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With elections and NHI, this is a big year for healthcare in SA, By Marcus Low

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South Africa is barrelling towards its most consequential and most competitive national and provincial elections since 1994, expected to take place in May. That the ANC’s share of the vote, will be further eroded this year seems inevitable, given ongoing power cuts, failing railways, water management problems, high crime rates, and dysfunctional basic education and public health systems.

Covering elections is tricky at the best of times for media houses. Spotlight plans to follow the advice of Jay Rosen, journalism professor at New York University, to focus on reporting “not the odds, but the stakes”. As far as the odds does go, however, it seems likely that the ANC – alone or in coalition – will govern nationally, but they could lose power in the country’s two most populus provinces, Gauteng and KwaZulu-Natal.

The stakes in these two provinces could not be higher when it comes to healthcare. The day-to-day running of our public healthcare system is after all the domain of provincial health departments.

Limping from crisis to crisis

Take Gauteng. From alleged health department corruption worth more than R1.2 billion in 2007/2008, to the Life Esidemini tragedy of 2016, to more recent issues such as the lacklustre response to alleged corruption at Tembisa Hospital, ongoing problems with food and security contracts, and the persecution of whistleblowers like Dr Tim de Maayer, the province’s health department has stumbled from crisis to crisis under the ANC for well over a decade now. New starts under new members of the executive council (MECs) and heads of department have been a dime a dozen, but if anything, the quality of governance has decayed over time. What is at stake is literally basics like whether there is sufficient food available for people in hospital.

There is, of course, no guarantee that this atrocious situation will be turned around if, for instance, a multi-party coalition of the DA, Action SA and others run the province – but the prospect of such a change certainly is intriguing. Just imagine the DA’s Jack Bloom having a go as Gauteng’s MEC for Health after decades of holding other MECs and heads of department to account from the sidelines.

The future of NHI

The year’s other headlining health story seems set to again be National Health Insurance (NHI), which promises healthcare for all – employed or unemployed – South Africans, permanent residents, refugees, inmates, and specific categories of foreign nationals. After making it through Parliament at the end of last year, the NHI Bill is likely to be signed into law by President Cyril Ramaphosa any day now. Much of the bill won’t come into effect for quite some time, and we are sure to see several court cases challenging its constitutionality. There is also an outside chance that later this year the balance of power in Parliament could shift against NHI, or at least certain elements of NHI. It is not too much of a stretch to say the future of NHI is one of several important things on the line at the ballot box.

Also at stake in the elections is government’s response to seemingly intractable problems like South Africa’s shortage of healthcare workers, budget shortfalls, and health sector corruption. It would be naïve to think a change in power will solve these problems overnight – much of the world is struggling with shortages of healthcare workers and South Africa’s budget restraints are all too real, but some will argue that a change in power may nevertheless be a necessary first step given the extent to which all three of these issues have been allowed to drift in recent years. There is certainly an argument to be made that the current lack of progress is rooted in a lack of state capacity and that the lack of state capacity, in turn, is a consequence of the ANC’s explicit policy of cadre deployment.

Whether or not voters again back the ANC, some specific questions should provide a good gauge of progress in 2024. Will we finally see convictions for the alleged corruption uncovered by public servant Babita Deokaran? Will government publish an implementation plan for addressing our healthcare worker crisis (we already have a good strategy) and, this is the key, put money and political capital behind its implementation? Will the new Parliament pass a good State Liability Bill (which could help reduce the state’s liability for medico-legal claims) and finally get round to amending South Africa’s Patents Act to better balance medicine monopolies with the right to health (as set out in a policy adopted by cabinet back in 2018)? Will the establishment of the National Public Health Institute of South Africa remain stalled? Will government continue to ignore recommendations from the Competition Commission’s Health Market Inquiry on how to better regulate private healthcare in South Africa (the commission’s very impressive report was published in 2019)? Will the new health MECs and heads of provincial health departments appointed after the elections bring real change?

HIV, TB and NCDs

The National Department of Health has generally produced good HIV and tuberculosis (TB) policy over the last decade or so. In some respects, those policies have been well implemented – think the massive amount of HIV testing done in the country, in other respects they have been undermined by the general dysfunction in the public healthcare system – think long queues, staff shortages, and poor TB screening and infection control. Some innovations, like pills to prevent HIV or new TB treatments, could have been rolled out more quickly and better marketed to users.

At stake in the elections is thus not so much whether we produce good policies in areas such as HIV, TB and non-communicable diseases (NCDs), but whether we will get the leadership we need to ensure better and faster implementation of those policies.

On the HIV front, we will be keeping a close eye this year on the ongoing rollout of HIV prevention pills. While the rollout has gathered some momentum in recent years, the pills are generally still too hard to get hold of for those who could most benefit from it. Pilot projects should shed light on how to best make breakthrough new HIV prevention injections available in South Africa, but the high price of these injections is likely to mean the many young women who could most benefit from it won’t be able to get it.

New HIV figures from Tembisa, the leading mathematical model of HIV in South Africa, will be keenly watched this year since it will integrate recent findings from the Human Sciences Research Council (HSRC) survey (which contained some unexpectedly positive numbers). On the negative side, the HSRC survey also indicated that condom use was significantly down in 2022 compared to 2017 – this while a recent HIV investment case found that condoms are the only cost-saving HIV intervention for the health system. Either way, the extent to which condoms are made easily available will remain an important measure of government’s commitment to fighting HIV, both now and after the elections.

Last year, we saw significant changes in how TB is tested for and treated in South Africa. In short, many more people became eligible for TB tests and eligibility for TB preventive therapy was dramatically expanded. How impactful these new policies will be this year will depend on how well they are implemented, which again brings us back to the ongoing problems of healthcare worker shortages and a lack of management capacity in most of our provincial health departments. Maybe then, in a context of generally reasonable HIV and TB policy, what matters is not so much what different political parties have to offer on these diseases specifically, but what they can do to improve the functioning of our healthcare system more generally.

That said, one notable thing with TB is that, despite South Africa having often made good TB policy and having played an important role in raising the profile of TB at the United Nations, TB has never really become a political or elections issue here in the way one might expect from a disease that claims over 50 000 lives, of mostly poor people, in the country per year. So far, there is no indication that any political parties are set to change this in 2024.

Finally, while the long-term trends with HIV and TB are downward, the trend with non-communicable diseases (NCDs) like diabetes and hypertension in South Africa is in the opposite direction. Government has set HIV-style diabetes and hypertension targets and published a national plan, but again there are serious questions about whether these plans will be implemented and whether the public health system has the capacity to offer the levels of testing, treatment and care that is required. Meanwhile, breakthrough weight loss medicines that made headlines in 2023 are likely to remain out of reach for most people in South Africa and interventions like the sugar tax will remain highly contested before and after the elections.

Whatever happens at the ballot box, one thing is clear, given the rising NCD threat, healthcare worker shortages, budget shortfalls, and endemic corruption, whoever is in power nationally and provincially after this year’s elections will have their work cut out for them. While we will not endorse any political parties at Spotlight, we do urge voters to consider what is at stake in these elections when it comes to healthcare. Part of the picture will of course be painted by political party manifestos (which we will analyse in detail in the coming months), but as important as the policies, is the track record of what parties have done when they’ve held power. Whether in Gauteng, the Western Cape, or nationally, voters will hopefully send a clear message on whether or not they think those currently in power are on the right track.

Strictly Personal

Nigeria’s Currency Crisis: Time to deploy Amotekun, By Chinedu Chidi

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I have thought long and hard about just the right solution to the downward spiral of the Naira, and confidently believe I have come up with the perfect response. It is my humble proposal that the time is right to deploy the dreaded Amotekun to arrest this situation. I’ll explain why.

 

Since it is now clear that the Naira’s salvation is not in the hallways of the CBN or the gold-plated policy rooms of Bretton Woods, but in the battle grounds of the nook and cranny of Nigeria, all patriotic Nigerians must now rightly ignore suit-wearing technocrats and search for militant solutions with real promise. As a patriotic citizen, I have risen to this challenge. I would humbly like to thank the patriotic Nigerian leadership, from the CBN to the Executive, for leading us into this new era of mortal combat.

 

Only a few days ago, we were greeted with the live action scene of security operatives combating BDC operators in the nation’s capital, discharging live ammunition in broad daylight in an open civilian space like fearless patriots at the battle front. The EFCC and accompanying security operatives charged forward and backwards as the enemies of state dared challenge them. It was almost like a combat scene from Gibson’s Braveheart. I was touched. I’m not too sure, but I may have heard the humming of the national anthem from these fearless patriots as they battled the savage saboteurs. What a touching moment! Someone who was at the scene mentioned that these patriots recited the pledge before the onslaught. I can’t confirm this for sure, but if it did occur, it would be consistent with the new nationalistic fervour of the Tinubu administration as reported in the news recently that citizens would be required to recite the pledge at events. I also hear the operation is going on in different parts of the country. All these, coming only days after Sahad Stores, a retail supermarket in Abuja, was forcibly shut down for “economic sabotage”, fill me with great joy. Some unpatriotic citizens had shockingly opposed the move, claiming Sahad Stores was one of the good ones, and that deploying force would not resolve the inflation crisis. Cowards and co-conspirators! They’re too distracted by textbook ideas to see that we’re in war. Shame.

 

Normally, I would have recommended the army for this most important national assignment, but they’re overstretched. They’re battling terrorists, bandits, armed robbers, secessionists, their welfare; just about every violent aggressor around. The police would have been my second option but they too are preoccupied and, as some mischievous people claim, have a special DNA for compromise. For these and some other reasons which I will explain, Amotekun has my blessings.

 

I know Amotekun is also seriously engaged with battling bandits in the South West, but they must be pleaded with to spare some personnel for this all-too-important national emergency. Their stealth, daredevil disposition, and my favourite—charms from the gods— will come in handy.

 

I have heard rumours that some of the BDCs hide their stockpile of dollars in forests. This is the domain of the Amotekun warriors. Through their local intelligence gathering and tactical navigation of the forests, they can uncover these dollar chests and win for the country a huge deliverance. Their spiritual protection against wild animals and attacks from dark forces will be very useful here.

 

I am also confident that what has for so long appeared to be the near-impossible goal of finding the dollars some loud-mouthed people claim are hidden by politicians, bank executives and— I struggle to even contemplate it— CBN officials will be spiritually detected by Amotekun. We desperately need this.

 

It was with great joy that I also received the news that our gallant security personnel are now stopping truckloads of food from leaving the country. What took them so long! How can any patriotic businessman think of trade and profit at a time of economic crisis? This beats my imagination. I am even more infuriated by the argument of their unpatriotic defenders that we don’t have food scarcity, just food unaffordability, and that we can’t seriously let them abandon their goods in warehouses while the vast majority of Nigerians can’t purchase them. This is so inconsiderate and sad. Their argument that the exports bring in needed forex at this time of forex crisis is also another textbook nonsense. Shame on them.

 

I am particularly touched by Cardoso’s sincerity and humility. Realizing that the air-conditioned policies have hit the brick wall and that the fight has morphed into street combat, he did not try to deceive the populace about it. This is uncommon (apologies to Akpabio) pragmatism.

 

I want to enjoin the President to rally leaders in the South West towards mass mobilization of Amotekun for this national assignment. We can’t afford to fail!

 

Chinedu Chidi is a public affairs commentator. He can be reached via: chiobe24.cc@gmail.com

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Strictly Personal

The problem of DRC’s beautiful wife, maize it planted by roadside, By Charles Onyango-Obbo

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Watching the upheaval in the Democratic Republic of Congo in recent days, one is tempted to invoke the African proverb that “the man who marries a beautiful woman and the farmer who grows maize by the roadside have the same problem.”

The police fired tear gas on Monday to disperse protesters who burned tyres and US and Belgian flags near Western embassies and UN offices in the capital Kinshasa, angry about insecurity in eastern Congo.

The protesters claim the West supports Rwanda, which they and their government accuse of backing the M23 rebellion, whose advance could see them seize the strategic border city of Goma in the east.

This is a new phase of what has become an entrenched tradition of the Congolese oscillating between blaming everyone else but themselves for their problems, and demanding that other people solve these problems, including fighting for them.

In recent years — rightly — the Congolese have railed, then attacked, the long-running and ineffectual United Nations Organisation Stabilisation Mission in the Democratic Republic of the Congo (Monusco) for not ending the rebellion in the east.

In late 2022, DRC’s kin in the EAC dispatched the East African Community Regional Force (EACRF) to separate the warring sides. Before long, Kinshasa and the people had risen against them, hounding them to go out to the jungle and fight the rebels for them. At the end of last year, EACRF left DRC with its tail between its legs.

Because the Congolese are our brothers and sisters, and we have a responsibility to love them, we also have a duty to tell them uncomfortable truths that will help them overcome.

So, we will return to our proverb. African proverbs are complicated. First, one needs to know that they passed into society through the mouths of men who were not feminists, so too many of them tend to portray women in bad light.

This one paints a heroic hard-working farmer (although it is mostly women, not men, who work the land in Africa) whose maize is stolen by passers-by, in contrast with the beautiful wife who betrays her husband and falls to the charms of other men.

However, African proverbs are also layered, so there is what they say, and the many things they mean. In this case, that people will covet a good thing — a good crop, a beautiful woman and, if we may add, a handsome, enterprising man. The “problem” here is how to keep your maize, beautiful wife, and enterprising husband. If you are better than all the men who hit on her, your beautiful wife will stay faithfully by your side.

Having your wife, husband, girlfriend or boyfriend run off with someone else can be very hurtful, but if you have a cantankerous truth-telling African aunt or uncle, they will also whisper to you that a partner whom no other man or woman has ever or will ever want is probably not worth having.

In real-world Congo politics, then, the reality is rebels will have friends and allies at home and abroad. Even Uganda’s Lord’s Resistance Army (LRA), as despicable as a rebel group can ever be, had friends outside who backed it.

The thing that should terrify everyone is a rebel group that no one wants to touch with a 10-metre pole, both in the day and night. The opposite is also true of rebels fighting to overthrow a government. If it is a government that doesn’t have a single friend even in the cynical world of geopolitics, then it’s probably worse than a cabal of cannibals.

For Congo, what is left is how to solve this “problem”. To stay with the farmer and the beautiful wife, what the Congolese are doing is like the strapping young man in old Africa who spent all his time attacking his parents, relatives, neighbours, and their friends because they failed to give him cattle to pay a bride price for a wife and build a hut for him to live in with her.

The scale of surrender of agency by many Congolese, including the political class and the government, is unsettling.

It’s partly understandable, too. The unusually brutal Belgian rule; the exploitation of all sorts of vultures for its vast minerals lasting over 100 years now; and an unbroken long spell of corrupt and cruel rule, have broken its self-confidence. The way to come to terms with the scale of failure and remain sane is to externalise all the problems to evil forces.

It has led to national paralysis, a belief that they can’t do much on their own to overcome.

DRC’s neighbours to the east, Uganda and Rwanda, offer good lessons. When President Yoweri Museveni took to the bush with his small band of rebels in 1981, the odds were stacked up against them. The British had a big programme with a special police force; the Tanzanian army that helped overthrow military dictator Idi Amin was on the side of the government, and hardy North Koreans soon got into the fight against them. They still won.

The prospects were even worse for the Rwanda Patriotic Army/Front when it crossed from Uganda and took to treacherous hills in 1990. Apart from Uganda, it was alone against the world, including one of the world’s superpowers at the time, France, which was in bed with the government in Kigali. They suffered setbacks, picked themselves up, and won.

Congo can win, but first, it will have to plant its own maize and fight its war for its own beautiful wife.

Charles Onyango-Obbo is a journalist, writer, and curator of the «Wall of Great Africans». Twitter@cobbo3

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