Various stakeholders within the medical schemes value chain have sharply raised concerns over the unending court challenges brought by the Board of Healthcare Funders (BHF) against CMS. As an agile regulator, the CMS endeavours to clarify any misconception and confusion over BHF’s court challenges.
Chronology of Events
Initially, the main issue brought by BHF in this case was to request the court to grant them a general exemption for medical schemes to offer low-cost benefit options and to declare an alleged moratorium unlawful by the CMS and Ministry of Health in order to prevent medical schemes from offering low-cost benefit options.
In response, the CMS vehemently opposed the application on the basis that there was no moratorium as alleged by BHF and it would be thus unlawful to grant BHF a general exemption for medical schemes to offer low costs benefit options.
“It must be noted that while the main case/dispute was still ongoing (even after CMS submitted an extensive record of documents that were compliant with relevant information and documents having been exchanged between CMS and BHF), surprisingly BHF brought an interlocutory application alleging that CMS and the Minister were hiding certain information.”
Accordingly, the interlocutory application requested CMS and the NDOH to release an exhaustive list of documents which the CMS believed were irrelevant and had no bearing on the main application.
Despite CMS’s vehement contestation to the court on the additional requested documents by BHF, Judge Botha granted the BHF the order they sought, and the CMS, as well as the Minister of Health were ordered to produce the documents listed in Notice in terms of Rule 30A within 10 (ten) days of the Court Order, being 24 July 2023.
Before the expiration of rule 18 of the superior court, CMS filed leave to appeal the court order of Judge Botha as CMS believed that the order was flawed in law and that the judge had no reasons for ordering CMS and the Minister to produce those documents.
While the CMS legal team was studying the order, BHF concurrently lodged a contempt of court on an urgent basis.
CMS, through its attorneys, moved swiftly and wrote to BHF urging them to withdraw the contempt application as the CMS had already lodged its leave to appeal the court order of Judge Botha and this meant that the court order by Judge Botha would been suspended.
BHF refused to withdraw the contempt application and the application was heard on 8th August 2023 and the court dismissed BHF’s application on 10 August 2023 with costs in favour of CMS and Minister.
Citing Judge E van der Schyff who emphasised that “in the Practice Manual of the Gauteng High Court Division that while an application maybe urgent, it may not be sufficiently urgent to be heard at the time selected by an applicant” and also strongly highlighted that it does “not mean that applicants can indiscriminately approach the urgent court on the basis of extreme urgency without having regard to the context and facts of each individual application.”
Based on this order, the contempt application is now in our view moot or rather has been overtaken by the leave to appeal lodged by CMS and the Minister and CMS/NDOH. The leave to appeal will be heard somewhere September 2023.
The main application brought by BHF is likely to be heard in later parts of 2024.
In South Africa, the use of pit latrines remains a prevalent human rights issue, infringing on every person’s right to life, dignity, and health, as well as their right to access water and adequate basic sanitation. Despite their unavoidable application in certain contexts, pit latrines pose numerous risks to life, health, and safety, particularly in schools and areas lacking proper sanitation infrastructure such as informal settlements, prompting efforts to eliminate their presence in the country.
As far back as 2019, the Department of Water and Sanitation (DWS) launched a campaign called Khusela, which means “to eradicate” in isiZulu, to abolish pit latrines by 2030. Given the extensive challenges related to sanitation infrastructure, eradicating pit latrines is going to take time, particularly in rural areas. Nonetheless, this human rights issue must be squarely addressed and that functional, sustainable alternatives to open pit latrines are given the proper prioritisation.
Pit latrines: the shocking numbers
From a sanitation perspective, there are 380 schools in South Africa with no running water. 3392 schools still use pit latrines, which affects 34 489 teachers and 1 042 698 learners. While it is difficult to ascertain exact population figures, it is estimated that there are still four million pit latrines in use by communities throughout the country, of which only two million are Ventilated Improved Pit (VIP) latrines, while the remainder are ordinary pits with, or without covers. VIP latrines are a type of pit latrine that has a ventilation pipe that allows air to circulate through the pit, which helps to reduce odours and the breeding of flies. These latrines are also typically constructed with a more substantial exterior structure than ordinary pit latrines.
Endangering communities
The use of pit latrines can be perilous, posing a safety risk, particularly for young children, females, and vulnerable individuals. Without proper maintenance or safety precautions, accidents such as falls, injuries, and even drownings occur. Pit latrines contribute to the spread of disease, posing a major health hazard to users and nearby residents, as inadequate waste management and poor sanitation practices contaminate the groundwater and soil, as well as nearby water sources which lead to the transmission of waterborne diseases like cholera, diarrhoea, and dysentery. Pit latrines often lack essential sanitation facilities, such as handwashing stations or proper waste disposal systems, which results in unhygienic environments, poor personal hygiene practices, and an elevated risk of infections and diseases.
For affected communities, the lack of access to clean water and proper sanitation has a significant impact on health and well-being. The lack of access to safe and hygienic sanitation facilities can lead to health problems, which can make it difficult for people to work and earn a living. The correlation between adequate sanitation and poverty is a complex issue, with several contributing factors. As such, it is important to address these factors to improve sanitation and ultimately reduce poverty.
Challenging to service
Pit latrines are used primarily in areas that do not have access to water. These gradually fill up over time, primarily with solid waste as most liquid waste evaporates or is absorbed into the soil. Originally estimated to last seven to ten years, these latrines often require maintenance in just two to three years due to the significant amount of additional waste they receive. Decisions must then be made to either close the latrine and dig a new hole or seek servicing, a challenging task that involves treating the solid waste to create a more liquid environment before using a honey sucker or vacuum tanker to extract and dispose of the waste in a treatment plant. The remote locations of many facilities add to the complexity of the process.
Seeking practical solutions and facing reality
This highlights the urgent need for practical solutions when addressing the challenges posed by pit latrines. To illustrate the practicalities, consider the sheer number of pit latrines – four million, with two million being VIPs and two million standards. Replacing all of these with waterborne sanitation is simply unfeasible in the short term, as this would require an additional one billion litres of water daily for flushing alone. This is currently an insurmountable obstacle in terms of water supply and treatment, considering the condition of existing waste treatment plants. The South African private sector has sought to find the most practical and effective way to address the critical issues of safety, environmental impact, and serviceability of these facilities. To make a tangible difference, it is necessary first to acknowledge that an immediate conversion to waterborne solutions is not practical, in the short and medium term.
Attainable, cost-effective alternatives
A safer alternative to pit latrines has been developed and tested extensively and is ready for implementation in communities. It is a cost-effective, dry sanitation unit that addresses health and safety shortfalls, installation difficulties and servicing problems with pit latrines while ensuring that environmental and underground water contamination cannot occur. The main structure consists of concrete and the door is made of injection moulding plastic, with a ventilation pipe to limit odours. The waste containment unit has a 1500-litre bladder with a 3–5-year guaranteed life cycle, which can be removed without disabling the unit. The units are mobile, and no pit must be dug, which reduces installation costs and limits the abandonment of land. The unit itself is shaped in an ellipse to maximise space utilisation and waste containment, using a rotating bowl to dispose of waste, which prevents contact with faecal matter. The unit is sealed to prevent insects from entering or exiting the system and uses environmentally friendly products to treat waste, all of which address environmental concerns.
A cleaner, safer future
The need to eliminate pit latrines in South Africa is clear, given the multitude of risks they pose to the health, safety, and environment of communities. While an immediate conversion to waterborne sanitation may not be practical due to water supply and treatment limitations, the development of safer alternatives, such as the dry sanitation unit, offers promising possibilities. By prioritising the implementation of such practical and effective solutions, South Africa can significantly enhance the well-being and quality of life of its communities, making strides towards a future where pit latrines are replaced with safe, sustainable, and healthier sanitation options for all citizens.
Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/
The South African Pharmacy Council (SAPC) has been given judicial go-ahead to introduce its Pharmacy-Initiated Management of Antiretroviral Treatment (PIMART) initiative, which will allow specially trained pharmacists to manage and prescribe medicine to patients with HIV and tuberculosis.
Pretoria High Court Judge Elmarie van der Schyff has dismissed an application brought by a doctors’ organisation – the IPA Foundation – for the setting aside of the programme.
She said the pilot project had emphasised the value of the initiative, which was in line with the World Health Organisation’s vision to promote widely accessible primary health care.
“The untapped value of pharmacists in fighting HIV was also emphasised by the efficient role pharmacies played in meeting health care needs and providing health care services during the Covid-19 pandemic,” she said.
“The need to widen access to first line ART and TPT therapy on a community level is not a figment of SAPC’s imagination but a dire need that is also evinced in other countries.”
The IPA Foundation approached the court, under the Promotion of Administrative Justice Act (PAJA), seeking to review and set aside the SAPC’s decision to implement PIMART.
IPA claimed that the SAPC had failed to give interested parties an adequate opportunity to comment before the initiative was implemented. It further contended that PIMART unjustifiably encroached on the domain of medical practitioners and was in conflict with legislation.
IPA also accused SAPC of misleading the Director-General of Health, claiming there had been extensive consultation with stakeholders, which led to the approval and issuing of permits for the initiative.
The SAPC said the application should be dismissed. It said pharmacy-provided primary healthcare was a well known and functional concept in South Africa and PIMART was simply a “widening of this”.
Referring to the background and context, Judge van der Schyff said, in line with WHO recommendations that all people living with HIV must be provided with ART, the department of health had requested the SAPC to consider and implement interventions that would ensure that patients had increased access to medicines.
This led to the SAPC requesting the Director-General in August 2018 to consider issuing permits to pharmacists who had completed supplementary training, to manage patients and to dispense medication under PIMART.
In March 2021, the SAPC published a notice for public comment regarding the adoption of PIMART. The first permits were issued in August that year.
However, IPA submitted objections outside of the timeline for comments. It said this was because its members were struggling with another wave of the Covid-19 pandemic.
“Pharmacists and doctors operate in distinct and separate professional domains, the boundaries of which are closely guarded and some tension exists … IPA’s objection to PIMART seems to be rooted, partially at least, in this professional tension.
“This is evidenced by its fear that the decision to implement PIMART might ‘open the floodgates’ and ‘pave the way for pharmacists to ultimately treat and prescribe other schedule 4 drugs in respect of acute illnesses’,” the Judge said.
She noted, however, that the National Drugs Policy, in line with WHO guidelines, promoted “task shifting” to advance access to medicine and that at primary level, prescribing should be competency based, not occupation based.
Any alleged adverse effect that PIMART held for a medical practitioner had to be considered against the need to expand primary health care services aimed at preventing and treating HIV and providing first-line ART therapy.
Judge van der Schyff said the initiative gave members of the public a choice as to whether they wanted to approach a pharmacist, who had been issued with a permit, or a general practitioner.
In considering procedural fairness, the judge said there was nothing sinister in the timing of the notice calling for comment, that the project was not something hidden in secrecy and “I find it improbable, as alleged, that none of IPA’s members had timeous knowledge of the board notice”.
The decision to implement PIMART also fell within the ambit of the SAPC’s powers.
Evidence also showed that the PIMART training course was developed to ensure that pharmacists who successfully completed the training would be suitably qualified to safely and effectively assist in providing ART.
Judge van der Schyff dismissed the review application and ordered IPA to pay the costs.
Professor Francois Venter, former President of the Southern African HIV Clinicians Society and Director of Ezintsha, an HIV research organisation at Wits University, commented, “I hope this is the end of it. The pharmacies are an essential part of the health system, and pharmacists internationally play a big role in expanding HIV services.”
Doing ‘the right thing’ for one’s health, be it eating well, exercising, or going for an annual HIV test or blood pressure check, is easier said than done. One way to nudge people to make these ‘right’ decisions is to offer rewards or incentives. Discovery Health Medical Scheme’s Vitality programme is probably the best local example of such an incentive programme.
While incentive programmes have made a splash in private healthcare, they’ve hardly caused a ripple in South Africa’s public sector. In fact, the only public sector incentive of any notable scale of which we are aware was the vouchers that were offered to people who got vaccinated against SARS-CoV-2. There have been several scientific studies of cash transfers and other incentives, but the data is relatively limited and the differences between studies were substantial, as indicated in this review of cash transfers for HIV prevention, among others.
Evidence from other countries has shown that a targeted public sector incentive programme could yield significant positive results. The Indian Government launched a programme called Janani Suraksha Yojana (JSY) in 2005, “with the goal of reducing the numbers of maternal and neonatal deaths” using a conditional cash transfer scheme to encourage giving birth in a health facility. In those who benefited from the scheme, there was a reduction of 4.1 perinatal deaths per 1000 pregnancies and a reduction of 2.4 neonatal deaths per 1000 live births.
As Spotlight has recently reported, South Africa is doing relatively poorly against its diabetes and hypertension targets and substantially better against its HIV targets. Yet, we can find no evidence that the Department of Health has given serious thought to incentive programmes in these various areas.
Some might argue that the impact of such programmes is unproven and that they are too expensive. No doubt, a carbon copy public sector version of Vitality is wishful thinking. But are there any elements of it worth copying or adapting for the public sector?
“It has always amazed me that incentives are always so OK for rich people like me, on Discovery, but somehow unacceptable for poor people ‘who should do it for their own good’ in the public system,” says Professor Francois Venter, who heads up Ezintsha at the University of the Witwatersrand. He describes it as patronising.
Venter says that while hugely complex issues like controlling non-communicable diseases (NCDs) and obesity can’t be solved with incentives, they could certainly be added to the very limited toolbox of the existing arsenal being used to prevent disease or death through early detection, testing, and screening. He says incentives “definitely should not be dismissed right off the bat when it comes to the 84% of people who rely on the public system”.
The power of ‘points’
An estimated 60% of diseases across the board are caused by unhealthy lifestyles, according to a 2022 study published in the International Journal of Environmental Research and Public Health. In line with such evidence, Discovery’s Vitality programme is primarily focused on encouraging its members to make healthier lifestyle choices.
“Vitality aims to leverage behaviour change techniques, most notably using incentives, to motivate or nudge members to adopt healthy behaviours,” says Dr Mosima Mabunda, who is the Head of Wellness at Vitality. She says that four core factors are implicated in most NCDs, namely an unhealthy diet, a lack of physical activity, smoking, and alcohol misuse.
The Vitality programme is complex and uses a wide range of incentives and rewards to motivate members, including giving members monetary rebates for healthy food purchases, subsidised gym membership, and a comprehensive points-based system that rewards a range of healthy lifestyle choices. These points can be converted to cash or used at a range of local retailers. There is an incredible variety of Vitality rewards that range from discounts on flights to discounts at movie theatres.
According to a Discovery report, the “overall impact of Vitality on mortality rates is significant”. By “making people healthier” they say they have achieved an average reduction in mortality of 13%.
Several experts interviewed by Spotlight point out that most of this data has not been published in reputable, peer-reviewed journals. Even so, it is certainly plausible that Vitality’s annual incentivised health check helps with earlier diagnosis of hypertension, diabetes, and even HIV. Similarly plausible is the idea that points may successfully incentivise some people to exercise more. Scepticism of the health benefits of other elements of the Vitality programme may well be warranted – it is hard to know without independent analysis.
Importance of early detection
The underlying logic of such incentive systems is typically that the savings due to behaviour change or early detection outweighs the cost of the incentives. Put another way, the private sector isn’t just doing this to help people stay healthy, they are also doing it to save money. The costs and benefits for state-run incentive programmes will obviously look very different, but there may well be cases where the benefits of incentives outweigh their costs.
It is also possible that in some instances incentives are actually needed more urgently by users of the public sector than the private. As Professor Harsha Thirumurthy, who is an expert on behavioural economics and health incentives based at the University of Pennsylvania points out, “the majority of Vitality members don’t face barriers like transport costs” or even being located many kilometres away from the nearest state facility.
Late diagnosis or poor disease control has high human and economic costs in both the public sector and private. According to a 2013 study published in the Global Health Action journal, uncontrolled diabetes caused 8000 new cases of blindness and 2000 new amputations in South Africa in 2009 alone. More recent statistics reveal the situation is getting worse. In 2018, then KwaZulu-Natal MEC for Health Dr Sibongiseni Dhlomo revealed that six amputations occur every single day – which equates to over 2100 a year – in that province.
And the financial implications are staggering. For example, a 2022 literature review that looked at the costs of treating common NCDs in South Africa, estimated the cost of treating one person for one year with medication for type 2 diabetes to be roughly between R1000 and R3500 in the public sector. In comparison, the study also looked at the costs of treating common complications of uncontrolled diabetes. For example, diabetes-related renal disease was estimated to cost roughly R67 000 per person per year.
Screening for diabetic retinopathy, an eye condition that causes vision loss, costs between R110 and R370 per person. In comparison, the cost of treating ophthalmic disease in people with diabetes is estimated to be R59 000 per person per year.
These are only the health system costs and don’t include the costs of serious complications and lifelong disability to individuals, families, and communities.
Barriers to healthy lifestyle choices
Most experts we spoke to agree that the Vitality programme in its entirety is too complex and expensive to be replicated at scale in the public sector. Additionally, helping the majority of the population make healthy lifestyle choices, particularly those around healthy diets and physical activity, is a mammoth task and exceeds the ambit and powers of the National Department of Health.
“It’s really important to appreciate that there are so many environmental, social, [and] structural factors that make it difficult for people to quote-unquote ‘do the right thing’ when it comes to health-related behaviours,” says Thirumurthy. “For example, people are constantly subjected to advertising of unhealthy food products. Many are living in environments that make it hard to eat a healthy diet even if they wanted to.
“To really make a difference, we have to take a step back and identify the overall system-level or structural changes that could be made to influence people’s diets and other health behaviours. We need to think about what types of government regulation and policy levers can be utilised to achieve better health outcomes,” says Thirumurthy, who is also the co-founder of South Africa’s first ‘nudge unit’, based at Wits University called Indlela: Behavioural Insights for Better Health, which is focused on identifying low-cost behavioural solutions to public health challenges.
As Spotlight previously reported, many of these issues are flagged in South Africa’s recently published Strategy for the Prevention and Management of Obesity in South Africa 2023 – 2028. But while most experts we interviewed felt the strategy flagged the right issues, there was also agreement that the strategy didn’t set out a realistic plan for dealing with those issues. And not finding ways to deal with these issues is costing a lot of money.
In 2018, the public sector cost of treating patients diagnosed with diabetes alone totalled R2.7 bn “and would be R21.8 bn if both diagnosed and undiagnosed patients are considered”, according to a 2020 report about the health promotion of NCDs published by the South African Medical Research Council (SAMRC). Moreover, in real terms, it is estimated that by 2030 the cost of all type 2 diabetes cases will soar to R35.1 bn.
According to Thirumurthy, incentive-based interventions represent one creative solution with the potential to help improve health outcomes and reduce the financial burden on the health system in the long term. “I’m not saying incentives or rewards-based programmes are going to save the day, so to speak. However, they do represent a small but important part of an overall policy package that is necessary to address NCDs. Global experience suggests this policy package should prioritise regulatory interventions, including taxes on sugary sweetened beverages and other unhealthy foods, but incentive-based interventions can certainly be a useful addition to a broader strategy or policy package,” he says.
A public sector annual health check?
Early detection is one area where the public sector could potentially benefit from copying a private sector incentive scheme.
Vitality’s annual health check is a free screening and testing consultation that includes HIV testing, mental health screening, body mass index evaluation, blood pressure check and a blood glucose test, among other things. Members are rewarded handsomely with points, simply for showing up. Critically, these checks are offered at many pharmacies and are thus relatively easy to access.
According to Belinda Kahler, Wellness Specialist for Vitality, there is data that suggests that the inclusion of a screening questionnaire for depression in their annual health check yields significant benefits for both the scheme and its members. She says that members who complete the screening and are flagged as high-risk are over three times more likely to seek professional help which “fosters early detection and management which reduces complications and ultimately reduces healthcare costs”.
One way a public sector version of this could work would be for the state to contract with nurses at private sector pharmacies and GPs to provide the checkups in addition to public sector clinics. This would make it much easier for people to access these checkups, and may well boost early diagnosis of diabetes, hypertension, and other diseases, especially if an incentive is included. For this to work, the public sector data systems to facilitate the capturing of measurements and test results will have to be in place, but presumably, work along these lines is already underway for the NHI data system that is being developed. Many public-sector clients already collect their medicines from private-sector pharmacies and some were vaccinated against SARS-CoV-2 at private-sector pharmacies – so it won’t be breaking entirely new ground to add checkups to the mix.
According to Thirumurthy, programmes that are ongoing, requiring daily or weekly action, are not feasible or sustainable for the public health system at this stage as they are too resource-intensive, requiring constant monitoring, and reward allocation. “But incentivising a once-off or annual behaviour, such as going for a vaccination or health check, is not only more likely to succeed compared to daily behaviours like going to the gym or taking a certain number of steps, it is also much more cost-effective and much easier for a government to implement,” he says.
He says addressing healthy lifestyles is incredibly difficult and preventive care interventions represent a more attainable goal for the National Department of Health. Screening, preventive care, and early detection save money and lives, but it is notoriously difficult to get patients to engage in the health system before they get really sick or experience noticeable symptoms. More often than not, patients seek care too late to prevent costly complications.
“Depending on the particular behaviour, test or screening combination that is incentivised, a programme like this could really move the needle on the intended health outcome and equate to money well spent in future averted healthcare costs,” says Thirumurthy.
Dr Brendan Maughan-Brown, who is the Chief Research Officer at the Southern Africa Labour and Development Research Unit, points out that “we really are going to have a collision of comorbidities in the next seven to eight years” fuelled by an ageing HIV population. “All these NCDs are going to become even more burdensome to the health system – already in some areas, over 25% of people over 50 are living with HIV. This is going to be a major challenge for the health system, insurers, and the NHI, so thinking about solutions now, including a proposed annual health check or screening, is a good place to start.”
What should incentives look like?
Once-off or annual programmes do not need to be expensive, according to Dr Sophie Pascoe, who is the Indlela Co-Director. “They would require a level of coordination, but there are many companies who I’m sure would be willing to come on board as sponsors. The big supermarket chains could subsidise grocery vouchers or incentives could be in the form of airtime backed by one of the big mobile networks, for example,” she says. These partnerships would “benefit everybody” by encouraging those targeted behaviours, while sponsors would profit from the exposure and an increase in their customer base.
“I think part of the problem is, when we mention the word ‘incentives’, everyone imagines a lot of money and big rewards. But the rewards don’t need to be big or costly,” she says.
Maughan-Brown, who is also an expert in behavioural economics and the behavioural determinants of HIV risk, says that for an incentivised preventive programme to be successful, there needs to be a comprehensive understanding of the various “hassle factors” faced by those who rely on the public health sector. What would be valuable to people? Transport, airtime, grocery vouchers, child care, paid leave from work or something else? He says a lot of work would need to be done to understand what rewards will work and there needs to be a level of flexibility because different people will need or value different incentives.
Pascoe, in turn, suggests that a lottery incentive could be added and would be inexpensive to augment an immediate but smaller reward that would be received directly after the health check or screening intervention, for example.
She adds that another difficulty when it comes to advocating for this kind of programme is that tangible benefits or outcomes will only be seen in the long term, while government is more receptive to programmes or policies with clear and quick results.
Venter has similar concerns. He says there is a perception that these programmes are expensive to implement and run. “But that is only part of the issue,” he says, “I find it bizarre that I get incentivised left, right, and centre by Discovery, yet every time we raise it for poor people, I get told ‘they should be doing it, anyway’. It makes no sense.” As it stands, Venter says that problematic and pervasive perceptions need to be addressed before any incentive-based programme will even likely be considered by policy-makers and government officials, and even international funders, civil society, and the media for that matter.
‘Already incentivised’
National Department of Health Spokesperson, Foster Mohale, told Spotlight that his department “is not against incentivisation but each preventive programme has its own issues and each community of health system user has different incentives for staying well”. He agrees that the “public health benefits of health checks and health screening” have the potential to “result in early detection and reduced costs to the health system”.
However, he says that these services are already incentivised and that considering interventions inspired by Vitality is “inappropriate”. Asked about the nature of the current public sector incentives, he said, “[It] depends on what one sees as an incentive! For me, a gym membership, Fitbit, express check-in queue or cheap flights are of no value and I regard them as an insult. For others, they rush to ‘benefit’. For the majority of South Africans, a visit from the [community health worker] is the incentive!”
Mohale argues that, by definition, incentive “means inducement, motivation, motive, reason, encouragement” and that, “in the true spirit of incentives”, “testing and screening services are incentivised through health promotion in ALL public health clinics, and in school health programmes”.
He says that “the massive programme for HIV testing [is] incentivised through free testing [and] specific clinics”. He adds that the department offers another incentivised programme in the form of adherence clubs, where groups of about 30 people who are on chronic medication meet regularly, share their experiences with each other and receive some screening and counselling from healthcare workers.
NOTE:Professor Francois Venter is quoted in this article. Venter is a member of Spotlight’s Editorial Advisory Panel. The panel provides the Spotlight editors with advice and feedback on the quality and relevance of Spotlight’s public interest health journalism. The Spotlight editors, however, remain editorially independent and solely responsible for all editorial decisions. Read more on the role and purpose of the panel here.
Allmed Healthcare Professionals, a leading healthcare agency, has launched its innovative Pay Slip App, designed to provide convenience and efficiency to its valued staff. The app, available for both Android and iPhone devices, revolutionises the pay slip distribution process, eliminating the need for staff to physically visit the office.
The development of the Pay Slip App began in January 2022 with the vision of addressing the challenges staff faced while collecting their pay slips. “We saw that our staff were spending time and money to come to our offices, which led to inefficiencies and unnecessary expenses,” explained Zukisani Sirwaxa, Operations Manager at Allmed. “Our goal was to save costs, improve accessibility, and streamline the entire process for our staff.”
The user-friendly app allows staff to access all their pay slips since they started working for Allmed, aiding them in financial planning and loan applications. Staff can easily check their pay details, including overtime, leaves, and earnings for specific shifts. This real-time access empowers staff to proactively manage their finances.
Karishma Dayaram, Business Unit Manager at Allmed, highlighted the app’s broader benefits, saying, “The Pay Slip App not only saves costs in printing and delivery but also frees up valuable staff time that was previously spent on manual processes. It enhances transparency and empowers our staff with immediate access to their essential pay information.”
Donald McMillan, Managing Director of Allmed, shared his excitement about the app’s unique features, stating, “As one of the first agencies to introduce such a dedicated Pay Slip App, we have been at the forefront of technology adoption in the industry. We are continuously exploring ways to improve the app’s functionality to meet our staff’s evolving needs.”
The Pay Slip App, developed in collaboration with a third-party developer, underwent a rigorous testing phase to ensure its efficiency and reliability. Since its launch, the app has received several thousand downloads, and Allmed has been proactive in addressing any technical challenges to ensure a seamless user experience.
Looking towards the future, Allmed envisions expanding the app’s functionalities to provide enhanced communication with our staff. “We are exploring the possibility of using the platform to share important updates, memos, and notices directly with our staff,” said Zukisani Sirwaxa. “This will further streamline our communication and foster a dynamic and connected community.”
As a forward-thinking company, Allmed recognises the importance of environmental responsibility. “We are also proud to align ourselves with the green initiative,” stated Donald McMillan. “By embracing digital solutions like the Pay Slip App, we are reducing paper usage and contributing to a sustainable future.”
In the recent judgement handed down by the Pretoria High Court in favour of Board of Health Funders (BHF), the Council for Medical Schemes (CMS), Registrar of Medical Schemes and the Minister of Health were ordered to deliver a complete record, which will shed light on the moratorium on granting exemptions to medical schemes to provide LCBO benefits. The order directed the CMS and the Minister of Health to deliver all documents or information requested under Rule 30A within 10 days of the order, but all the respondents failed to meet the deadline.
After the ten-day deadline had passed and noting that the documents were still not produced and there was no appeal to the court order, the BHF was forced to return to court to seek answers. The BHF filed a contempt of court order on an urgent basis. In this application, the BHF highlighted that no complete record had been submitted even though the deadline for the Minister of Health and CMS to do so was on 24 July 2023. In response, the CMS and the Minister of Health opposed the contempt of court action and appealed the rule 30A judgement delivered on 10 July 2023. The Minister of Health, acting through his attorneys, allowed his own team to submit certain documents in terms of rule 30A, and the attorneys have stated that the delivery of the documents demonstrates good faith. This is despite the appealing of the judgement and order delivered in the rule 30A application.
The legal battle against the CMS and Minister of Health not only highlights their failure to comply with the court’s order, but also raises concerns about transparency and accountability within the healthcare system. This delay not only hampers the progress towards implementing affordable healthcare solutions, but also undermines public trust in the decision-making process of these regulatory bodies. This lack of adherence to court orders highlights the urgent need for effective enforcement mechanisms to ensure that court decisions are respected and implemented by the relevant parties.
In a media briefing on Tuesday, 8th August, the Council for Medical Schemes (CMS) sought to clarify its process and recommendations over the approved 5% increase to medical aid scheme contributions, levels above which the medical schemes must motivate for. As for low-cost benefit options (LCBO), the CMS indicated that they would only provide a report to the Health Minister by the end of the month. This could prevent medical schemes from applying for new LCBOs in 2023.
Mr Mondi Govuzela, Senior Manager of Benefits Management, explained that the 5% approved increase is based on the Consumer Price Index (CPI) for 2022, which indicated a 4.9% increase. Schemes therefore may raise contributions by 5%, in line with the Reserve Bank’s inflation prediction for 2024. A prudent percentage markup should be incorporated to take into account cost increases and demographic changes, he advised. Before COVID, contribution increases have typically been 2.4–5% above CPI. The years 2020 to 2022 saw contribution increases dip below CPI.
One of the cost drivers that Mr Govuzela noted in the media briefing was supplier pressure stemming from fewer doctors and specialists, who were pushing for higher remunerations. Increased costs elsewhere in the healthcare industry. On the member side, growing rates of chronic diseases, membership ageing and coverage for medical services also added pressure.
LCBO would appear to be a solution for many individuals to access private healthcare for at least some urgent conditions, but the CMS has yet to comply with a Pretoria High Court ruling ordering that they provide a report on their moratorium on granting exemptions to medical schemes to provide LCBO benefits. The case was brought by the Board of Health Funders (BHF).
As to what the CMS’s response to the LCBO ruling was, CMS Registrar Dr Sipho Kabane said that the CMS was preparing a report that would be delivered to the Health Minister “by the end of the month”, but would not be drawn on what it might say. The deadline for registering new benefit options is September 1.
In their circular explaining the decision increase, the CMS acknowledged the persistent macroeconomic headwinds facing medical schemes and their members, with a meagre 1% increase predicted for SA’s GDP next year. “Against the backdrop of the current adverse macroeconomic conditions characterised by multi-year higher interest rates due to stubbornly higher inflation rate, volatile domestic currency and surging energy prices and overall lacklustre economic growth, it is evident that most household budgets will remain constrained for a foreseeable future, leaving most consumers under a precarious financial position. To cushion members of medical schemes against further financial distress and the probable risk of losing their health insurance cover due to affordability constraints, medical schemes are advised to limit their cost increase assumptions for contribution increases for the 2024 benefit year to 5.0%, in line with CPI.”
Before being diagnosed with bipolar disorder Type 1, Sifiso Mkhasibe says he was often labelled as the “black sheep” of the family and he did not know where to go for help. He was often dismissed as crazy and told that this is a white man’s illness.
“My immediate family did not know how to help or support me,” he says. “I was always labelled the black sheep of my family. I was told that I was crazy, bewitched and that I was just pretending to be sick. I was told to be strong and to get over myself and that this disease is a white man’s illness and black people do not have such things.”
Mkhasibe says his family thought it was a cultural thing and that he had an ancestral calling to become a traditional healer. He did not agree.
The South African Federation of Mental Health (SAFMH) defines stigma as “an attribute, quality, or condition that severely restricts or diminishes a person’s sense of self, damaging their self-worth, social connections, and sense of belonging”.
The challenge of getting help
“It was extremely challenging to get help and support from my family. They played a big role in stigmatising me,” Mkhasibe tells Spotlight.
A delay in accessing mental healthcare services led to Mkhasibe’s condition deteriorating. He says some of his symptoms were racing thoughts, impulsive spending, hearing voices, and insomnia. “I was always high on life with extreme energy levels. Things became worse, whereby I became violent and aggressive. I was eventually admitted to Chris Hani Baragwanath Hospital in 2007 and later transferred to Sterkfontein Psychiatric Hospital in Krugersdorp.”
“I was never informed about my diagnosis. What it was and how to manage it. I had no idea what to do when I was diagnosed. The challenge was that I was not educated about my mental illness,” he says.
Mkhasibe says he was in Sterkfontein Hospital until 2011. By then, he was estranged from his family and moved around a lot staying with cousins, aunts, and his late grandmother.
“I was at Sterkfontein for four years. My family did not want me back home. I moved from one ward to the other during that time. Now I’m close to my sister and mother again but it took a while to mend those bridges.”
He says his experience with the illness prompted him in 2011 after he was discharged from hospital, to start volunteering and creating awareness on mental health conditions. Mkhasibe is now 39 years old and was until recently a project leader for mental health at the SAFMH. He started at the organisation in 2017. On leaving the organisation, he says he has learned a lot but now has a newborn son and wants to spend time with him. Mkhasibe describes himself as a family man. He is married and has two children.
Stigma and seeking care
Ashleigh Craig, a clinical psychologist who runs a Johannesburg-based private practice and has also worked in the public sector, says beliefs around mental health contribute to stigma because there are negative connotations surrounding mental illness.
“People seeking care are often called names such as bewitched or crazy. This prevents people from seeking out care,” says Craig. “This results in people seeking care when their condition is acute and recovery will take much longer. Stigma can often lead to people completely stopping to take treatment.”
Claire Hart, a post-doctoral fellow at Wits University’s Developmental Pathways for Health Research Unit (DPHRU), says the label of any mental illness is often also associated with a mark of social disgrace or stigma. This has been shown in South African communities, where studies revealed high levels of stigmatisation towards individuals with mental disorders. The label of having a “mental illness” is socially stigmatised and constitutes negative external perceptions, which may, in turn, be internalised and negatively impact an individual’s internal sense of self.
“As a result, these individuals may avoid using existing mental health care services in fear of being labelled even when experiencing severe psychological distress. Thus, both having a mental illness and seeking help may be viewed as undesirable,” says Hart.
Under-funded, under-resourced
Hart says fighting stigma requires a two-fold approach that involves education and providing adequate resources. “People with a lived experience can help in terms of fighting mental health stigma and raising awareness. However, mental health is underfunded and there is a shortage of psychologists in the country. To become a registered psychologist, you need a Masters degree and most universities only take six to 12 Masters candidates per year,” says Hart.
Craig says people in the public sector can wait up to four months just to see a psychologist. She says private psychologists are very expensive and in the public sector most mental health services are only available at tertiary hospitals.
According to South Africa’s new National Mental Health Policy Framework and Strategic Plan 2023 – 2030 (the mental health framework,) the country has less than one psychologist for every 100 000 people. This is among the reasons why there are limited mental health services in the public health sector, especially in rural areas.
“At present, mental healthcare in rural areas, preventive and promotive aspects of mental health, and the provision of services to children, adolescents and those with anxiety, mood, and other non-psychotic disorders remain under-resourced and underdeveloped. Furthermore, primary healthcare workers are under considerable strain due to high caseloads and have minimal training in mental health, resulting in patients receiving inadequate mental health care,” says Hart.
The social and economic costs
Data in the mental health framework indicates that about 5% of the total public health budget was allocated to public mental health expenditure in 2016/2017. Provincial public health budget allocations towards mental health showed marked inequality, ranging from 2.1 to 7.7% across provinces.
According to the mental health framework, social costs of mental illness can include disrupted families and social networks, stigma, discrimination, loss of future opportunities, marginalisation, and decreased quality of life.
Mental illnesses such as depression and anxiety have been estimated to cost the economy more than R61.2 billion in lost earnings, according to the mental health framework. It states that at a societal level, lost income associated with mental illness far exceeds public sector expenditure on mental health care. In other words, it costs South Africa more to not treat mental illness than to treat it.
What to do?
Although the mental health framework goes to great lengths to stress the impact of stigma on mental health, its plans to address this are relatively low in detail. According to the framework, all health staff working in health settings will receive basic mental health training, inclusive of anti-stigma training, and ongoing routine supervision and mentoring. Provincial departments of health are meant to look at expanding their mental health workforce.
The framework also sets out to strengthen mental health promotion, prevention and advocacy. “Currently, however, no concerted national programme exists,” the framework states. “In 2024, a national public education programme for mental health will be established, including knowledge of mental health and illness; stigma and discrimination against people with lived experience of mental illness.” This, according to the policy framework, will be steered by the national health department and provincial health departments. Other relevant government departments, including Employment and Labour, Education, and Social Development will, among others, introduce mental health literacy programmes into curriculums or workplace policies and decrease stigma.
But according to Michel’le Donnelly, a project leader for advocacy and awareness at the SAFMH, there is no clear outline for any anti-stigma programming in the mental health policy framework. “As the SAFMH we hold the view that the South African government needs to actively ensure that there is sufficient funding targeted for anti-stigma programming. Monitoring, evaluation, and implementation of these programmes should be done in collaboration with people with lived experience of mental health conditions and NGOs working in the sector. These programmes should include contact-based education as part of governments intended activities because, through evidence and research, this has proven to be a way of ending stigma.”
Mkhasibe agrees that we need more support to make people aware of mental health services and how to fight stigma. ”We need more community engagement in terms of mental health education and awareness. People all over South Africa need to know that mental health is more prevalent than we think. Businesses and organisations need to instil mental health training as a culture in the office,” he says.
“Schools, colleges, and universities should make mental health a priority within education. Awareness campaigns should be done at churches, malls, taxi ranks, airports, and bus stations. Basically, everywhere where people gather,” he says.
Boehringer Ingelheim, one of the world’s leading bio-pharmaceutical companies, appointed César Nieto as General Manager and Head of Human Pharma for the Southern Africa region. As part of his responsibilities, Cesar will manage the Southern Africa region which includes South Africa and Sub-Saharan Africa countries.
A qualified physician, César has previously held senior leadership positions with the company in North and Central America, Caribbean, United Arab Emirates, and the company’s headquarters in Germany.
Mohammed Tawil, Regional Managing Director and Head of Human Pharma for Boehringer Ingelheim’s India, Middle East, Turkey and Africa (IMETA) region, said, “César has a proven track record of success in driving growth for Boehringer Ingelheim. His diverse experience will be key to our ability to drive sustainable growth and we are confident that he will help us fulfil our purpose of transforming lives for generations by bringing innovative healthcare solutions to address areas of unmet medical needs in the region.”
Commenting on his appointment, Cesar Nieto said, “Through strong partnerships with our stakeholders and Boehringer Ingelheim team, I’m confident that we can positively impact the patients and communities and contribute to healthcare innovation.”
César was previously the Regional Cardiovascular Therapeutic Area Lead at Boehringer Ingelheim IMETA, where he played a key role in the transformation of the company’s cardiovascular and stroke portfolio. His strategy in this role served as a blueprint for other regions such as Brazil, Mexico, UK and Ireland, and led to an increase in profitability in IMETA.
Boehringer Ingelheim has been in the South African market since 1962 and later grew the network into Namibia and Botswana. Recently, the regional headquarters has extended its representation to the Sub-Sharan African region.
An initiative of Wits University’s MRC/Wits Agincourt Research Unit, the Traditional Healers Project convened two ‘open houses’ at local primary healthcare facilities – Rolle Clinic and Thulamahashe Community Health Centre in rural Bushbuckridge, Mpumalanga – in March 2023.
An ‘open house’ is a community and stakeholder gathering hosted at a public health facility in partnership with the Department of Health.
The aim of these sessions is to build on the relationship that the MRC/Wits Agincourt Research Unit has established between local traditional healers, community members, and healthcare facility staff to support the end of HIV through regular HIV counselling and testing.
Traditional healers in public health
The sessions supplement research that began almost a decade ago, which focuses on the role of traditional healers in healthcare access and delivery.
Specifically, this research aims to determine:
whether traditional healers can conduct HIV counselling and testing (HCT)
whether the patients of traditional healers are willing to undergo HCT that is administered by a traditional healer
whether traditional healers and biomedical healthcare workers can work together to help link patients to HIV/AIDS diagnosis and care.
The open house sessions form part of this research and provide a platform where traditional healers and biomedical healthcare workers can come together and build mutual understanding and trust, with a view to linking those who test positive for HIV with healthcare providers who can then administer lifesaving antiretroviral treatment (ART) and care.
15 traditional healers certified HIV counsellors and testers
The open houses drew an audience of more than 150 participants, including 15 traditional healers, local indunas [tribal chiefs], community healthcare workers (CHWs), community members, and representatives from Right to Care (a local collaborating partner on HIV) and the Department of Health.
Mr Wonderful Mabuza, Project Manager at the MRC/Wits Agincourt Research Unit, oversees the open houses and says that the successes to date have far surpassed expectations:
“It is exciting to be part of the group that is doing this work, knowing that we have a lot of people who visit traditional healers in our communities. It’s groundbreaking to have traditional healers trained to provide HIV counselling and testing – and amazing to see community members respond, with some never having tested previously.”
Gogo Singabeni, one of the 15 traditional healers who has completed the programme, says: “I was very excited to be invited to the HIV training, and that we would be certified in HIV testing and counselling. It’s important to show people proof that I am certified to do HIV testing.”
She adds: “The first day of testing [a patient] was very difficult for me. I was even shaking as I was conducting the test. I started with the first client, although I was shaking, and I managed to complete the process according to how we were trained. After the client left, I drew strength in seeing that I am able to do it.”
Partnerships imperative
Dr Ryan Wagner, Senior Research Fellow at the MRC/Wits Agincourt Research Unit, leads the traditional healers programme known collectively as Ntirhisano (Shangaan for ‘working together’).
He emphasises the importance of the Ntirhisano team, traditional healers, community healthcare workers, and the Department of Health collaborating to strengthen the referral system.
“In order to expand coverage and increase uptake of HIV testing – and thereby contribute to ending new HIV cases – we need to embrace innovative approaches, such as traditional healer-initiated HIV counselling and testing,” says Wagner.
“We have recruited and trained 15 traditional healers in the Thulamahashe/Rolle area who, for the past six months, have been successfully testing their patients for HIV/AIDS. Those who tested positive have been referred to a local clinic or community healthcare worker.”
The Department of Health’s Primary Healthcare Supervisor, Sister Mariah Mkhari, says: “The Department of Health alone cannot do it, but with such collaborations between MRC/Wits and other stakeholders we will be able to conquer HIV. We welcome the initiative, and we hope Wits can expand to other areas in Bushbuckridge and train all traditional healers to test for HIV.”
