By 19 June 2021 the real death total associated with Covid-19 in South Africa had risen to 173,132. This is the actual number of “excess deaths” recorded by the Medical Research Council (MRC) from 3 May 2020. Put bluntly, it’s the number of corpses counted. It is nearly three times the official total of 60,028 Covid-19 deaths given on Tuesday and much more accurately reflects the toll that this coronavirus has had on all health and mortality.

South Africa is now shedding lives at an alarming rate. But many of these deaths should have been preventable had our health services been ready. The failure to save lives is certainly not a reflection on our heroic health workers, but on the politicians and many of the senior officials who oversee the system.      

If we were complacent – and having gone through the worst of the AIDS epidemic we should not have been – then Covid has taught us how central health and the full gamut of healthcare services are to dignity, development and economy.

We should have been more prepared. I remember when Dr Aaron Motsoaledi took over as health minister in 2009 how he banged on about South Africa’s “quadruple burden of disease”, drawing from a Lancet Commission report of August 2009 that had noted: “A nation and a health system under extra pressure from a quadruple health burden, requires extraordinary effort. South Africa has many of the essential ingredients in place to save hundreds of thousands of lives – will we act in time?”

Twenty-one years later the answer would appear to be no. 

Experts I consulted agreed that in a few areas – HIV treatment and prevention, maternal and child mortality, malaria control – we have made significant progress. As one former senior official put it: “The biggest challenge has been the health systems performance. A mixed bag of excellence and poor performance intra- and interprovincially.”

This proves the potential that still resides within our health system. But it is blighted by the fact that on many core health indicators we have shown little sustained and concrete progress. Instead we have a long string of scandals – AIDS and TB and stockouts, metastatic corruption, Life Esidimeni – and expensive summits, glossy reports and unimplemented policies.

Most recently we can’t even place 288 qualified medical interns in the heart of an epidemic apparently because of a shortage of funding. 

This should not be. 

The question is how can we diagnose the causes of system failure?

For pocket and country

The way in which the different levels of the health system are meant to be run is carefully prescribed in the National Health Act of 2003, an important piece of legislation meant to create the framework for health delivery. But since the advent of Covid-19 there’s no evidence that the government or Department of Health has operated within the framework of this law. 

For example, to the best of my knowledge, there has not been a single meeting of the National Health Consultative Forum, a body meant to distill the combined experience and ideas of the government and civil society organisations working on health. Instead, apart from the Business4Health initiative, civil society has mostly been bypassed by opaque command councils, heavily laden with politicians who often have a conflict of interest between advancing public health and their private companies and/or political interests. 

The dual loyalties of soon to be former health minister Zweli Mkhize, to his job and to his pocket, would appear to be a case in point. But there are many others.

As a result we have the type of implosion seen in the Eastern Cape health system, and now in Gauteng: so predictable, so preventable, so costly in life. In the words of one very experienced health administrator I consulted:

“We got here because of a failure of leadership, overly politicised management of the pandemic and inability or lack of attention to the key ‘messages’ that the statistics or information give us. We knew six to seven weeks ago that the figures were increasing in Sedibeng. No one did anything about it. Instead we wait for a crisis of the exploding wave before we panic, then use blunt instruments of another level 4 shutdown.” 

This litany of life shedding should be making us probe deeply to understand why healthcare is so badly managed in South Africa and whether it can be fixed?

Why is it that despite a clear legal and policy framework the health system has been spectacularly mismanaged for more than 20 years? 

When it comes to matters economic, President Cyril Ramaphosa and business are willing to look at systemic and structural problems. The same approach is needed to put the lights back on in the Health Department. The crises we encounter are not accidents but indicators of a darker malaise. 

While Eskom is load shedding the health system is lives shedding and frequently the causes are the same. 

Consider the following:

1. Debt: Eskom is deeply in debt and so is the health system. According to the Auditor-General’s 2019/20 report outstanding medico-legal costs now total more than R105-billion. In the Eastern Cape the amount of R36-billion is 459% of its annual budget! In Gauteng it is 114%. This accrued debt paralyses health departments and diverts funds from essential services. Alarmingly, tucked away on page 64, the Auditor-General reported that the “Eastern Cape, Free State and Northern Cape disclosed significant doubt whether they will be able to continue with their operations as planned based on their current financial position”. For more analysis see here and here;

This way lives are shed.

1. Corruption and irregular expenditure: it is unfortunate that corruption in the health sector has not been analysed by Parliament or the Zondo Commission with the same forensic detail as Eskom. The size of the iceberg is therefore unknown. But what is visible is huge. According to a parliamentary question answered by Mkhize in May 2021, irregular expenditure by provincial health departments over the past five year runs to more than R33-billion – and almost all of it takes place with utter impunity; 
2. Senior management and department capture: in recent years most competent managers have either been driven out of or elected to leave the Health Department. This leaves its senior leadership at national and provincial level extremely thin and inexperienced. Although South Africa has a world-renowned reservoir of managerial, clinical and research experience in health, almost all of it is now  outside of government, either in the private sector or in large university-linked research institutes that often constitute small empires;
3. Regulation: human health and healthcare services are complex and require extensive and expert regulation – but most of our regulators are broken. The Office of Health Standards Compliance is underfunded and ignored. After a promising start with Life Esidimeni the Health Ombud has released only two more reports. The Health Professions Council of South Africa and the South African Nursing Council have been in crisis for years. The Council for Medical Schemes seems rudderless. SAHPRA is the only statutory health body where there does seem to be leadership and progress. Most ministerial advisory committees (and there are quite a few) are dormant; their advisories sometimes sit for years on the shelf – ask the cancer crew or the demoralised advocates for palliative care. The important recommendations of the Healthcare Market Inquiry, an inquiry that cost more than R100-million, are now two years in limbo; and
4. Politicisation and the provinces: there is only one (relatively) well-run provincial health department in the country, the Western Cape, and it is successful not because of the DA but because for 20 years it has kept itself above party politics. This exception proves another world of health management is possible, but that depends on freeing healthy departments from political interference and piggybankism.

As a result of all the above we are living through an extended period of lives shedding. And it will get worse.

Ramaphosa needs to wake up and smell the corpses. CR, if it is only the economy that moves you, then understand health as an economic issue: it constitutes 8.5% of our GDP; it is an economic subsystem; it has catalytic power.

CR, if it is lives that move you then understand that far too many lives are being lost unnecessarily. As this article by a junior doctor explains, the system is already broken, but now it’s on the verge of imploding. This is an emergency in an emergency.  

Understand that the problem is not the legal architecture of the health system, or policies or a lack of data and information. It is a problem of management. The pool of politicians into which Ramaphosa frequently dips have been tried, tested and mostly failed. It’s time to appoint a new generation, people with integrity and with knowledge of health and the health system, people who may succeed precisely because they don’t have a track record of failure.

It sure won’t be easy. But it has to be done. Lives are at stake. DM/MC