In-Depth – Top 10 Health Issues to Watch in 2022 [analysis]

COVID-19 will continue to dominate headlines in 2022, but from National Health Insurance to the availability of a new HIV prevention injection, it will also be an important year for other areas of health service delivery and for health system governance and reforms in South Africa. Here is Spotlight's pick of the top ten issues to keep an eye on.

1. COVID-19 corruption - will we finally see significant prosecutions?

Last year, clean governance and public trust in the state was dealt a huge blow after the Special Investigation Unit's (SIU) findings on alleged corruption in the COVID-19 response, which implicated various officials - also in the health department.

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, who is opposing the application, had 30 days from 9 November last year to file its opposing affidavit.

Meanwhile, the disciplinary processes of six health department officials implicated in the Digital Vibes scandal who was suspended with full pay last year are ongoing. Among them is the deputy director-general in the health department, Dr Anban Pillay. Director-general Sandile Buthelezi, who himself was suspended and then reinstated, during a press briefing on Friday said their legal team is dealing with the matter and the department is expected to finalise the disciplinary process by mid-February.

Taking action against those found guilty in the disciplinary process will be an important litmus test for Health Minister Joe Phaahla who last year assured the public that the department "is going to thoroughly and decisively act to ensure nothing is swept under the carpet".

At the same time, the crisis presents an opportunity to clean house and to address the department's chronic human resource capacity constraints but as always, whether the rhetoric of building a more capable state will be backed up with the appointment of enough suitably qualified and committed professionals remains in doubt.

2. Will the NHI Bill become law this year?

National Health Insurance (NHI) is set to be one of the most far-reaching health reforms in South African history. Yet, in 2022, we are still fitting and adjusting the mechanics of the vehicle that must help us get 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 in Parliament later in January. Last week, Parliament's Programme Committee noted that the national health department is expected to provide its responses to the public submissions before the end of February. The committee is then expected to finalise its report and deliberations on the NHI Bill by 1 April 2022. The Bill will then have to be considered by the National Council of Provinces. In short, barring any major snags, the legislative process in parliament might well be concluded before the end of 2022.

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 will take these inputs on board and make significant changes to the bill, or whether they will simply force through a mostly unchanged version of the bill. (See the excellent PMG website for a concise timeline of the Bill.)

3. Ballooning medico-legal cases: Will government manage to rein it in?

In December last year, the Financial Mail reported figures showing that medico-legal claims against the state have doubled, from R37bn to R74bn, over the past five years.

In an attempt to address this long-standing Achilles heel for provincial health department budgets, the health minister asked the South African Law Reform Commission (SALRC) to investigate and make proposals for a new legislative framework to regulate these claims. The SALRC released a Discussion Paper in November 2021.

"The discussion paper was prepared to elicit responses on the preliminary findings and proposals put forward in the paper. It will serve as a basis for the SALRC's further deliberations in the development of a final report with proposed draft legislation," said State Law Advisor Adv Ronel van Zyl. The public now has until 28 February 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 new settlement structure. During an earlier briefing on the Bill in the Justice Committee, a state law advisor said the Bill proposes a "pay as you go" system of smaller, scheduled payments, which will relieve the strain on the budgets of hospitals. The Justice Committee is expected to schedule a meeting for deliberations soon.

Given that a final report from the SALRC is at best many months away, and that Parliament probably won't finalise any legislation without the final report, we do not think the State Liability Bill will become law this year. What might happen, however, is that a clear way forward may emerge on how to deal with the seemingly intractable problem of medico-legal claims, which would constitute real and meaningful progress. Of course, the most valuable progress would be to prevent medico-legal 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. Maybe most importantly, limited health budgets at provincial level are likely to perpetuate chronic human resource challenges at public healthcare facilities.

As we reported last year, employing more nurses could in some circumstances lead to reductions in total health spending by reducing hospital stays and medico-legal 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. The implications of this are huge.

Briefing MPs last year, the health department's CFO noted that because the infrastructure indirect grant is cut by almost 20%, it will have an enormous impact on nationally managed programmes, especially infrastructure projects that will have to be postponed due to limited funding.

This means the current infrastructure backlog and maintenance issues at health facilities are set to continue. Add to this an entity mandated to ensure compliance at these facilities 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, "As much as the OHSC would like to cover every facility, there was a complement of only 61 inspectors. There were 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."

The OHSC was expected to start inspections of private sector facilities this year, but this will in all likelihood be put on the back burner pending more resources.

5. Will HIV prevention injections become available in SA in 2022?

Back in November 2020, we reported on a landmark study showing that an antiretroviral injection administered every two months is highly effective at preventing HIV infection. Injections like these can be a true game-changer in our fight against HIV, especially for groups with stubbornly high rates of new infections, such as young women.

Last month the injection was approved by the United States Food And 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' - although the picture is obviously much less hopeful in countries with lower 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 would have been due to COVID-19.

But one of the key lessons of the COVID-19 pandemic so far is that the future is highly unpredictable. Maybe the biggest unknown is whether we will see new more deadly variants emerging and spreading. While we are for now in a moment of relative optimism, we simply don't know with much certainty how deadly any future waves might be.

As Director of the Medical Research Council, Professor Glenda Gray, said during a Department of Health media briefing on Friday, "this year will teach us whether we are moving towards a more endemic nature of SARS-CoV-2 but as long as we have ongoing transmission there's the possibility of viral evolution so it will be crucial for us to continue our excellent [genomic] surveillance."

The winter months, she said, will be critical and "will give us direction on whether a fifth wave will be less [severe] than the fourth wave and whether we are on the road to endemic status. We can help control the fifth wave by making sure we increase our vaccination rates."

7. Will SA's tuberculosis response recover and improve in 2022?

The COVID-19 pandemic has been devastating for the tuberculosis (TB) response in South Africa and elsewhere. There has been talk of government's TB recovery plans for many months, but whether the plans are ambitious enough and whether they will 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 is of course 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. Firstly, the rollout of 3HP (a newish and improved form of TB prevention therapy) will hopefully go to scale in 2022. It has been disappointingly slow so far. Secondly, government should this year be reporting back on a series of pilot projects looking at the use of X-ray technology to improve TB detection.

Thirdly, 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. Lastly, we expected an updated version of Thembisa, the leading mathematical model of HIV in South Africa, to be published in 2021 that would for the first time include TB estimates - hopefully, we will now see this happening 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 and to ensure that people living with mental health conditions receive the care they need. But as important as finalising this policy framework, is finding the money and resources to implement it properly, which was a major impediment to implementing the previous framework.

Government currently spends about 5% of the country's total health budget on mental health, but these services only reach about one in ten people who need mental health support. There are also huge inefficiencies in how and where we spend the little we have.

We highlight the mental health framework here, but similar questions can be asked about government's commitment to funding and implementing a range of other policies and strategies, maybe most notably the Human Resources for Health Strategy and the TB catch-up plans.

9. Will new legislation aimed at improving public procurement make it to Parliament?

Another important piece of legislation for the health sector is the Draft Public Procurement Bill. Treasury published the Draft 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.

Asked about the status of this piece of legislation, 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. Treasury drafted the Bill as a response to persistent procurement irregularities and the huge costs to the fiscus of such irregularities.

Given the crisis in public procurement, as vividly illustrated with the aforementioned COVID-19-related corruption, a revised Bill taking into account feedback on the 2020 version of the Bill must urgently be sent to parliament and subjected to the parliamentary process of public consultation. Unfortunately, however, critically important legislation does sometimes simply disappear, as appears to have happened with 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 was making headlines last year has generally fallen off the front pages.

Asked for an update, national health department spokesperson Foster Mohale said the no-fault compensation fund has been established and the department is now busy finalising the directives which will give greater detail to the regulations published earlier. "These will be published soon (this year) for public comment." Mohale says there have been some claims against the fund, but investigations 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 until now, no pay-outs have been made, which is not necessarily a bad thing.