Health Systems

Political Obstacles to Improving Access to Healthcare in South Africa

Anele Yawa, TAC General Secretary – Speech at SA AIDS 2015 Plenary

Ladies and gentlemen, friends, comrades, thank you for the opportunity to address you this morning.

I am Anele Yawa. I am the General Secretary of the Treatment Action Campaign. We are a civil society organization with 182 branches and over 8,000 members across the country.

Our members are users of the public healthcare system. I am a user of the public healthcare system. We know the challenges faced on the ground. We experience first-hand how good or how bad the quality of healthcare services is where it matters, which is in our communities.

Our vision is that everyone living and or working in South Africa irrespective of nationality should have access to quality healthcare services, irrespective of their ability to pay. This vision is in line with Section 27 of the Bill of Rights in the Constitution of South Africa. And as you know, this right is what allowed us to win a court case against the government in 2002 – which forced the state to start providing treatment to HIV-positive pregnant mothers to prevent HIV transmission to their babies.

Friends and comrades, there are many obstacles standing in the way of quality healthcare for all. I want to divide them into two kinds.

Firstly, there are the technical and public health obstacles. This is what most people at this conference are here to address. These are the questions about how we should improve data collection, how we should best make use of the Gene Xpert machines, how we need to change our HIV treatment guidelines, and so on. These are very important issues and as TAC we are engaging with them.

However, today I want to talk about the second kind of obstacle, a set of obstacles not many people at this conference will be talking about. These obstacles, that are the elephant in the room at this conference, these are the political obstacles.

I will argue that some of these political problems can only be solved politically. This was true in much of the AIDS struggle. Ultimately, and in spite of the 2002 Constitutional Court judgement, the HIV treatment programme only really took off when President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang were forced out. And, as we all know, it was politics that forced them out.

Just as Mbeki and Tshabalala-Msimang held back the AIDS response in South Africa, some provincial MECs for health are now holding back their provincial healthcare systems. We at this conference can come up with the cleverest technical and public health plans and policies, but while unqualified and uncommitted MECs and heads of departments are in charge, our healthcare systems will continue to struggle. We ignore this reality at our peril. Better cars do not help much if we employ bad drivers.

Let’s take for example the Free State.

Over the years, we have witnessed a gradual deterioration in the Free State provincial health care system. This unfortunately has some dire consequences for many people who depend on the public health system.

In May 2014 the TAC conducted a fact-finding mission in the Free State. Some of the issues that were brought to light include;

1.A lack of equipment and supplies to conduct life-saving tests and monitor chronic conditions such as diabetes, hypertension and heart disease;

2. Stockouts and shortages of drugs for many conditions such as TB, HIV, diabetes and epilepsy. Most stockouts appeared to be due to poor management of the healthcare system. (To date the Free State remains the province affected by the most stockouts);

3. A lack of laundry services in several hospitals which means there is no bedding, as well as a lack of basic medical supplies such as theatre gowns and surgical gloves which in turn translates into a suspension of services such as surgery;

4. A critical shortage of staff with some facilities reporting for example situations where two nurses care for more than 75 ill patients in a ward. Patients are often turned away because there are no doctors at the hospitals.

5. A lack of water, electricity and toilets in many facilities.

 6. Patchy or non-existent access to emergency medical services such as ambulances, which sometimes results in unnecessary loss of life.

Repeated attempts to engage with the Free State Department of Health and the MEC for health, Benny Malakoane, were fruitless. Instead, whistleblowers were threatened and intimidated.

In the early hours of 10 July 2014, 127 community healthcare workers, mainly elderly women and some TAC activists were arrested for staging a peaceful night vigil at Bophelo House, the headquarters of the Free State Provincial Department of health.

What was their crime? Holding a peaceful protest against their unfair dismissal.

Next month, from 6-9 July, these community healthcare workers will be standing trial in Bloemfontein. The trial will cost the taxpayers thousands of rands.

We see no rational or just reason why the Free State government is persecuting these CHWs. We believe that they are trying to teach the community healthcare workers a lesson – that lesson is that you’ll be made to pay if you protest. I am asking everyone here to sign a petition to drop the charges. You can sign at the table outside this hall or at any time at the TAC stand in the community area.

In February this year, concerned doctors in the Free State wrote an open letter. Their letter was a call for help.

They provided pictures like these:

–       In this hospital the elevators have been broken for months. Patients have to be carried up and down the stairs.

–       This man on the floor is recovering from brain surgery.

The Free State department of health responded with denials and accusations against the doctors. They did not say “yes, these are serious problems and we will investigate”. They did not heed the call for help.

Quite apart from everything I have mentioned, MEC Malakoane is also on trial on multiple charges of fraud and corruption. The horrific picture we have painted of the Free State is in the hands of a man with a huge cloud hanging over his head.

But, never mind the dysfunction in the provincial healthcare system or the fraud and corruption charges, MEC Malakoane is still in his job. He is loyal to the ANC in the province, and that appears to be all that matters. He is a loyal cadre that has been deployed by the ruling party. He presents us with a perfect example of how cadre deployment is harming our public service.

To take one step back to the national picture, MEC Malakoane answers to Free State Premier Ace Magashule. Magashule dominates the ANC in the Free State and brings a significant support base to the ANC nationally. As in some other provinces, this gives Magashule significant power and makes him essentially untouchable.

This political dynamic is the elephant in the room at this conference.

My comrades and I met with a delegation of senior ANC leaders at Luthuli House in October last year where we discussed the Free State health crisis at length. They listened and said they would report back. We discussed the Free State again in a meeting with the Minister of Health in February.

But, as we are here at this conference, Benny Malakoane is still the MEC for Health in the Free State. Healthcare workers are being told not to cooperate with the Stop Stockouts Project. Dismissed community healthcare workers are still being persecuted. And, above all, the healthcare crisis on the ground is continuing.

Friends, comrades, surely this is a political problem?

The Free State is bad, but so are Gauteng, Mpumalanga, Limpopo, the Eastern Cape and increasingly the North West. Rather than going into each of them, let’s shift gears and take a look at what happens to a good policy made at national level when it arrives in provinces.

In 2011 the National Department of Health released a policy on the decentralization of treatment and care for people with drug-resistant TB. In short, this policy aimed to take treatment to the people – instead of taking the people to the treatment. It was a good and sensible step forward in our struggle against DR-TB.

It has been four years since that policy was released by the Minister of Health. What has happened since then? Have provinces implemented the policy?

Here is a table that was kindly shared with us by the Department of Health earlier this year. The key column to look at is the second one.

How is it that the Western Cape has 185 decentralized sites while Mpumalanga only has 3?

How is it that a province as large as the Eastern Cape has only 14 decentralised sites? How does Limpopo only have 9?

How is it possible that four years after the policy was released the numbers is still this low?

In his 2014 Budget Vote speech Minister of Health Dr Aaron Motsoaledi set a target of 2,500 decentralised sites for the country. As of March this year we were only on 298.

And I remind you that these figures have a real meaning. They mean that many of our people cannot get treatment for DR-TB near where they live. It means the contact tracing that we need to prevent further infection is not happening. It means that provincial governments are failing to take treatment to the people as set out in national policy.

I ask you. Are provinces free to simply ignore policies made by the national department of health?

Friends, comrades, surely this is a political problem.

On World TB Day TAC a partner organisations marched to parliament in the “We die of TB” march. We asked all MPs to show their solidarity by getting tested for TB. The Desmond Tutu TB Centre provided a mobile screening caravan outside parliament.

Not one MP came out to test.

In his budget vote speech on May 5 Minister of Health Dr Aaron Motsoaledi also asked all MPs to get tested for TB. To the best of our knowledge his call has not been heeded.

From having been in parliament myself at meetings of the portfolio committee on health, I can tell you that many MPs get defensive when you raise issues from the ground. Especially those from the ruling party seem mostly concerned with towing the party line – rather than taking up the struggles of the people. Instead of holding the Department of Health to account, they seem focused on defending it at all costs.

When we raised some of our issues at a sitting of the portfolio committee of health last year, the chair of the committee told us that we were lucky not to be shown the door. What does it mean to us when our parliament stops listening to the needs of the people?

How do we start to fight the scourge of TB if our parliamentarians are so disinterested that they won’t even agree to be screened for TB? What is happening in our democracy when MPs show no interest in the number one reported cause of death in the country?

Friends, comrades, surely this is a political problem.

We have only touched on the tip of the iceberg of the healthcare problems we’re facing in our country. We haven’t even mentioned the problems at the National Health Laboratory Service or the ongoing crisis of medicines stockouts. These urgent problems will be discussed in other sessions at this conference and I urge you to engage with these issues.

I know it may feel as if there are too many problems, that our health system is crumbling before our eyes. However, our commitment must remain to the users of the public healthcare system and therefore we have no choice but to engage with all these issues. The struggle must continue.

Diverse as the problems in our healthcare system are, there is a common thread. What we’re seeing in healthcare is similar to what we’re seeing in other spheres like education and energy. It is not so much that we don’t know what to do, but that our public service is incapable of meeting the needs of our people.

There are real financial and human resource constraints that make it difficult to improve the quality of healthcare services. We do not dispute this. Where possible we want to play a constructive part in overcoming these obstacles. As you will here at the launch of the new report of the Stop Stockouts Project tomorrow, there are some impressive cases of constructive engagement between government and this project – of which TAC is a part.

But, there are too many times when despite our best efforts and the best efforts of healthcare workers, we just can’t make any progress through constructive engagement. Some MPs, some MECs and their officials just show no urgency to meet the needs of our people. With the exception of some dedicated healthcare workers and committed officials, we are faced with a widespread culture of mediocrity. Too often, the tone for this mediocrity is set by MECs and heads of department. Too often, the people in those positions are there for the wrong reasons.

As users of the public healthcare service, we cannot accept this.

Friends, comrades, our healthcare system is at “code red”. It is at “code red” because our provinces are failing. Our provinces are failing mainly for political reasons. Our provinces are failing because people like MEC Benny Malakoane are untouchable.

–       It is time to face the elephant in the room.

–       It is time to make the struggle against HIV and TB political again.

–       It is time to hold provincial MECs for health accountable

–       And to begin with, it is time to fire MEC Benny Malakoane.

I thank you.