Covid-19 will continue to dominate headlines in 2022, but from national health insurance (NHI) to the availability of a new HIV prevention injection, it will also be an important year for other areas of health service delivery, governance and reforms in South Africa. Here is Spotlight’s pick of the top 10 issues to watch:
1. Covid-19 corruption – will we finally see significant prosecutions?
Last year, clean governance and public trust in the state were dealt a huge blow after the findings of the Special Investigating Unit (SIU) on alleged corruption in the department of health’s Covid-19 response involving various officials there.
In a country beset by graft and impunity, and where consequence management is often lacking, it was encouraging to see some action in bringing the implicated wrongdoers to book.
Former health minister Dr Zweli Mkhize resigned amid allegations of wrongdoing in the Digital Vibes scandal. Mkhize took the SIU findings implicating him on judicial review. The review application is continuing in the high court and the SIU, which is opposing the application, had 30 days from November 9 last year to file its opposing affidavit.
Meanwhile, the disciplinary processes of six health department officials implicated in the Digital Vibes scandal who were suspended with full pay last year are ongoing. Among them is deputy director-general of health Dr Anban Pillay.
Director-general Sandile Buthelezi, who himself was suspended and then reinstated, said in a press briefing on Friday that the department’s legal team was dealing with the matter and the disciplinary process was expected to be completed by mid-February.
Taking action against those found guilty in the disciplinary process will be an important litmus test for Minister of Health Joe Phaahla, who last year assured the public that the department would:
The crisis also presents an opportunity to clean house and address the department’s chronic human resource capacity constraints, but – as always – whether this rhetoric will be supported by the appointment of enough suitably qualified and committed professionals remains in doubt.
2. Will the NHI Bill become law this year?
NHI is set to be one of furthest-reaching health reforms in South African history. Yet, in 2022, we are still adjusting the mechanics of the vehicle that must get us there.
For now, the NHI Bill is still with MPs in Parliament’s portfolio committee on health, who are expected to complete the last of the public hearings later in January. Last week, Parliament’s programme committee noted that the national health department was expected to provide its responses to the public submissions before the end of February. After that, the committee is then expected to finalise its report and deliberations on the NHI Bill by April 1. The Bill will then have to be considered by the national council of provinces.
Until now, public inputs on the bill broadly centred around governance issues, especially relating to the powers of the minister and the administration and transparency of the NHI
Fund. A critical issue to watch this year is whether MPs take these inputs on board and make significant changes to the bill, or simply force through a mostly unchanged version of the bill.
3. Will government rein in ballooning medicolegal claims?
In December last year, the Financial Mail reported figures showing that medicolegal claims against the state had doubled, from R37 billion to R74 billion over the past five years.
In an attempt to address this increase, the health minister asked the SA Law Reform Commission to investigate and make proposals for a new legislative framework to regulate these claims. The commission released a discussion paper in November 2021.
State law advisor Advocate Ronel van Zyl said:
The public now has until February 28 to make submissions on the proposals in the discussion document.
At the same time, the State Liability Bill is back on Parliament’s agenda, almost a year after it was last discussed in Parliament’s justice committee. First introduced in Parliament in 2018, the bill is government’s answer to the ballooning medical negligence claims against departments. Instead of government departments paying a lump sum for successful medical negligence claims, the bill proposes a “pay-as-you-go” system of smaller, scheduled payments, which will relieve the strain on hospital budgets. The justice committee is expected to schedule a meeting for deliberations soon.
Given that a final report from the SA Law Reform Commission is, at best, many months away and that Parliament probably will not finalise any legislation without the final report, we do not expect the State Liability Bill to become law this year. However, a clear way forward may emerge on how to deal with the problem of medicolegal claims, which would constitute real and meaningful progress. Of course, the most valuable progress would be to prevent medicolegal claims from occurring in the first place.
4. Will the country get a reprieve from the impact of budget cuts on health?
Most likely not. As the country’s fiscal outlook remains grim, the ripple effect of budget cuts on health sector outcomes will continue. Perhaps most importantly, limited health budgets at provincial level are likely to perpetuate chronic human resource challenges at public healthcare facilities. Employing more nurses could in certain circumstances lead to reductions in total health spending by reducing hospital stays and medicolegal claims. Instead, nurse shortages in South Africa seem set to get worse.
Threadbare budgets are also impacting important entities of the national health department, such as the Office of Health Standards Compliance (OHSC), which – by its own admission – is severely hamstrung by budget cuts and staff shortages. This means it cannot fulfil its mandate of ensuring that health facilities comply with set national norms and standards.
Briefing MPs last year, the health department’s chief financial officer noted that because the infrastructure indirect grant had been cut by almost 20%, it would have an enormous impact on nationally managed programmes, especially infrastructure projects that would have to be postponed due to limited funding. Add to this an entity mandated to ensure compliance at these facilities which is now on its knees due to budget constraints and we have an undesirable cocktail where quality patient care will be the biggest loser.
During a briefing to MPs in the portfolio committee on health in November last year, the OHSC’s CEO, Dr Siphiwe Mndaweni, said: “Much as the OHSC would like to cover every facility, there are only 61 inspectors and in excess of 5 000 public and private health establishments. It would be a challenge to reach out to all of them, even if the OHSC was required to inspect once every four years.”
5. Will HIV prevention injections become available in SA in 2022?
Back in November 2020, a landmark study showed that an antiretroviral injection administered every two months was highly effective at preventing HIV infection. Injections like these can be a true gamechanger in the fight against the virus, especially for groups with stubbornly high rates of new infections, such as young women.
Last month the injection was approved by the US Food & Drug Administration – but several things still need to happen before it is registered and available here. Either way, whether the injection reaches our clinics in 2022 provides a perfect test of whether there is any substance to the popular rhetoric of bringing the urgency of Covid-19 to HIV.
6. Will the Covid-19 pandemic subside in 2022?
As we start 2022, there are hopes that the Covid-19 pandemic may have entered a new phase in South Africa where the virus kills fewer people than before and most people have some form of immunity, either from vaccination or from having been infected, or both. There is a tantalising narrative whereby the Omicron variant signals the beginning of the end of the pandemic and a return to “normal” (at least in countries with higher vaccination rates). It is also worth stressing that the immunity we do have in our population has, in part, come at a huge cost in human lives – there were around 200 000 excess deaths in South Africa in 2021, most of which were due to Covid-19.
However, the future is highly unpredictable – and perhaps the biggest unknown is whether we will see new and deadlier variants emerging and spreading.
As director of the Medical Research Council Professor Glenda Gray said during a department of health media briefing on Friday:
7. Will South Africa’s tuberculosis (TB) response improve in 2022?
The Covid-19 pandemic has been devastating for the TB response in South Africa and elsewhere. There has been talk of government’s TB recovery plans for many months, but those plans are ambitious enough or be implemented with the required urgency remains to be seen. A TB dashboard launched by the Western Cape department of health last year is making progress in that province easier to track – so far we have seen no similar moves toward greater TB transparency from other provincial departments of health.
The reality, of course, is that simply getting back to where we were pre-Covid-19 is not good enough. The TB response was struggling even then. There are a few specifics we will be looking out for this year. First, the rollout of 3HP (a newish and improved form of TB prevention therapy) will hopefully go to scale this year. It has been disappointingly slow so far. Second, government should be reporting back on a series of pilot projects looking at the
use of X-ray technology to improve TB detection. Third, based on the findings from those X-ray pilot projects and recent findings on a targeted universal testing approach, we may see changes this year in how we go about screening and testing people for TB. Finally, we expected an updated version of Thembisa, the leading mathematical model of HIV in South Africa, to be published in 2022.
8. Will the health department walk the talk on resourcing the national mental health policy framework?
South Africa’s new national mental health policy framework and strategic plan are expected to be finalised this year, after it lapsed in 2020. This policy is crucial for improving access to mental health services in the country. However, finding the money and resources to implement the framework properly may be a major impediment.
Government currently spends about 5% of the country’s total health budget on mental health, but these services only reach about one in 10 people who need mental health support. There are also huge inefficiencies in how and where we spend the little we have.
9. Will new legislation aimed at improving public procurement make it to Parliament?
The Treasury published the Draft Public Procurement Bill for public comment early in 2020 and later that year, MPs were briefed on it – but since then, there has not been much movement.
Treasury spokesperson Ntsakisi Ramunasi could not immediately provide an update.
The draft bill proposes a single regulatory framework for all goods and services procured by government departments and has the potential to strengthen and streamline procurement processes. The Treasury drafted the bill as a response to persistent procurement irregularities and their huge costs to the fiscus.
Given the crisis in public procurement, a revised bill taking into account feedback on the 2020 version of it must urgently be sent to Parliament and subjected to public consultation. Unfortunately, however, critically important legislation sometimes simply disappears, as appears to have happened to the Medical Schemes Amendment Bill of 2018.
10. What will happen to the no-fault compensation fund?
With the country’s vaccination programme now in full swing, the Covid-19 vaccine injury no-fault compensation fund that made headlines last year has generally fallen off the front pages.
Asked for an update, national health department spokesperson Foster Mohale said the fund has been established and the department was busy finalising the directives which would give greater detail to the regulations published earlier.
Mohale added that there had been some claims against the fund, but investigations had found no link between the cases and the vaccines. The department this week again urged people to report adverse events following vaccination through the proper channels.
According to the amended disaster management regulations, the scheme/fund aims to “provide expeditious and easy access to compensation for persons who suffer vaccine injury”, but so far, no payouts have been made – which is not not necessarily a bad thing.