As of Sunday, reports indicate that 23 people have died so far in the recent cholera outbreak in Hammanskraal, a direct result of the town’s neglected water sanitation infrastructure. A further 48 have been hospitalised, with six emergency field tents being set up to prop up the overburdened Jubilee Hospital, which has seen 215 patients since 19 May, as reported in the most recent Gauteng Department of Health bulletin.
The temporary field hospital has been set up to immediately attend to cases of dehydration, supplying oral rehydration solution (IRS) as well as intravenous fluids. More critical patients are taken to Tshwane hospitals.
The Gauteng Department of Health also notes that as of Friday, 27 of the 75 confirmed cholera cases had recovered and been discharged. The Gauteng Department of Education has said that it will intensify efforts to supply schools in Hammanskraal with clean drinking water.
South Africa’s most serious outbreak of cholera in recent history was from November 2008, when a massive cholera outbreak occurred in Zimbabwe and spread to South Africa. Within the first 5 months of the outbreak, more than 73 000 cases and 3500 deaths (case fatality rate of >4.7%) had been reported, and it spread to South Africa through Musina. Between 15 November 2008 and 30 April 2009, a total of 12 706 cases of cholera were reported by the National Department of Health. Of the total number of cases, 1114 (9.0%) were laboratory-confirmed cases, and 65 deaths (case fatality rate of 0.5%) were recorded. In this outbreak, microbial analysis published in the Journal of Infectious Diseases found the emergence of antimicrobial resistance in Vibrio cholerae 01 strains.
The National Institute of Communicable Diseases has posted guidelines [PDF] for the management of suspected cholera chases.
Almost 100 former nurses at Jubilee District Hospital in Hammanskraal are calling on the Gauteng Department of Health to employ them permanently. Originally contracted in July 2020 to deal with the Covid pandemic, their employment contracts were periodically renewed but terminated at the end of March 2023.
The nurses have been sitting outside the hospital since Monday.
“They want us to work under agencies, and we don’t want that,” said a nurse.
“This hospital is very understaffed, but they are being stubborn. Inside the wards there are only two nurses working, and they are overstretched. They are struggling but the department doesn’t want to employ more nursing staff,” she said.
“It’s heartbreaking to see our people in distress, and I know I am a qualified person and could help. We are told there is no budget for us,” she said.
In a statement on Monday, the Democratic Nursing Organisation of South Africa (DENOSA), said as a result of the cholera outbreak “Jubilee Hospital is now experiencing an influx of patients, which is stretching the facility to breaking point.”
“Nurses in the facilities in the area will also be made to perform duties that are outside their scope of practice where they may be expected to carry water buckets to the water tankers. DENOSA does not encourage that nurses perform duties that are outside their scope.”
DENOSA Gauteng provincial secretary Bongani Mazibuko said there was a shortage of nurses and that it had been agreed at the provincial level to extend the contracts of Covid contract nurses.
Mazibuko said the contracts were due to end on the 31 March 2023 and the Gauteng health department was supposed to have given the nurses new contracts for 1 April 2023 to March 2024.
He said nurses whose contracts had been terminated should contact the union.
GroundUp made several attempts, all in vain, to get comment from the Gauteng health department.
Scanning electron micrograph image of Vibrio cholerae. Source: Wikimedia CC0
The Hammanskraal cholera outbreak continues with 17 deaths from the disease reported so far. Poverty is exacerbating the situation, with residents being advised to drink bottled water – but unable to afford it. According to GroundUp, the microbiological compliance (a measure of faecal bacteria) at sewage treatment plants was as low as 2% and 0%, where below 50% is considered ‘bad’.
Characterised by watery diarrhoea and dehydration, cholera is caused by infection by the bacterium Vibrio cholerae and in some cases can cause death within hours. It is spread through contaminated water, and asymptomatic individuals can contribute to the spread by shedding bacteria in faeces for seven to 14 weeks.
The National Institute for Communicable Diseases (NICD) says that treatment is with oral rehydration solution (ORS), with intravenous ringer’s lactate for severe dehydration and antibiotics recommended in hospitalised patients.
For acute cases of watery diarrhoea, the National Institute for Communicable Diseases (NICD) advises the following course of action:
– Notify the case as suspected cholera by completing a Notifiable Medical Conditions case notification form. Do this immediately; don’t wait for laboratory results.
1. Assess and reassess the degree of dehydration frequently.
2. Replace fluid and maintain hydration status based on the degree of dehydration (see flowchart)
3. Antibiotic therapy is recommended for hospitalised patients. Ciprofloxacin is currently the antibiotic of choice: Paediatric dose: 20 mg/kg (max 1g) po stat Adult dose: 1g po stat
4. Children < 5 years of age should be given zinc supplementation.
5. Patients should be fed as soon as they can tolerate food
6. Patients who are no longer dehydrated and can take ORS and have decreased frequency of diarrhoea may be discharged.
Millions of doses of the Pfizer-BioNtech COVID-19 vaccine procured by the South African government have expired and the shot is largely unavailable to people in the country.
Several people who have contacted Spotlight have expressed “frustration” and “dismay” that despite government having announced in February that it was sitting on a massive stockpile of almost 30 million vaccines, they are struggling to access the Pfizer shot.
Explaining the vast quantity of unused vaccines, the Health Department at the time said vaccine uptake has been low due to decreasing cases, people’s erroneous perception that the pandemic is over, and hesitancy affected by vaccine disinformation.
Expired but not expired?
National Department of Health spokesperson Foster Mohale confirmed that seven million Pfizer doses had expired but they would not be disposed of. Instead, the vaccine manufacturers would test the vaccines to ensure continued safety and efficacy. The South African Health Products Regulatory Authority (SAHPRA) will review the test results and, if satisfied that the vaccine will still work as well as data showed before, they will approve an extended shelf life.
The remaining estimated 23 million Johnson and Johnson (J&J) vaccine doses in South Africa are due to expire in 2024 and 2025.
“The expiry of a vaccine is not the same as the expiry date of food which cannot be extended,” Mohale says, adding that the Pfizer vaccine has a short shelf life and that the vaccine’s expiry date has been extended twice in the past. He says the testing should be done by June and the Pfizer shots would become available in July.
Photo by Mat Napo on Unsplash
A mother from East London, who is hoping to emigrate to the United States, told Spotlight that she was “frantically” trying to get shots for her 12-year-old son in time to leave. In South Africa, none of the currently available COVID-19 vaccines have been authorised for use in children under the age of 16. Elsewhere in the world, for example, in the United States, the Pfizer vaccine has been tested and authorised for use for children from the age of 12. “It is mandatory that he get the vaccine before entering the United States,” she says.
An intern responding to people’s questions on the Department of Health’s hotline says, “Many callers have phoned in stressing about travelling, emigrating, or getting vaccinated for the first time. We have been told that there are very few sites that still have some stock. If people have had two Pfizer doses, they can boost with a J&J dose. However, if they have only had one Pfizer, they will have to wait.”
The public exasperation expressed directly to Spotlight and on social media also relates to the health department’s vaccination website being outdated and it being hard to find places to get vaccinated. As GroundUp reported in January, getting a COVID-19 booster jab is not as easy as it should be.
‘The pandemic is not over’
Referring to the World Health Organization’s (WHO) lifting of the COVID-19 Public Health Emergency of International Concern(PHEIC) on May 5th, Mohale says, “The pandemic is not over and people, especially those who are at highest risk of severe disease and death should get vaccinated.” These included people with co-morbidities and the elderly. He says vaccination for COVID-19 has been integrated into routine primary healthcare facilities, which is where people should go for their jabs.
WHO director-general Tedros Ghebreyesus said it was the end of the emergency phase but not the end of the threat of COVID-19. In the week prior to the announcement, he said the disease claimed a life (globally) every three minutes, “and that’s just the deaths we know about”.
The decision to lift the emergency was based on the decreasing number of deaths and hospitalisations from COVID-19, the high levels of population immunity against SARS-CoV-2, and the widespread availability of COVID-19 vaccines and treatments.
Ghebreyesus warned that the COVID-19 pandemic is not over and that the virus could still pose a serious threat to public health. The WHO has urged countries to continue to monitor the situation closely and to maintain preparedness measures, such as surveillance, testing, and contact tracing.
Some experts have criticised the WHO’s decision to end the emergency phase, arguing that it is premature and could lead to a resurgence of the pandemic. Others have defended the decision, arguing that it is based on the best available evidence and that it is important to give countries the flexibility to manage the pandemic in a way that best suits their own circumstances.
‘Momentous’ announcement
Professor Salim Abdool Kariem, Director of CAPRISA, described the announcement as “momentous”. Writing in his regular COVID-19 updates blog, he says, “… we are still living in the midst of a pandemic with thousands of cases each day. Since SARS-CoV-2 is going to be with us for a long time, a pragmatic decision was needed as the COVID-19 pandemic emergency has been steadily receding and a new variant of concern has not emerged in the last 17 months. But the risk of a new variant of concern is ever-present, even if it is getting progressively smaller with time. The public is also tired of the pandemic and many have simply put it out of sight and out of mind.”
Kariem writes that globally there are currently far more COVID-19 cases, hospitalisations, and deaths each day than we had on the day (30 January 2020) that COVID-19 was initially declared a PHEIC. “So, it (the WHO decision) was not based on the situation getting to a point pre-PHEIC. Waiting to reach that point may take many years or may never happen and so ending the PHEIC is a judgement call, taking many factors into consideration.”
‘Still with us’
Speaking at a recent webinar, hosted by Internews, science writer David Quammen, who wrote a book on COVID-19 called ‘Breathless: The Scientific Race to Defeat a Deadly Virus’ and before that, ‘Spillover’, says, “The coronavirus is still with us, it’s circulating worldwide among humans, and circulating also among whitetail deer, feral mink, and probably other wild mammals.”
He says efforts currently need to be directed to approaching COVID-19 as a long-term cause of human illness, suffering, and death, not “a short-term catastrophe”.
He says laboratory techniques need to be improved as well as manufacturing capacity for updated COVID-19 vaccines. Inequitable access to vaccines will need to be solved. “We will need to dissolve vaccine reluctance and refusal – among the privileged but obdurate, and also among those historically ill-served by Western medicine – with better communication and education.” Diagnostic testing needs to be maintained and not reduced, as well as the sequencing of genomes from patient samples to detect and trace new and immune-evasive variants, he says.
“We will need to prepare, not just for the next coming of SARS-CoV-2 (when it emerges from some infected human, or some deer or mink) but also for the next coronavirus or influenza virus (more than likely H1N1) or other highly adaptive animal-borne virus (there’s a whole rogue’s list of possibilities) that appears in humans, seemingly out of nowhere,” he says. “But they don’t come out of nowhere. They come from nature.”
Loadshedding is affecting waiting times at the Dunoon Community Health Centre in Cape Town, with patients saying they queue for hours and are still sent home without their medication.
Dunoon resident Mavis Matomane, 54, said she woke up early on Thursday 11 May to be at the clinic in time for an appointment made five months ago.
When she arrived at 7am, she joined a long queue standing outside in the rain. Matomane needs medication for arthritis and high blood pressure. She said the clinic was serving people who had arrived the day before but had not been seen to and had been told to return on 11 May.
She was seen by nurses for diagnosis after 11am and only left the hospital with her medication at 3pm.
Neliswa Bobotyana, who lives in Ibaleni informal settlement in the township, said she accompanied her boyfriend to the Dunoon centre on Monday 8 May. He was seen by a doctor and told to wait to get X-rays, but the X-ray facility closed while he was still waiting. On Tuesday his condition had deteriorated and she took him back to the health centre where he was told to open a new folder. He was sent back home and returned on Wednesday 10 May and was taken to the New Somerset Hospital where he was finally given medication.
Other residents have complained on a neighbourhood online group.
Western Cape Department of Health spokesperson Natalie Watlington said as a result of loadshedding and problems with the data centre in George, pharmacy applications for patient medication were offline on 10 May.
“Our pharmacist therefore requested patients to return the next day for their medication. We acknowledge that at times loadshedding may affect our phone lines and IT systems. It may take more time to draw your folder or process your details as a patient,” said Watlington.
She said on average 150 adults and 180 children arrived without appointments every day. This was on top of about 120 clinician appointments and 100 family planning appointments per day.
She said there were problems when patients who did not arrive on their appointment day arrived as walk-in patients on other days. There were an average of 80 missed appointments a day, Watlington said.
Watlington said patients sticking to appointment times did not need to arrive early. Waiting times differed according to the nature of the complaint and the treatment.
A population-based study of 22 million people in the UK estimates that around one in ten individuals in the UK now live with an autoimmune disorder. The findings, published in The Lancet, also highlight important socioeconomic, seasonal and regional differences for several autoimmune disorders, providing new clues as to what factors may be involved in these conditions.
There are more than 80 known autoimmune diseases, including conditions like rheumatoid arthritis, type 1 diabetes and multiple sclerosis, some of which have been increasing in the last few decades.
This has raised the question whether overall incidence of autoimmune disorders is on the rise and what factors are involved, such as environmental factors or behavioural changes in society. The exact causes of autoimmune diseases remain largely unknown, including how much can be attributed to a genetic predisposition to disease and how much is down to exposure to environmental factors.
The study used anonymised electronic health data from 22 million individuals in the UK to investigate 19 of the most common autoimmune diseases. The authors examined whether incidence of autoimmune diseases is rising over time, who is most affected by these conditions and how different autoimmune diseases may co-exist with each other.
They found that the 19 autoimmune diseases studied affect around 10% of the population. This is higher than previous estimates, which ranged from 3–9% and often relied on smaller sample sizes and included fewer autoimmune conditions. The analysis also highlighted a higher incidence in women (13%) than men (7%).
The research discovered evidence of socioeconomic, seasonal and regional disparities for several autoimmune disorders, suggesting that these conditions are unlikely to be caused by genetic differences alone. This observation may point to the involvement of potentially modifiable risk factors such as smoking, obesity or stress. It was also found that in some cases a person with one autoimmune disease is more likely to develop a second, compared to someone without an autoimmune disease.
Dr Nathalie Conrad at the University of Oxford said: “We observed that some autoimmune diseases tended to co-occur with one another more commonly than would be expected by chance or increased surveillance alone. This could mean that some autoimmune diseases share common risk factors, such as genetic predispositions or environmental triggers. This was particularly visible among rheumatic diseases and among endocrine diseases. But this phenomenon was not generalised across all autoimmune diseases. Multiple sclerosis, for example, stood out as having low rates of co-occurrence with other autoimmune diseases, suggesting a distinct pathophysiology.”
These findings reveal novel patterns that will inform the design of further research into the possible common causes of different autoimmune diseases.
Professor Geraldine Cambridge at UCL Medicine said: “Our study highlights the considerable burden that autoimmune diseases place upon individuals and the wider population. Disentangling the commonalities and differences within this large and varied set of conditions is a complex task. There is a crucial need, therefore, to increase research efforts aimed at understanding the underlying causes of these conditions, which will support the development of targeted interventions to reduce the contribution of environmental and social risk factors.”
Today we celebrate Nurses as we do every year on 12 May. The International Council of Nurses proclaimed this year’s slogan as ‘Our Nurses, Our Future’, but what is the future of nurses in South Africa?
During the height of the COVID pandemic, we saw a huge campaign launched by the World Health Organization, uplifting the stature of nurses and midwives and showcasing them as the backbone of health systems at a global level. In the South African context, the story goes that they will also be central to the health system once National Health Insurance is implemented yet there are many red flags raised as we continue the planning discussions in preparation for this change with little to no answers about that future.
“I will never be a nurse”
By the time my mother had to decide on a career, nursing was one of those professions that provided stability and security to black and coloured women during Apartheid. You had two choices – become a nurse or a teacher. That’s how my mother began her nursing journey, but she was so passionate about it so that it would probably have been her choice, regardless.
Her passion was not what spurred me on to become a nurse, though. I looked at her long hours and tireless devotion to her community and the mental health fraternity and literally uttered the words, “I will never be a nurse”. Then I met a young staff nurse during a youth weekend away. She was so proud of her profession. She just oozed pride, and at that moment, I went from a potential engineering student to a nursing student.
My father was livid. He could not comprehend why his only daughter would observe the work hours of her mother and still choose to become a nurse. But in many ways, I believe nursing chose me. Once I made the decision, I never looked back. I remember being mocked and berated for my choice in social circles, but feeling a deep connection to this calling.
I have not entered it blindly though. I was aware of my privilege and the weight of caring for people at their most vulnerable. The experiences I have made while holding the hand of someone taking their last breath, supporting a mother delivering a stillborn baby, to engaging with my first person living with HIV, or watching someone slip away after a huge battle with cancer have been deeply embedded in my consciousness. I do not believe these experiences to be without life-altering potential and believe it has shaped me into the healthcare worker I am today.
Threats to nurse autonomy
It is often believed that nurses are the handmaiden to the doctor and we should not think but do. Those sayings were so wrong, but even today, the inferiority of the quality of nurse training, lack of supervision, and only very limited mentoring all threaten the autonomy of the nurse.
Nurses, despite having a day and even a week dedicated to celebrating them, are still, for the most part, underpaid, overworked, and professionally stunted. By stunted I am referring to the lack of mandatory continuous professional development and upskilling. Somehow, as the backbone of primary healthcare, they are often unable to take time out for much-needed training.
One often hears of nurses being rude and impatient. Though some may very well display these horrible traits, for the most part, people have entered this profession to improve healthcare services to individuals, families, and communities at large. In my 21 years of experience, the issue is hugely exacerbated by the healthcare system, which does not support nurses. The hours are long and gruelling – exacerbated by staff shortages in facilities. The environment is hostile, the workload unequal, and the pay shoddy. Many nurses find themselves moonlighting to make ends meet.
Advocate for us
Though not an excuse for unprofessional behaviour, I do want activists and health advocates to fight for better working conditions, upskilling opportunities, and a larger health workforce in our public health sector.
The mental health of our clients and communities appears topical at the moment, but what about the nurse? The trauma of loss, observation of patient suffering, and abuse by many of the actors in the health space can take its toll on the mental health and well-being of our nurses, too. When we plan for the public, we must remember to include the healthcare workers and their health and well-being.
This is even more critical now as we embark on establishing the National Health Insurance (NHI) system.
As NHI looms, the threat that nurses will be ill-equipped to render quality healthcare services is a glaring reality. The South African Nursing Council (SANC) notes that 47% of the nurses on its database are older than 50 years of age. This narrative of aging nursing personnel started years ago and if we had a proactive plan to address this, South Africa may in fact have had some fighting chance to implement NHI smoothly.
In a damning article published in February, the Democratic Nursing Organisation of South Africa (DENOSA) highlighted that the South African public health sector has a deficit of 27 000 nurses and yet there are 5 000 nurses currently unemployed. How can this be acceptable? It further noted that the South African government has placed certain nursing specialities on a scarce skills list in the hope of recruiting from other countries instead of planning to upskill and uplift domestically.
Part of me wants to speak about accountability, collaboration, and change management, but the other part bleeds for nurses as the workload and responsibilities increase and the work environment becomes more hostile. All this makes it hard to see the silver lining.
I do, however, believe that if the South African Nursing Council and National Department of Health actually engage the people on the ground, those at the coal face, those with expertise, and review their current implementation plans, they will see the same glaring gaps that we see every day.
There must be a call to action for all nursing leadership, nursing activists, nurses, and nursing education establishments to collectively take a stand and demand that we revise our current approach to the nursing curriculum and work on making nursing more appealing to the youth. This could be one step in the right direction.
When I qualified as a nurse, it was a four-year course. The nursing degree I completed included Community Nursing, Psychiatric Nursing, General Nursing, and Midwifery, and although I might not practise it all, I am able to fall back on that knowledge during client or patient engagements. Now it is a five-year course with one qualification with the nurse trained as a generalist. The fear is how does that serve our communities? We need midwifery, for example, to do NIMART (initiate people on HIV treatment) and you need community nurses to be working in primary healthcare, If you come out with one general qualification – how exactly will this pan out?
We need a rethink of how we train nurses and how we can strengthen the curriculum so that we can get nurses who can address HIV and all issues in primary healthcare. In my programme – HIV testing, for example, nurses don’t get trained on HIV testing. It is just monkey see, monkey do and unfortunately, that doesn’t translate into quality service.
Very often nursing practice is see one, do one, and then you’re the expert. I’m arguing that these things must be part of the curriculum. For example, why must a nurse come out of nursing school and then only learn IMCI (Integrated Management of Childhood Illness) Why is IMCI not being done practically in the facility and the theory in class, as part of the curriculum?
Nurses, today, are expected to know everything, which is impossible but we are not upskilling them and making sure the curriculum is so robust that it addresses all disease profiles and our communities’ healthcare needs. We are talking about integrative and holistic healthcare so we cannot be only training nurses in one way. There is a malalignment of what our communities need and what nursing schools are churning out.
We must fix that.
We need an urgent change in the curriculum of nurses to ensure we can support the needs of the health system and communities, build great leadership for the future, and ensure quality health services for all.
* Sparks is a nurse, health equity advocate, and Tekano and Aspen New Voices Fellow with 21 years’ experience working across South Africa with a focus on ensuring equitable and just access to quality healthcare for all.She is also a Quote This Women + Voice of the Year Award Winner.
Chris Hani Baragwanath Academic Hospital (CHBAH) has been hit with shortages of essential foods as contractors fail to deliver the quantities of food tendered for, Daily Maverick reports.
Last week, a head of department at CHBAH notified Daily Maverick of the developing crisis, saying “So once again there is a food crises at Bara – suppliers weren’t paid, also no soap and hand towels and as a result infections spreading 😡.”
The unnamed healthcare worker said that the crisis was due to small suppliers being unable to fulfil the quantities for tenders they secured. Dry goods were particularly affected, and protein substitutes were having to be purchased from petty cash which was now depleted. This was verified by another healthcare worker, who described a situation of hospital kitchens having to borrow from one another.
One doctor spoke of elective surgeries being cancelled due to financial pressure, and an atmosphere of intimidation. Motalatale Modiba, spokesperson for the Gauteng Department of Health, denied that there was a food shortage situation, but said that delivery of some protein food items, such as chicken and fish, had been withheld due to administrative payment delays.
South Africa’s long-awaited new National Mental Health Policy Framework and Strategic Plan 2023 – 2030 has been published. The policy framework was presented at the SA mental health conference this week. PHOTO: DOH/Twitter
But even though there has been a gap from 2020 to 2023, speaking to Spotlight at the conference, Minister of Health Dr Joe Phaahla said that it doesn’t mean there was a gap in terms of updating. “Every either three or five years, we revise the policy. So, it is not that there has been a gap. There has been a policy, which has been guiding,” he said.
“But as things change, and in each cycle of the strategy and planning, we have a particular timeframe so that we can evaluate. And so now we have evaluated, and that’s why we are adding [additional things], as we learned from the previous implementation.”
Phaahla said that gaps in the country’s mental health services are not because of a lack of policy and plans but due to implementation issues and sometimes the shortage of resources and psychiatrists.
“If you look at the area of psychiatrists, it is just the two-tier system of our health service, which makes it very difficult because what psychiatrists can earn providing the services to more of the insured patients – it is something we can’t really match with the public sector salaries generally,” he said. Phaahla said that psychiatrists, who mostly work in the private sector, were typically trained at public-sector teaching hospitals. “But once they’re qualified, they stay for one year or so, then they are attracted by better income,” he told Spotlight.
According to Phaahla, to deal with the shortage of psychiatrists in provinces such as the Northern Cape where there are only three psychiatrists, the department plans to contract psychiatrists from other provinces. “We can have part-time psychiatrists, maybe take some from Gauteng where the majority are and in Western Cape and contract them to provide services in Northern Cape. Even if it’s on a weekly rotation,” he said.
Concerns over delays
While several mental health experts have welcomed the new policy framework and agree with Phaahla about the importance of implementation, they are not happy about the delays.
“We’re now sitting in 2023, three years late,” said Cassey Chambers of the South African Depression and Anxiety Group (SADAG). What that means, she said, is that civil society did not have a working document with which to engage government at provincial or district level.
Bharti Patel of the South African Mental Health Federation expressed similar concerns. “As the Federation for mental health, we are disappointed that it has taken this long for the policy to be reviewed, given the fact that the initial policy was launched in 2013,” said Patel.
“We had a crisis during that period from 2013 to 2020. We have witnessed mental healthcare users losing their lives during Life Esidimeni. The [Health] ombud report, the South African Human Rights Commission Report, have all given recommendations,” Patel said. Patel argues that those recommendations should have informed policy and implementation more quickly.
Implementation problems
Chambers described the previous strategic policy framework as a “very good document”. Then, she said, the problem came in the implementation. “And I think perhaps this is [why there was a] delay in having an updated document that is now running from 2023 to 2030. It is because the document was good, the policy was good. However, how it was implemented was not happening,” she said.
Speaking to Spotlight, Professor Crick Lund, Co-Director, of the Centre for Global Mental Health at King’s College London, explained that there are a number of factors that create implementation challenges. “The one is ignorance on the part of senior decision-makers about mental health, ignorance about the scale of the problem, and ignorance about the fact that something can be done about it,” he said.
According to Lund, the new policy framework has stronger implementation monitoring mechanisms and implementation can be tracked in a much clearer way over time.
For the new policy framework to work better than the previous one, Lund believes there is a need to create greater public awareness about mental health and about the mental health policy. He says, “We need to get all the sectors involved working together – the Department of Health, Education, Social Development, the criminal justice system, and also the NGO sector.”
Along similar lines, Patel stressed the importance of getting more government departments involved. “While the policy is developed at the national level, the National Department of Health is responsible for training the provinces and not only the Department of Health; they need to train all government departments within the province who have bought this policy,” she said. “You can’t have the Department of Health alone implement a policy. This is a policy that requires inter-sectoral collaboration so that different departments can also put budgets towards implementation.”
Lund said that there is a lot of common agreement on what the priorities are and a lot of energy going forward. “So I’m hopeful that we can move things forward.”
Budgets and human resources
While there seems to be consensus on the need for more training and getting wider buy-in, there is also a shared awareness that successful implementation will depend on the availability of sufficient funds and human resources.
“We need to see structured action plans in the provinces with budgets allocated so that we can hold the government departments accountable,” said Patel.
Chambers agrees that in order to get implementation of the new policy framework right, we will have to get the budgets right. “You need to allocate a budget in order to help with the implementation plan, especially knowing that our previous policy framework was not implemented. So, we have to overcompensate for that now, which is concerning because this year, the health budget has been reduced. Therefore, meaning that the national mental health budget has been reduced,” she said.
According to the new policy framework, the case for investing in mental health is strong. It states that at a societal level, lost income associated with mental illness far exceeds public sector expenditure on mental healthcare – in other words, it costs South Africa more to not treat mental illness than to treat it. The impact of mental illnesses such as depression and anxiety has been estimated to cost the economy more than US$3.6 billion (R61.2 billion) in lost earnings per year. Certain conditions such as perinatal depression and anxiety have lifelong cost consequences. For example, it is estimated that the lifetime costs of perinatal depression and anxiety in South Africa amount to US$2.8 billion (R47.6 billion) per annual cohort of births.
Chambers also stressed that we are facing shortages of human resources and appropriate facilities. “We don’t have the human resources or the capacity to fulfil that implementation plan and that’s a worry and a concern,” she said.
NHI and provincial plans
According to the new policy framework, mental health will be financed according to the principles adopted for all health financing in South Africa, and people will be protected from the catastrophic financial consequences of mental ill-health.
According to the policy framework, in the financing of the National Health Insurance (NHI) system, mental health services will be given parity with other health conditions, in proportion to the burden of disease and evidence for cost-effective interventions. NHI will specifically include packages of care for mental health, in line with the evidence for the most cost-effective interventions. The policy framework states that private medical aid schemes should be required to provide similar parity between mental health and other health conditions.
“Budget will be allocated to meet targets set for the implementation of the policy and regular discussions will be held with provinces to discuss strategies and monitor progress with implementation. At provincial level, mental health budgets will be reviewed annually to align mental health with national priorities, for each of the areas for action in 2023 and annually thereafter,” the policy framework reads.
The policy also says that all provinces will develop provincial strategic plans for mental health, in keeping with national policy, which outlines specific strategies, targets, timelines, budgets, and indicators in 2023 and annually thereafter, informed by specific unique local challenges.
Survivors of out-of-hospital cardiac arrest (OHCA) who received initial bystander defibrillation with a nearby automated external defibrillator (AED) reported better outcomes at 12 months after arrest compared with those initially defibrillated by paramedics, according to a new study from Monash University which appears in Heart.
The retrospective study recruited adult non-traumatic OHCA with initial shockable rhythms between 2010 and 2019. Survivors at 12 months after arrest were invited to participate in structured telephone interviews. Outcomes were identified using the Glasgow Outcome Scale-Extended (GOS-E), EuroQol-5 Dimension (EQ-5D), 12-Item Short Form Health Survey and living and work status-related questions.
Of 6050 patients, 3211 (53.1%) had a pulse on hospital arrival, while 1879 (31.1%) were discharged alive. Survival rates were highest with bystander defibrillation (52.8%), followed by dispatched first responders (36.7%) and paramedics (27.9%). Of the survivors, 1802 (29.8%) survived to 12-month post-arrest; of these 1520 (84.4%) were interviewed. 1088 (71.6%) were initially shocked by paramedics, 271 (17.8%) by first responders and 161 (10.6%) by bystanders. Bystander-shocked survivors reported higher rates of living at home without care (87.5%), upper good recovery (GOS-E=8) (41.7%) and EQ-5D visual analogue scale (VAS) ≥ 80 (64.9%) compared with first responder and paramedics, respectively. After adjustment, initial bystander defibrillation was associated with higher odds of EQ-5D VAS ≥ 80 (adjusted OR (AOR) 1.56), good functional recovery (GOS-E ≥ 7) (AOR 1.53), living at home without care (AOR 1.77) and returning to work (AOR 1.72) compared with paramedic defibrillation.
