This year is likely to be another tumultuous one for healthcare services, policy and governance in South Africa, with the National Health Insurance (NHI) Bill winding its way through Parliament, healthcare worker shortages and the ongoing electricity crisis.
Writing in Spotlight, Alicestine October and Marcus Low list issues to watch out for in 2023, grouped under three broad headings: leadership and governance, policy and legislation, and HIV, TB and the NSP.
Leadership and governance
1. Likely Cabinet reshuffle
Since the ANC’s national leadership conference in December, there is anticipation of a possible Cabinet reshuffle, although President Cyril Ramaphosa, until now, has refused to be drawn on possible dates for this. In the event of a reshuffle and should Health Minister Dr Joe Phaahla survive this, it would mean a nod of approval from Ramaphosa for the work he has done in this portfolio. Notwithstanding, the bar for leadership in government is, with few exceptions, set very low: surviving a reshuffle is not a yardstick for leadership excellence.
Less of a political heavyweight in the ANC than his predecessor, Dr Zweli Mkhize, Phaahla picked up the baton dropped by Mkhize after the Digital Vibes scandal. He brought some stability to the health portfolio, but public trust in the country’s health leadership remains low and the national Department of Health remains mired in the same dysfunction as under his predecessors. Phaahla missed various opportunities to take a stand on important matters, including xenophobia in the public health sector, and he showed little appetite to tackle the chronic health worker shortages, the biggest challenge in SA’s healthcare.
He came in at 51 on the ANC’s NEC list – below Mkhize (16th) and also Mmamoloko Kubayi (12th) who briefly acted as Health Minister at the height of the pandemic in 2021 with Phaahla as her deputy. Other than former Health Minister Dr Aaron Motsoaledi, there are no obvious choices for Health Minister among names on the list.
Current deputy health minister, Dr Sibongiseni Dhlomo did not make the NEC list, which puts him in a vulnerable position. However, Dhlomo, like Phaahla, is a medical doctor with a track record, albeit not a radiant one, in health governance as MEC for Health in KZN and as chair of Parliament’s health portfolio committee. A seat on the NEC is also not a guarantee of a ministerial position since ministers like Ebrahim Patel have been serving without having made it on to the ANC’s NEC.
2. Leadership in provinces
While the national Health Department is often in the headlines, it is provincial Health Departments that actually run our public healthcare system. Apart from maybe Gauteng and the Eastern Cape, these often fly under the radar. Accordingly, a key focus for Spotlight is to hold the relevant provincial leadership accountable.
By the end of 2022, Gauteng had its third Health MEC since the 2019 elections. With the appointment of a permanent HoD for the province’s Health Department also last year, there are now two new people at the helm of health in the province. They will be under close scrutiny as the rebuild of Charlotte Maxeke Johannesburg Academic Hospital and the probe into corruption at Tembisa and other hospitals continue.
3. The ongoing impact of load shedding
Last year, Phaahla announced a plans to mitigate the impact of load shedding on public health facilities. Since then, the country’s electricity crisis has deteriorated, although some additional health facilities have been exempted from power cuts. At the start of this year, 77 hospitals relying on Eskom had been exempted.
But tackling load shedding and water shortages in health services also depends on other departments, including Cogta and Mineral Resources & Energy, among others. Though the Health Department should take steps to mitigate the impact of load shedding, the biggest chunk of responsibility to end it ultimately sits with other departments.
Policy and Legislation
4. The National Health Insurance Bill
There are several important pieces of legislation to watch for this year – foremost being the National Health Insurance Bill that Parliament’s National Assembly is set to finalise when Parliament reopens. Before the parliamentary recess last year, the committee finalised deliberations on the Bill but made no substantial changes to the original Bill. Concerns raised during the public participation process have largely been rejected.
Chances are the Bill will be approved with the ANC majority in the NA. It will then be referred to the National Council of Provinces (NCOP), where the provincial legislatures will have a chance to deliberate on the Bill. During this period, the provinces may decide to have another public consultation process, however, the ANC and its MPs are insistent on pushing the Bill through as soon as possible. Given that the ANC holds eight of the nine provinces and its majority in the NCOP, they should be able to avoid another round of public comment.
While experts like Professor Alex van den Heever from the Wits School of Governance in his submission on the Bill referred to this as emasculating provincial powers, deputy director-general in the Health Department, Dr Nicholas Crisp, told MPs in a presentation that this centralisation “does not infringe on their (provinces) constitutional mandate”. He said the Constitution assigns health as a concurrent function, but it is the National Health Act (NHA) that assigns functions to provinces.
5. The State Liability Bill and medico-legal claims
The State Liability Bill is a priority in the government’s fights against the multi-billion rands of medical negligence claims against provincial Health Departments. Reintroduced in the National Assembly in 2021 after it had lapsed, the Bill was again stalled, pending the South African Law Reform Commission’s investigation into medical negligence. It is not clear when the SALRC will release its final report, but MPs during the last briefing on the Bill in Parliament made it clear work on the Bill will only resume once the SALRC has finalised its work.
Meanwhile, some developments relating to medical negligence on other fronts tare expected to come to a head this year. One is the Special Investigating Unit’s ongoing investigation into allegations of corruption and maladministration in the national and provincial Health Departments.
The Presidency said the SIU will focus on all medical negligence claims from 2013 until July 2022 and track any fraudulent and unlawful claims. The report will be published later this year.
6. Decriminalising sex work
For more than a decade, activists have lobbied for sex work to be decriminalised. Now, legislation decriminalising sex work is finally on the cards after Cabinet approved the publishing of the Criminal Law (Sexual Offences and Related Matters) Amendment Bill of 2022 for public comment last year. The public has until 31 January to submit comments. The Bill is likely to be controversial as it makes its way through Parliament and whether ANC MPs will be as committed to this Bill as they’ve been to the NHI Bill is questionable.
7. The Public Procurement Bill
The Public Procurement Bill is also expected to finally get to Parliament. Finance Minister Enoch Godongwana last year said it would be introduced in March this year. The Draft Public Procurement Bill was first published for comment in February 2020 and has taken a long-winded road to the March 2023 date. The draft has reportedly since been revised to incorporate insights from the Zondo Commission where various abuses in state procurement have been revealed.
The Bill aims to tighten and standardise procurement – essentially creating a single framework for streamlining and regulating government procurement. Given huge inefficiencies in state spending and billions lost to corruption and mismanagement of government contracts, this could be an important lever in ensuring the country gets value for money spent.
The Bill is an important step out of the quagmire of poor supply chain management processes from which the auditor-general has tried for years to pull the country. In the latest audit outcomes for provincial and national departments (2021/2022) the AG noted that government departments that have been audited since 2019, disclosed “fruitless and wasteful expenditure totalling R5.83bn”.
8. The Professionalisation of the Public Service Framework
Another important development for health will be how government departments, including national and provincial Health Departments, implement and stick to the aims of the Professionalisation of the Public Service Framework Cabinet approved last year.
The framework is set to, among others, help build state capacity through attracting and developing the right skills and spotlighting merit rather than cadre deployment in public service appointments. Over the years, Spotlight has flagged concerns over politicising health administration through cadre deployment and its impact on providing quality health services.
But does this signal the death knell for the ANC government’s cadre deployment policy? The answer, says principal of the National School of Government Busani Ngcaweni, is no. During a briefing in Parliament last year, Ngcaweni made it clear the directive to ditch cadre deployment is “not official government policy until the instruments to implement all the proposals are in place”. Ngcaweni told MPs now that Cabinet had approved the Framework, it is up to the lead departments and institutions throughout the public sector to finalise their implementation plans before the first Cabinet Lekgotla this year – either in January or February.
While some of the signals here are positive, delivering on such rhetoric will require a major investment of political capital from senior ANC leaders.
9. A new Mental Health Policy Framework?
South Africa’s last Mental Health Policy Framework expired at the end of 2020. Despite assurances from the Health Department in October 2021 that a new one was being developed, none had yet been published by the end of 2022.
Such policy delays are all too common at the National Department of Health. And where policy processes have eventually been concluded, implementation has often lagged – maybe most notably with the Human Resources for Health Strategy 2030, which despite the country’s very serious healthcare workers shortages, is gathering dust.
Widespread consensus is that a policy framework is required to help focus and transform mental health services. Whether we will see a new framework in 2023 and how it is implemented will say a lot about government’s commitment to improving its mental health services, but also about the National Department of Health’s ability to develop and implement policy.
10. Questions about migrant health
Last year, Health Minister Phaahla was slammed by activists for not taking a stance against statements fuelling xenophobia in the health system. This followed Limpopo Health MEC Phophi Ramathuba’s remarks about immigrants crowding the public health system. Phaahla said government would conduct a study into the treatment of foreign nationals at public health facilities and some feedback on this is expected this year.
Unfortunately, however, we expect xenophobia to remain in the headlines in the run-up to the 2024 elections.
The ongoing NHI Bill process will also keep the issue in the news. During public consultations on the Bill, human rights experts and activists raised concerns over the exclusion of asylum seekers and undocumented migrants from accessing healthcare.
HIV, TB and the NSP
11. Getting the most out of new HIV prevention technologies
This will be an important year for HIV prevention. Access to pills that prevent HIV infection (cPrEP or pre-exposure prophylaxis) has increased substantially in the public sector over the past three years, but the absolute number of people using these remains low. A key question is whether government is able to take the steps required to facilitate greater uptake of the pills.
At the same time, pilot projects of a two-monthly HIV prevention injection will start early this year – trials have already shown t the injections are highly effective. The South African Health Products Regulatory Authority approved the jab in December. The pilots are worth watching for what they will tell us about how to best make these injections available, especially to young women. Developments regarding the injection’s price are also worth keeping close tabs on since high prices may end up restricting the scale or timing of the wider rollout of these injections.
12. Changing times in TB
There are several ongoing or imminent changes both in how we diagnose and how we treat TB in South Africa. On the diagnostic side, X-ray screening and targeted universal testing pilot programmes in 2022 showed great promise for helping diagnose more people with TB more quickly. According to some estimates, more than 100 000 people who get TB in SA every year are undiagnosed. Whether targeted universal testing and X-ray screening will be scaled up and whether we will see a substantial boost in TB detection in 2023 are big questions.
On the treatment side, we should see treatment for most children being cut from six to four months, and a six-month treatment regimen becoming the new standard for adults with drug-resistant TB. We are likely to see wider use of shorter course TB preventive therapy – three months rather than six or more – although the relevant TB prevention guidelines have still not been made public, despite having been in the works for several years.
13. New plan for HIV, TB and STIs
In November, a draft of the South African National Strategic Plan (NSP) for HIV, TB and STIs 2023 – 2028 was published for a brief period of public comment. It had promising things to say about mental health support and the decriminalisation of sex work and largely ticked the right boxes for key HIV and TB issues. But, unfortunately, it was also dry and uninspiring – and unlikely to find much resonance outside the usual HIV and TB circles. There is also little sign that the new NSP and the processes around its development will buck the trend of HIV and TB policy largely being made in parallel with the NSP rather than being informed by it. The final NSP is due to be launched around World TB Day in March.
Spotlight article – OPINION: Health in 2023 – 13 things to look out for (Creative Commons Licence)
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