Motsoaledi pleased no donor funds were wasted in illicit procurement of oxygen plant
Motsoaledi said Tuesday's release of the findings of the forensic report ordered by Public Works Minister Dean Macpherson clears his department of any wrongdoing in the more than R800 million tender.
The investigation found the CEO of the Independent Development Trust, Tebogo Malaka, failed to exercise the necessary oversight over ballooning costs.
ALSO READ: Macpherson on irregular oxygen plant tender after R13m spend: 'We have effectively lost'
Minister Aaron Motsoaledi says the finalisation of this investigation removes the dark cloud that's been hanging over the health department.
Motsoaledi said those who've been implicated in wrongdoing - not only committed financial corruption - but deprived patients of urgent life-support in the form of oxygen.
Motsoaledi's spokesperson Foster Mohale, said: 'Minister Motsoaledi is pleased that the Department of Health lost nothing and all the money that has been donated by the Global Fund is safe. It would have been a sad day if donor funds' money was to disappear under our watch.'
The tender has since been removed from the IDT and is now under the management of the development bank.
Motsoaledi said that with the finalisation of the forensic investigation, the remaining work will be expedited to conclude the project.
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Daily Maverick
4 hours ago
- Daily Maverick
Rethinking HIV treatment with tailored solutions for improved patient engagement and outcomes
The health department has R622-million extra to prop up South Africa's HIV treatment programme in the wake of foreign aid cuts. But it's only about a fifth of the total gap. We look at how data can help drive decisions to make the most of this lifebuoy. Just over two weeks ago, Health Minister Aaron Motsoaledi announced that the Treasury had given R622-million of emergency funding to his department to prop up South Africa's HIV treatment programme, with about R590-million for provinces' HIV budgets and R32-million for the chronic medicine distribution system, which allows people to fetch their antiretroviral treatment from pick-up points other than clinics, closer to their homes. This extra budget is just over a fifth of the roughly R2.8-billion funding gap that the health department says the country needed after US President Donald Trump's administration pulled the plug on financial support for HIV in February. (The Pepfar/Aids relief budget for this financial year was just under R8-billion, but the health department calculated that it could fill the void with R2.8-billion if it trimmed extras and ruled out duplicate positions.) So, how to get the best bang for these limited bucks — especially with the health department wanting to get 1.1-million people with HIV on treatment before the end of the year and so reach the United Nations targets for ending Aids as a public health threat by 2030? By getting really serious about giving people more than one way of getting their repeat prescriptions for antiretroviral (ARV) medicine (so-called differentiated service delivery), said Kate Rees, the co-chairperson of the 12th South African Aids Conference to be held later this year, from Kigali last week, where she attended the 13th IAS Conference on HIV Science. At another Kigali session, Lynne Wilkinson, a public health expert working with the health department on public health approaches to help people stay on treatment, said: 'People who interrupt their antiretroviral treatment are increasingly common, but so are people who re-engage, or in other words start their treatment again after having stopped for a short period.' A big part of South Africa's problem in getting 95% of people who know they have HIV on ARVs (the second target of the UN's 95-95-95 set of cascading goals) is that people — sometimes repeatedly — stop and restart treatment. For the UN goals to be reached, South Africa needs to have 95% of people diagnosed with HIV on treatment. Right now, the health department says, we stand at 79%. But the way many health facilities are run makes the system too rigid to accommodate real life stop-and-start behaviour, says Rees. This not only means that extra time and money are spent every time someone seemingly drops out of line and then comes back in, but also makes people unwilling to get back on board because the process is so inconvenient and unwelcoming. Rees and Wilkinson were the co-authors of a study published in the Journal of the International Aids Society in 2024, whose results helped the health department update the steps health workers should follow when someone has missed an appointment for picking up their medicine or getting a health check-up — and could possibly have stopped treatment. 'We often have excellent guidelines in place, built on solid scientific evidence,' says Rees, 'but they're not necessarily implemented well on the ground.' To make sure we track the second 95 of the UN goals accurately, we need a health system that acknowledges people will come late to collect their treatment and sometimes miss appointments. This doesn't necessarily mean they've stopped their treatment; rather that how they take and collect their treatment changes over time. 'The standard ways in which the public health system works mostly doesn't provide the type of support these patients need, as the resources required to provide such support is not available,' says Yogan Pillay, the health department's former deputy director-general for HIV and now the head of HIV delivery at the Gates Foundation. 'But with AI-supported digital health solutions and the high penetration of mobile phones, such support now can — and should — be provided at low cost and without the need to hire additional human resources.' We dived into the numbers to see what the study showed — and what they can teach us about making the system for HIV treatment more flexible. Does late equal stopped? Not necessarily. Data from three health facilities in Johannesburg that the researchers tracked showed that of the 2,342 people who came back to care after missing a clinic appointment for collection medication or a health check, 72% — almost three-quarters — showed up within 28 days of the planned date. In fact, most (65%) weren't more than two weeks late. Of those who showed up at their clinic more than four weeks after they were due, 13% made it within 90 days (12 weeks). Only one in 14 people in the study came back later than this, a period by which the health department would have recorded them as having fallen out of care. (Some incomplete records meant the researchers could not work out by how much 8% of the sample had missed their appointment date.) The data for the study was collected in the second half of 2022, and at the time national guidelines said that a medicine parcel not collected within two weeks of the scheduled appointment had to be sent back to the depot. 'But it's important to distinguish between showing up late and interrupting treatment,' notes Rees. Just because someone was late for their appointment doesn't necessarily mean they stopped taking their medication. Many people in the study said they either still had pills on hand or managed to get some, despite not showing up for their scheduled collection. Pepfar definitions say that a window of up to 28 days (that is, four weeks) can be tolerated for late ARV pick-ups. Pepfar is the US HIV programme that funds projects in countries like South Africa, but most of them were cut in February. Research has also shown that for many people who have been on treatment for a long time already, viral loads (how much HIV they have in their blood) start to pass 1,000 copies/mL — the point at which someone could start being infectious again — about 28 days after treatment has truly stopped. Sending back a parcel of uncollected medicine after just two weeks — as was the case at the time of the study — would therefore add an unnecessary administration load and cost into the system. (Current health department guidelines, updated since the study and in part because of the results, say that a medicine pick-up point can hold on to someone's medicine for four weeks after their scheduled appointment.) Does late equal unwell? Not always. In fact, seven out of 10 people who collected their next batch of medication four weeks or more late had no worrying signs, such as possible symptoms of tuberculosis, high blood pressure, weight loss or a low CD4 cell count, when checked by a health worker. (A low CD4 count means that someone's immune system has become weaker, which is usually a sign of the virus replicating in their body.) Moreover, given the large number of people without worrying health signs in the group for whom data was available, it's possible that many of those in the group with incomplete data were well too. When the researchers looked at the patients' last viral load results on file (some more than 12 months ago at the time of returning to the clinic), 71% had fewer than 1,000 copies/mL in their blood. A viral count of fewer than 1,000 copies/mL tells a health worker that the medicine is keeping most of the virus from replicating. It is usually a sign of someone being diligent about taking their pills and managing their condition well. Yet clinic staff often assume that people who collect their medicine late are not good at taking their pills regularly, and so they get routed to extra counselling about staying on the programme. 'Most people don't need more adherence counselling; they need more convenience,' says Rees. Offering services that aren't necessary because of an inflexible process wastes resources, she says — something a system under pressure can ill afford. Rees says: 'With funding in crisis, we really have to prioritise [where money is spent].' Does late equal indifferent? Rarely. Close to three-quarters of people who turned up four weeks or more after their scheduled medicine collection date said they had missed their appointment because of travelling, work commitments or family obligations. Only about a quarter of the sample missed their appointment because they forgot, misplaced their clinic card or for some other reason that would suggest they weren't managing their condition well. Part of making cost-effective decisions about how to use budgets best is to offer 'differentiated care', meaning that not every patient coming back after a missed appointment is treated the same way, says Rees. Health workers should look at by how much the appointment date was missed, as well as a patient's health status to decide what service they need, she says. Giving people who've been managing their condition well enough medicine to last them six months at a time can go a long way, Wilkinson told Bhekisisa's Health Beat team in July. 'Getting 180 pills in one go reduces the number of clinic visits [only twice a year], which eases the workload on staff. But it also helps patients to stay on their treatment by cutting down on their transport costs and time off work,' Wilkinson said. Zambia, Malawi, Lesotho and Namibia have all rolled out six-month dispensing — and have already reached the UN's target of having 95% of people on medicine at a virally suppressed level. According to the health department, South Africa will start rolling out six-month dispensing in August. 'But not everyone wants this,' said Wilkinson, pointing out that experiences from other countries showed that 50 to 60% of people choose six-monthly pick-ups. It speaks to tailoring service delivery to patients' needs, says Rees, rather than enforcing a one-size-fits-all system when more than one size is needed. Says Rees: 'Facing funding constraints, we really need tailored service delivery to keep the [HIV treatment] programme where it is.' DM
Daily Maverick
17 hours ago
- Daily Maverick
Three decades in, is the Cuba-SA doctor training programme still worth the expense?
The Nelson Mandela-Fidel Castro medical training programme has been controversial from the start. It's had high points, low points, and now many say it should have an end point. Almost 30 years since the Cuba-SA doctors' training programme was launched, it still divides opinion. This year only Gauteng and North West interviewed candidates for the bursary programme that sends students from South Africa to be trained in the island country. Critics say the dwindling interest shows the Nelson Mandela-Fidel Castro medical training programme has passed its sell-by date. But supporters remain committed to its ideals, and some beneficiaries of the programme still think of it as the opportunity of a lifetime. Between the differing views, what can be glimpsed is a chequered story of three decades of trying to transform South Africa's healthcare system. The programme has its origins in the ANC's political fraternity with Cuba and the laudable ideal of boosting doctors numbers in under-serviced rural areas. But it is also a tale of political inertia arguably blurring overtime into a blind spot as conditions changed. In the background is the stranglehold of corruption and maladministration in the health sector, shrinking provincial health budgets, the transformation of doctors' training, and changing curricula. One concern is that little is actually known about the programme's impact. There is a lack of clear data on the costs and the numbers of doctors produced. Shockingly, for such a long-running programme, no comprehensive evaluation reports have been published, as far as Spotlight has been able to establish. A comprehensive evaluation would weigh the benefits of the programme against its costs, compare it to other options for training medical doctors, and contextualise it within the current reality of very tight health budgets in provincial health departments — as it is, not all the doctors we are training are being employed. Given this context, it is not surprising that the national Department of Health recommended a scaling back of the programme a decade ago. While most provinces have taken this advice, the Gauteng and North West health departments have instead pushed ahead with the programme. Old histories and old allegiances The agreement that put in place the medical training programme was signed in 1996, with the first cohort of students leaving for Cuba a year later, in 1997. It was a mere two years into democracy and South Africa urgently needed to address the gaps in the provision of healthcare. Under apartheid, services prioritised a white minority mostly in urban settings and healthcare had a strong slant towards hospital or tertiary care. There was a shortage of doctors, and those with the least access to healthcare services were rural communities made up mostly of black South Africans. Medical schools mostly had curricula designed for the status quo, and there were few academic pathways for underprivileged students who had good marks at school but were not top achievers, leaving them overlooked for scholarships and bursaries. So the new government looked to Cuba. With its focus on primary healthcare, preventive medicine and community-based training, the Cuban approach to healthcare ticked many of the boxes for the South African government then led by Nelson Mandela. Since the communist revolution in Cuba in 1959, it has provided free healthcare to all its citizens. While there remains some scepticism over data collection and interpretation, the politicisation of medicine, and limited freedom to criticise the state, Cuba's healthcare system is also widely lauded. According to the Primary Health Care Performance Initiative, the country registers average life expectancy at 78 years (South Africa is at about 66), infant mortality dropped from 80 deaths per 1,000 live births in 1950 to just 5 deaths per 1,000 by 2013, and it has one of the world's highest doctor to patient ratios. In 2021, it was at 9.429 physicians per 1,000 people, according to World Bank Open Data. In the same year, South Africa tracked at 0.8 per 1,000. Since the 1960s, Cuba has established itself as a hub for training international fee-paying students and sending them back to their mostly lower-income countries as graduate doctors. One of its biggest universities, the Latin American School of Medicine, has graduated more than 30,000 students from 118 countries in the 21 years since it was established. Another tick was Cuba's staunch support for the ANC. SA History Online emphasises the depth of solidarity. It notes: 'Cuba was a state in alliance with provisional governments and independent states on the African continent. Cuba's military engagement in Angola kept the apartheid state in check, foiling its geopolitical strategies and forcing it to concede defeat at Cuito Cuanavale, and ultimately forcing both PW Botha and FW de Klerk to the negotiating table.' Costs and benefits The political and historical bonds sealed the doctors' training deal. But from the start, the bursary programme, funded by provincial budgets, came under fire. The estimated costs over nearly three decades are massive, but the details remain fuzzy. Spotlight's questions to the national health department were 'answered' in one paragraph by department spokesperson Foster Mohale. 'More than 4,000 [lower numbers are quoted by government in other instances] doctors have been produced through this medical programme since its inception. The programme is still relevant today and complements the local medical schools to produce more doctors. Qualified doctors have options of joining either public or private health sector,' he wrote. But discrepancies have shown up in the government's own figures. In November 2022, Haseena Ismail, the then DA member on the portfolio committee of health, raised concerns about the quality of government data. The Minister of Health at the time, Dr Joe Phaahla, said the preparatory year, including a stipend, cost $4,400 per student, and each of the following five years cost $7,400 per student. But a separate table from the health department listed higher figures — $8,400 for the preparatory year and up to $15,900 per student by the fifth year. Added to this, the department listed annual costs of $6,472 per student for food, accommodation, and medical insurance. There were also expenses for two return flights over six years, plus the cost of 18 months of tuition and accommodation for clinical training at a South African medical school. Phaahla said that as of November 2022, 3,369 students had been recruited into the programme, and 2,617 had graduated. However, he noted there was no information on what happened to these doctors or where they were employed. Each bursary student was required to work for the state for the same number of years for which they received funding. The programme also faced criticism over selection criteria for bursary candidates and for requiring two extra years of training compared with local medical programmes. Students spend one year learning Spanish, five years training in Cuba, and then return to South Africa for an additional 18 months of clinical training at a local medical school. Controversies have dogged the programme over the years. In 2013, the Afrikaans newspaper Beeld reported that by 2009, only half of the students enrolled in the programme during its first 12 years had completed their studies. In 2012, the government ramped up the numbers of students it sent abroad. In 2018, this backfired when about 700 fifth-year students returned home only to find they could not be accommodated at any of the then 10 medical schools in the country. It was at about this time that the national health department issued recommendations for the provinces to phase out the programme. Gauteng and North West Despite all of the above, the Gauteng Department of Health continues to fund students — about 20 last year and an expected 40 this year. Spotlight's questions on this to the Gauteng health department went unanswered. Compounding the administrative and planning blunders for returning students is the impact of deepening corruption and mismanagement in Gauteng's health department. It has been under routine Special Investigating Unit scrutiny as well as coming under fire for service delivery issues such as the ongoing backlog of cancer patients lingering on treatment waiting lists. In March, the South Gauteng Division of the High Court in Johannesburg ruled that the Gauteng health department had failed in its constitutional obligation to make oncology services available. In April, the department failed to pay its doctors their commuted overtime pay on time. These payments ensure there are doctors for 24-hour coverage at hospitals and make up as much as a third of doctors' take-home pay. The situation in the North West is also bleak. It's health facilities routinely face medicine stock-outs and understaffing. Its health department regularly struggles with accruals and paying suppliers on time. Given all these challenges, it is puzzling that these two provinces in particular are so committed to sending students to Cuba, at what we understand to be higher cost than for training doctors locally. 'Better investments' Professor Lionel Green-Thompson, now the dean of the faculty of health sciences at the University of Cape Town, was involved in managing returning students from the Cuba-SA programme between the mid-2000s and 2016. At the time, he was a medical educator and clinician at Wits University, where he oversaw the 18-month clinical training of more than 30 returning students. 'Some of these students were among the best doctors that I've trained, and I remain a stalwart supporter of the ideals of the programme. But at this point, there are better investments to be made, including directly funding university training programmes in South Africa,' he said. 'A programme that's rooted in our nostalgic connection with Cuba and its role in our change as a country is now out of step with many of the healthcare settings and realities we face in South Africa,' said Green-Thompson. He added that a proper evaluation of the programme needed to be conducted. There were also lessons to learn, he said, including a review of admissions programmes. How some students who entered a programme at 20% below the normally accepted marks and exited the programme as excellent doctors, offered clues on how great doctors could be made, he said. Green-Thompson also suggested that we needed to ask why specialisation had become a measure of success for many doctors in South Africa, often at the expense of family medicine. This, he said, took away from the impact doctors made at the community healthcare level as expert generalists. But changing the perspectives of healthcare professionals required early and sustained exposure to working in community healthcare settings, said Professor Richard Cooke, the head of the department of family medicine and primary care at Wits. Cooke is also the director of the Wits Nelson Mandela-Fidel Castro Collaboration since 2018 and serves on the Nelson Mandela-Fidel Castro Ministerial Task Team. 'I'm not in support of further students being sent to Cuba for the undergraduate programme, because these students are not being trained in our clinical settings,' he said, speaking in his Wits capacity. 'The Cuban system is far more primary healthcare based than South Africa's, but that doesn't necessarily translate into these students ending in primary healthcare,' said Cooke. And curricula at Wits were shifting, for instance, towards placing students at district hospitals for longer periods of time, rather than weeks-long rotations, he said. 'When students become part of the furniture at a hospital, they become better at facilitating, at critical thinking, problem solving, teamwork and collaboration,' Cooke said. But making this kind of transformation in local training took government funding and commitment. Students and doctors needed to be attracted to the programme and needed reasons to stay. But the money and resources to make this happen were simply not there — even as the Cuba training programme continued. Cooke added: 'There hasn't been definitive data on the Nelson Mandela-Fidel Castro programme. But even if the programme over 30 years has done well and met its targets, it's not been cost efficient. What's needed now is to leverage expertise and establish partnerships in different, more cost-effective ways like in research, health systems science and health science education.' Up to three times more expensive? Professor Shabir Madhi, the dean of the faculty of health sciences at Wits, said the Nelson Mandela-Fidel Castro programme costs an estimated three times more than it cost to train a student in South Africa. This, he said, should be enough reason for a beleaguered health department like Gauteng's to stop sending students to Cuba. He added: 'The government is aware that it simply can't absorb the number of medical graduates being produced.' Madhi says some trainee doctors were sitting at home while others trying to finish specialisations were being derailed. Broadly, he pinned the blame on the mismanagement of resources, including the department underspending R590-million on the National Tertiary Service Grant meant to subsidise specialised medical treatment at tertiary hospitals. Madhi said universities had worked hard to close the gaps identified by the Nelson Mandela-Fidel Castro programme 30 years ago, but now student doctors were being let down by the government not playing its part. 'Across the universities, there's been a complete overhaul of the curriculum to be focused on primary healthcare. Students are also getting community exposure as early as first-year training,' he said. He added that when it came to admissions, the majority of students entering medical schools across the country were now black South Africans, and additional changes had been made to the selection process. 'We used to have a race quota, but in further revisions we have introduced criteria that focus on the socioeconomic component, with 40% of the admissions coming from students in quintile 1, 2 and 3 schools [no-fee public schools],' he said. South Africa had 11 medical schools, with the most recent addition being North West University — specifically focused on rural health — and the University of Johannesburg in the pipeline to join the list. So the number of doctors being trained and graduating was increasing. Madhi estimated that the total number being trained was above 900 per year for Gauteng alone. The bottleneck of getting doctors into clinics and hospitals, he maintained, was not a shortage of doctors, but the government's inability to pay doctors' salaries or to create functioning, well-resourced workplace environments. 'You can't put a price on that' For Dr Sanele Madela, the ongoing challenges could not detract from the goal to get doctors into communities — including through the Nelson Mandela-Fidel Castro programme. Today, he is the health attaché at the Havana Mission for the Nelson Mandela-Fidel Castro training programme. Madela was also at one time a schoolboy with a dream of becoming a doctor. Growing up in Dundee in KwaZulu-Natal, he remembers almost never seeing a doctor in his community. 'Then when we did see a doctor, it was a white person or an Indian person and they never spoke our language — a nurse would have to translate,' said Madela, who was part of the 2002 Nelson Mandela-Fidel Castro intake. The six years abroad, he said, exposed him to very different reasons for becoming a doctor. 'When people finish medical school, they say thank God it's over, but in Cuba people say thank God for the knowledge and information so they can give back to their country,' he said. When Madela got back to South Africa, his journey eventually led him to work in Dundee district hospital. It was the same hospital where his mother had worked as a cleaner. The Nelson Mandela-Fidel Castro programme, Madela said, still played a vital role because of its objective to get more doctors into rural and township areas — 'and you can't put a price on that'. 'We are used to seeing the Nelson Mandela-Fidel Castro programme from the point of view of adding human resources, but it's also about the impact it makes for a community,' he said. It's the impact of a community finally getting their own doctor. His argument is that, thanks to the Nelson Mandela-Fidel Castro programme, he got to be that person for his community. DM
IOL News
21 hours ago
- IOL News
Misuse and wastage of medication in the health sector
A letter writer raises concern about the misuse and wastage of medication in government health facilities. Image: Pixabay Open letter to Health Minister Dr Aaron Motsoaledi Sir, do you know the wastage and misuse of drugs that is occurring in our health facilities, costing the taxpayer millions?* There are hundreds of much-needed medical personnel who are unemployed, with the Department of Health citing lack of budgets as an excuse for such unemployment. Yet the gratuitous wastage and shrinkage in health facilities and the misuse of medication add to this growing scourge. This spans across major state hospitals to Community Health Centres (CHCs) to peripheral clinics, and budgets are exhausted long before the financial year end, placing facilities in an invidious position of not providing essentials and life-saving drugs. When last, if ever, did you or any of your directors-general do a spot oversight visit to a health facility to ascertain even a cursory look at how the facility is being run and the control measures implemented? Do you have any idea as to how drugs are being prescribed to the patients, and at times, misused in the manner in which they are prescribed? Video Player is loading. Play Video Play Unmute Current Time 0:00 / Duration -:- Loaded : 0% Stream Type LIVE Seek to live, currently behind live LIVE Remaining Time - 0:00 This is a modal window. Beginning of dialog window. Escape will cancel and close the window. Text Color White Black Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Background Color Black White Red Green Blue Yellow Magenta Cyan Transparency Opaque Semi-Transparent Transparent Window Color Black White Red Green Blue Yellow Magenta Cyan Transparency Transparent Semi-Transparent Opaque Font Size 50% 75% 100% 125% 150% 175% 200% 300% 400% Text Edge Style None Raised Depressed Uniform Dropshadow Font Family Proportional Sans-Serif Monospace Sans-Serif Proportional Serif Monospace Serif Casual Script Small Caps Reset restore all settings to the default values Done Close Modal Dialog End of dialog window. Advertisement Next Stay Close ✕ The EDL (Essential Drugs List), which is used as a tool from which to prescribe drugs, has become meaningless - oftentimes, many of the drugs are not available due to non-payment to suppliers. Lazy or incompetent doctors (some, not all) prescribe drugs as if it were a grocery shopping list - up to 18 to 20 items per script. Is this even necessary? There are some doctors who simply add items onto a script at the behest of a patient - this goes beyond the pale, especially noting the fact that a doctor should know better, but panders to the pleadings of a patient. Sadly, this goes unchecked, but importantly it ultimately burdens the taxpayer significantly. Have you implemented any strict due diligence at all health facilities in the country to help prevent the theft of medication by staff, in one form or another? The fact that drug suppliers are not paid duly and withhold medical supplies handicaps medical practitioners from effectively implementing proper and cost-effective health care. Ask any state pharmacist the amount of unused drugs that are returned to the facility beyond the expiry date rendering such drugs unusable - strict patient compliant measures and control need to be implemented - are they? Sir, do not use the lack of funds as an excuse - change what is changeable, even if it is not palatable to the unscrupulous who care less about cost, and the availability of funds will increase exponentially. As the minister responsible for a critical aspect of our society, it is incumbent upon you not to be an ivory tower administrator but rather an activist of change and progress, and I hope that you do just that - else our failing state health care system will degenerate even further. I do not want to get started on the National Health Insurance (NHI) - that elephant in the room, in my candid opinion, will become tuskless - in time. THE MERCURY
