EDITORIAL: With elections and NHI, this is a big year for healthcare in SA

EDITORIAL: With elections and NHI, this is a big year for healthcare in SA

Spotlight Editorial 24 Jan 2024  https://bit.ly/3SwSdLt 

South Africa is barrelling towards its most consequential and most competitive national and provincial elections since 1994, expected to take place in May. That the ANC’s share of the vote, will be further eroded this year seems inevitable, given ongoing power cuts, failing railways, water management problems, high crime rates, and dysfunctional basic education and public health systems.

Covering elections is tricky at the best of times for media houses. At Spotlight, we plan to follow the advice of Jay Rosen, journalism professor at New York University, to focus on reporting “not the odds, but the stakes”. As far as the odds does go, however, it seems likely that the ANC – alone or in coalition – will govern nationally, but they could lose power in the country’s two most populus provinces, Gauteng and KwaZulu-Natal.

The stakes in these two provinces could not be higher when it comes to healthcare. The day-to-day running of our public healthcare system is after all the domain of provincial health departments.

Limping from crisis to crisis

Take Gauteng. From alleged health department corruption worth more than R1.2 billion in 2007/2008, to the Life Esidemini tragedy of 2016, to more recent issues such as the lacklustre response to alleged corruption at Tembisa Hospital, ongoing problems with food and security contracts, and the persecution of whistleblowers like Dr Tim de Maayer, the province’s health department has stumbled from crisis to crisis under the ANC for well over a decade now. New starts under new members of the executive council (MECs) and heads of department have been a dime a dozen, but if anything, the quality of governance has decayed over time. What is at stake is literally basics like whether there is sufficient food available for people in hospital.

There is, of course, no guarantee that this atrocious situation will be turned around if, for instance, a multi-party coalition of the DA, Action SA and others run the province – but the prospect of such a change certainly is intriguing. Just imagine the DA’s Jack Bloom having a go as Gauteng’s MEC for Health after decades of holding other MECs and heads of department to account from the sidelines.

The future of NHI

The year’s other headlining health story seems set to again be National Health Insurance (NHI), which promises healthcare for all – employed or unemployed – South Africans, permanent residents, refugees, inmates, and specific categories of foreign nationals. After making it through parliament at the end of last year, the NHI Bill is likely to be signed into law by President Cyril Ramaphosa any day now. Much of the bill won’t come into effect for quite some time, and we are sure to see several court cases challenging its constitutionality. There is also an outside chance that later this year the balance of power in parliament could shift against NHI, or at least certain elements of NHI. It is not too much of a stretch to say the future of NHI is one of several important things on the line at the ballot box.

Also at stake in the elections is government’s response to seemingly intractable problems like South Africa’s shortage of healthcare workers, budget shortfalls, and health sector corruption. It would be naïve to think a change in power will solve these problems overnight – much of the world is struggling with shortages of healthcare workers and South Africa’s budget restraints are all too real, but some will argue that a change in power may nevertheless be a necessary first step given the extent to which all three of these issues have been allowed to drift in recent years. There is certainly an argument to be made that the current lack of progress is rooted in a lack of state capacity and that the lack of state capacity, in turn, is a consequence of the ANC’s explicit policy of cadre deployment.

Whether or not voters again back the ANC, some specific questions should provide a good gauge of progress in 2024. Will we finally see convictions for the alleged corruption uncovered by public servant Babita Deokaran? Will government publish an implementation plan for addressing our healthcare worker crisis (we already have a good strategy) and, this is the key, put money and political capital behind its implementation? Will the new parliament pass a good State Liability Bill (which could help reduce the state’s liability for medico-legal claims) and finally get round to amending South Africa’s Patents Act to better balance medicine monopolies with the right to health (as set out in a policy adopted by cabinet back in 2018)? Will the establishment of the National Public Health Institute of South Africa remain stalled? Will government continue to ignore recommendations from the Competition Commission’s Health Market Inquiry on how to better regulate private healthcare in South Africa (the commission’s very impressive report was published in 2019)? Will the new health MECs and heads of provincial health departments appointed after the elections bring real change?

HIV, TB and NCDs

The National Department of Health has generally produced good HIV and tuberculosis (TB) policy over the last decade or so. In some respects, those policies have been well implemented – think the massive amount of HIV testing done in the country, in other respects they have been undermined by the general dysfunction in the public healthcare system – think long queues, staff shortages, and poor TB screening and infection control. Some innovations, like pills to prevent HIV or new TB treatments, could have been rolled out more quickly and better marketed to users.

At stake in the elections is thus not so much whether we produce good policies in areas such as HIV, TB and non-communicable diseases (NCDs), but whether we will get the leadership we need to ensure better and faster implementation of those policies.

On the HIV front, we will be keeping a close eye this year on the ongoing rollout of HIV prevention pills. While the rollout has gathered some momentum in recent years, the pills are generally still too hard to get hold of for those who could most benefit from it. Pilot projects should shed light on how to best make breakthrough new HIV prevention injections available in South Africa, but the high price of these injections is likely to mean the many young women who could most benefit from it won’t be able to get it.

New HIV figures from Thembisa, the leading mathematical model of HIV in South Africa, will be keenly watched this year since it will integrate recent findings from the Human Sciences Research Council (HSRC) survey (which contained some unexpectedly positive numbers). On the negative side, the HSRC survey also indicated that condom use was significantly down in 2022 compared to 2017 – this while a recent HIV investment case found that condoms are the only cost-saving HIV intervention for the health system. Either way, the extent to which condoms are made easily available will remain an important measure of government’s commitment to fighting HIV, both now and after the elections.

Last year, we saw significant changes in how TB is tested for and treated in South Africa. In short, many more people became eligible for TB tests and eligibility for TB preventive therapy was dramatically expanded. How impactful these new policies will be this year will depend on how well they are implemented, which again brings us back to the ongoing problems of healthcare worker shortages and a lack of management capacity in most of our provincial health departments. Maybe then, in a context of generally reasonable HIV and TB policy, what matters is not so much what different political parties have to offer on these diseases specifically, but what they can do to improve the functioning of our healthcare system more generally.

That said, one notable thing with TB is that, despite South Africa having often made good TB policy and having played an important role in raising the profile of TB at the United Nations, TB has never really become a political or elections issue here in the way one might expect from a disease that claims over 50 000 lives, of mostly poor people, in the country per year. So far, there is no indication that any political parties are set to change this in 2024.

Finally, while the long-term trends with HIV and TB are downward, the trend with non-communicable diseases (NCDs) like diabetes and hypertension in South Africa is in the opposite direction. Government has set HIV-style diabetes and hypertension targets and published a national plan, but again there are serious questions about whether these plans will be implemented and whether the public health system has the capacity to offer the levels of testing, treatment and care that is required. Meanwhile, breakthrough weight loss medicines that made headlines in 2023 are likely to remain out of reach for most people in South Africa and interventions like the sugar tax will remain highly contested before and after the elections.

Whatever happens at the ballot box, one thing is clear, given the rising NCD threat, healthcare worker shortages, budget shortfalls, and endemic corruption, whoever is in power nationally and provincially after this year’s elections will have their work cut out for them. While we will not endorse any political parties at Spotlight, we do urge voters to consider what is at stake in these elections when it comes to healthcare. Part of the picture will of course be painted by political party manifestos (which we will analyse in detail in the coming months), but as important as the policies, is the track record of what parties have done when they’ve held power. Whether in Gauteng, the Western Cape, or nationally, voters will hopefully send a clear message on whether or not they think those currently in power are on the right track.

*Low is editor of Spotlight.

COVID-19 “adjusted” Phase 2 vaccine rollout 5 July 2021

COVID-19 “adjusted” Phase 2 vaccine rollout 5 July 2021

The NDoH official policy communication on vaccination 5 July outlines how the adjusted vaccination rollout. It differs from the original PHASE 2 rollout hence the use of “adapted.” It is not explicitly linked to phase 2 but it is hard to see where else it fits.  Missing are those with comorbidities like NCDs, including diabetes and cancer.

1.4 Every vaccination site (public or private) must have a pro-active plan for managing walkins for vaccination.

 

  • Age group (+40) and congregate responsibilities government supported by private ;
  • Essential workers according to government sector “vertical” rollout
  • Workers by priority “economic” sector (mining, automotive industry, taxi operators) rollout via companies. Not clear if limited to the above sectors.
  • A general caveat about using EVDS to register all who are vaccinated.
  1. NDoH & provincial DOH (PDoH) collaboration with private sector responsibilities

    1.1 Vaccination registration & administration by age groups (5 subpoints around EVDS and reimbursement).
    1.2 Working group 1: capacity analysis including underserved areas for the attention of PDoH, presumably with the prospect of solving problems (members NDoH/Business for SA).
    1.3 Working group 2: NDoH equity monitor of demand in districts/municipalities to resolve coverage issues & look at rollout to 40+.
    1.4 Walkins are OK & every vaccination site (public or private) must have a pro-active plan for walkins.  (6 subpoints)
    1.5 Congregate settings: homes for people with disabilities, old age homes and later on prisons (correctional facilities) remains PDoH / privates sector responsibility.

Roll-out of essential worker programme public sector

2.1  “Vertical” rollout with key government “sector” “projects” departments (9 subgroups)
2.2  PDoH not responsible for the above except “DBE project and around 220,000 people from 6 categories.
2.3  Vaccination of remaining health care workers (HCWs) according to V4HCW registration site and these also include “private employers.”  (5 items)
2.4  Police (SAPS) is managing its own vaccination project.
2.5 Department of Defence and Military Veterans for the SANDF programme due to start on 8 July.
2.6 A number of government services still to be finalisied e.g. correctional services vaccination.

3 Prioritised sectors of the economy

3.1  President listed these previously mining, automotive manufacturing and taxi operators.
3.2  Many private sector companies have started vaccination of employees and contract workers.
3.3  Companies using in-house or outsourced health services.[/vc_column_text][vc_column_text]

4  EVDS-related issues

Four caveats about the importance of registering via EVDS in all circumstances.

Vaccine rollout to healthcare workers in South Africa

Vaccine rollout to healthcare workers in South Africa

Sisonke! Working together to protect healthcare workers

Day One of the first phase of COVID-19 the vaccine rollout to health workers was a huge success today. South Africa secured the single-dose Johnson & Johnson (JnJ) vaccine for use in the Sisonke (‘Together’) programme. Sisonke will be rolled out to up to 500,000 healthcare workers starting in 18 public sector hospitals across all nine provinces.

As a demonstration of confidence in the safety and efficacy of the vaccine leaders from organised labour took their shots at Steve Biko Academic Hospital today. These are leaders who are health workers themselves from organisations like DENOSA, HOSPERSA, NEHAWU, NAPSU, NUPSAW and others.

Protecting our healthcare workers is an urgent priority

Phase 1 of the vaccine programme is focused on healthcare workers. This is the first step in rolling out a comprehensive vaccine distribution strategy for the nation. Healthcare workers are the frontline of the country’s COVID-19 response and are 3-4 times more likely to contract COVID-19 than the general population. To date 40,000 South African health workers have contracted COVID-19, 6,473 have been hospitalised and 663 of our colleagues have passed on.

Phase 1 of South Africa’s three phase vaccine rollout strategy was paused temporarily earlier this month following concerns regarding the efficacy of the Oxford-AstraZeneca (also known as CoviShield) vaccine against mild-moderate COVID caused by the 501.V2 variant. CoviShield may still play a role in the National Programme. However, more research is needed to determine how and when it will be used. Vaccination using a safe and efficacious vaccine must start without delay to protect healthcare workers during a likely 3rd wave this winter. The switch to the JnJ vaccine allows for the country to restart Phase 1 vaccine rollout to keep our health workers safe.

Single-dose JnJ vaccine

The single-dose JnJ vaccine protects against severe COVID-19 in South Africa. The safety and efficacy of the vaccine was assessed in the international Phase 3 study, ENSEMBLE, which was conducted across Latin America, USA and South Africa with more than 43 000 participants. South Africa contributed around 7,000 participants to the trial between October 2020 and February 2021, including participants who were exposed to the 501.V2 variant. The long-term follow-up of study participants is still ongoing, as is required for the process of regulatory approval by the South African Health Products Regulatory Authority (SAHPRA) for commercial or emergency use. However, since the safety and efficacy of the vaccine has already been proven, the current rollout is being conducted under The Sisonke Open Label Program, to assess real world effectiveness among health care workers, who have already been prioritised for vaccination by the South African Government’s Covid-19 Vaccination Strategy.

The JnJ vaccine has been shown to be safe, with no safety concerns reported from past trials or rollouts. The ENSEMBLE trial showed excellent protection of a single-dose vaccine against severe COVID-19, including in South Africa, and as such a delay in rolling out the vaccine would be unethical.

There is a clear process for vaccine rollout to healthcare workers. To receive the vaccine, healthcare workers must:
(1) register on the South Africa Electronic Vaccination Data System,
(2) respond to an SMS invitation, and
(3) provide informed consent to take part.
Healthcare workers will receive a vaccination voucher and communication once a vaccination centre is open to render the service. To register use this link: https://vaccine.enroll.health.gov.za/#/

The Sisonke rollout will include meaningful collaboration between the original team who were involved in the ENSEMBLE trial, JnJ, and the NDoH and the SAMRC. The partners will closely monitor, track and assess the real-world rollout of the vaccine. They will measure:
(1) the occurrence of hospitalizations and deaths,
(2) the incidence of severe SARS CoV-2 infections,
(3) the diversity of breakthrough infections; and
(4) evaluate vaccine uptake among healthcare workers in South Africa.

This experienced team will utilise their trained and qualified staff including pharmacists, clinicians and others to receive, store and oversee the dispensation of the JnJ vaccine. Sisonke staff will work very closely with national and provincial health public and private vaccine centres to ensure that the vaccination of healthcare workers is done safely and carefully managed.

The protection of our healthcare workers through the rollout of the safe and efficacious vaccine is an urgent priority for South Africa.