improvements, who are committed to good leadership and management and governance,” Fonn said. “But I think we need leadership to kind of show the way and one of the first things that we felt was important was to revisit what our public values are, what are the social goals that we want to set for the health system, and can we all agree on that and move towards that? [We need] that kind of leadership and stewardship from the political and national government level.”

Mixed response from government

Spotlight asked the National Department of Health and Minister of Health Dr Aaron Motsoaledi for their responses to the report and its findings. The spokesperson for the health department indicated he had only been able to access an abstract of the report and would not be able to respond without seeing the full report. A copy of the report was then sent to the spokesperson, but no response or comment was received by the time of publication (more than a week later).

However, according to Dudley, the report was presented last year to the Minister of Health, senior managers in the provinces, and health MECs.

“There was actually quite a bit of interest from the new MECS [for health] … the MECs were quite keen to hear more about it, engage more about it and wanted to know what we need to do to actually respond and to start implementing some of these recommendations,” she said.

By comparison, Dudley said there was less interest from the National Department of Health.

She however pointed out that the burden of changing governance in the healthcare system doesn’t rest entirely on the health department’s shoulders.

“There are multiple stakeholders that need to take action, we do try to emphasise that in the report. Yes, government and politicians do have particular roles, but everybody has a role,” Dudley said.

These include academic institutions, she said, which need to ensure when training health professionals and leaders they are provided with the kind of competencies that will improve the management, leadership and governance of the health system.

Research institutions also have a role to play in addressing some of the unanswered questions around governance and how to implement interventions that can bring about change. Civil Society will also have a part to play through activism to hold those in positions of power to account.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags : 30/1/25 GroundUp healthcare funding international aid USA WHO

Stopping Health Funding in Africa Weakens America

On January 30, 2025January 30, 2025 By ModernMedia

This is an opportunity for President Ramaphosa to lead

By Nathan Geffen and Marcus Low

President Donald Trump’s administration took a cruel decision this past week to freeze US foreign aid for health, potentially leaving millions of people in many African countries without their life-saving antiretroviral treatment.

On Wednesday morning, Trump’s secretary of state Marco Rubio backtracked on part of that decision. But if it is not reversed permanently we can expect advances in life expectancy in sub-Saharan Africa of the past two decades to start coming undone. We can also expect HIV infection rates to start picking up again, as people with HIV start getting viral rebound and become more infectious.

The President’s Emergency Plan for AIDS Relief (PEPFAR) was started by the Republican administration led by George W. Bush in 2003. The complexity of world politics is such that the president who perhaps did more than anyone else to unravel confidence in global rules and norms – by invading Iraq – also championed a programme that has saved many millions of lives. Bush described PEPFAR as “compassionate conservatism”.

PEPFAR had bipartisan support. It is one of the greatest contributions the US has made to the world. It is now under threat by people claiming with straight faces – who came to power while the US economy is booming – to make America great again.

About $5-billion went into PEPFAR last year. Although it’s a huge amount of money it’s a tiny fraction of the US budget. It’s not straightforward to measure how many lives PEPFAR has saved but it is in the millions. This is a lot of bang for the buck.

The US government is also the largest contributor to the other major funder of global health: the Global Fund. Its future is also bleak.

Already in South Africa, vital services for extremely vulnerable clients had to pause, such as those provided by the Wits Reproductive Health and HIV Institute clinics in Johannesburg. Hopefully with Rubio’s announcement these can now resume but the situation remains chaotic and the future of this and other US-funded health programmes across Africa is fraught with uncertainty.

Opportunities

America’s abandonment of foreign aid for health relinquishes soft power. There is an opportunity here for the European Union, Canada, Australia, Japan and China to step into the breach and increase their contributions to the Global Fund, or even to directly plug holes left by PEPFAR using bilateral aid – though such funding may come too late for some.

This would not merely be an act of charity. In the post-World War II world, what has made countries great, powerful, prestigious and influential is not nastiness and murder, but investing in projects of solidarity that make the world a better place. US wars in Vietnam, Afghanistan and Iraq degraded US power. Its arming of Israel, especially during the war on Gaza, has shown US concern for universal human rights to be hypocritical and worsened its global standing. By contrast PEPFAR unequivocally enhanced its superpower status.

President Cyril Ramaphosa can display great leadership by meeting with leaders of wealthy countries and convincing them to increase spending to support the health systems of poorer countries.

But perhaps the biggest opportunity is for African countries themselves. Many remain far too dependent on foreign aid to run their health systems. A country like South Africa should be able to pay for every last cent of its health systems. Corruption and mismanagement have had an inordinate role in making this difficult.

For countries like Malawi, Mozambique and others, there is a long way to go before they can pay their own way for HIV treatment. But pressure, from within and out these countries, must be put on their governments to build robust economies capable of delivering tax revenue to spend more on health.

In a very divided world where illiberal nationalist populism is on the rise and African governments are for the most part still weak and corrupt, these opportunities seem unlikely to be seized. But we hope we are proven wrong.

Geffen is the editor of GroundUp. Low is the editor of Spotlight. Both served in the Treatment Action Campaign which successfully campaigned for HIV medicines in South Africa, as well as other countries.

Republished from GroundUp under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Categories : Healthcare Politics and RegulationsTags : 24/1/25 NHI private healthcare

Pressure Grows for NHI Compromise Ahead of Cabinet Lekgotla

On January 24, 2025January 24, 2025 By ModernMedia

By Chris Bateman

Whether or not the ANC and DA can find common ground on the future of medical schemes is set to be a major test of South Africa’s Government of National Unity. Ahead of a Cabinet lekgotla where the issue is expected to be on the agenda, momentum has been gathering behind a compromise option.

Little more than a month after President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law in May last year, the ANC entered into a government of national unity (GNU) following a large drop in their share of the vote in South Africa’s 2024 elections. This raised questions over the future of NHI, given that the second largest party in the GNU, the DA, is vehemently opposed to NHI.

The NHI Act has not yet been promulgated and could be amended if the ANC and DA agree to do so. But whether the parties can agree to a compromise remains unclear, especially since there appears to be a hardline faction in the ANC that is committed to NHI as currently encapsulated in the NHI Act. As it stands, the Act foresees a dramatically reduced role for medical schemes whereby they will not be allowed to cover services that are already covered by the NHI fund.

Also in play are at least four High Court challenges to NHI legislation – by the Board of Healthcare Funders (BHF) challenging Ramaphosa’s assent to the NHI Bill just before the elections last year, Solidarity, and the SA Private Practitioners Forum, both claiming government overreach which impacts on people’s right to choose their own health cover and run their own businesses. The South African Medical Association (SAMA) is also preparing a legal challenge.

Two proposals

Meanwhile, momentum has been growing with two compromise proposals: one from Business Unity South Africa (BUSA), the country’s apex business organisation broadly representing the banking, mining and retail sectors, but more pertinently here, the Health Funders Association, the Hospital Association of South Africa, and the Innovative Pharmaceuticals Association of SA. The other is from the United Healthcare Access Coalition (UHAC), a large coalition of healthcare worker groups including, among others, SAMA, the South African Private Practitioners Forum, and the Progressive Healthcare Forum.

BUSA last year met with Ramaphosa and, on his request, provided a detailed yet currently “confidential” proposal, wanting key sections of the NHI Act amended and/or thrown out to enable medical schemes to remain in play by punting mandatory health insurance.

“The BUSA proposal is being processed by the Department of Health and National Treasury. Once processed, a response to BUSA will be formulated accordingly,” presidential spokesperson Vincent Magwenya told Spotlight this week.

The fundamental difference between the two objecting groups is that the UHAC thinks the NHI Act should be thrown out completely and replaced with their detailed blueprint, while BUSA wants the existing Act amended to accommodate private funders. In its proposal, the UHAC urges implementation of long delayed fundamental systemic reform in both healthcare sectors to enable what they say would be efficient, pragmatic and more politically neutral, consultation-driven universal healthcare measures.

We understand that in a meeting between the two groups, shortly before BUSA lodged its proposal with the Presidency, not enough common ground could be found to join forces.

But there are significant overlaps in their proposals. Both groupings embrace mandatory health insurance and dismiss a single central fund as envisaged under NHI as dangerous and financially unfeasible.

DA spokesperson for health, Michelle Clarke, said her party backs mandatory insurance. She also said the party agrees with the UHAC proposals – and would not hesitate to mount a legal challenge should the NHI go ahead without substantial amendments.

Mandatory health insurance was part of government’s longer term health reform plans until the pendulum swung in favour of NHI at the ANC’s national conference in Polokwane in 2007 when Jacob Zuma became president of the party. The idea was placed back in the spotlight last September when Dr Richard Friedland, immediate past CEO of the Netcare Hospital Group and a key member of BUSA’s health delegation, made the case for it at the HASA conference.

Under mandatory health insurance, everyone who is in formal employment, or who earns above a certain threshold, would be forced by law to be a member of a medical scheme. This, it is argued, would result in medical scheme membership swelling substantially and pressure being taken off the public healthcare system. It is also expected to result in medical scheme premiums being reduced because more healthy, younger people will join the schemes. People who are unemployed or who cannot afford health insurance will still be taken care of by the public healthcare system, which would also take paying medical aid members.

Friedland said at the time that mandatory healthcare insurance would triple the medical scheme market from 9.2 million to potentially 27.5 million beneficiaries over time and reduce those dependent on the state from 53.8 million to 35.5 million.

This week Friedland declined to reveal the contents of the BUSA proposal, saying it was with Ramaphosa and thus confidential.

Meanwhile, Health Minister Dr Aaron Motsoaledi last week rubbished media reports that the cabinet lekgotla scheduled for month end would be taking on board the BUSA proposal. He did however confirm that he will shortly announce which of the far-ranging and long-outstanding recommendations of the Competition Commission’s Health Market Inquiry (HMI) into the private healthcare sector will be implemented, something many have been calling for in recent years.

Far-reaching reforms

Adjunct Professor Alex van den Heever, Chair of Social Security Systems Administration and Management Studies at the University of the Witwatersrand, who with Dr Aslam Dasoo, founder and chair of the Progressive Health Forum, forms part of the UHAC, said their fundamental point of departure is that the status quo is unacceptable.

According to the UHAC report, irregular provincial health expenditure levels provide a proxy indicator for corruption. The combined irregular expenditure for eight of the nine provinces from 2017/18 to 2022/23 consistently averages around 12.3% (around R9 billion per annum) of non-personnel expenditure compared to 0.1% for the DA-run Western Cape.

“The difference in performance between the Western Cape and the other eight provinces is reasonably attributable to governance differences,” the report reads.

Observes Van den Heever: “We’re losing an enormous amount of performance in the public sector because of political appointments into the system. It compromises leadership and results in a massive waste of resources. The Western Cape shows you the difference governance can make.”

He said that in the “dismally” regulated private sector, funding the pooling system was identified as a problem even before 1994, “but you don’t now disrupt the system to amalgamate into a monopoly fund to solve this (i.e. NHI). Risk equalisation would force medical schemes to compete on the value of what they cover, and nobody would be discriminated against in accessing healthcare.”

Van den Heever says the NHI intention to increase taxes and move funding money from the private to the public sector is “unworkable”.

He added: “The way to address pooling problems is to separate pooling from purchasing. The NHI process has pooling and purchasing in the same organisation, centralising everything – which is highly inefficient, unworkable and with negative consequences all the way through.

“The UHAC proposal separates them out with the provinces and medical schemes remaining as purchasers while strategic pooling or resource allocation is a national function. So, risk equalisation and taxation form part of strategic national pooling functions, while the purchasing and provision of health services are protected from political appointments – including national ministers and provincial MECs.”

Dasoo, who is also a founder member of trade union NEHAWU, said the UHAC collaborative proposal draws on all the research developed over several decades including the Taylor Commission, which made recommendations on an effective social security system for South Africa, the HMI, and numerous other official inquiries.

Dasoo described the UHAC report as “everything that the NHI is not. This health pathway requires easy legislative changes and is within current fiscal constraints. We can start the process immediately. It requires a change in governance structure of the provincial health systems where politicians relinquish all direct authority they have over health care institutions and instead focus on strategic policy.”

BHF hearing in March

A spokesperson for the BHF, Zola Mtshiya, confirmed their NHI legal challenge, set for hearing in March, but said the BHF was only invited to sign up to the UHAC proposal after it was made public. The BHF represents most medical aid schemes – except for the largest, Discovery Health.

BHF Managing Director, Dr Katlego Mothudi, said his organisation is “engaging the association [UHAC] on the document”. he added: “We welcome the willingness to collaborate as an industry as strengthening health systems is everybody’s business.”

Cabinet lekgotla next week

Despite all these developments, whether the ANC is open to a potential compromise on NHI remains unclear. On the one hand, the presidency says they have asked Treasury and the Department of Health to consider the BUSA proposal, on the other, Motsoaledi has rubbished suggestions that the ANC’s position on NHI has shifted and appears committed to an NHI system that dramatically limits the role of medical schemes. His position is thus incompatible with that of the DA.

According to media reports, things got very heated between Motsoaledi and DA ministers when NHI and the future role of medical schemes were discussed at a Cabinet meeting last October.

The matter is likely to again be on the agenda at the Cabinet lekgotla set to take place next week.

Asked about how the GNU might eventually influence universal healthcare, Clarke said: “ANC arrogancy has tapered down a lot compared to what I’m used to. There’s a lot more transparency – but we cannot allow for a very badly written law with huge implications for people’s lives and the economy to go ahead.”

Foster Mohale, spokesperson for the national health department, declined to provide comment for this article, referring Spotlight to the Presidency and Motsoaledi. “What I can say is we’re still working on the Health Market Inquiry recommendations and will let you know when there’s an announcement,” he said.

Magwenya did not provide responses to most of Spotlight’s questions, other than saying that both Treasury and the health department are considering the BUSA proposal and confirming that the President had met with BUSA.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags : 22/1/25 Quicknews original USA WHO

Healthcare Organisations React to US Withdrawal from the WHO

On January 22, 2025January 22, 2025 By ModernMedia

One of the first acts President Trump took on assuming office again on January 20, 2025, was to unilaterally withdraw the United States from the World Health Organization (WHO). Trump complained of the WHO’s “mishandling” of the COVID pandemic, influence by other countries, and the US financial support was excessive compared to China, which “has 300 percent of the population of the United States, yet contributes nearly 90 percent less to the WHO.”

The WHO released a statement, expressing its regret at the decision and pointing out its importance: “WHO plays a crucial role in protecting the health and security of the world’s people, including Americans, by addressing the root causes of disease, building stronger health systems, and detecting, preventing and responding to health emergencies, including disease outbreaks, often in dangerous places where others cannot go.”

The organisation also took aim at Trump’s criticism of its lack of reforms: “With the participation of the United States and other Member States, WHO has over the past 7 years implemented the largest set of reforms in its history, to transform our accountability, cost-effectiveness, and impact in countries. This work continues.”

Critics say that the move would only hand China the opportunity to effectively take control of global health if it chooses to becomes the WHO’s main contributor: though the US is the single largest contributor, it contributed only $1.3 billion in the 2022-23 biennium. An affordable amount compared to the vast sums both countries spend on their militaries. While the WHO did lavish praise on China, many experts saw it as undue and perhaps concerning – but China’s contribution, while currently small, is rising: $86 million in the 2018-19 biennium. After the US, the next largest contributors are Germany ($856 million) and the Bill and Melinda Gates Foundation ($830 million).

The Society for Healthcare Epidemiology of America (SHEA) stressed the importance of global health cooperation. In a statement, the organisation wrote: “It is essential that the United States continues our connection with the WHO to coordinate surveillance, monitoring, detection, prevention, research, and response to public health threats including outbreaks, antimicrobial resistance and high consequence pathogens such as viral haemorrhagic fevers (Ebola, Marburg), Mpox, and highly pathogenic avian influenza (eg, H5N1).”

Indeed, Trump may not simply be able to withdraw by presidential decree; since the US joined the WHO by an act of Congress, it would likely take congressional approval to leave it and Trump may face a lawsuit over this.

Trump previously announced his intention to withdraw the US from the WHO in 2020, something which Gostin et al. warned in The Lancet would not work out well for the US and the world. “Withdrawal from WHO would have dire consequences for US security, diplomacy, and influence. WHO has unmatched global reach and legitimacy.” Additionally, they warned of the sheer difficulty of such a messy divorce: “The US administration would be hard pressed to disentangle the country from WHO governance and programmes.”

Categories : General Interest Healthcare Politics and RegulationsTags : 8/1/25 NHI South Africa Spotlight

Health in 2024: The Year in Fewer than 1000 Words

On January 8, 2025January 8, 2025 By ModernMedia

By Marcus Low and Adiel Ismail

From the NHI Act to major advances in HIV prevention, it has been another busy year in the world of healthcare. Spotlight editors Marcus Low and Adiel Ismail recap the year’s health developments and identify some key trends in fewer than 1000 words.

For a few weeks in June, it seemed that the surprising outcome of South Africa’s national and provincial elections would usher in far-reaching political and governance changes in the country. As it turns out, some significant changes did come, but not in the health sector.

Rather than a new broom, it was déjà vu as Dr Aaron Motsoaledi returned as Minister of Health – he was previously in the position from 2009 to 2019. In both Gauteng and KwaZulu-Natal – the country’s most populous provinces – ANC MECs for health from before the elections kept their jobs. The ANC garnered well under 50% of the votes in both of those provinces and nationally and accordingly had little choice but to form national and provincial coalitions.

To be fair, five of the nine MECs appointed after the elections were new, but these changes were mainly in the less populous provinces.

Policy-wise, the trajectory also remains much as it was a year ago. Two weeks before the elections, President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law (though most of it has not yet been promulgated). While Ramaphosa has since then asked Business Unity South Africa (BUSA), the country’s largest employer association, for new input on NHI and while talk of mandatory medical scheme cover had a moment in the headlines, there is no solid evidence that the ANC is open to changing course – if anything, Motsoaledi has doubled-down in the face of criticism. The Act is being challenged in various court cases.

The sense of discord in healthcare circles was further deepened in August when several organisations distanced themselves from Ramaphosa’s updated Presidential Health Compact. The South African Medical Association, the South African Health Professionals Collaboration—comprising nine associations representing over 25 000 public and private healthcare workers—and BUSA all declined to sign the accord. BUSA accused government of “unilaterally” amending the compact “transforming its original intent and objectives into an explicit pledge of support for the NHI Act”.

Away from these reforms, a trend of health budgets shrinking year-on-year in real terms continued this year. This funding crunch, together with well-documented shortages of healthcare workers, has meant that even well-run provincial health departments are having to make impossible trade-offs – that while governance in several provincial health departments remains chronically dysfunctional. This was underlined by a landmark report published in July that, among others, highlighted leadership instability, lack of transparency, insufficient accountability mechanisms, and pervasive corruption. New reports from the Auditor General also didn’t paint a pretty picture.

Gauteng health has again been in the headlines for the wrong reasons. The provision of cancer services in the province remains mired in controversy as the year comes to an end, with plans to outsource some radiation services to the private sector apparently having stalled, despite the health department having the money for it. A deal between the department and Wits University was also inexplicably derailed. With high vacancy rates, serious questions over senior appointments, reports of corruption at Thembisa Hospital, and much more, it seems that, if anything, governance in the province has gotten even worse this year.

In a precedent-setting inquest ruling in July, Judge Mmonoa Teffo found that the deaths of nine people moved from Life Esidimeni facilities to understaffed and under-equipped NGOs “were negligently caused by the conduct of” former Health MEC Qedani Mahlangu and former head of the provincial health department’s mental health directorate Dr Makgabo Manamela.

Outside our borders, Donald Trump’s election victory in the United States is set to have far-reaching consequences. A return of the Global Gag Rule seems likely, as does major changes to the Food and Drug Administration, the President’s Emergency Plan for AIDS Relief, and the National Institutes of Health – the latter funds much HIV and TB research in South Africa.

Away from politics and governance, the biggest HIV news of the year came in late June when it was announced that an injection administered every six months was extremely effective at preventing HIV infection. It will likely be several years before the jab becomes widely available in South Africa.

Another jab that provides two months of protection per shot is already available here, but only to a small number of people participating in implementation studies.

It is estimated that around 50 000 people died of HIV related causes in South Africa in 2023 and roughly 150 000 were newly infected with the virus (reliable estimates for 2024 will only be available in 2025). A worrying one in four people living with HIV were not on treatment in 2023. There was an estimated 56 000 TB deaths and around 270 000 people fell ill with the disease. While these HIV and TB numbers have come down dramatically over the last decade, they remain very high compared to most other countries.

There are some concerns that a new TB prevention policy published in 2023 is not being universally implemented. We have however been doing more TB tests, even while TB cases are declining – as we have argued, this is as it should be. Also positive, is that a massive trial of an TB vaccine kicked off in South Africa this year.

With both TB and HIV, South Africa is making progress too slowly, but we are at least trending in the right direction. With non-communicable diseases such as diabetes, there are unfortunately signs that things are getting worse. As we explained in one of our special briefings this year, our diabetes data in South Africa isn’t great, but the little we have painted a worrying picture. As expected, access to breakthrough new diabetes and weight loss medicines remained severely constrained this year, largely due to high prices and limited supply.

Ultimately then, at the end of 2024, South Africa is still faced with chronic healthcare worker shortages, severe governance problems in several provinces, and major uncertainties over NHI – all while HIV and TB remains major public health challenges, though a shift toward non-communicable diseases is clearly underway.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags : 13/11/24 NHI public health South Africa

The NHI Act: a Flawed Execution of a Laudable Idea

On November 13, 2024November 19, 2024 By ModernMedia

By Prelisha Singh, Partner, Martin Versfeld, Partner and Alexandra Rees, Senior Associate, Webber Wentzel

Robust contestation on how to best fulfil the fundamental rights of South Africans complements and strengthens our constitutional democracy. Recent debate has centred on the effective realisation of the right to access healthcare, which the state is required progressively to realise for all South Africans, irrespective of their background and income.

The right to access healthcare came into sharp focus on 15 May 2024, when President Cyril Ramaphosa signed the National Health Insurance (NHI) Act into law, prompting the initiation of constitutional challenges by concerned stakeholders. The most recent of these was filed on 1 October 2024 in the North Gauteng High Court, Pretoria by the South African Private Practitioners Forum (SAPPF), represented by Webber Wentzel.

According to the government, the NHI Act is intended to generate efficiency, affordability and quality for the benefit of South Africa’s healthcare sector.

An assessment of South Africa’s current healthcare landscape shows a stark difference between private and public healthcare. The country has a high quality, effective private healthcare offering. However, it is currently inaccessible to the many South Africans who cannot afford private care or medical aid payments. Public healthcare, on the other hand, is understaffed, poorly managed and plagued by maladministration and limited facilities.

The NHI Act has been positioned as the vehicle to address this disparity and a desire to take steps towards achieving universal healthcare in South Africa. But a closer reading of the Act highlights numerous problems with its content and implementation design. The absence of clarity, detail or guidance contained in the Act makes it impossible to assess how the Act will actually be implemented (or, by extension, what the effects of this implementation will be).

This is particularly concerning given that years have passed since the economic assessments, on which the Act was based, were undertaken. Also problematic is the apparent lack of consideration given by the government to submissions made by affected stakeholders during multiple rounds of constitutionally required public participation.

SAPPF underscores these deficits in seeking both to have the President’s decision to assent to the Act reviewed and set aside, and the Act itself declared unconstitutional.

President Ramaphosa was obliged, in terms of sections 79 and 84(2)(a) to (c) of the Constitution, not to assent to the Act in its current form. Section 79 requires the President to refer back to Parliament any bill that he or she believes may lack constitutionality. In this case, it is difficult to conceive how the President, or any reasonable person in the President’s position could not have had doubts regarding the constitutionality of the NHI Bill. The decision by the President to sign unconstitutional legislation into law, instead of referring it back to Parliament for correction, is also irrational.

The President’s duty properly to have referred the NHI Bill back to Parliament is affirmed by the fact that the President is enjoined, by section 7(2) of the Constitution, to respect, protect, promote and fulfil the rights contained in the Bill of Rights.

SAPPF’s application demonstrates that the NHI Act, in its current form, infringes upon the rights to access healthcare services, to practice a trade, and to own property. Patients, including those using private healthcare, will be forced to use a public healthcare system that currently fails to meet its key constituents’ needs. Practitioners’ rights to freedom of trade and profession will be infringed upon, and the property rights of medical schemes, practitioners, and financial providers will be unjustifiably limited.

On its current text, the Act could make South Africa the only open and democratic jurisdiction worldwide to impose a national health system that excludes by legislation private healthcare cover for those services offered by the state – notwithstanding the level or quality of case.

Concerns regarding the rights infringements in the NHI Act are exacerbated by its lack of clarity and the fact that crucial aspects of its implementation are relegated to regulations, with no clear guidance provided in the Act itself.

For example, section 49 provides that the NHI will be funded by money appropriated by Parliament, from the general tax revenue, payroll tax, and surcharge to personal tax. However, this stance does not reconcile with section 2, which provides that the NHI will be funded through ‘mandatory prepayment’, a compulsory payment for health services in accordance with income level. Crucially, the extent of the benefits covered by the NHI’s funding mechanism and its rate of reimbursement, which impact affordability and the provision of quality healthcare, remain unknown.

The Act is, at best, a skeleton framework, seemingly assented to in haste. It is conceptually vague to the extent that the rights it seeks to promote will, in fact, be infringed if implemented. This renders the Act irrational, in addition to its other constitutional defects.

The NHI Act represents a radical shift of unprecedented magnitude in the South African health care landscape. This should be – and is required to be – underpinned by meaningful public participation, up-to-date socio-economic impact assessments and affordability analyses and final provisions that provide a clear and workable framework for implementation.

It is not sufficient for these vital issues to be addressed after the fact. Further engagements with stakeholders and the solicitation of proposals by the government cannot be used to splint broken laws. Collaborative engagement, including the solicitation of inputs for meaningful consideration, should take place during the law-making process, not after its conclusion.

A shift of the magnitude proposed by the Act, absent compliance with the structures of the law-making process and adherence by the state to constitutional standards, including rights protections, would be detrimental to the entire healthcare sector – public and private – and not in the best interests of patients and practitioners.

Notwithstanding the legal contestation surrounding the Act, it and the laudable goals underlying it can also be a watershed. The achievement of universal health coverage is an opportunity for the different stakeholders in South Africa’s healthcare system to meaningfully collaborate and inform well-supported, factually informed, rational and genuinely progressive legislative steps by the state.

Given the questions surrounding the Act and the evident need it seeks to address, the space exists for healthcare stakeholders to align around shared goals and values. They can leverage their available resources to design a healthcare system that serves all of South Africa’s people fairly and equitably, using the significant existing resources invested in the country’s healthcare sector.

Categories : Healthcare Politics and RegulationsTags : 7/11/24 SAHPRA side effects

SAHPRA Encourages the Safe Use of Medicines and Reporting of Suspected Side Effects This #MedSafetyWeek

On November 7, 2024 By ModernMedia

The South African Health Products Regulatory Authority (SAHPRA) encourages members of the public to always report any suspected side effects they may experience from taking medicines, vaccines and/or using medical devices, to help make medicines safer for everyone. While humanity benefits greatly from medicines in the treatment of illness and management of certain conditions, medicines may at times cause side effects. However, the risk of side effects and severe harm can be drastically reduced by taking medicines correctly and following the advice of a healthcare practitioner.

SAHPRA, together with over 90 other medicines and health products regulators as well as healthcare organisations globally, is participating in the annual #MedSafetyWeek awareness initiative, which takes place between 4 and 10 November 2024, under the theme “the importance of using medicines in the right way to prevent side effects, and to report side effects when they do occur”.

The awareness initiative is spearheaded by the Uppsala Monitoring Centre under the auspices of the World Health Organisation (WHO) Programme for International Drug Monitoring, a programme whose member organisations work nationally and collaborate internationally to monitor and identify adverse effects of medicines and vaccines, to reduce risks to patients, and to establish worldwide pharmacovigilance standards and systems.

During this #MedSafetyWeek and beyond, SAHPRA is calling upon patients, caregivers and healthcare professionals to utilise its reporting tools to report all suspected side effects and adverse reactions.

SAHPRA Chief Executive Officer, Dr Boitumelo Semete-Makokotlela, indicates that handling and storing as well as taking medicines as directed by a healthcare professional is key in reducing the incidence of adverse reactions. “Research shows that about half of all side effects are preventable. Patient safety is our top priority and during #MedSafetyWeek, we wish to remind patients to take their medicines as instructed and healthcare professionals to review therapies as well as each patient’s unique health conditions before prescribing or dispensing medicines,” says Dr Semete-Makokotlela.

SAHPRA calls upon the South African public and healthcare professionals to use either the MedSafety App or the eReporting portal both accessible on the SAHPRA website to report suspected side effects from health products. All reports are assessed and examined by SAHPRA to determine the correct steps to protect medicine users in South Africa from harm. The purpose is to gain better knowledge about known side effects and to discover new ones. This can result in warnings and changes to how a medicine is used. SAHPRA’s MedSafety App and eReporting portal can be used for reporting suspected adverse drug reactions from medicines, vaccines, herbal products, biological medicines and any quality issues relating to health products.

Source: SAHPRA

Categories : Expert Opinion Healthcare Politics and RegulationsTags : 6/11/24 patient access to medicines patient interaction public health South Africa

Building a Patient-centric Healthcare Ecosystem in SA: A Bold New Vision

On November 6, 2024November 5, 2024 By ModernMedia

Bada Pharasi, CEO of The Innovative Pharmaceutical Association of South Africa (IPASA)

Imagine a healthcare system which ensures that every patient’s voice helps shape their treatment, where barriers to life-saving care are dismantled, and where innovation is driven by meaningful collaboration. In South Africa, this vision is no longer a distant aspiration; it’s an urgent mission to create a system that truly serves its people, writes Bada Pharasi, CEO of the Innovative Pharmaceutical Association of South Africa.

South Africa’s healthcare system stands at a critical crossroads. Despite remarkable medical advancements, countless patients remain on the sidelines, hindered by financial, regulatory, and logistical barriers. Today, there’s an opportunity to reshape this reality by building a patient-centred healthcare model that expands access, amplifies patient voices, and creates strategic partnerships.

Empowering patient voices

In a truly inclusive healthcare system, patients aren’t just recipients of care; they are active contributors. By integrating patient perspectives into decision-making, healthcare becomes more responsive to those it serves.

Through collaborations with patient advocacy groups, educational campaigns, and year-round initiatives, there’s a growing movement to create an environment in which patients feel heard and empowered to influence the care they receive. While events such as World Patient Safety Day help highlight the importance of prioritising patient needs, the goal is to make this a constant focus, not just an annual observance.

Key prerequisites for achieving this are efficient regulatory frameworks, impactful public-private partnerships, rare disease management, and a true commitment to innovation.

Streamlined regulatory partnerships

Timely access to groundbreaking treatments depends on efficient regulatory frameworks. Collaborating closely with regulatory authorities such as the South African Health Products Regulatory Authority (SAHPRA) is pivotal in expediting access to new therapies.

Such partnerships ensure that treatments meet rigorous safety standards while streamlining approval processes so that life-changing therapies reach patients without unnecessary delays. Maintaining high standards for post-market safety also strengthens public trust and reinforces the resilience of the healthcare system.

Public-private partnerships: Catalysts for innovation

Expanding access to quality healthcare in South Africa demands strong public-private partnerships (PPPs) that leverage both public resources and private sector innovation.

Collaborative efforts with the Department of Health and other key stakeholders maximise impact by ensuring that resources are effectively allocated and that patients benefit from the latest treatments. These alliances are vital for achieving universal health coverage (UHC) under the National Health Insurance (NHI) framework, helping to ensure that equitable, high-quality healthcare becomes a reality for all.

Closing gaps in rare disease management

For patients with rare diseases, access to treatment is often riddled with obstacles, from limited therapies and high costs to a lack of awareness. Multi-stakeholder collaborations, including advisory boards initiated by organisations such as Rare Diseases South Africa, bring together patients, healthcare professionals, and industry experts to advocate for better support and access to treatments.

This prioritisation of open communication and patient-centred outcomes offers hope to rare disease patients who, through these partnerships, gain better access to essential treatments and the support they deserve.

Breaking down barriers to innovation

The drive for a more accessible healthcare system also requires addressing policy barriers. Streamlined processes, simpler registration pathways for new drugs, and patient-centred reimbursement policies ensure that patients receive the right treatment at the right time.

Working alongside policymakers, healthcare providers, and civil society, a concerted effort is being made to create a system in which innovation and equity go hand-in-hand to provide better outcomes and quality of life for all South Africans.

Shaping the future of healthcare

The future of South Africa’s healthcare lies in a system that prioritises patients, breaks down barriers, and capitalises on partnerships to make innovation accessible.

The call to action is clear: build a healthcare ecosystem that is dynamic, inclusive, and adaptable to ensure that every South African has access to the care they need. By promoting patient voices and ensuring collaboration across sectors, we can transform South Africa’s healthcare system to be more responsive, resilient, and equitable – a system that truly serves its people.

Categories : Expert Opinion Healthcare Politics and RegulationsTags : 25/10/24 NHI primary healthcare public health Spotlight

NHI Offers an Opportunity to Boost Primary Healthcare – We Must Seize it

On October 25, 2024October 25, 2024 By ModernMedia

By Russell Rensburg

To see National Health Insurance primarily as the setting up of a state-run medical aid scheme risks underplaying its massive potential to restructure how public healthcare services are organised and funded, and with that, its potential to boost the delivery of primary healthcare services in South Africa, argues Russell Rensburg.

It has been 30 years since South Africa emerged from centuries long racial suppression and state-sponsored apartheid and took her place among the community of sovereign, democratic nations. In 1996, we adopted the final Constitution, in which we committed to addressing the injustices of the past and building a society based on social justice and human dignity. That promise is carried through in the Bill of Rights, which under Section 27 includes the right to healthcare, food, and social assistance. The right to access healthcare services, like many socio-economic rights, is subject to the state taking reasonable legislative and other measures within available resources to progressively realise the right.

Pursuant to this, the National Health Act, which provides the framework for a structured uniform health system within the country, was adopted in 2003. The Act assigns the minister of health the obligation to ensure the provision of essential health services, which must include primary healthcare services. But, to date, no health minister has published regulations that define the exact scope of essential health services, nor has a framework been offered for the development of a defined package of care to be provided within the resources available.

The result is that, despite significant investments in public funded healthcare, the system and the services it provides has largely been shaped by existing infrastructure inequity. Put differently, health investments have typically gone where the infrastructure exists, rather than being guided by providing a defined package of primary healthcare services in all the places where it is most needed.

In the near term, the health system faces several immediate challenges. Per capita spending is declining. Spending is biased towards hospitals, with 42% of the national health budget spent on central and provincial hospitals. Another problem is that health service planning and budgets do not sufficiently account for our changing demographic profile – life expectancy has increased and we have a growing population of young people.

The National Health Insurance (NHI) Act is an attempt to address this through the establishment of the national health insurance fund, which initially will be the only purchaser of public sector healthcare services. Broadly, the NHI aims to pool funds to provide access to good quality, affordable healthcare services for all South Africans and certain foreign nationals, based on their health needs and irrespective of their socio-economic status.

This shift marks a substantial change from the existing setup, where 85% of the national health budget is allocated at the provincial level. In South Africa, the share provinces get of the national budget is largely determined by the equitable share formula. The health component of the formula includes a number of variables to account for healthcare need, including premature mortality (as a proxy for unmet need ), multi index deprivation (to account for social determinants of health such as poverty ), income, housing, and measures of sparsity (to account for rurality). But the biggest driver of funding is historical utilisation, which shapes resource allocation at the provincial level. The result is that the funding is overly focused on providing care under the existing systems, rather than progressively expanding access to healthcare, and boosting access to primary care in particular.

In short, NHI represents a major shift away from this paradigm by which provinces receive healthcare funds via the equitable share and based on historic spending.

How it will work

Under NHI, the public sector will budget according to level of care, initially prioritising the district health system through the establishment of district health management offices. These offices will support contracting units for primary care, which will comprise a district hospital, community health centres , primary healthcare clinics, and ward based outreach teams as well as provisions for integrated practice comprising GPs, pharmacists, dentists, and rehab professionals (occupational health, physiotherapy, and speech therapy). The district health management offices will be responsible for the achievement of health outcomes in districts.

In theory, this will allow for healthcare priorities to be shaped at the district level and for services to be more responsive to the healthcare needs of communities. For example, a district like OR Tambo could prioritise more resources towards addressing maternal mortality by expanding ante-natal services or developing responses to address the health access gaps for older people in rural areas. In urban districts, like the City of Johannesburg, it could prioritise expanding access to reproductive health services by contracting in private health providers who are better placed to respond to the needs of working women. Ultimately, such a shift to a more responsive and more localised health system could also help increase uptake of TB and HIV prevention and treatment services across the board.

How to get the ball rolling

Reorientating our health system towards primary healthcare will be a difficult and time-consuming process, given the complex nature of health systems. But, there are things we can do right away to get things moving. We don’t have to wait for full implementation of NHI.

The current District Health Programme Grant can be expanded to enable provinces to increase primary healthcare services. The grant currently focuses on resourcing the country’s response to HIV, which seems to have reached a plateau with fewer people initiated on treatment. Contracting in private providers using this grant could improve service accessibility for testing, reproductive health services and routine healthcare for the working poor. Indeed, contracting in non-state healthcare providers, such as healthcare NGOs, pharmacies, and GPs, can significantly improve the patient experience and help build the public trust that is needed for NHI. As we repurpose the District Health Programme Grant, we can also start building the systems we will need for the district health management offices envisaged under NHI, thus helping to ease the transition when it comes.

The biggest immediate opportunity however lies in improving the accessibility and acceptability of district health services for the working poor. A study by the Bureau of Market Research at UNISA estimated that around 75% of working people in South Africa earn less than R6 000 a month. The current structure of publicly funded primary healthcare services do not respond to their routine needs, which include accessing family planning, seeing a GP when ill, a dentist to address oral health issues or access to rehab services. Apart from meeting the needs of these people, expanding service points, particularly in urban areas, can also improve disease surveillance through increased testing, and increased uptake of HIV prevention and treatment services.

There are more areas where we can make progress now that will ease the transition to NHI. For example, the current National Tertiary Services Grant, with an allocation of R15 billion, can be used to support a deep dive into what services our hospitals offer, what resources they are allocated and why, and how all of that lines up with the health need in our districts. The data isn’t currently there to really know whether we are getting value for money from our public hospitals. As with primary care, we need to get a clearer understanding of the need and start re-engineering the system so that we are in a better position to meet that need as we start implementing NHI.

Ultimately then, it is limiting to think of NHI exclusively as the establishment of a state-run medical aid scheme – as it is often portrayed in the media. A public discourse dominated by debates over the future of medical schemes risks obscuring the substantial potential NHI offers for improving and restructuring how public health services are organised and funded. The reality is that with NHI, we have an opportunity to shift the focus of our healthcare system toward primary healthcare and in the process to make our health system much more efficient and equitable. It is imperative that we do whatever is needed to deliver on that potential.

*Rensburg is Director of the Rural Health Advocacy Project.

Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Republished from Spotlight under a Creative Commons licence.

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Categories : Healthcare Politics and RegulationsTags : 21/10/24 family health family physicians

Family Physicians Poised for Bigger Role in Public Healthcare – after Years on the Sidelines

On October 21, 2024October 21, 2024 By ModernMedia

Family physicians undergo an extra four years of training, with an emphasis on clinical governance and knowledge of social factors influencing people’s health. Photo by cottonbro studio

By Chris Bateman

Around twenty years ago, family physicians seemed set to take up roles as critical cogs across South Africa’s public healthcare system, but in the years since, doctors trained in this speciality have largely been underutilised. That is now finally set to change, according to the Department of Health, Chris Bateman reports.

The National Department of Health has signalled that they want to see more family physicians appointed as clinical managers tasked with leading multi-disciplinary district hospital teams. This follows years of lobbying by the South African Academy of Family Physicians (SAAFP) advocating for the greater utilisation of family physicians in the country’s public healthcare system.

The SAAFP has long argued the cost and clinical effectiveness of these “super generalists”, who undergo an extra four years of training, with an emphasis on clinical governance and knowledge of social factors influencing people’s health. And it seems their patience has been rewarded with a five-year district health blueprint from government.

This was confirmed to Spotlight by Dr Luvuyo Bayeni, Chief Director of Human Resources for Health at the National Department of Health.

Advocates for the speciality argue that family physicians have been neglected, with posts thin on the ground and their potential contribution under-estimated. The discipline was registered with the HPCSA in 2007.

Professor Bob Mash, Distinguished Professor at Stellenbosch University where he heads the Division of Family Medicine and Primary Care, describes the specialty as “one of the most underutilised solutions to many of the problems facing district health service delivery”. Mash is the immediate past president of the SAAFP.

Bayeni, a former clinician/administrator in the Eastern Cape, was appointed to lead the health department’s human resource operations in July last year. Since then, he attended the last two annual SAAFP conferences and has been meeting regularly with the academy’s leadership.

With austerity measures being the catch-all rebuttal by provincial heads of department whenever the wisdom of freezing posts is questioned, Bayeni is trying to persuade his provincial counterparts to adopt a policy of appointing family physicians to clinical manager posts as a highly cost-efficient move, citing successes in the Western Cape. The idea is that family physicians are able to quickly diagnose and treat patients while mentoring junior colleagues. They also help design or tweak hospital and referral clinic systems for efficiency and identify preventative health interventions at community level.

Blueprint approved

In a wide-ranging interview with Spotlight, Bayeni said his family medicine oriented blueprint had been approved by the Presidency’s Department of Policy Planning, Monitoring and Evaluation for inclusion in all future health indicators. His plan is to initially get family physicians as clinical managers into all medium to large district hospitals (150 beds and above), before ensuring they are placed in every health district, including at lower level hospitals and community health centres, at all times leading a multi-disciplinary team.

“Instead of waiting for HR plans and organograms, this is going into the mid-term framework for monitoring. It’s a strategic opportunity, where we ask ourselves, ‘how do we define a multi-disciplinary team for a district hospital?’ and then work through and with them. We’ll define and map where our priority district hospitals are, starting with the medium to large district hospitals,” he said.

Bayeni said he met with his provincial counterparts and military health service chiefs last week, (14-18 October), where he said he was going to, “make sure they all know about this. Organograms are all fine and well and necessary, but I want this top of mind when they consider them.”

“Personally, by April next year, (the new financial year), I want to see more family physicians being appointed, either in the district or in the position of clinical managers wherever there are vacancies. I’ll ask the provinces to help me with monitoring and evaluation,” he said.

He said his ambition is to change the mindset of provincial healthcare leaders “wherever necessary” about family physicians being regarded as “just another specialty” when creating and enumerating posts.

Positive responses

Several top family medicine academics and clinicians around the country who have been at the forefront of providing data and lobbying for a more pragmatic healthcare delivery approach, welcomed the renewed focus on family physicians.

Professor Steve Reid, a veteran rural family physician and head of Primary Health Care at the University of Cape Town (UCT), told Spotlight the main problem was what he called a framing issue.

“The way we think about medicine is to just go to the doctor and get it sorted, rather than how a huge number of diseases can be managed and prevented early on – it’s been a major shift over the last fifty years. I mean we now have studies that link pre-natal health to later chronic diseases. The whole idea of social medicine went out of vogue, and the idea that health has far more to do with the social determinants of health than it has to do with the health system had too little purchase,” he said.

Reid observed that no family physician can work in isolation – they made the most difference when they had a multi-disciplinary team around them.

Labelling family physicians “boundary-spanners par excellence”, he said “they join the dots rather than work in silos like other specialties who tend to guard their turf jealously.”

“Brazil is a middle-income country just like South Africa and their simple model of one doctor, a nurse and four to six community health workers per 4 000 population has got 80% of their population covered, including vast urban areas like Sao Paulo and Rio de Janeiro,” he said. In South Africa’s case, having a family physician as the leader will further enhance this model.

‘Around 400 needed’

Mash said South Africa’s previous health policies saw family physicians as a sub-specialty of internal medicine or as specialists who should work at tertiary hospitals and within primary care teams. Currently, chiefly due to the lack of posts, only a third of family medicine graduates were retained in the public sector, with ten percent emigrating and eleven percent giving up medicine altogether. Most were employed in the Western Cape, where the health system had committed to appointing family medicine practitioners at district hospitals and primary care facilities, Mash added.

The SAAFP recommends a mid-term goal of one family physician at every district hospital, community health centre or sub-district.

To achieve this, said Mash, another 400 family physicians are needed, but at current training rates this could take up to two decades, (not accounting for the current shortage of posts).

He agreed with Public Health Medicine Specialist Tracey Naledi, that only when there’s wider and stronger investment in primary healthcare across provinces will better deployment of Family Medicine practitioners begin to make a real difference to district level health and wellness. Naledi is Associate Professor in Public Health Medicine and Deputy Dean of Social Accountability and Health Systems at UCT’s Faculty of Health Sciences.

Naledi said that while there are many highly skilled veteran ‘utility’ Medical Officers in the district health system, the greater utility of family medicine is in clinical governance, health systems strengthening initiatives and capacity development. Besides teaching, monitoring, and evaluating healthcare delivery, she said family physicians also more appropriately and timeously refer patients to secondary and tertiary care.

Specialist support

“The family physicians should not just be seeing sixty patients at their door daily. They are specialist support – the Medical Officers should be calling them for advice. If family physicians were optimized, we’d see far less referral to tertiary level services,” she said.

The problem is structural, she believes.

“There are not enough human resources for health in general, so at district level people get pulled into doing what’s needed on the shop floor. There’s not enough time to do the strategic work,” she said.

“You can’t just talk about family medicine without talking about full staff requirements. When a family physician goes on outreach, it should not just be about dealing with difficult cases but building the capacity of the outlying areas. They need to ask themselves what they’re leaving behind. Otherwise, you’re cleaning the floor but not closing the tap,” she added.

Mash agreed that family medicine practitioners are “not the magic bullet – but introducing them into district health services can go quite a way towards strengthening the system”.

“We’ve trained them to work independently, to be the senior clinician with the full spectrum of needed skills, on top of which they provide the confidence for the doctors who are there to practice the skills they have. It’s very reassuring having a senior person to help if things go wrong, so it’s a combination of increased confidence and bringing in additional skills,” he said.

“A primary health nurse and community health worker can provide coverage and connection to the community, but a [family medicine] FM practitioner brings in a level of expertise so the team has both coverage and quality,” he added.

History and training

As Mash tells it, from the nineties into the first decade of the 2000s, no medical schools exposed undergraduates to Family Medicine. However, nearly thirty years on, curricula have completely turned around.

Mash says some twenty to thirty family medicine practitioners graduate from the ten South African campuses every year, among the chief disincentives to the specialisation being the paucity of available posts. He said it’s critical to create more family medicine posts “if we are to attract people into that career path. If managers believe a family physician’s contribution is worthwhile, they can outmanoeuvre these restrictive budgets.”

He said public health was being “hugely damaged” by an austerity mindset.

Professor Shabir Moosa, Family Physician in the Department of Family Medicine at Wits University, suggested offering a two-year distance learning diploma in family medicine to get family medicine practitioners into practice faster and then offering in-service further tuition to a full post-graduate degree. Moosa is a former President of the World Organization of Family Doctor’s Africa region.

“Right now, you have family physicians in community healthcare centres which see a thousand people a day. Their job is capacity building, but they’re stuck with menial tasks. Also, right now qualified Family Medicine practitioners, at Wits at least, have a thirty percent teaching commitment so they’re being pulled in many different directions.”

Like Mash, he said “turnstile leadership” in the provinces wrecked progress while leadership in primary healthcare at district and lower levels was mainly by nurses, who were uncomfortable sharing space with family physicians whom they saw as a “power threat”.

Moosa says most family medicine practitioners in rural South Africa (with the exception of the Western Cape), are foreign qualified doctors who found studying it an “easy entrance route”. He takes issue with the emphasis on training family physicians exclusively for use in rural areas, saying that with accelerating urbanisation, this is short-sighted.

Parallel with clinical associates

Associate Professor Tasleem Ras, President of the SAAFP and Postgraduate Programme Director of Family Medicine at UCT, drew a parallel with clinical associates which some provinces had adopted and others not, saying they had no career pathways which has become “a political hot potato”. (Spotlight previously reported under the under-utilisation of clinical associates here and here.)

Ras was alluding to the provincially disparate usage of both categories of healthcare professionals. In the case of family physicians at least, senior medical officer and registrar posts are being creatively used by some provinces to place them, with salary adjustments built in. Clinical associates have no such luxury.

Naledi says she suspects that healthcare delivery leaders in individual provinces have widely differing views on how to use family physicians, with commensurately differing patient care outcomes. She says the grading of healthcare facilities by the Office for Healthcare Standards Compliance eloquently illustrates an overemphasis on curative service-based funding, with lower-level primary healthcare facilities scoring worst, followed by secondary or district hospitals with tertiary hospitals scoring the highest. Unless this changes, she says “we will continue failing to get bang for buck”.

She adds: “If you look at the district health system, it doesn’t have the full cadre of staff. I mean palliative care, mental health, dental services – these are all structural and broader resource issues for me. You can’t look at family medicine in isolation.”

The argument is that building more capacity for prevention and health promotion would begin to dismantle a self-perpetuating cycle of predominantly curative services. Family medicine training, Naledi says, focuses a lot more on the social determinants of health, prevention, rehabilitation, and palliative care. “It’s not just about clinical abilities but about them being family and community doctors,” she adds.

Republished from Spotlight under a Creative Commons licence.

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Wonderful! Primary health care is so important.

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