How has the government contributed to healthcare in South Africa?

The challenges facing the South African government’s desperate need to create an equitable, accessible and affordable health system to serve the needs of all South Africans since the dawn of democracy in 1994 have been largely unprecedented and to a point, unique globally.

The apartheid system in itself was unique to South Africa, being on the statute books. In healthcare terms, it was defined back then by the new ruling party, the African National Congress (ANC), as “being sustained through the years by the promulgation of racist legislation and the creation of institutions such as political and statutory bodies for the control of the health care professions and facilities”. 

“These institutions and facilities,” it noted in its inaugural health policy document, “were built and managed with the specific aim of sustaining racial segregation and discrimination in health care. The net result has been a system which is highly fragmented, biased towards curative care and the private sector, inefficient and inequitable.”

Solution? “A single comprehensive, equitable and integrated National Health System 
(NHS) must be created. There will be a single governmental structure dealing with health, based on national guidelines, priorities and standards. It will coordinate all aspects of both public and private healthcare delivery and will be accountable to the people of South Africa through democratic structures.

“All existing public sector departments of health including local authority, homeland, military and prison services, will be integrated into the NHS. All racial, ethnic, tribal and gender discrimination will be eradicated. Both public and private providers have major contributions to make and will operate within a common framework that will encourage efficiency and high-quality care.”

Well-intentioned indeed amidst the euphoria stimulated by the new dawn. Equality, accessibility and affordability became the order of the day and quite rightly so. The millions of South Africans who had been deprived of quality healthcare through the years were now at the needs forefront and had to be accommodated accordingly.

Back in the late 1960s a young journalist colleague (we were all young then!) pronounced that if and when the country’s race laws changed, the country would have to be well prepared for what he predicted would be “rapid urbanisation” – first time I had heard the term! But he (who incidentally became a publishing icon in the engineering world) was spot on as reflected by the related experiences of every sector since, from suburban infrastructure, housing, education, essential services, and not least, health.

Come 1994 the government had a job to do and under new Minister of Health, Dr Nkosazana Dlamini-Zuma, set about implementing the changes and requirements as identified in the National Health Policy of the new ruling party. 

First task was to revise existing legislation, much of which was deemed to be biased towards the private sector and from the start inadvertently formalised what was soon to become known as a two-tier health system and more generally, a private/public sector divide.

Existing bills had to be amended, notable among which were the Medicines and Related Substances Act Amendment Bill, the Health Professions Amendment Bill and the Pharmacy Bill. These were among the first developments to spark a simmering relationship between government and the private sector, elements of which still exist today.

While equality became the primary objective, accessibility and affordability were very much to the fore in the new government’s objectives, clearly manifesting in healthcare delivery practices and pricing.

An early move was to dissolve the original SA Medical and Dental Council (forerunner to the Health Professions Council of SA) and introduce an Interim National Medical and Dental Council (INMDC).

In its argument to retain the regulatory powers vested in the D-G of Health by the new government – which included the licencing of medical practitioners – a prominent issue to emerge was the INMDC’s proposed ruling on the right of medical practitioners to dispense. In one of my reports at the time (Medicine Today, November 1997), I wrote: “Mechanisms to deal with any conduct on the part of registered persons which may be regarded as unprofessional – including the dispensing of medicines – are in place at the INMDC.

“Dispensing of medicines cannot be isolated from other aspects of professional practices and unprofessional practice in its totality is subject to scrutiny and disciplinary steps by the Council.”

As far as the newly formed National Convention of Dispensing was concerned, this, I also reported in the same issue, would “intensify the medical brain drain, increase cost of healthcare to patients, increase state expenditure, and discourage international investment in South Africa.”

This feud – not only between doctors and government but also, for obvious reasons, between doctors and pharmacists  - would persist for close to a decade until the Constitutional Court ruled in 2005 that doctors had the right to dispense, honouring the NCD’s ongoing contention that “dispensing general practitioners play a significant role in providing cost-effective medication, dispense at a much lower dispensing fee than most pharmacies and, as proven by cost reviews, provide the most cost-effective scripts for their patients”.

While the sensitivities between the two provider groups appear to have ameliorated over time, another development involving the two already demanding government attention is the Pharmacy Council application for Pharmacy-Initiated Management of Antiretroviral Therapy (PIMART). Seen as a move to extend the pharmacist’s scope of practice, doctor groups were quick to declare that this poses a serious threat to general practice and take legal action accordingly.

Doctors can now apply to the HPCSA for dispensing licences. What now with PIMART…? 
Another medicines pricing issue which took time to resolve immediate post-democracy included the intellectual property rights of the pharmaceutical brand manufacturers, exacerbated by the proposed “parallel importation” of medications. On the relationship between government and industry, Health Minister Dr Dlamini-Zuma was quoted as saying: “Tension will always be there but it must be a healthy tension” (Medicine Today April 1997).

This, in a sense, also applied to the Department of Health’s simultaneous resolve to enforce a non-discriminatory medicines pricing system through the establishment of a Pricing Committee as part of the National Drug Policy “to stamp out certain practices by non-aligned service providers ‘whose businesses thrived on the distorted market which is created by bonusing and other unethical market practices such as rebates, kick-backs, pay-backs…etc.” 

Also contended at the time was the “tired argument” that the present remuneration system (for pharmacists) encouraged the dispensing of more expensive medicines.
Interestingly, the department’s  Chief Pharmacist, Drug Policy and Planning, Marius Fourie, went on to note in my report that one worrying aspect that should not be overlooked was the fact that the new system created an incentive for the dispensing of more generic products: “This,” he said, “ will lead to a reduction in prescription prices. The argument could then be made that the professional fee, as a percentage of the prescription price, will escalate.”

Needless to say, there were more hard Acts to follow until it was realised that all that had transpired could be consolidated into one. And so emerged the National Health Act 61 of 2003. Stated intention was to “provide a framework for a structured health system within the Republic, taking into account the obligations imposed by the Constitution and other laws on the national, provincial and local governments with regard to health services; and to provide for matters connected.”

Again, well-constructed and well-intentioned at the time, this proposed piece of legislation has been plagued by distractions resulting in matters for debate and contention that are still very much at play today. Not least among these is the controversial Certificate of Need (CoN), legislation devised to equalise the distribution of primary care. Its implications, however, in terms of enabling government to dictate to doctors where they can practice and under what conditions, has not unexpectedly created a sub judice situation.

Two major developments that were to preoccupy the government and thereby “temporarily” thwart the National Health Act’s progress shortly after its release were, firstly, the infamous Aids Denial debacle brought on by President Thabo Mbeki who, with his Minister of Health, Dr Manto Tshabalala-Msimang, “were fiercely criticised for playing down the extent of the Aids crisis, questioning the link between HIV and Aids and whether Aids drugs worked”. 

Second preoccupation was a priority adjustment with the ANC party’s resolve at its 2007 conference in Polokwane to “re-affirm the implementation of the National Health Insurance system by further strengthening the public health care system and ensuring adequate provision of funding” - an already decade-old proposal for a health financing system “designed to pool funds to provide access to quality affordable personal health services for All South Africans based on their health needs, irrespective of their socio-economic status”.

The NHI Bill, purportedly in its final stages, is yet to pass through parliament
And so today the government now sits with many challenges, some historic, and some which now can be deemed as very African.

On the historic side, issues between public and private sector still persist. Huge bone of contention in the public sector has been infrastructure, much of which has been regarded as still unsuitable to accommodate the needs of a desired universal healthcare system such as that delineated in the proposed National Health Insurance system. And the private sector is not without its shortcomings, much of which can be attributed to an unregulated environment and strained inter-provider and funding relations as a consequence.

The COVID-19 experience, to a large extent, exposed some of these deficiencies – “the soft underbelly of the South African healthcare system”, as pointed out by Gift of the Giver’s’ Imtiaaz Sooliman, in a stimulating Health Summit presentation last year: “Now we're not blaming any individual, any minister, any D-G, any staff, it is the system that needs to be looked at.”

On the strength of these and earlier observations, can South Africa now be bracketed with other African countries and their healthcare experiences? “African health systems are weak,” noted Ugandan-based public health specialist and African Development Bank consultant, Peter Ogwal Ogwang, told his audience recently in an  African Health webinar on “Quality health systems and access” on the continent.

“The continent is still faced with a persistent high burden of disease and uneven access to health services,” he added. A case in point, he noted, was health infrastructure, “which is at the centre of health systems but is weak and neglected”. Integral to and generally accepted as the root cause of many of the healthcare problems in South Africa and across the continent at large is poor communication – inadequate information dissemination and resulting education inefficiencies.

A shining light emanating from the dark tunnel of these frustrations must be the advent of digitisation of healthcare – a technology-based source enabling all healthcare practitioners and the relevant stakeholder authorities to be in touch between themselves and others 24/7 on any matter of import to their daily healthcare endeavours regardless of their status, location or disposition.

AxessHealth, almost two years in the making, is a new platform now available to provide healthcare practitioners with access to knowledge resources and tools that will enable them to provide better care to a larger portion of the populations in which they work and live.

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