Health in 2023 – 13 Things to Look Out For

Set against the backdrop of the ongoing COVID-19 recovery, the National Health Insurance Bill winding its way through Parliament, healthcare worker shortages, and the ongoing electricity crisis - 2023 is set to be another tumultuous year for healthcare services and health policy and governance in South Africa. Below we've picked 13 things to look out for this year arranged under three broad headings: leadership and governance, policy and legislation, and HIV, TB and the NSP.

We've mostly opted for issues where there is a specific policy, legislative, or implementation process to keep tabs on in 2023. Accordingly, critical issues like antimicrobial resistance, COVID-19, or the diagnosis and treatment of non-communicable diseases in the public sector were left out, not because we don't consider them to be important, but because we are not aware of any specific developments to watch out for in 2023.

Leadership and governance

Likely cabinet reshuffle

Following the ANC's national leadership conference in December, there is widespread 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 cabinet 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. That said, the bar for leadership in government is, with a few exceptions, set very low, and surviving a reshuffle is not a reliable yardstick for leadership excellence.

Considered less of a political heavyweight in the ANC than his predecessor Dr Zweli Mkhize, Phaahla - also a medical doctor - picked up the baton dropped by Mkhize following the Digital Vibes scandal. He brought some stability to the health portfolio, but our sense is that public trust in the country's health leadership remains low and the National Department of Health remains mired in essentially the same types of dysfunction as under his predecessors. Phaahla missed various opportunities to take a firm stand on important matters, including xenophobia in the public health sector (see migrant health further down) and he showed no real appetite to tackle the country's chronic health worker shortages, which is arguably the biggest challenge in healthcare in South Africa.

... the bar for leadership in government is, with a few exceptions, set very low, and surviving a reshuffle is not a reliable yardstick for leadership excellence.

He came in at 51 on the ANC's NEC list - below his predecessor Mkhize (16th) and also Mmamoloko Kubayi (12th) who briefly acted as health minister at the height of the COVID-19 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, who hails from KwaZulu-Natal (KZN) did not make it onto this NEC list, which may put him in a vulnerable position. However, Dhlomo, like Phaahla, is a medical doctor with a track record, albeit not an all-glowing 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 onto the ANC's NEC.

Whether these two will survive or not ultimately is the president's prerogative. But should Phaahla survive, it can ensure leadership stability in the health portfolio at least until the elections. Some would argue this is positive. Others, however, will argue that keeping him at the helm signals the same old way of doing things which can stave off much-needed changes while health, like many government portfolios, can do with fresh ideas and new minds.

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 provincial departments often fly somewhat under the radar. Accordingly, a key focus for Spotlight is to hold the relevant provincial leadership to account.

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 - both in the most important positions of the health department having to hit the ground running. They will be under close scrutiny this year as the rebuild of Charlotte Maxeke Johannesburg Academic Hospital and the probe into alleged corruption at Tembisa and other hospitals continue. Spotlight has also reported on similar governance issues in the Free State and Northern Cape.

A big thing to watch in 2023 may thus simply be whether we will see greater stability and competence in provincial health departments and whether the nine current MECs for health will still be here in 12 months' time.

The ongoing impact of loadshedding

Last year, Phaahla announced a lofty plan to mitigate the impact of loadshedding on public health facilities. Since then, the country's electricity crisis has gotten worse, although some additional health facilities have been exempted from scheduled power cuts. At the start of this year, 77 hospitals which rely on Eskom for electricity had been exempted.

But tackling loadshedding and water shortages that affect health services also depends on other departments, including Cogta and Mineral Resources and Energy, among others. Though the health department can and should take steps to mitigate the impact of loadshedding, the biggest chunk of responsibility to end it ultimately sits with other departments. As in other areas, healthcare services remain deeply entangled in South Africa's wider struggle for clean and effective governance.

Policy and Legislation

The National Health Insurance Bill

There are several important pieces of legislation to keep an eye out for this year - foremost among them is 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.

As things stand, chances are that 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 leg of the legislative process, the provinces may decide to have another public consultation process, however, the ANC and its MPs have been 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 if they wish.

The NHI Bill has huge implications for the role of provinces in healthcare service delivery, something that on paper at least the NCOP may take more seriously than the NA. Consider The provincial equitable share, which is the provinces' biggest source of income. As NHI is currently envisaged, much of this income will be redirected to the National Health Insurance Fund.

The NHI Bill has huge implications for the role of provinces in healthcare service delivery, something that on paper at least the NCOP may take more seriously than the NA.

While experts like Professor Alex van den Heever from the Wits School of Government in his submission on the bill referred to this as emasculating provincial powers, Deputy Director-General in the health department, Dr Nicholas Crisp, disagrees and told MPs in a presentation last year 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. Crisp also said that the bill aims to devolve more responsibilities to the districts, bringing health and resource planning closer to communities.

The State Liability Bill and medico-legal claims

The State Liability Bill is an important part of government's potential arsenal 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 put on ice, pending the South African Law Reform Commission's investigation into medical negligence. It is not clear when the SALRC will wrap up its work and 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, there have been some developments relating to medical negligence on other fronts that are expected to come to a head this year. One of which is the Special Investigating Unit's ongoing investigation into allegations of corruption and maladministration in the national and provincial health departments.

Announcing the proclamation authorising this investigation, the presidency in a statement said the SIU will focus on all medical negligence claims from 2013 until July 2022 and track any fraudulent and unlawful claims. The report on this investigation is set to be published later this year.

Decriminalising sex work

For more than a decade, activists have lobbied for sex work to be decriminalised - something many argued would have profound positives for the safety of this marginalised group but also for their health. 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. Members of the public have until 31 January to submit comments on the bill. The bill is likely to be highly 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 remains to be seen.

The Public Procurement bill

Another long-awaited piece of legislation - the Public Procurement Bill - is also expected to finally make its way to Parliament. Finance Minister Enoch Godongwana last year said that the bill will be introduced in Parliament in March this year. The Draft Public Procurement Bill was first published for comment in February 2020 and has since 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 a pandora's box of abuses in state procurement has been revealed.

The bill is aimed at tightening and standardising 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 bill can be an important lever in ensuring the country gets value for money spent, especially now as the country buckles under serious and chronic fiscal constraints.

Although not a magic bullet, this bill is still an important step out of the quagmire of poor supply chain management processes which the auditor-general has tried for years to pull the country from. 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 R5.83 billion".

Given huge inefficiencies in state spending and billions lost to corruption and mismanagement of government contracts, this bill can be an important lever in ensuring the country gets value for money spent.

The Professionalisation of the Public Service Framework

Another important development for health this year will be how government departments, including national and provincial health departments, implement and stay true to the aims of the Professionalisation of the Public Service Framework that 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 appointments to the public service. Over the years, Spotlight has flagged concerns over politicising health administration through cadre deployment and the impact this has on providing quality health services. This framework is a potentially important step for building institutional autonomy and insulating the public service from political interference.

But does this signal the death knell for the ANC government's cadre deployment policy? As it stands, the answer according to the Principal of the National School of Government Busani Ngcaweni, is no. Ngcaweni during a briefing in Parliament in November last year 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 all 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, actually delivering on such rhetoric will require a major investment of political capital from senior ANC leaders. Whether they care enough about the greater good to see such reforms through is of course another question.

A new Mental Health Policy Framework?

South Africa's last Mental Health Policy Framework expired at the end of 2020. Despite assurances from the Department of Health in October 2021 that a new framework was being developed, none had yet been published by the end of 2022.

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

Unfortunately, such policy delays have been all too common at the National Department of Health over the last decade. And in cases 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, appears to be gathering dust.

There seems to be widespread consensus that a policy framework is required to help focus and transform mental health services in the public sector. 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.

Questions about migrant health

Last year, health minister Phaahla came under fire from 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 allegedly crowding the public health system. Phaahla announced that government will conduct a study into the treatment of foreign nationals at public health facilities in the country. It is expected that there will be some form of feedback on this study this year.

FRIDAY READ: Mothers and babies pay the price for #Medical #Xenophobia. @SECTION27news @SJDStevenson @Kholo21 @ScalabriniCT @LHR_SA @CALS_ZA @GautengHealth @HealthZA @FoMohale @FrancoisVenter3 @migrants_rights @MigrationProj @Migration_Just @DrMokgethi https://t.co/daQacrpWog

-- Spotlight (@SpotlightNSP) September 9, 2022

Whatever happens with the study, we can, unfortunately, 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. Many have argued that provisions in the bill are not only contrary to the principle of universality and regressive, but the constitutionality of the provisions if passed may be legally challenged because the Constitutional right to healthcare is not conditional on one's immigration status.

HIV, TB, and the NSP

Getting the most out of new HIV prevention technologies

2023 is set to be an important year for HIV prevention in South Africa. Access to pills that prevent HIV infection (called PrEP or pre-exposure prophylaxis) has increased substantially in the public sector over the last three years, but the absolute number of people using these pills remains low. A key question in 2023 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 are set to start early this year - trials have already shown that the injections are highly effective. The South African Health Products Regulatory Authority approved the jab in December.

The pilots are worth watching closely for what they will tell us about how to best make these injections available, especially to young women. Developments regarding the price of the injection are also worth keeping close tabs on since high prices may well end up restricting the scale or timing of the wider rollout of these injections.

Changing times in TB

There are several ongoing or imminent changes both in how we diagnose and how we treat tuberculosis (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, well over 100 000 people who fall ill with TB in South Africa every year are not diagnosed. Whether targeted universal testing and X-ray screening will further be scaled up and whether we will see a substantial boost in TB detection in 2023 are some of the year's big questions.

On the treatment side, we are set to see treatment for most kids being cut down from six to four months, and a six-month treatment regimen is set to become the new standard for adults with drug-resistant TB. We are also set 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.

South Africa's 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. The draft had very promising things to say about mental health support and the decriminalisation of sex work and largely ticked the right boxes in terms of the key HIV and TB issues.

But, unfortunately, the document was also quite dry and uninspiring - and accordingly is unlikely to find much resonance outside of 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 set to be launched around World TB Day in March.