Advancing the Right to Health in South Africa!
For a People’s NHI!
In December 2015, the Department of Health released the White Paper on National Health Insurance for South Africa, a 97-page document that provides a roadmap to universal health coverage and a restructuring of the health system to meet the health needs of all. A new plan that addresses the inadequacies of the current health system could not have come sooner, however the question remains as to whether what is proposed adequately addresses the health context and needs of this country.
South Africa faces a national health crisis manifesting itself through a large burden of infectious and chronic disease, high rates of mortality due to violence and accidents, and unacceptable levels of maternal and child mortality.
Enormous economic and social inequities exist in South Africa and this disparity is reflected not only in the contrasting health outcomes in our population, but also in the two-tier health system. Health care insurance is purchased by 17% of the population to access private health care towards which 41.8% of total health expenditure goes. Despite this, the benefits of private insurance continue to be squeezed each year, with subscribers paying for more and receiving less.
The majority of South Africans access public sector health care which is inadequate and of poor quality: health infrastructure, materials and personnel are lacking. This is where drug stock outs and the Human Resources for Health shortage is most felt. Health facilities are often not easily accessible because of distance, long waiting times, discrimination, and disrespectful treatment of marginalized groups, such as farm workers and migrants.
While the South African Constitution promotes the right to health for all, the inequitable delivery of health care in this country suggests that health in reality is nothing more than a commodity, which can be bought at a price which too many cannot afford. Poverty is a risk factor for poor health and access to health care. Medical schemes (private health insurance) in South Africa finance care that is predominantly delivered by private providers (i.e. private hospitals, specialists, general practitioners, pharmacies). Not only do we have a dearth of medical staff, but many would argue that there is a lack of leadership and vision which is needed to turn the South African health system around.
The members of the People’s Health Movement–South Africa (PHM) are concerned with these issues and PHM supports the global call for universal health coverage. While the White Paper describes a health system with free universal coverage at its centre, there is little clarity on how exactly this will be achieved, and what stands to be gained by for-profit private sector through the proposed purchasing of services.
Not since the days of AIDS activism in the early 2000s have we been at such a point of crisis in health. An enormous responsibility rests on a progressively-oriented civil society to hold government accountable for addressing not only the weaknesses in the health system, but the social determinants of health and the social inequality that leads to deleterious health outcomes in the marginalized and poor. Given the release of the NHI White Paper, we need to ensure that authorities listen to and incorporate the People’s vision of Health for All. Central to this vision is the role of the People: health committees and community health workers who, by their work at grassroots level, are in touch with and sensitive to the needs of their communities.
Solidarity is a powerful tool in the hands of the People, however, it is challenging to link up and build coalitions in civil society. Different organizations have unique but sometimes competing strengths, some have more resources than others, and many are bound to follow single issue directives as set by their funders. Despite these obstacles, PHM, TAC and Section 27 built a strong and supportive coalition this year which culminated in a successful National Health Assembly in June, 2016, out of which many initiatives will flow in the months to come which seek to address the inequality gap in South Africa by highlighting the importance of community participation in health; the impact of the social determinants of health, the need for improved access to health services; improved emergency services and quality of care more generally, and a strengthened and accountable leadership and management for health.
The PHM Steering Committee
While 2015 was reported at our previous AGM as being a year of reflection for PHM, in contrast, 2016 was a year of organizational growth, implementation and one of building coalitions. At the start of 2016, the Steering Committee (SC) engaged in a planning and vision exercise. With an 18 member – and largely new – SC, there was a welcome diversity of background, experience and opinion. Themes explored included reflecting on the meaning and role of activism in health, and how to revitalize it in anticipation of the National Health Assembly (NHA) which was scheduled for June 2016.
We have continued to meet monthly this year, with the Executive meeting independently. The frequency of meetings is set to change to every two months next year and a model of subcommittees with separate portfolios has been proposed as a more efficient way forward.
PHM’s response to the release of the NHI White Paper and the continued advocacy for a People’s NHI
The December 2015 release of the NHI White Paper was a catalyst for action, with a PHM analysis and initial response published on www.groundup.org soon thereafter. The PHM Steering Committee (SC) members continued to promote awareness of and public engagement in the NHI throughout 2016, with their involvement in newspaper correspondence, conference workshops, and television and radio interviews. PHM made a submission to the NHI White Paper commenting process in May 2016, and assisted other organizations with their submissions.
See our contributions here:
Louis Reynolds’ letter to the Cape Times: http://medsearch.co.za/articles.php?article=2164
Is there a better pill in the house? Civil Society action to treat the National Health Crisis Report on the 2016 PHASA
Conference Workshop, hosted by Professors David Sanders, Leslie London, and Ms Shenhaz Munshi
The first Public Meeting of 2016 – held in February in Khayelitsha – focused on The People’s NHI, with Professor Leslie London and Dr Lydia Cairncross as speakers. Focus groups were subsequently held to ascertain community attitudes towards the NHI. An NHI “wishlist” with four priority areas was made. These areas included a strengthened public health system; increases in and improvements to the accessibility of services and the patient’s right to seek services irrespective of where he/she lives; a marked effort by government to invest in the training and capacity building of staff and management within the health services, and a demonstrated engagement of the public health sector with communities on health policy and implementation.
The meeting report is accessible on our website: https://phm-sa.org/report-the-peoples-health-movementpublic-meeting-on-the-national-health-insurance-20-february-2016/.
At the PHASA pre-conference workshop in East London in September, the NHI was included in broader discussions on civil society involvement in the implementation of policy, through increased generation of evidence and public awareness in order to transform policy into practice. The role of community health workers (CHWs) and the social determinants of health were identified as areas of importance with regards to health systems strengthening. Once again, transformative leadership and an intersectoral approach to action and policy implementation were identified as crucial to the success of CHW interventions in health. Clinical training programmes need to incorporate curricula for
CHWs are needed to ensure that they can become agents of change and members of the multidisciplinary medical team approach.
PHM – Youth engagement with the NHI
The NHI white paper sparked the need for a student understanding and response to the white paper. In response to
this, a student NHI discussion was held at the University of Cape Town on 6 April 2016. The discussion was led by a Government representative Krish Valabjee, community leaders such as Masindi Zibaya, academics such as Lydia Cairncross as well as student leaders such as Thandani Mlambo. It was attended by about 80 students.
Subsequent to the event, a PHM -SA youth network whatsapp group was launched by Megan Harker. Through this whatsapp group and use of other appropriate technology, students drafted a youth response to the NHI white paper, entitled “Young People’s recommendations on South Africa’s NHI White Paper”. This was submitted to the NDoH in May 2016. Seeing themselves as future beneficiaries and contributors to an NHI fund, and acknowledging their future role in leadership, this collaboration documented many issues emanating from the White Paper, and posed questions to the NDoH. The PHM youth whatsapp group still exits and is the forum for many critical debates on issues which affect health locally and globally.
You can read the submission here: https://phm-sa.org/young-peoples-recommendations-on-south-africasnhi-white-paper/
The South African People’s Health University (SAPHU)
At present, in all nine provinces in South Africa, community-based health workers (CBHWs) are either volunteering or are employed under different, uncertain and tenuous conditions of service. There is an urgent need for
improvement in their economic, legal and professional conditions of services, and to build on their competence in a Primary Health care oriented national health system.
In acknowledgement of the critical role played by community workers in health, including CCWs, the South African People’s Health University was launched by PHM in 2013. The course was developed jointly by organisations that support CBHWs, namely the SA Community Care Workers’ Forum, Sinani, Sophiatown Psychological Services, the Wellness Foundation and the Women on Farms Project. Given its huge success, SAPHU was repeated in 2014, evaluated in 2015 and repeated once again this year.
Based on the findings of the evaluation, the recruitment process was changed by engaging with organizations to select two CBHWs to attend the SAPHU. They committed to supporting activism for transformation within their organizations, communities and the health system. We expanded the length of the programme by asking selected participants, together with other members of their organisation, to prepare a case study over a two month period from their area as preparation for the five day residential SAPHU course. The case studies were used for critical analysis of the social determinants of health and for planning strategies for community mobilisation and intersectoral campaigns. These case studies were sent to Cape Town two weeks prior to the SAPHU and used to focus the content of the input and discussions and make the inputs more relevant. We introduced more skills and practice in planning community based activities and mobilization and advocacy campaigns related to the social determinants of health.
We identified mentors to help selected participants prepare a case study from their area as preparation for a 5-day SAPHU. Mentors will support participants for at least 6 months after the 5- day course. Participants have just returned to Cape Town for a 2 day follow up workshop (December 2016) to evaluate their progress, and to add to their knowledge and skills and develop a longer term plan. Therefore the programme has been extended over 9 months.
Mentorship started pre the short course and continues afterwards and is ongoing as needed. We also decided to start with three provinces, and hope to repeat and improve on the process with the other 6 provinces in 2017 and 2018, depending on available funding. The intention is to develop depth of knowledge and skills and a critical mass in each province, which will over time expand the process in each province.
The 5 day residential programme was held from 20 – 24 June 2016. Two CBHWs were Gauteng, the Eastern Cape and Western Cape from four different organizations or clinics respectively. Gauteng was represented by CBHWs from Kaya Sands, Jeppestown, Orlando and Chiawelo clinics, eight participants in total and one mentor from the province. The Eastern Cape was represented by CBHWs from the Advice Centre and Creative Young Women in Port St Johns, two community health worker organisations in Mdantsane, and from the Small Trust Foundation in Pot Elizabeth. Because of the great distances in the Eastern Cape there is a mentor in Port St Johns and East London, therefore ten participants in total. The Western Cape was represented by the Women on Farms Project, Kheti Mphilo and a volunteer who is starting an organisation that focuses on the health of the elderly. Unfortunately, participants from two organisations in the Western Cape withdrew at the last minute due to unforeseen circumstances. The PHM coordinator and the SAPHU educationalist filled the role of mentors in the Western Cape, assisted by other steering committee members. Each of the mentors has submitted a report on the developments of the implementation of the action plans.Linked to this was support for the Women on Farms Project (WFP) in Rawsonville campaign for return of mobile clinic & education about Constitution & human rights.
The National Health Assembly (NHA)
The People’s National Health Assembly (NHA) was the largest event PHM held this year, held from 24-25 June at the University of the Western Cape. The NHA was held in collaboration with Section 27 and TAC. Planning for the NHA started in early January with our partners, where the priority themes (commissions) were set as guiding content for the meeting. Provincial assemblies were held in order to create awareness and collect evidence for the commissions to be discussed, and to recruit participants for the NHA. The provincial assemblies were held between March and May 2016, I; Eastern Cape and Northern Cape; the Western Cape, Gauteng and North West; KwaZulu Natal; Free State and Limpopo. Each of the organizing partners their networks in the provinces to galvanise support. For example, at the
Western Cape Provincial Assembly, PHM hosted 7 organizations to discuss the Right to Health, and the following themes were debated, each of which fed into the NHA 8 commissions:
1. The causes and the Causes of Ill health (The social determinants of health)
2. Health facilities, equipment, medication and supplies
3. Staffing and resources at health services
4. The Manner in which health services are provided (staff attitudes etc)
5. Specific services (HIV, TB, Mental health)
6. Community participation in health
7. Leadership and management in health services
8. Private health care and public health care
The event was attended by 156 delegates from 31 organizations. Five national campaigns were resolved upon to be conducted after extensive discussions on the 8 commissions convened. The campaigns were adopted by the provinces represented, each province taking responsibility for implementation of aspects which most aligned to their respective organizations’ strengths and advocacy mandates at provincial and community level. For example, Gauteng and the Western Cape have resolved to prioritize Community Health Committees, while Mpumalanga resolved to focus on drug stock outs. The report of the NHA can be found on the PHM website, but in summary, the 5 national campaigns are as follows:
1. Community Health Workers: The foundation for Primary Health Care
2. Clinic Health Committees: One clinic, one committee, one policy
3. Health financing and Tax Justice: Stop subsidising the private health sector
4. Stop Stock-Outs: Medicines when we need them
5. Human Resources for Better Health: People make the health system
PHM’s involvement in research
This year, PHM-SA implemented and completed the first round of an International Development Research Centre, Canada (IDRC) funded research project that seeks to establish how health activism contributes to realizing Health for All. The research is being undertaken by six PHM country circles (Italy, Colombia, Democratic Republic of Congo, India, South Africa and Brazil). The South African research team collected data by doing desktop analysis, surveys, participant observation, focus group discussions, key informant interviews, participation in training or knowledgebuilding workshops and meetings and ethnographic research. Key to this study was information gathered from the SAPHU meetings to demonstrate capacity building, and community health worker research in collaboration with the Division of Social and Behavioural Sciences at the School of Public Health and Family Medicine, University of Cape Town. Knowledge building was described in context of the activities carried out by PHM, including our public meetings, engagement in media and training, release of statements of support, and information and training materials. Using PHM as a case study, the research report also describes PHM’s historical role in initiating the Right to Health and the Campaign for a “People’s NHI”, and the work done to publicize infringements of the right to health – including inequities in the social determinants of health, the promotion of comprehensive primary health care as the core strategy for health development and its critical support for various national and local health policies. This research was shared in two meetings. In July 2016 a regional meeting, held at the University of the Western Cape, was organised by PHM-SA where the initial findings of the IDRC research were shared with PHM and health-sector activists based in Southern, East, Central and West Africa. In November 2016 representatives of the six country circles participating in this study met in Vancouver, Canada to share their findings with each other, plan the second stage of the research and to present the findings to date at the 4th Global Symposium on Health Systems Research. The latter meeting was attended by SC members David Sanders and Lauren Paremoer, and the report will be available on the PHM website soon.
Support of PHM in other provinces
Sadly, our year started with the tragic death of Lulamile Timbiliti, our Eastern Cape Comrade in December 2016. We will be hosting an annual memorial lecture, starting in March 2017, in tribute to this remarkable man who was a huge source of support and leadership to PHM-SA.
In 2016, PHM SA is still based largely in the Western Cape, but has a presence in Limpopo, KwaZulu Natal and the Eastern Cape. These circles have continued entirely through the voluntary efforts of committed local members. We are excited about the growth of our Gauteng cadre post-NHA, due to the efforts of the NHI Youth Movement and Shehnaz Munshi, Janine Bezuidenhoudt, Nsovo Mayimele, Laurel Baldwin-Redgraven and Kate Rees, to mention a few. Thanks to support of FOS, we were able to ensure provincial representation at the NHA from all provinces, which has in turn, rekindled provincial level enthusiasm for mobilization. In addition, having new, young activists and researchers join PHM has brought a fresh perspective on the culture of learning and exploring, and an opportunity to build stronger collaboration with progressive academics and students
Public meetings form the backbone of PHM’s work by providing a way to grow knowledge and awareness of the Right to Health while building the movement. A large focus of the public meetings this year was on the NHI White Paper and galvanizing support for the NHA on the commissions, and three in the Western Cape were dedicated to these topics.
We also held a public meeting on the rights of Junior Doctors, with guest speakers Dr Yumna Moosa and Dr Michael van Niekerk (Junior Doctors Association of South Africa) in light of a motion to change the excessively long working hours to limit occupational hazards and to raise awareness of abuse of junior doctors by their superiors.
Health Committee consultations
Following on from the 2015 Health Committee Consultations and our theme, the “Right To Participate; Health Committees in the Western Cape Health system”, PHM marched with the Learning Network, the Cape Metro Health Forum and others, and handed over a memorandum to the Western Cape Department of Health concerning the lack of community involvement mentioned in the Draft Western Cape Health Facilities Boards and Committees Bill in December 2015.
The functioning of the SC relies heavily on volunteers for their time and expertise, and we have a small Secretariat of
1.5 FTE. We received some financial training from our funder, FOS this year, and we continue to support our coordinator through an adult education training programme. We also worked on improving our communications through whats-app groups, email lists and social media.
PHM published popular materials such as a brochure on the NHI in three languages, the NHA commission documents and report in collaboration with Section 27 and TAC.
Activities in 2016
PHM public meetings
Can the National Health Insurance Deliver the Right to Health? (20 February 2016, Khayelitsha) National Health Insurance Student Discussion (6 April 2016, University of Cape Town)
Western Cape Provincial Health Assembly (4 June 2016, Athlone)
Junior Doctors Speak Out: The rights and occupational safety of Junior Doctors (September 2016, Tygerberg Campus, Stellenbosch University, with live stream to University of Cape Town and the public)
Work with Health Committees
12 October – Eastern Health Committees
19 July – Heideveld Health Committee
13 May – Provincial Parliament public hearing on Western Cape health facility boards and committees bill
24 March – World TB Day
IRDC research into Health Activism in Southern Africa
Marches and demonstrations
Vigil: Speak out on the Government’s Nuclear Deal (November 2016)
Medical Students demands/Fee Must Fall (October 2016)
Against discrimination in schools (October 2016)
Against vandalisation, crime and violence in our health services (September 2016)
Zuma must Go/Fall (April 2016)
Against Health Committees Bill (December 2015)
Press and statements (available on the PHM website)
In solidarity with the Gauteng Community Health Care Forum (November 2016)
The People’s Health Movement stands behind the call for free higher education for all (October 2016)
The People’s Health Movement joins the call from civil society for an end to the Zuma Presidency (April 2016)
World TB Day statement by the People’s Health Movement (March 2016)
NHI, NHI youth (May 2016)
NHI: Educate Women Educate a Nation (15 April, Africa Health News written by Megan Harker Elliott)
NHI Pie in The Sky (7 April, Africa Health News and PHM Website written by Megan Harker Elliott)
Death of psychiatric patients was a violation of constitutional dispensation’ – open letter to Gauteng Health MEC (Submitted to Times Media by Megan on 26 September 2016. Published 27 September 2016)
NHI – the good and the bad – Groundup December 2015
Reponses in the Cape Times letter pages to private health care and it’s relationship to the NHI – Louis Reynolds
Television: Worker’s World – The current context of the NHI – August 2016, David Sanders
Radio interviews, invited panel discussions
Twitter Chat session
We hosted a NHI White Paper chat session with youth and young people on Twitter on the 16 June 2016 about theNHI White Paper using the hashtag #YNHI. It was done in collaboration with UNFPA (United Nations Population Fund South Africa).
Our Facebook page and the website was maintained throughout the year by our Secretariat
Paper information and education materials
NHI Khayelitsha meeting pamphlet creation and translations: What was different with this pamphlet was that we attempted to translate the pamphlet into as many South African Languages as possible. This was an ambitious undertaking as we successfully translated the pamphlet fully from English into IsiXhosa and Afrikaans. At one time we were working on about six languages. We were unable to release the other languages as we did not have enough resources to undertake the necessary checks and balances to ensure credibility of the other translations.
Posted audio clip online of the Khayelitsha meeting held in February for the broader public and media to access
NHA/PHM Y-mobilise mobi site
During a meeting at the AIDS-2016 Conference in Durban, and by networking with potential partners, Right 2 Know, BWISE, UWC ICT4Development, Soul City, JuPHASA and Amandla.mobi, PHM-SA was included in the conceptualization of an upcoming social media platform to promote the right to health and health promotion-related messages, using the mobile phone. Through this interaction, the Ymobilise mobi site was developed as a concept at the PHASA Health IT special interest group meeting at the 2016 PHASA conference towards the end of 2016. We look forward to developing this further in 2017 with our partners, as part of the follow up to the NHA outcomes.
We plan to develop our fundraising capacity in order to bring longterm financial security to the organization.
We will also work with our partners on the follow up and implementation of the NHA campaigns, which cut across our own mandate with health committees, community care workers and continuing the fight for the right to healthcare for all.
The activities undertaken and the outcomes achieved this year would not have been possible without the help of a dedicated Secretariat, Executive and Steering Committee. Special thanks go to Anneleen de Keukelaere and Tinashe Njanji for their hard work as the Secretariat. Many hours were put in to making sure that our public meetings, the NHA and SAPHU were successful, and these staff also managed our books and financial reports , as well as the day to day running of a busy office. My thanks go to the SC for their commitment to PHM-SA as volunteers, who generously continued to give their time and expertise throughout 2016, through thoughts, words and actions often into the late night hours.