Second Presidential Health Summit – summiting while the health system burns

2 May 2023

This week, the Presidency and the Health Department will host a second Presidential Health Summit. The first took place in 2018.

This summit takes place at a time when the health system is breaking: basic services have all but collapsed in several provinces. For example, in the Eastern Cape there is a waiting list of 5,000 people for wheelchairs; the burden of non-communicable disease is growing while the number of health workers is shrinking.

Health experts warn that even gains made in the past, particularly the flagship HIV/Aids programme, are being rolled back.

There is a vast disjuncture between what health researchers know about what is wrong with the health system and what we do to fix it; between talk and action; between policy and implementation.

The summit takes place at the Birchwood Hotel & OR Tambo Conference Centre in Gauteng, in a province where the health system is collapsing. Yet ironically it will be opened by premier Panyaza Lesufi who, despite the bold promises he made to fix Gauteng health he made when he took office in October 2022, has so far made little tangible impact on improving the provincial health system.

Read more in Daily Maverick: Nomantu Nkomo-Ralehoko is appointed Gauteng health MEC – mainly for financial expertise rather than health knowledge

In fact it’s getting worse.

For example, as we report today, Chris Hani Baragwanath Academic Hospital, the biggest hospital in the country, doesn’t have enough food to feed its inpatients.

Since the last health summit in October 2018 the health system has gone through its own trauma and trial by fire. It has shown us its best and its worst.

Nearly 2,500 health workers died in the line of duty during the Covid-19 pandemic. Today’s health workers are exhausted and traumatised, and many are trying to leave the public health system.

Read more in Daily Maverick: A junior doctor’s battle to keep death at bay for state patients

Despite their best efforts there were 340,000 “excess deaths”, most related to Covid-19, between 2020 and 2023. But tens of thousands of lives were also saved.

However, while health workers gave their best and their lives, on the other hand we saw the venality of corrupt politicians, including the former health minister, and some senior public servants who cumulatively stole billions of health rands. Every week still seems to bring new revelations of corruption, and yet many of those implicated, such as Gauteng acting head of department, Arnold Malotana, remain in senior positions in the very department they stole money from.

Pride in our health workers

Despite this we can have pride in our health system. The truth is that we have thousands of dedicated and innovative health workers, in many different sectors and specialities, with ideas for how to improve patient care and outcomes, who know exactly what the solutions are.

But they are mostly not heard. They work in facilities or provincial health systems that punish innovation. They are being disorganised, disrupted and demoralised by a relatively small number of people involved in the administration and management of health. If this problem were to be solved, which truly is in the purview of politicians to fix, many improvements would flow from it.

Read more in Daily Maverick: Fixing South Africa’s imploding public health system – time to take over from the politicians

But they don’t seem to have the appetite to prosecute their comrades.

In this context questions have to be asked about what the summit will achieve and – in a system that is extremely financially stressed – whether it is an appropriate use of resources.

On Monday, Foster Mohale, spokesperson for the national department, said it would involve 500 delegates, but didn’t answer how much it had been budgeted for: “The final cost may be available after the summit once we reconcile the costs,” he said. We guess it will cost upwards of R5-million. Yet its outcomes are far from clear.

A list of objectives sent to us by Mohale (published in full below) suggest that much of the summit will focus on the elusive National Health Insurance (NHI), rather than the nuts and bolts of health promotion and service delivery.

I would wish to be proven otherwise. After Covid-19 there is a need to create spaces for reflection and learning. But as currently constructed the summit looks like half tick-box exercise and half pre-2024 election strategy, but with not much to do with finding solutions for the real problems facing the health system. The 2018 summit, for example, led to a glossy 80-plus-page compact (its report is here), very little of which has been carried out.

One of the papers prepared for this summit notes that “whatever good intentions informed the [2018] Presidential Health Compact and whatever administrative initiatives have been taken by the National Department of Health, the sector is yet to implement a clear, decisive and systemic effort to confront corruption and maladministration.”

True.

It then adds:

“Fiscal constraints and budget shortfalls are eroding the capabilities of the public healthcare system in South Africa, contributing directly to falling levels of service provision. The retrogression in the resource envelope for healthcare is likely to continue and intensify in the years ahead. In this context it is doubtful that the plans laid out in the Presidential Health Compact to strengthen the South African health system will be adequately resourced.” (My emphasis)

True.

So, why do we need another summit now when there is so much obviously outstanding on our to-do list?

Instead of an expensive summit, the President could call a family meeting and make a simple declaration on behalf of himself, the minister and MECs of health.

It would read something like this:

“We will listen to frontline health workers and the recommendations they make for how to manage their facilities better;

“We will conclude all investigations and disciplinary enquiries recommended by the SIU within three months and dismiss all those found guilty with immediate effect;

“We will develop a plan to end corruption and invest the ‘savings’ back into the health system, particularly on training and employing more health workers;

“We will budget for the 2030 Human Resources for Health Strategy and implement it with urgency;

We will implement the recommendations of the Health Market Inquiry into private healthcare that we commissioned and were released in 2019”

“We will implement all policies that have been finalised and not implemented, such as the 2017 palliative care strategy;

“We will negotiate and agree a Minimum Service Level Agreement with health worker unions before the end of 2023 to ensure that in future wage disputes do not harm patients.

“We will audit, consolidate and carry out the recommendations made by the Health Ombudsperson, the SA Human Rights Commission, the SIU and the courts.”

“We recognise that ‘access to healthcare services for everyone’ and ‘basic healthcare services for every child’ is a constitutional right in South Africa, that is central to everyone’s dignity and equality. We will not deny any human access and will budget for and manage the health system accordingly.

“We will appoint a small independent committee of experts and activists to inform the public twice a year whether we are fulfilling these promises.”

If they did this the savings of millions of rands, and the food not eaten by not hungry delegates, could be redirected to hungry patients at Chris Hani Baragwanath Hospital or 5,000 people needing wheelchairs in the Eastern Cape. Deal? Unlikely.

That being the case, we urge delegates to the summit this weekend to use their time wisely and insist on an action plan that is actually capable of fixing the health system. Anything less will leave them complicit in fruitless and wasteful expenditure and the human rights violations that arise from it. DM/MC

According to Foster Mohale, spokesperson for the National Health Department: “The following is expected to be achieved from the Presidential Health Summit-II

Stakeholder engagement and commitment are reinvigorated for joint efforts to accelerate the journey towards National Health Insurance (NHI)

Progress is assessed and documented on all the nine pillars of Compact against the set targets, and mechanisms are identified to address the bottlenecks and scaling up the enabling functions for attaining the Compact targets and milestones

The lessons from the journey taken so far towards NHI and the Covid-19 response are synthesised and stakeholder views collated for outlining urgent measures to recalibrate the system and accelerate the NHI reforms

Acknowledgement of the unsustainable escalation of demand on the public sector and mobilising an all of society alignment (particularly with the private sector) towards the implementation of NHI

Acknowledging the lack of growth and stagnant number of medical scheme beneficiaries over the past ten years and the evident sustainability risks. There is therefore an increased need to improve the effectiveness of regulation of private health sector funding through a revised Medical Schemes Act and Regulations. Ensure alignment of minimum standards across the public and private sectors to correct current inequalities in health service delivery

Create awareness of government's intention to procure health services from all service providers under NHI- including NGOs, public and private providers

Action-oriented, aligned and well-articulated report of the Presidential Health Summit-II with clear strategic priorities for accelerating roll-out of NHI and implementing initiatives for health systems strengthening and resilience is produced.

Strategic priorities in the Action Oriented Report of the Presidential Health Summit-II will also aim to guide the national health system towards the attainment of the health goals of the National Development Plan (NDP) 2030 and the Sustainable Development Goals 2030, noting that the period 2024-2029 is the last 5-year planning horizon before the endpoint of both the NDP and SDGs 2030.

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