By Mark Heywood, Director of the AIDS Law Project
Last week the great and good of the South African private health industry and the national Health Department gathered for four days at Sun City to deliberate on the future of health care and the proposed system of National Health Insurance (NHI). They started their conference with a golf day and ended with a banquet, dress: ‘black tie or traditional’. Whilst the pro- and not-so-sure NHI’ers differed on the conference floor, they mixed easily on the dance floor.
Intense debates about the future health system took place, with much sound and fury about equality in access to health care services. But, an unfolding health crisis in the Free State was neither noticed nor discussed.
Unknown to delegates, it seems, is the fact that most babies in the Free State are not receiving routine immunisations; that TB and ARV drugs are in constant shortage in many hospitals and clinics; that many of the health care workers who remain working in the public system do so under unbearable pressure (it is reported that Pelenomi hospital in Bloemfontein was without a doctor in its ARV clinic for three weeks recently); and that people needing health care are being subjected to terrible indignities, pain and deprivation of essential life saving medicines.
The Free State population is over 2.5 million, bigger than some of our neighbouring countries. It has an HIV prevalence rate of nearly 13% and an infant mortality rate of about 50 per 1,000 births, worse than Eritrea, Iraq, Namibia and most countries of the world. In 2006 over 6,000 people died of TB and nearly 8,000 from flu and pneumonia. There are 60 thousand births a year, about a third of them to women with HIV.
The crisis in the Free State is known to the national health department. It came sharply to attention earlier in 2009 with the publicity surrounding the four month moratorium on ARV treatment. Although we were assured at the time that it was being resolved – and that we should not protest or take legal action against those responsible -- the crisis rages on.
Earlier this year, a special report on the Free State health system was commissioned, and carried out by a group known as the ‘Integrated Support Team’ (IST). But whilst there is a damning report of their findings there is no integrated support. The report itself is being withheld and there is no evidence yet that it is being acted upon.
The crisis in the Free State should have been relevant to the delegates at Sun City, because analysing it and resolving it, would tell us a great deal about the challenges that are going to face NHI. This crisis is about inequality of access, because most private hospitals and private doctors in the Free State carry on their business oblivious to the health needs of the majority of the population. If you are employed and on medical aid, you will get your ARVs when you need them or be treated for TB. You will not die. You will not be insulted by overtired health workers. Your pain will be relieved.
But, that it not the whole story.
The crisis in the Free State is also a reflection of the gross mismanagement of the health system by the provincial and national governments, and the culture of impunity and lack of accountability that exists. There is a funding shortfall. But that is only half the story. As the national Treasury is well aware, what money is available is misused. The most basic of systems seem to fail. Corruption is rife. Monitoring and evaluation non-existent.
President Zuma has promised that government officials will be held accountable for service delivery and fired for gross failure. Minister of Health Motsoaledi has set an important new tone in his openness and commitment to health improvement. But this is a test of their words.
There are multiple levels of failure in relation to the governance of the health system. At the apex of the health system the Director General is supposed to maintain vigilant oversight over the delivery of health care services. But visiting senior officials seem easily parried with promises that measures are in place to fix the mess. Recently, the Free State MEC for Health, Sisi Mabe, lied on national radio saying that there is not a shortage of medicines. In this context, somebody should be held to account and fired.
But the purpose of this article is not just to lament or point fingers. The life-saving question is what should be done?
We believe the Free State health crisis should be treated as a disaster by the national government, and that an emergency response should be devised. The 4-month moratorium cost over 3000 lives, many more lives have been lost since then. Is that not the equivalent of an earth quake or a small Tsunami? Section 100 of the Constitution requires the national executive to intervene in Provinces in order to “maintain essential national standards or meet established minimum standards for the rendering of a service”, such as health. The Public Finance Management Act (PFMA) allows the Treasury to investigate Provinces and override them when considered necessary.
We call on the National Minister of Health, Dr Motsoaledi, to convene an urgent meeting of all providers of health care (including the private hospital sector, universities, NGOs and the SANDF) and instruct them to provide him with an operational plan that will immediately restore services, set up an independent monitoring system and develop a mid-term plan to stabilise the system. If there is not a plan, then TAC, the AIDS Law Project and the Free State Health Coalition will be left with no options other than litigation.
The Constitution should insure people’s lives. A reasonable NHI system that can deliver more funding for health care is necessary. But it will never succeed on the bones of a collapsed public health system. Neither will it bring back to life those who are dying today of preventable illnesses.