The Cervical Cancer Screening and Prevention Clinic at Helen Joseph Hospital in Johannesburg was forced to shut down in mid-May after losing all its funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). Photos: Elna Schütz
Hundreds of cervical cancer patients will likely be referred to overburdened hospitals following the closure of the Cervical Cancer Screening and Prevention Clinic at Helen Joseph Hospital in Johannesburg.
Following over 20 years of operations, the clinic was forced to shut down in mid-May after losing all its funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). It relied on some financial reserves to taper its activities over several months. Most clinic staff have been let go.
The clinic served women who were referred from across Johannesburg and as far as Springs. A significant part of that group lives with HIV.
“Many of these women are from underserved communities with limited access to specialist care,” says Dr Mark Faesen, Specialist Gynaecologist with the Clinical HIV Research Unit (CHRU).
The clinic offered critical cervical cancer screening and follow-up services, including Pap smears and colposcopies – a cervical examination for abnormalities. The clinic was managing around 1,400 patients annually. “It served as a clinical and research hub, preventing many cancers,” Faesen says.
We spoke to Zinhle (name changed) who was screened at the clinic after feeling ill for a year and who sought help at four different hospitals.
“When I got [to this clinic], I was received with a warm welcome,” she says, emphasising that every step of the process was explained to her and she was made to feel comfortable. “Where else are we supposed to go?”
Zinhle says she is deeply upset that she can no longer be treated at the clinic if she needs it again.
Faesen says the clinic’s closure will put immense pressure on other public hospitals offering these services, like Rahima Moosa or Chris Hani Baragwanath. This is likely to lead to longer waiting times for screening, diagnosis and treatments. “Early detection is important,” Faesen says. “Without timely diagnosis, outcomes are far poorer.”
Lorraine Govender, the National Manager of Health Programmes at the Cancer Association of South Africa (CANSA) says they are deeply concerned by the closure, as it is a serious setback in the ongoing fight against the disease.
Cervical cancer is the second most common cancer in women in South Africa, and results in the most deaths. It is curable if diagnosed and treated early. A Human Papillomavirus (HPV) vaccination also reduces the risk of cervical cancer. While low screening rates and backlogs in treatment have been long-standing across the country, Johannesburg appears to be particularly burdened. The shutdown of this clinic adds to a larger shortage of screening and treatment in Gauteng.
The Department of Health has previously stated that while it has improved vaccination efforts against cervical cancer, “screening and treatment are lagging behind”. The national health policy calls for women aged 30 to 50 to be screened at least three times in their lives. Women living with HIV should be screened at least every three years.
Cervical cancer screening services are limited and overwhelmed at most public hospitals, Faesen says. “The funding cuts have a knock-on effect: increasing patient loads at the few remaining colposcopy clinics.”
Lorraine Govender, the National Manager of Health Programmes at the Cancer Association of South Africa (CANSA) says they are deeply concerned by the closure, as it is a serious setback in the ongoing fight against the disease.
“Cervical cancer is both preventable and treatable when detected early, making continued access to screening services vital … The closure of this Johannesburg clinic must be a call to action,” Govender says.
Faesen stresses the urgent need for increased funding for decentralised screening services to fill the gaps created by clinics like the one at Helen Joseph Hospital. “Equipping more public sector sites with colposcopy capability and training personnel is also essential.”
There are two vaccines against shingles – an often painful and debilitating condition caused by the same virus that causes chickenpox – but neither are available in South Africa. Photo by Mika Baumeister on Unsplash
By Catherine Tomlinson
The only shingles vaccine on the market in South Africa was discontinued last year. A newer and better vaccine is being used in some other countries, but has not yet been registered in South Africa, though it can be obtained by those with money who are willing to jump through some hoops.
Shingles is a common and painful condition that mostly affects the elderly and people with weakened immune systems. It generally appears with a telltale red rash and cluster of red blisters on one side of one’s body, often in a band-like pattern.
“Shingles is pretty awful to get – it’s extremely painful, and some people can get strokes, vision loss, deafness and other horrible manifestations as complications,” said infectious disease specialist Professor Jeremy Nel. “Shingles really is something to avoid, if at all possible,” he added.
One way to prevent the viral infection is by getting vaccinated against it. But while two vaccines against shingles have been developed and broadly used in the developed world, neither of these are currently available in South Africa.
Two vaccines
Zostavax, from the pharmaceutical company MSD, was the first vaccine introduced to prevent shingles. It was approved for use in the United States in 2006 and in South Africa in 2011. It is 51% effective against shingles in adults over 60.
A more effective vaccine, Shingrix, that is over 90% effective in preventing shingles was introduced by GlaxoSmithKline (GSK) in the United States in 2016. It is not yet authorised for use in South Africa, but GSK has submitted paperwork for approval with the South African Health Products Regulatory Authority (SAHPRA), said the company spokesperson, Kamil Saytkulov.
The superior protection offered by Shingrix compared to Zostavax quickly made it the dominant shingles vaccine on the market. As a result, MSD discontinued the production and marketing of Zostavax. MSD spokesperson Cheryl Reddy said Zostavax was discontinued globally in March 2024. Before then, the vaccine was sold in South Africa’s private healthcare system for about R2 300, but it was never widely available in government clinics or hospitals.
No registered and available vaccine
Since Zostavax has been discontinued and Shingrix remains unregistered, the only way to access a vaccine against shingles in South Africa is by going through the onerous process of applying to SAHPRA for a Section 21 authorisation – a legal mechanism that allows the importation of unregistered medicines when there is an unmet medical need.
“Access will only be available to those who are able to get Section 21 approval” and “this is a costly and time-consuming process, requiring motivation by a doctor,” said Dr Leon Geffen, director of the Samson Institute For Ageing Research.
The cost of the two-dose Shingrix vaccine imported through Section 21 authorisations is currently around R15 600, said Dr Albie de Frey, CEO of the Travel Doctor Corporation.
People who do go through the effort of getting Section 21 authorisation typically have to pay this price out of their own pockets.
“Shingrix is not covered [by Discovery Health] as it is unregistered in South Africa and is therefore considered to be a General Scheme Exclusion,” Dr Noluthando Nematswerani, Chief Clinical Officer at Discovery Health, told Spotlight.
The Department of Health did not respond to queries regarding whether Section 21 processes are being pursued for priority patients in the public sector or whether there has been any engagement with GSK regarding the price of this product.
People who receive organ transplants, for example, should be prioritised to receive the shingles vaccine as the medications they are given to suppress their immune system puts them at a high risk of developing shingles.
Why is the price of Shingrix so high?
Unlike South Africa, where companies must sell pharmaceutical products at a single, transparent price in the private sector, the United States has no such requirement. Even so, the US Centers for Disease Control and Prevention (CDC) pays $250 or R4600 for the two-dose Shingrix vaccine through CDC contracts. This is less than a third of the price charged when Shingrix is imported into South Africa.
Equity Pharmaceuticals, based in Centurion in Gauteng, is importing GSK’s Shingrix for patients that receive Section 21 authorisations to use the unregistered vaccine. It is unclear what price Equity Pharmaceuticals is paying GSK for Shingrix to be imported into South Africa under Section 21 approvals, or what Equity Pharmaceuticals’ mark up on the medicine is.
When asked about the price of Shingrix in South Africa, Saytkulov told Spotlight: “Equity Pharmaceuticals is not affiliated with GSK nor is it a business partner or agent of GSK. Therefore, we cannot provide any comments with regards to pricing of a non-licensed product, which has been authorized for importation through Section 21.”
Equity Pharmaceuticals also said it was difficult to comment on the price. “The price of a Section 21 product depends on a number of fair considerations, including the forex rate, the quantity, transportation requirements, and the country of importation. Once the price and lead time are defined for an order, the information is shared with the healthcare provider to discuss with their patient and the medical aid,” the company’s spokesperson Carel Bouwer told Spotlight
Nematswerani pointed out that “Section 21 pricing is not regulated” and that price can change due to many factors including supplier costs, product availability, and inflation.
What causes shingles?
Shingles is caused by the same highly infectious virus that causes chickenpox. Most people are infected with the varicella-zoster virus (VZV) during childhood. Chickenpox occurs when a person is first infected by VZV. When a person recovers from chickenpox, the VZV virus remains dormant in their body but can reactivate later in life as one’s immune system weakens. This secondary infection that occurs, typically in old age when the dormant virus reactivates, is called shingles.
People who were naturally infected with chickenpox, as well as those vaccinated against chickenpox with a vaccine containing a weakened form of the VZV virus, can get shingles later in life.
But, people who were vaccinated against chickenpox have a significantly lower risk of developing shingles later in life compared to those who naturally contracted chickenpox, according to the World Health Organization (WHO).
The chickenpox vaccine is available in South Africa’s private sector but is not provided in the public sector as part of government’s expanded programme on immunisation. Chickenpox is usually mild in most children, but those with weakened immune systems at risk of severe or complicated chickenpox should be vaccinated against it, said Professor James Nuttall, a paediatric infectious diseases sub-specialist at the Red Cross War Memorial Children’s Hospital and the University of Cape Town.
Who should be vaccinated against shingles?
South Africa does not have guidelines regarding who should receive the shingles vaccine and when they should receive it. The US CDC recommends that all adults over 50 receive the two-dose Shingrix vaccine. They also recommend that people whose immune systems can’t defend their body as effectively as it should, like those living with HIV, should get the vaccine starting from age 19.
While Shingrix works better than Zostavax at preventing shingles, it has other advantages that make it a safer and better option for people with weak immune systems.
The Zostavax vaccine contains a weakened live form of the VZV virus and thus poses a risk of complications in people with severely weakened immune systems. “In the profoundly immunosuppressed, the immune system might not control the replication of this weakened virus,” explained Nel. The Shingrix vaccine does not contain any live virus and therefore does not present this risk.
In March 2025, the WHO recommended that countries where shingles is an important public health problem consider the two-dose shingles vaccine for older adults and people with chronic conditions. “[T]he vaccine is highly effective and licensed for adults aged 50 years and older, even if they’ve had shingles before,” according to the WHO. It advised countries to look at how much the vaccine costs compared to the benefits before deciding to use it.
The cost of not vaccinating against shingles
The cost of not vaccinating against shingles is high for people who develop the condition, as well as the health system.
“[T]he risk of getting shingles in your lifetime is about 20 to 30%…by the age of 80 years, the prevalence is almost 50%,” said Geffen. “Shingles is often a painful debilitating condition, with significant morbidity. It can result in chronic debilitating pain which affects sleep, mood and overall function,” he added.
Beyond preventing shingles and its complications, new evidence suggests that getting the shingles vaccine may also reduce one’s risk of developing dementia and heart disease.
In April, a large Welsh study published in Nature reported that people who got the Zostavax vaccine against shingles were 20% less likely to develop dementia seven years after receiving the vaccine compared to those who were not vaccinated.
In May, a South Korean study published in the European Heart Journal reported that people vaccinated against shingles had a 23% lower risk of cardiovascular events, such as strokes or heart disease for up to eight years after vaccination.
Minister of Health Dr Aaron Motsoaledi. Source: GCIS
By Anna Grimsrud and Sibongile Tshabalala-Madhlala
Minister of Health Dr Aaron Motsoaledi’s recent claim that over half a million people have been newly started on HIV treatment in less than six months has raised eyebrows in health circles. In this open letter, Anna Grimsrud and Sibongile Tshabalala-Madhlala, associated with CHANGE – South Africa, ask the Minister to explain numbers that, on the face of it, seem contradictory.
Dear Minister Motsoaledi,
We write to you in response to your 15 May 2025 press statement and subsequent remarks in Parliament on the current status of the national HIV, AIDS, and TB campaign.
You stated that since the launch of the Close the Gap campaign, 520 700 people have been initiated on HIV treatment, reaching “more than 50% of the target”. You also stated that 5.9 million people are currently on antiretroviral therapy (ART). However, at the campaign’s launch on 25 February 2025, you reported the same number on HIV treatment — 5.9 million. This raises a critical question: if over half a million people have started or restarted treatment, why has the total number of people on treatment not increased?
If both figures are accurate, this would mean that approximately 520 000 people have been lost from care over the past few months — a deeply concerning and unprecedented level of attrition. We respectfully request that you provide the underlying data and clarify the current total number of people remaining on HIV treatment.
There are several reasons why we are concerned:
Static treatment numbers: As noted, the number on treatment was reported as 5.9 million in both February and May 2025. If 520 700 people have been initiated or re-initiated during this period, the same number must have exited care — a scenario that requires urgent explanation.
Slow growth in the number of people on treatment: According to official statements, the total number of people on HIV treatment increased by only 100 000 between March and December 2023 — from over 5.7 million to 5.8 million. The claim that the cohort has now grown by over 500 000 in a matter of months contradicts recent trends.
Declining lab numbers: National Health Laboratory Service data reported by the Daily Maverick and Reuters, show notable declines in viral load testing and early infant diagnosis in March and April 2025 compared to the same months in 2024. These indicators should increase alongside meaningful growth in treatment uptake — not decrease.
In light of these concerns, we believe it is essential that you provide a transparent accounting of the current number of people on treatment and the metrics being used to assess progress under the Close the Gap campaign. Specifically, we request data demonstrating that the programme is on track to meet its stated goal: increasing the number of people on treatment from 5.9 million to 7 million.
We share your commitment to a strong and effective HIV response, especially in this period of financial and operational strain. Like you, we believe it is vital that accurate and complete information is shared with the public and Parliament at this critical moment.
*Anna Grimsrud is an epidemiologist with a PhD in Public Health and writes in her personal capacity. Sibongile Tshabalala-Madhlala is openly living with HIV and currently serves as the National Chairperson of the Treatment Action Campaign (TAC).” CHANGE is a coalition of more than 1 500 people from civil society organizations in South Africa and around the work — people living with HIV, activists, community health workers, researchers, programme members, epidemiologists, clinicians, economists, and others. CHANGE stands for Community Health & HIV Advocate Navigating Global Emergencies.
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. Views expressed in the original article are not necessarily shared by Quicknews.
Trade unions, medical associations and universities are raising the alarm that Gauteng budget cuts at the cost of doctors’ take-home pay will have dire consequences for public sector health. Meanwhile, the National Minister of Health has convened a committee to review the future of overtime for state doctors.
Dysfunction in the Gauteng Department of Health hit home hard for many public sector doctors on 29 April when their overtime payments due for the month went unpaid.
The non-payment came without notice and affected medical staff in facilities across the province, according to the South African Medical Association (SAMA). Only by 6 May did some doctors start to see payments reflect in their bank accounts. More payments are expected soon given that, according to the Basic Conditions of Employment Act, the employer has seven days to settle, said SAMA.
But tensions are rising as this payment blunder follows a protracted row over the department’s unilateral decision to cut and change the terms of commuted overtime in the province. Proposals to cut down on commuted overtime come in the light of a very tight provincial health budget. As with most other provincial health departments, Gauteng’s health budget has been shrinking in real terms for several years.
The delayed payments and the ongoing review of cuts and changes to commuted overtime pay has led to threats of protests and legal action. SAMA says they will make civil claims for salaries owed, including for interest and legal costs. Registrars and medical officers at Dr George Mukhari Academic Hospital in Ga-Rankuwa collectively wrote to the hospital giving notice of withdrawal of overtime services until the non-payment issue is completely resolved. By 7 May, the head of anaesthesiology at Sefako Makgatho Health Sciences University wrote to the CEO of George Mukhari Hospital informing him that no anaesthesia services would take place at the hospital starting 8 May, given the decision by registrars and medical officers to down tools outside of regular work hours.
Those from the medical fraternity that Spotlight spoke to have set out a series of concerns. These include resignations; an exodus of doctors, especially specialists from the public sector; plummeting staff morale; negative impacts on the training of doctors as fewer consultants and seniors are available to supervise – which then puts universities’ training accreditations at risk. Ultimately, several sources point out, it is the services offered to the public that suffer.
Committee appointed
By the beginning of April, there appeared to be some walking back by the Gauteng health department of its unilateral cutback proposals after meeting with the South African Medical Association Trade Union (SAMATU). In the same week, a circular was issued announcing that the national health department was conducting a review of its own, instructing provinces to hold off on their plans. Health Minister Dr Aaron Motsoaledi then set up a committee of experts to review certain human resource policies in the public healthcare sector. This includes a review of community service, commuted overtime, remunerative work outside the public service for health professionals, and rural and related allowances.
Commuted overtime is a pre-determined amount of overtime that doctors employed by provincial health departments are allowed to work. The amount is historically decided by hospital management and is based on an employee’s role, seniority, the department they work in and the amount of overtime they are allowed to safely work. It’s a fixed rate of 1.3 times the applicable hourly tariff for a specific work grade.
There are five contract options. A is no overtime worked; B is overtime of between four and eight hours a week; C is overtime between 9 and 12 hours a week; D is overtime between 13 and 20 hours per week; and an option E is where, on approval, a doctor can be authorised to work more than 20 hours of overtime a week.
As a fixed amount, commuted overtime is predictable supplemental income and for many doctors, it amounts to about a third of their take-home pay.
The long rumblings to cut their overtime pay has seen doctors being required to motivate why they should remain on contracts that pay for more overtime hours and junior doctors say they are being pressured to sign option C contracts, which will pay for fewer overtime hours. There are also proposals to change some of the terms relating to overtime, including scrapping overtime payments for doctors who are on call but not physically present at a facility.
Many doctors already exceed the maximum hours of their contracts because of the emergency nature of their work, gross understaffing and backlogs at their hospitals.
Costly, but essential?
The commuted overtime pay model has been contentious for years because it adds up to a sizeable chunk of the healthcare budget. According to a spending review conducted in 2022 on behalf of National Treasury, the country’s health departments spent R6.9 billion on commuted overtime in 2021. This made up about 70% of the total R9.9 billion spent on all types of overtime.
In an editorial published in the South African Medical Journal in April 2025, health sciences academics, associations, and unions slammed the Gauteng health department’s handling of pay issues. They argue that the basic salaries of medical professionals in the public health sector are already much lower than what would be considered fair pay.
“COT [commuted overtime] has long served as a critical mechanism to ensure that doctors are available beyond the standard workday, safeguarding round-the-clock care in the public health system…The abrupt curtailment of this framework risks hollowing out the after-hours safety net, leaving emergency rooms, wards and clinics dangerously under-resourced,” they wrote.
A co-author of the editorial, SAMA CEO Dr Mzulungile Nodikida, told Spotlight: “Medical doctors in South Africa’s public sector are severely underpaid. A study by SAMA has shown that even the annual cost of living adjustments that have been made on the salaries have not matched inflation in the last 5 years. Commuted overtime has had the effect of masking a deficient salary.”
He said the Gauteng health department has shown itself to be an “unreliable employer”, adding that its relationship with doctors remains fractured as a loss of confidence in the department deepens.
“This breach of the most basic employment obligation: timely remuneration, has cascading effects. It jeopardises morale, compromises service delivery, and calls into question the department’s commitment to its workforce. Doctors now operate under a cloud of uncertainty, unsure whether they will receive their salaries at month-end. This anxiety permeates every aspect of the employment relationship, from retention efforts to the willingness to engage in additional responsibilities,” said Nodikida.
View from the wards
Two doctors who spoke to Spotlight independently, and from two different Gauteng hospitals, say the commuted overtime pay disaster is yet another symptom of weak human resources and poor management from the department of health. For them, proposals to cut commuted overtime is the department shirking from addressing the staffing crisis; the need to improve human resources systems; and rooting out corruption, maladministration and wasteful expenditure. Both doctors asked not to be named for fear of reprisals.
Dr A, who is based at Charlotte Maxeke Johannesburg Academic Hospital, said: “Instead of having a system in place to record how many hours each doctor is actually working and what overtime that person should be paid, the department pays everyone this commuted overtime fixed sum….[Y]ou could be a dermatologist or a psychologist and have very few overtime hours or be a surgeon who is doing a lot of overtime but you all get paid the same if you’re on the same contract option,” she said. “But right now, in my career I’m working way more overtime hours than my contract and I’m not being reimbursed for any of it.”
Dr A said the overtime pay cuts and proposed changes will impact her decision to stay in the public sector.
“It used to be the case that you were happy, once specialised, to stay because the overall lump sum of money from your salary and commuted overtime made up a decent pay – not comparable to what you could earn in private – but decent enough to stay,” she said.
She said she feels like doctors are now being under-valued and coming under attack by their own employer. “The message we are getting is that ‘if you’re not happy, there’s the door’ – but what the department doesn’t understand is that you can’t just replace someone with 10 years’ experience or someone who has 30 years’ experience, it has a huge impact,” she said.
“Our patients are suffering; and every day it’s like a game of Survivor. We run multiple clinics in one clinic space at Charlotte Maxeke, but you can’t offer a functioning service like that. It’s noisy, the computers don’t work, and the intercom is going off the whole time.
“The other day, I had a 90-year-old patient have a panic attack in the waiting room. He had been waiting for a while and left his wife, who is blind, in the car. He had to park far from the hospital building because the parking lot from the hospital fire [in April 2021] is still not properly repaired and he was overcome with worry,” she said.
Dr B works at Chris Hani Baragwanath Hospital and he said the debacle over doctors’ overtime pay has pushed him to the edge. He said doctors are already overworked and disheartened from working within a failing system. He sent photos to Spotlight of theatres and wards in darkness as power went off at the Soweto hospital for days at the end of April.
Chris Hani Baragwanath Hospital plunged in darkness after days-long power outage in late April. (Supplied)
He said staff bring in their own toilet paper because they’re told there’s none. Most alarming, he said “doctors are not getting the training and supervision they need” and regularly perform surgeries and procedures without adequate experience and with no supervision.
“They are overwhelmed, overworked and doing way too many overtime hours that they’re not being paid for. Then they go home overtired, eat a pizza and crash, sleep a few hours then do it all over again the next day, and the next day,” he said.
“We, doctors, are literally the ones putting patients’ lives at risk,” he said, adding that he is “surviving on anti-depressants” and has sometimes shut himself away in hospital storerooms crying tears of sheer frustration, exhaustion and exasperation.
Dr B does still count the wins though. It’s days when he clears an impossibly long patient list of children who need procedures done. It’s when he and his colleagues decide to push through to make sure no child’s procedure gets cancelled.
“Those are the good days – they’re just few and far between. And now the department is coming for us by cutting our overtime pay and forcing us to sign contracts to downgrade our overtime pay,” he said.
Resignations and impact on training
Professor Shabir Madhi is dean of the faculty of Health Sciences at the University of Witwatersrand. He said the proposed cuts and freezing of posts and changes to commuted overtime pay has already resulted in resignations of some senior staff at state hospitals.
“If we don’t have the proper consultant staff complement in these hospitals who can provide supervision throughout the day, it compromises our training of specialists as well as of undergraduate students.
“If the Health Professions Council of South Africa were to do an audit and find that there isn’t adequate consultant cover and supervision, they could remove the accreditation of the training programmes offered by the universities.
“The medical schools are completely dependent on the Gauteng Department of Health to retain consultants and other categories of staff, and to ensure that staff are allocated time for supervision and training of future medical doctors, including specialist, as well as other academic activities.
“It means decision-making around cuts to overtime pay need to be cognisant of the overall impact that it would have, and not only in how it would assess budget constraints. This situation needs meaningful and informed decision-making,” he said.
Dr Phuti Ratshabedi, Gauteng chairperson of SAMATU, said the non-payment of commuted overtime pay in April was a slap in the face from the provincial health department as the union had a meeting with the department that month and left with the department agreeing to uphold their contractual agreements to leave contracts terms for commuted overtime pay unchanged at least till the end of March 2026 – the end of the financial year.
“What we saw is that the department will promise one thing and do another. But we will be holding them to what they stated in their own circular or we will look to legal action.
“What we want to see in this review period is that they go after departments [where overtime is not being performed, but being paid for] but leave other departments alone – they cannot put everyone under the same blanket.
“If the government is able to bail out over and over things like Eskom and Transnet, how can they not prioritise healthcare – this sets our country way back and we doctors will no longer be silent about this,” said Ratshabedi.
Spotlight sent questions to the Gauteng health department, including on how the payment delay happened; the number of people affected; how the department is addressing the wide-spread knock-on effects of their proposed commuted overtime cuts; and what amendments they hope will come out of the national review. Despite several reminders, the department did not respond to our questions.
In a move that will come as a relief for the hundreds of unemployed doctors currently seeking positions within public healthcare, the Department of Health has announced the creation of 1650 new positions for healthcare professionals. The move includes 1200 new positions for doctors – but only 200 for nurses.
Health Minister Dr Aaron Motsoaledi made the announcement at a media briefing on Thursday 10 April.
“We believe we’re in a position to announce today that the council has approved the advertisement of 1200 jobs for doctors, 200 for nurses and 250 for other healthcare professionals,” Motsoaledi stated. This would come with a cost of R1.78 billion – out of a healthcare budget that has not risen in line with inflation.
Jobless doctors picketed earlier this year as more than 1800 were left in limbo without positions – the true number is likely higher. The South African Medical Association (SAMA) had sent an urgent letter to President Cyril Ramaphosa, warning that if the problem was not addressed, doctors would leave for the private sector or emigrate, leading to the collapse of the public healthcare sector.
The road to specialisation had also been made more challenging by the shortage of positions, with junior doctors have been taking unpaid roles. Such unpaid work does not count toward the registrar component of specialisation and largely only serves to bump up the doctor’s CV by, for example, enabling them to apply for diplomas. Hiring freezes also saw GPs unable to move into government positions, and the limited number of registrar positions has also by some accounts become a bottleneck, with no additional registrar positions added for the past 10–15 years.
Regarding the loss of US funding for HIV programmes, he said that there was a buffer of stock for ARVS, and that “no person needing ARVs would lack” those drugs.
But the small number of new nurse positions was not well received. The Democratic Nursing Organisation of South Africa (DENOSA) was particularly unimpressed given the pressure on overburdened nurses.
DENOSA spokesperson Sonia Mabunda-Kaziboni said, “In the face of a nationwide crisis of nurse shortages, this announcement is not only shockingly inadequate but downright insulting to the nursing fraternity.”
Calling it a “slap in the face”, she continued: “The shortage of nurses in South Africa is nothing short of a devastating crisis. The Free State alone faces a 28% vacancy rate, and similar figures are reflected in other provinces such as the Eastern Cape. National projections estimate that South Africa could be short by over 100 000 nurses by 2030 if urgent interventions are not made.”
DENOSA plans to “name and shame” institutions that have become “dangerous to communities” as a result of unresolved poor conditions.
I waited five hours to get medical treatment at Mamelodi Regional Hospital in Tshwane, with a broken wrist and an injured head.
On 19 February 2025 at about 4pm I was walking in Mamelodi West. I was on a journalism assignment, heading to informal settlements that are prone to flooding.
The street was quiet, but I felt safe because I had walked there before. Suddenly, a car stopped in front of me, and two men got out of it and tried to rob me. I ran away and jumped into the stormwater passage, but slipped and fell, hitting my face against the concrete.
When I managed to stand up, I was dizzy and my vision was blurred. I was drenched in dirty water and my belongings — my cell phone, my wallet and my camera bag — were wet.
The men who attacked me were no longer on the street. My right wrist was swollen and painful, an injury above my eye was bleeding profusely, and my head was aching. But I was relieved that I was still alive and I still had all my belongings.
I decided not to call an ambulance, but to walk about 800 metres to Mamelodi Regional Hospital.
I went to the casualty unit, expecting that I would receive treatment quickly. At the front desk, a clerk took more than 20 minutes to fill in my file. He said the hospital’s computer system was offline and he had to fill in the file with a pen. I then went to sit at the reception area. My head was aching and I repeatedly requested headache tablets from the nurses, who gave me two tablets after 30 minutes. But my pain lingered.
The wound on my face was still bleeding and my wrist was swollen and bent. About 40 minutes after my arrival, a nurse cleaned my wound and wrapped it with a bandage, stopping the bleeding.
At about 8pm, a man sitting next to me said he had arrived at the hospital at 2pm after falling from scaffolding at a construction site. He was still waiting for his X-ray results.
I went for X-rays and long afterwards, at about 10pm, I had a cast put on my wrist. I was given injections which helped with the pain. I was discharged at 11pm and went home.
In September last year, the Gauteng MEC for Health Nomantu Nkomo-Ralehoko said that Mamelodi Regional Hospital was the first hospital in Gauteng ready to meet National Health Insurance (NHI) standards.
In response to GroundUp’s questions, Gauteng Department of Health spokesperson Motalatale Modiba said a triage priority system is followed at the hospital, meaning that four patients with critical wounds that required life-saving emergencies were attended to first. He said this affected my waiting time for wound care and the application of a cast.
“You were classified as Orange P2, that is a person who is in a stable condition and is not in any immediate danger, but requires observation,” said Modiba.
“At the time of your arrival, the casualty unit had 31 other patients to be seen. These include four critical cases in the resuscitation unit, ten trauma cases, 16 medical cases and four pediatric cases,” he said.
Modiba confirmed that the hospital’s computer system was offline when I arrived.
I asked Modiba whether the Gauteng Department of Health can still confidently regard this hospital as NHI-ready despite the slow delivery of medical services I experienced. Modiba said: “Mamelodi Regional Hospital remains committed to provide best healthcare services.”
Dr Ali Hamdulay, Chief Executive Officer (CEO) of Metropolitan Health, a subsidiary of Momentum Health
As we commemorate Universal Health Coverage (UHC) Day on Thursday, 12 December 2024, it is essential to reflect on the progress made in advancing healthcare access and quality in South Africa. Universal health coverage means ensuring that all individuals and communities receive the health services they need without facing economic barriers. In the South African context, this involves addressing the disparities in our healthcare sectors and ensuring that every citizen, regardless of their financial or social status, has equitable access to quality care.
In South Africa, a large portion of the population lacks medical protection cover, underscoring the urgent need for affordable healthcare solutions. Employed and insured individuals seek comprehensive yet affordable healthcare, while the employed but uninsured (6 to 8 million) face financial strain accessing quality care. Workers in the informal sector and SMEs often lack medical cover too, exposing them to significant out-of-pocket expenses. Those unable to afford any medical funding rely heavily on overburdened public healthcare facilities, highlighting the necessity for accessible and inclusive universal healthcare across all economic groups.
For over 60 years, South Africa’s healthcare sector has been characterised by a dual system of providers. Government has invested heavily in healthcare infrastructure and services and has made notable strides in improving access to quality healthcare. However, there is a significant opportunity for greater collaboration and meaningful partnerships within South Africa’s healthcare sector, focused on developing solutions that cater to the diverse needs of the population.
The healthcare ecosystem relies on the interdependence of various role players, including healthcare professionals, facilities, funders, administrators and government entities. Each of these contributors play a crucial role in ensuring the health and wellbeing of every citizen.
For the system to be sustainable, we must understand, recognise and cater to the unique contributions and requirements of each role player. This approach is vital for maintaining service continuity, quality, and access to necessary healthcare services through collaboration. Effective partnerships across these functions are critical to the success of the healthcare ecosystem.
To address the needs of low-income earners who are privately employed but uninsured, Momentum Health launched Health4Me, a healthcare insurance product that enables employer groups to provide affordable healthcare cover to those who might not otherwise be able to afford it. Our approach goes beyond merely paying claims; we focus on promoting health, wellbeing, and productivity, ultimately enhancing quality of life. This is achieved through primary healthcare facilities, technology, and incentivising wellbeing. The rapid growth of this healthcare insurance solution speaks to its success and its impact on offering more healthcare for more South Africans, for less. By expanding access to universal healthcare through primary healthcare, technological capabilities, and healthcare-strengthening initiatives, there are opportunities to collaborate and address the needs of additional population cohorts.
Through our vast experience in the design and management of healthcare solutions, we have learned valuable lessons that enable us to effectively collaborate across sectors. One of the critical lessons is the importance of clear communication and defined roles for all stakeholders involved in working towards establishing universal healthcare access. Successful partnerships have demonstrated that when goals are aligned across sectors to achieve a common objective, such as improving patient outcomes, success is possible.
As such, the success of creating a healthcare sector that ensures access for all hinges on flexibility and adaptability. The healthcare landscape is constantly evolving, and partnerships must be adaptable to address new challenges and opportunities. This includes being open to innovative solutions and technologies that can enhance service delivery and patient care.
Healthcare is essential not only for individuals and households, but also as a cornerstone of the economy. Without a healthy workforce, productivity declines, leading to far-reaching ripple effects on business sustainability. In this evolving landscape, preventative measures, therefore, become increasingly important. Providing wellness programmes that support both the mental and physical wellbeing of employees is crucial. Equally important is equipping healthcare consumers with the tools and knowledge to understand and improve their health status.
By investing in community health programmes and early interventions, we can address health issues before they escalate, easing the burden on healthcare systems. Collaboration across sectors can significantly increase access to preventative care by leveraging the resources and expertise of both sectors. Integrating preventative care into primary healthcare shifts the focus from reactive to proactive care.
It is advantageous to focus on co-creating platforms and mutually solving for the needs of our population through collaboration. This approach fosters consistency in service delivery and builds trust between entities. Metropolitan Health, a subsidiary of Momentum Health, has demonstrated its commitment to health strengthening by supporting leadership and professional development through its partnership with the National School of Government. By sharing and imparting knowledge, we are supporting the education and empowerment of future healthcare leaders through regular joint training and capacity-building programmes. This further improves collaboration by fostering a culture of continuous learning and development.
Building on these collaborative efforts, innovative models such as health hubs can further enhance healthcare delivery. These hubs combine offerings from both sectors, providing a range of services from primary care to specialised treatments under one roof. Telehealth is another innovative approach that has shown great promise. By utilising digital platforms, we can extend healthcare services to remote and underserved areas, ensuring that more people have access to quality care.
While effective collaboration is key to providing access to quality healthcare for more people, success cannot be achieved without fostering an environment that encourages innovation and supports conducive partnership development. By creating a more enabling environment, we can facilitate smoother collaboration and attract more private sector investment in healthcare.
Looking towards 2025, the vision for healthcare in South Africa is one of greater access, integration, and collaboration. By working together, we can create a more resilient and responsive healthcare system that meets the needs of all citizens. I envision the future of healthcare delivery as one that drives innovation and improves access to care. By leveraging partnerships and co-creation, I believe we can make significant strides towards achieving universal health coverage and ensure that no one is left behind.
Nomantu Nkomo-Ralehoko is the MEC for Health and Wellness in Gauteng. (Photo: GautengHealth/X)
Several opposition politicians and commentators have flagged what appears to be chronic leadership problems at the Gauteng Department of Health.
Criticism of leadership and governance at the Gauteng Department of Health (GDOH) is amping up as the department repeatedly makes headlines for questionable appointments. This unfolds alongside a damning auditor-general report, all while hospitals and clinics across the province grapple with ongoing challenges.
Arguably, the most controversial appointment is that of Arnold Malotana. He was quietly named head of department shortly after the May 29 national elections, following a year of serving in an acting capacity. Malotana has been with the department in various positions since 2008, according to his LinkedIn profile.
SIU investigation
Malotana has been implicated in a case being investigated by the Special Investigating Unit (SIU). It relates to the alleged manipulation of supply chain processes in 2016 and 2017 in favour of a company called BAS Medxpress (BAS Med). It has been alleged that Malotana and two senior officials – Edgar Motha and Sheriff Lecholo – took bribes to the tune of R8 million. The case made headlines a year and a half ago when amaBhungane lifted the lid on an affidavit from a whistleblower, who himself was part of the alleged tender-rigging scheme. The SIU investigation was however only ordered by presidential proclamation this November. According to amaBhungane’s reporting last year, all those implicated in the matter have denied wrong-doing.
SIU spokesperson Kaizer Kganyago said the probe will focus on two supply contracts – one for plastic containers and another for orthopaedic instruments – to determine if any actions broke laws, policies, or Treasury or health department rules, and whether they may be fraudulent.
“Such conduct may include manipulation of the department’s supply chain management processes by service providers, suppliers, officials, or other third parties, often in collusion with departmental employees or those in entities under its control, to secure undue benefits for themselves or others. This can result in unauthorised, irregular, or fruitless and wasteful expenditure incurred by the department, its entities or the State,” he said in a statement.
Questions over qualifications
Malotana has also been under separate investigation regarding his qualifications when his appointment as head of department was made. His LinkedIn profile lists his education as two years (2013 – 2014) at the Durban Institute of Technology and a master’s degree in public management from Regenesys Business School, with no dates provided.
Earlier this year, Jack Bloom, a DA member in the provincial legislature, wrote to the Public Protector to ask that they investigate Malotana’s appointment. Public Protector passed the matter to Parliament’s Portfolio Committee for Public Service and Administration. In turn, the committee chair requested the Public Service Commission (PSC) to investigate.
In mid-November, the PSC “reportedly” cleared Malotana on the allegations relating to his qualifications and appointment. The PSC report was leaked to The Star newspaper with the complainants – the DA – as well as the portfolio committee chairperson not yet having had sight of the report. Spotlight also hasn’t yet been able to access a copy.
According to The Star, the PSC found that a master’s degree was not explicitly listed as a required qualification, and as a result, the commission found that Malotana did meet the requirements.
Bloom told Spotlight: “It’s highly irregular that the PSC report is leaked to a specific newspaper.”
Meanwhile, the SIU investigation continues, and the DA has reiterated its call for Gauteng Premier Panyaza Lesufi to remove Malotana from his post. Heads of departments are appointed by provincial premiers.
The Office of the Premier did not answer Spotlight’s questions about Malotana or the SIU investigation. However, according to a statement from the DA, Lesufi said in a Gauteng Legislature meeting last week that he would wait for the SIU investigation to be completed before taking any action against Malotana.
Millions spent on suspended staff
In September, responses to questions posed by Bloom in the Gauteng Legislature revealed that the provincial health department spent over R13 million on salaries for nine suspended staffers in recent years. Among these were Advocate Mpelegeng Lebeloane, former chief director of legal services, who received R4.7 million while on suspension from July 2019 until 2023. He was later reinstated and then retired in July 2024.
Bloom said in a statement at the time: “Three senior staff were suspended since 26 January 2022 for alleged financial misconduct concerning the refurbishment of the Anglo Ashanti Hospital. One has recently resigned, but more than R6 million has been spent so far on their salaries in this inexcusably long-running matter.”
The other staff members had been suspended on a range of charges, including sexual assault, assault and a job-selling scam.
Bloom said the long delays in concluding disciplinary processes smacked of a failure of accountability and were a drain on taxpayers’ monies and resources.
Spotlight put questions to the health department about its mechanisms and processes to ensure efficient and appropriate disciplinary action. The department’s spokesperson Motalatale Modiba said the cases in question “cut across various departments”. He added: “The employees were suspended with full pay and the delays mainly had to do with ongoing SIU investigations.” This includes cases that were “handled through the Office of the Premier”.
Hospital CEOs
Also on Bloom’s radar are the appointments of Dr Nthabiseng Makgana, Dr Lehlohonolo Majake, and Dr Godfrey Mbara to positions of CEOs of Chris Hani Baragwanath, Steve Biko and George Mukhari academic hospitals respectively.
The appointments were made in March, and health MEC Nomantu Nkomo-Ralehoko responded to Bloom’s questions about them in October. Bloom highlighted irregularities, noting that none of the three appointees met the requirement of 8 to 10 years of experience for hospital CEO roles, while one also didn’t have the required education qualification level. These are contraventions of regulations, according to Bloom, adding that he is still to see proof of qualifications, as he’s requested.
Another high-profile appointment under scrutiny has been the redeployment of Dr Nozuko Makabayi – the former CEO of the Rahima Moosa Mother and Child Hospital. A doctor’s open letter in June 2022 exposed poor conditions at the hospital, leading to a Health Ombud investigation. The damning report criticised Makabayi for several failings, including being absent from work for nearly 100 days without explanation. The Ombud recommended that Mkabayi be removed as CEO, but she was shifted within the department to serve as acting director responsible for HIV and Aids, STIs and TB.
Bloom’s follow-up questions to Nkomo-Ralehoko brought to light that Makabayi has not been reporting for work, due to mental health stress, but continues to receive her salary. “This is outrageous. After all the trouble she caused, she is now on a long running paid holiday at taxpayers’ expense. If she can’t do any useful job, she should be medically boarded and leave the department,” he said in October.
“There has not been a permanent HR director for years in the department and the systems of appointments follow a consistent pattern of people placed in acting positions, protecting interests, and ensuring cadre deployment rather than service delivery,” Bloom told Spotlight.
“We have the wrong people in these key positions by design. We are talking about control, looting and siphoning of one of the largest budgets in the province,” he alleged.
Modiba said that “relevant bodies are investigating” and pertaining specifically to Makabayi, he said “internal processes are unfolding” but cannot be released to the media because of an “employer-employee clause”.
Scathing Auditor General report
Recently, the Gauteng Department of Health received another scathing report from the Auditor-General for the 2023/24 financial year.
The department underspent by R1.1 billion, including R590 million underspent on the National Tertiary Service Grant intended for specialised medical treatment. This in spite of backlogs and long patient waiting lists. In addition, the report showed that the health department racked up R2.7 billion in irregular spending, R17 million in wasteful spending, and lost another R2.7 billion in income.
Action SA member in the provincial legislature Emma More described the performance of the department as “clearly lacking effective leadership and management”.
She slammed the health department for providing incorrect and misleading statistics, as highlighted by the auditor-general. “For an institution like the [Gauteng] Health Department to provide such misleading information undermines public confidence in it and compromises the lives of our citizens in this province,” More said. “It is unacceptable that while our healthcare facilities are under-resourced and struggling to meet the needs of the population, significant portions of the budget are being wasted or mismanaged.”
Responding to More’s comments, Modiba said that the department had spent 98.9% of its budget allocated for 2023/2024. He said that of the 1.1% (R1.1 billion) under expenditure, R580 million has already been provisionally approved by Treasury to be carried over to the current fiscal year, subject to audited financial statements.
“While the department aims to spend every allocated cent, achieving this goal is not always feasible due to various factors impacting the operational environment. For instance, some of the money was committed to purchase orders or invoices that could not be processed within the previous financial year leading to a rollover of funds. The amount covers grants for human resource training, national tertiary services, district health programmes and the national health insurance,” Modiba said.
A ‘structural’ problem
Professor Alex van den Heever, chair of social security systems administration and management Studies at Wits University’s School of Governance, said the health department’s leadership crisis at its core is a structural one.
“South Africa has a huge pool of talent, and we are not short on good managers or people who understand health, and how to run a health service – but these are exactly the people the [Gauteng] department of health don’t want,” he said.
“Why would they want a Babita Deokaran [an acting chief financial officer who was assassinated in August 2021 after flagging what appeared to be corruption at Tembisa Hospital] or someone who is actually going to root out the nonsense or someone who is going to properly manage patient care?” Van den Heever asked.
Describing the department’s leadership as an “hourglass model”, Van den Heever said at the top are leaders with all the power, but little focus is on delivery. The pressure falls on an overstressed, underfunded middle management with limited decision-making power, which then trickles down as problems for those at the bottom.
He added: “Hospitals can’t afford this kind of leadership, they fall apart. There is no strategy behind anything, so no maintenance, proper training and supervision of staff or clinical governance. Problems aren’t solved, they’re hidden.”
Spotlight questioned the department’s alleged failure to attract “fit for purpose” candidates, resulting in more leadership and governance challenges for the department that filter down to hospital and clinic level.
In response, Modiba stated that, for the first time since 2006, they have reviewed organisational structures, which have now been submitted to the Office of the Premier.
“This is a major step towards ensuring that the Gauteng Department of Health has a structure fit for purpose that is geared to meet the service needs of the growing Gauteng population. Furthermore, a service provider has been appointed for the next three years to conduct ‘personnel suitability checks’. This will assist the department in its recruitment of suitably qualified employees who will be able to contribute meaningfully towards the achievement of the organisation’s strategic objectives,” he added.
Offering a solution to fix some of the challenges crippling the health department, Van den Heever said that changing leadership structures to orient towards service delivery could mean better governance and management, improved staff motivation, renewed public confidence and ultimately better patient care. This, he said, would require the decentralisation of powers so that competent people can take charge in hospitals, make impactful decisions about appointments and budgets, and be accountable for pockets within a complex provincial health system.
It’s acknowledged in key policy documents, well known at the coalface and much ventilated in the media: South Africa’s public healthcare system has too few healthcare workers, especially medical doctors, certain specialists, and theatre nurses. Less recognised however is the shortage of public sector pharmacists. We lift the lid on this until now largely hidden problem – and its impact.
There are too few public sector pharmacy posts across South Africa to deliver a comprehensive service, with no clear staffing norms, and an uneven distribution of pharmacists, especially in rural districts. This contributes in part to medicine stockouts and the emergence of deadly hospital-acquired drug-resistant infections.
This is according to Dr Andy Gray, a senior lecturer in the Division of Pharmacology at the University of KwaZulu-Natal’s School of Health Sciences and co-head of the World Health Organization Collaborating Centre for Pharmaceutical Policy and Evidence Based Practice. His views are echoed by at least two other key local stakeholder organisations.
Flagging the alarming rise in resistance to antimicrobials – an urgent global public health threat – driven by the misuse of antibiotics in hospitals and ambulatory care, Gray told Spotlight that there are not enough pharmacists to intervene if they see inappropriate use of medicines.
“This just continues without any effort to fix it. Inadequately trained and understaffed prescribers are working under immense stress, so they are prone to use the wrong medicines at the wrong time with the wrong doses,” he said. “There are also very few microbiologists and certainly not enough pharmacists at the bedside. They’re not doing what’s necessary to ensure the proper use of medicines – for example, better control over antimicrobials.”
The excessive dependence on antibiotics has resulted in the emergence of antibiotic-resistant bacteria, commonly known as superbugs. This is called bacterial resistance or antibiotic resistance. Some bacteria are now resistant to even the most powerful antibiotics available.
South Africa has been ranked 67th out of 204 countries for deaths – adjusted by age per 100 000 people – linked to antimicrobial resistance. It has been estimated that around 9 500 deaths in the country in 2019 were directly caused by antimicrobial resistance, while 39 000 deaths were possibly related to resistant infections.
The National Department of Health warned in a background document that rising antimicrobial resistance and the slow-down of new antibiotics could make it impossible to treat common infections effectively. This could also lead to an increase in the cost of healthcare because of the need for more expensive 2nd or 3rd line antimicrobial agents, as well as a reduced quality of life.
Low numbers
Gray said that while not matching the paucity of public sector doctors and nurses, pharmacists stand at 24% of the staffing levels calculated as necessary to deliver a comprehensive service.
“We need just over 50 pharmacists per 100 000 uninsured population as a target, but we’re sitting at around 12,” he said.
Gray said the SA Pharmacy Council (SAPC) has no data on the total number of pharmacists actually working in the country, or the number working in particular settings. A SAPC spokesperson said they had only provincial statistics, but could not track pharmacist movements.
“You can’t use their database to find out how many pharmacists are working where. The Health Systems Trust SA Health Review Indicator chapter has figures of public sector pharmacists per province and per 100 000 uninsured population,” Gray pointed out.
As at February 2024, there were 16 856 pharmacists registered in South Africa, (working and not working), excluding the 971 community service pharmacists.
The 5 958 pharmacists employed in the public sector represents the full complement of funded posts, but it is well below the number needed – and varies dramatically between provinces. While almost all funded posts are filled, Gray said the number of posts is less than needed to deliver a comprehensive, quality service.
Taken across South Africa’s population of around 62 million, there are around 28 registered pharmacists (working or not working), per 100 000 people (insured and uninsured). According to data from 2016, the mean global ratio stands at 73 per 100 000.
“We’re better than many other African countries, but that’s cold comfort,” said Gray.
Increases spread unevenly
There are some positives. The number of pharmacists in the public sector has grown since 2009, rising from five to 12 per 100 000 uninsured people by 2023. However, the ratio varies markedly by district – for example: from 15 in the best-served Western Cape district to a mere three in the poorest served Northern Cape district.
Gray said the more rural districts suffer the most when it comes to understaffing of pharmacists and this contributes to medicine stockouts. While the causes of medicine stockouts are complex, one of the major contributors is the refusal of suppliers to deliver any more stock until accounts are paid.
Understaffing of pharmacists often results in nurses managing patients without any pharmaceutical oversight, Pharmaceutical Society of South Africa Executive Director, Refiloe Mogale, told Spotlight. She associates such task-shifting with medicine misuse and inappropriate prescribing, noting that while it’s a vital strategy in budget-tight environments, medication errors are on the rise. This, she argues, could be solved by ensuring appropriate pharmaceutical personnel are placed to support primary healthcare facilities – such as pharmacist assistants.
“A Primary Care Drug Therapy (PCDT) trained pharmacist can diagnose, treat, and dispense medications. So, this is not as much about task-shifting as about the pharmacist providing comprehensive care. These PCDT pharmacists can do family planning, screening for diabetes, hypertension, and other clinical tasks that take the burden off doctors. We need more of them,” she said.
‘No clear staffing norm’
Addressing the human resources quandary, Gray said the core problem had always been that the number of pharmacist posts per hospital or clinic were not evenly distributed. “There’s been no clear staffing norm. The old ‘homeland’ hospitals are likely to be under resourced with pharmacists and pharmacists’ assistants. Posts are poorly distributed and by global standards, we’re nowhere near where we should be,” he said.
The National Department of Health’s most senior pharmacy official Khadija Jamaloodien agreed that pharmacy posts should be distributed better. But she said work protocols dictate that state pharmacists must visit each clinic in their district at least once per month. She said there are 3 000 primary healthcare facilities in the country and 6 000 (albeit maldistributed) public sector pharmacists.
Nhlanhla Mafarafara, President of the SA Association of Hospital and Institutional Pharmacists, told Spotlight too many of the almost 6 000 pharmacists in the public sector are doing stock management, dispensing, administration and management work in hospitals and pharmaceutical depots. He says the numbers do not necessarily reflect pharmacists in clinical or patient facing areas.
“The reality is that pharmacists are restricted to trying to get drug stock in and out,” Gray observed.
However, the lack of pharmacists and pharmacist assistants at clinics and hospitals means timely and/or knowledgeable ordering often results in shortages of essential medicines, something all experts interviewed for this article agreed on.
Mafarafara said that by defining what services a pharmacist should render and what’s needed to enable a quality service, more realistic staffing numbers could be reached. Pharmacies are central points in all hospitals, with closure for even an hour crippling a hospital. Thus, adequate staffing is critical to ensure uninterrupted access to good quality pharmaceutical care.
South Africa, Mafarafara added, was far behind many other countries in the effective use of pharmacists’ clinical expertise in leading evidence-based care in hospitals. “I’d even go so far as to say doctors should be stopped from dispensing in favour of pharmacists to improve quality of patient care,” he said.
‘If you don’t have a pharmacist, nothing gets done properly’
Jamaloodien said the cost of having too few pharmacists is more far-reaching than just antimicrobial resistance. “You can have stock outs because there’s nobody to manage the supply chain. In my experience, if you don’t have a pharmacist, nothing gets done properly,” she said.
Her solutions? Compliance with the “comprehensive and robust” evidence-based standard treatment guidelines, access to an updated and well-maintained cell phone-based application that gives everybody access to the latest information and medicine changes – and more attendance by all healthcare professionals of webinars held after every medicine’s committee meeting, plus clinicians regularly reading drug update bulletins to keep up with new medicines.
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.
