It was the deaths of Zinhle Maama, Isago Mabote, Njabulo Msimango, Katlego Olifant, Karabo Rampou and Monica Sebetwana that were the final straw. The children, all under the age of 9, died after eating a packet of chips tainted with a dangerous pesticide, which has since been found in three spaza shops not far from their home in Naledi, Soweto.

Their deaths — and the deaths of 16 other children and the nearly 900 people who were sickened from foodborne illnesses across the country over just two months — sparked outrage and the declaration of a national disaster.  

President Cyril Ramaphosa pulled together the departments of health; trade and industry; agriculture; basic education and small business development, as well as the police and military health services, the National Consumer Commission and National Institute for Communicable Diseases. A ministerial task force rolled out plans for rodent infestation clean-ups, community education programmes and a major push for the registration of small businesses and spaza shops. 

But the government response underscored the complex and sprawling, multi-agency way the nation’s food system is set up. Could part of the fix be a single food safety agency?

Not fit for purpose

Since the start of 2023, more than 3 000 people have got sick with suspected foodborne illnesses, which happen when someone eats contaminated food, whether because of germs or chemicals, including toxic substances. In South Africa, infections from bacteria like Salmonella — usually from meat, poultry, eggs or milk — and Clostridium perfringens, often linked to improperly heated gravy, poultry or other meat, are some of the more common causes of foodborne diseases.

Listeriosis, a disease caused by the microbe Listeria monocytogenes, which had contaminated ready-to-eat meat products, sickened 1 060 people and eventually caused 216 deaths in the country between January 2017 and July 2018.  

A study looking at the government’s response to the outbreak found that South Africa’s food safety system wasn’t “fit for purpose” because of a disjointed handling of the issue, with little interaction between different state bodies and confusion over whose responsibility it was to check that safe food is sold, including by informal traders. 

At the time, Ramaphosa announced plans to create a single agency for food safety. 

But more than six years later, this body has yet to be set up. 

“The work to establish a single food agency requires legislative changes and this will take some time to arrive at the final destination,” says Foster Mohale, spokesperson for the health department.

Work on this began in 2018 when a team from the health, agriculture and trade and industry departments submitted a report to parliament. But the government lawmakers’ term ended before a decision was made and the department will wait to see if the new committee will use the report or start over, says Mohale.

Food safety oversight

For now, making sure the food we eat is safe before it lands on shelves is the job of the health, agriculture and trade and industry departments, with support from the fisheries, forestry and environment department, border management authority and National Consumer Commission.

The health department checks that places that make, serve and sell food follow hygiene and safety rules and respond to foodborne outbreaks. The agriculture department handles the registration of pesticides and imports and exports of animal products, while the trade and industry department oversees the food products entering and leaving the country, ensuring they meet local and international standards. 

One of the authors of a study published in BMC Public Health in July that looked at food fraud in South Africa — when food suppliers deliberately sell goods they know aren’t safe for consumption — says it is that lack of coordinated oversight that allows unsafe food to enter the system. A single control authority, like the Food and Drug Administration in the US, or the Food Standards Agency in the UK, Phoka Rathebe, associate professor of environmental health at the University of Johannesburg, says, would help ensure coordination across the whole supply chain.

Below target

Much of the enforcement of rules meant to ensure that people can trust that their food is safe comes from environmental health practitioners (EHPs). But last year there were just 1 712 of these health inspectors across the country which, for a population of around 63 million, works out to about one for every 37 000 people. That’s far below the health department’s target of one for every 10 000 people, which they say is the norm.  

EHPs are responsible for everything from checking that public water supplies are safe and waste isn’t dumped in places it shouldn’t be to running campaigns to teach communities about things like how to clean their water and use paraffin to heat their homes and cook safely.

Enforcing safety rules that help prevent foodborne outbreaks coming from the informal sector, which is particularly difficult to regulate, is another part of their job.

But in a study among EHPs working in Ekurhuleni, a municipality in Gauteng, less than half of the 61 respondents said that they felt properly trained to handle foodborne outbreaks.

Blame game

Since November, inspections of spaza shops throughout the country found food stored alongside pesticides and fake and expired foods. More than 1 000 outlets, from spaza shops to warehouses, have been shut down since, for running without a licence and not following rules for storing and preparing food.

With a major small business and spaza shop registration drive, the government plans to create a database of informal shops, a move they say will help with regulation. 

“The biggest challenge,” says Mohale, “is that community members would just open [stores] without notifying the municipality. [These cases only] get picked up when there are joint operations or [when] incidents are reported.”

But Leslie London and Andrea Rother from the environmental health division of the University of Cape Town’s School of Public Health don’t believe the problem is solely rooted in informal shops but rather in weak regulations on toxic chemicals and badly run municipalities.

“Everyone wants to assign blame for this tragedy, but spaza shop owners are not the culprits,” they wrote in the Mail & Guardian in November. 

Many townships deal with rodent infestations because municipalities don’t collect rubbish, which builds up in the streets. Residents and business owners turn to cheap pesticides sold at train stations and taxi ranks to keep their homes and shops rat-free.

Rother has been studying these “street pesticides” — chemicals registered only for agricultural use, or banned outright, but sold in old beverage bottles or small packets as a cheap and quick fix to kill rodents — for more than 15 years.

In an op-ed published in The Conversation, she writes that these products end up on the streets because of poor enforcement, a lack of measures to keep children safe (who are especially vulnerable to the harmful effects of contact with pesticides), outdated legislation and the pay-to-access database of registered pesticides, which is run by the pesticide industry.

The agriculture department is inspecting the five manufacturers registered to sell organophosphate, the pesticide that killed the children from Naledi, to find out how it is making its way onto the streets. 

But that won’t take away the pain of the families of the 22 children who died.

“We are hurt as parents, Otlotleng Msimango, the mother of seven-year-old Njabulo, told the SABC. “Even Njabulo’s father, he can’t speak or utter a word.”

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Nearly 5% of the world’s carbon emissions come from the healthcare sector, according to a report launched last week at COP29, the UN’s annual climate change conference — and money for dealing with the disastrous effects of changing weather patterns on people’s health is “urgently needed”. 

South Africa is not yet a member of the Alliance for Transformative Action on Climate and Health, a World Health Organisation (WHO) group, whose plans were put in place in 2021 at COP26 in Glasgow, as a way to help countries make their health services greener. 

Keeping hospitals running adds to the rising level of greenhouse gases, because of the electricity used to power buildings and equipment; fuel needed to transport patients and get supplies delivered and dealing with waste, says Azeeza Rangunwala, coordinator for Africa at Global Green and Healthy Hospitals, a network of people who help healthcare facilities around the world to be more environmentally friendly. 

Burning fuels such as coal and oil to generate electricity releases carbon dioxide. This forms a layer in the atmosphere that traps heat. Because the heat can’t escape, the air heats up — much like in a greenhouse — and, over time, the air gets warmer and warmer.  

Last year, the air temperature was 1.45°C higher than about 150 years ago, when the world started burning coal and oil at a large scale to run factories and fuel cars and planes. It’s dangerously close to the 1.5°C rise in temperature that 196 countries, including South Africa, who signed a legally binding agreement in Paris in 2015, pledged not to exceed to avoid the catastrophic consequences of more floods, droughts and illness.

In South Africa, rules about how many types of modern healthcare products are used are essentially blocking simple ways in which hospitals — of which the government runs about 395 — can cut down on how much greenhouse gases caring for patients puts into the air. 

Here’s why this is a problem.

Waste from hospitals 

The amount of greenhouse gases the South African economy produces is close to 400 million metric tonnes of carbon dioxide a year (a metric tonne is 1 000kg) and makes up about 1% of the world’s carbon emissions. As a signatory to the Paris Agreement, the country has committed to reducing its carbon emissions to between 350 and 420 million metric tonnes by 2030. 

Research shows that hospital buildings are big energy users because they need a constant power supply to keep the lights and equipment on, keep wards and theatres at the right temperature and to heat water. 

In South Africa, coal for generating electricity makes up 70% to 80% of the fuel the country needs to run, adding about 188 million metric tonnes of carbon dioxide to the air a year. 

Another big contributor to carbon emissions is waste from hospitals, says Rangunwala, because it gets collected from facilities by trucks, travels over long distances, and then, by law, is incinerated at high temperature — both being things that run on diesel. Such items include waste like needles, medicine vials and bandages that have come into contact with blood.

Food and supply deliveries, together with transport for staff to get to a health facility, add still more greenhouse gas emissions. 

And food that’s left uneaten or thrown away, and which can make up 20% to 30% of a hospital’s waste, adds extra pressure. Not only were the emissions from making and delivering the food unnecessary but the waste has to be collected and driven away by trucks and then usually gets dumped on landfill sites. Here it breaks down and releases methane, another powerful greenhouse gas, into the atmosphere. 

What is SA doing about it? 

Research from the Food and Drug Administration shows that devices such as forceps used during biopsies, drill bits and bite blocks for dental work and some fittings attached to instruments used in surgeries done by camera can be safely sterilised and reused. 

But the South African Health Products Regulatory Authority does not allow this because the manufacturers’ instructions say that the devices can be used only once.

John Lazarus, head of urology at the University of Cape Town, has, together with other healthcare workers, called for reusing these devices. But without support from the regulator, he says “our hands are tied”.

“Hospitals and individual clinicians would not want to work outside the rules,” he says, and despite the group having met with the regulatory body on the issue, it “has been slow to make a decision”.

Another way to lower the health sector’s carbon emissions is to build so-called green hospitals. These are buildings that run on, for example, solar power instead of electricity generated from coal, or have been designed to benefit from sunlight instead of having to switch on lights or use materials that keep buildings naturally cool in summer and warm in winter. 

New public health facilities such as the Khayelitsha and Mitchells Plain hospitals in Cape Town are examples where this works.

The spokesperson for the Western Cape’s health department, Dwayne Evans, says through their energy-saving programme at pilot sites such as the Red Cross Children’s Hospital and Paarl Hospital, the department has saved about 4 000 tonnes of carbon dioxide emissions since 2022 — the same as about 13 750 homes not having to rely on electricity from coal for a year.

But getting the health sector on board to change how they work and so help slow climate change might prove difficult. 

Says Lazarus: “In general the motivation to transform health for sustainability is not well established in South Africa.” 

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Travelling around Nyandeni, a local municipality in the OR Tambo district in the Eastern Cape, is a bumpy ride. Here, like in most of the province, roads are mostly untarred. 

To get to a clinic, people have to either walk about 20km or take a guruguru (a bakkie that operates as a taxi), which travels to the health facility at 5am and back again at 5pm to take them home.

OR Tambo, which spans an area of about 12 140 square kilometres and has Port St Johns on the Wild Coast about halfway between its southern and northern borders, is deeply rural — and one of the poorest districts in South Africa. About 90% of people here live in so-called last-mile communities — villages and informal settlements that are far from services such as electricity, piped water and healthcare.

On the gravel roads of Nyandeni, you’re bound to see women like Nosizwe Peter, 58, walking in their bright green T-shirts.

Peter is one of 40 mentor mothers in OR Tambo, lay health workers employed by One to One (OTO) Africa, which is a nonprofit organisation that provides maternal and child health services in rural communities. 

But mentor mothers are different from community health workers employed by the health department — because they focus only on pregnant women and new mothers who, like they, are HIV positive. 

The idea behind this peer-support model, which has successfully been rolled out elsewhere in Africa such as in Malawi and the Democratic Republic of the Congo, is that because the mentors themselves have HIV, they understand the issues these new mothers grapple with and, in turn, clients feel more comfortable getting health advice from them. 

Could a programme like this help mothers, in a district where just over a third of pregnant women are HIV positive, stay healthy — and raise healthy children too?

We travel with some of these mentors to see how the system works. 

Twins, a mentor mother and a scale

When Peter arrives at a rondavel in KwaDontsa, she greets 21-year-old Aphiwe Tyhontsi, a mother of twins. 

The two girls, Alizwa and Aliziwe, are 11 months old, content while feeding at their mother’s breast. 

Peter praises Tyhontsi for breastfeeding and then asks her for their clinic cards. 

Breast milk is the best food for infants from birth up to six months, because it’s nutritious, easy to digest and contains antibodies that help protect babies against stomach bugs and ear infections. 

She pulls a scale out of her OTO-branded backpack, sets it on the ground and asks Tyhontsi to stand on it. 

Peter notes down her weight.

Soon one of the girls stretches out her little arms, motioning that she wants to be picked up. Tyhontsi heeds and steps onto the scale once more. After Peter has written down their combined weight, it’s her sister’s turn. 

Peter smiles as she looks at the reading on the scale. 

Both girls, who weighed less than 2.5kg at birth and which can be a sign of development problems, are now just over 9kg — right on target for a healthy weight at this age and showing that they’re growing well.

Then Peter looks at the girls’ clinic cards and says: “If there’s a measles outbreak your babies are at risk.” 

Why pregnancy checks and childhood shots are important

The first thing mentor mothers do is to help HIV-positive pregnant women understand why it’s important to start antiretroviral (ARV) treatment — and stick to it. Research shows that if soon-to-be mothers aren’t taking their anti-HIV medication, they could pass on the infection to their babies in up to 45% of cases.

But apart from that, these peer-support health workers also give women advice on staying healthy during pregnancy, tips on breastfeeding and nutritious foods, go with them to check-ups at clinics, and check that their babies are growing well and get their vaccinations on time. 

Mentors, who get six weeks of training, are recruited from the local area with the help of the chiefs and headmen of the villages — an important part of getting people to accept the programme, given the power these leaders have in their communities. 

Although Alizwa and Aliziwe have had their first doses of measles vaccine when they were six months old, they’re due for the final jab within the next month, by the time they’ll turn one. 

Check-ins like this can go a long way to boost childhood immunisation coverage in the district, which sat at only about 75% in 2022-23, well below both the national and provincial average of about 82%. (If enough children in a community aren’t vaccinated against diseases such as polio, measles and diphtheria, infections can spread quickly lead to a wide outbreak.)

With difficult access to clinics because of poor infrastructure and the rural nature of areas, last-mile communities often lag behind when it comes to things like antenatal clinic visits and childhood immunisations. OR Tambo is one of the worst performing districts in the country when it comes to kids getting their shots.

‘Sometimes the mobile clinic doesn’t come’

For this reason, the mentor mothers programme also has a mobile clinic, where “all of our services come together”, says Emma Chademana, programmes director at OTO Africa.

The truck, which stops at a different village each day, is on its way to Lucingweni today, about 80km southeast of Mthatha. 

Up on the hill on the other side of the bridge that crosses over the Mtakatyi River, waits the pregnant Carmel Vice, 32, with her toddler son. 

Vice, a teacher at a local school, isn’t at work today because she and her son have been feeling sick for a while, but she hasn’t had money to get transport to one of the local clinics. 

Since 2000, the government has been sending a mobile clinic to Lucingweni once a month, “but sometimes it doesn’t come”, says Aaron Makhabola, headman of the village.

But with OTO’s clinic-on-wheels being recognised by the provincial health department as a standalone facility, people are sure that they’ll be able to get medical care at least once every month. 

This is good news for someone like Vice, who can get her pregnancy check-ups at the truck instead of having to travel to the government clinic — or having to forgo a visit if she can’t get the money together.

Research shows that when women have regular check-ups during their pregnancy, there’s a lower chance of their babies dying shortly after birth. 

Early newborn deaths are particularly worrying in OR Tambo, where nearly 13 out of every 1 000 babies born in a hospital or clinic die in their first seven days of life. Compared with the national rate of just under 10 per 1 000, the district’s figure makes it one of the worst performers in the country for this indicator.

Why it’s important to work with the health department 

OTO works closely with the health department, says Chademana. Their mobile clinic offers the same services as what’s available in a state clinic, such as check-ups for patients with diabetes or high blood pressure, pregnancy care and teaching people about living healthy. 

Moreover, the app mentor mothers use to track their client visits is developed by the same company that made the government’s one for community health workers, and when they write a referral for someone to be treated at a hospital, the form shows the health department’s stamp, says Chademana.

“The relationship with the [health] department is critical. We can’t offer services that don’t exist in their system because who will service those clients [if] we leave? It’s important that we work to strengthen the existing system.”

To help with this, OTO has trained 27 of the government-employed community health workers in Nyandeni to support pregnant women or new mothers in the same way as mentor mothers do. Two of these are at Buchele Clinic in Lusikisiki, which has to look after more than 8 400 people in the surrounding villages. 

With the extra training, these community workers help with more than just making sure HIV-positive mothers stay on treatment — they also track their babies’ growth; give shots for vitamin A (which is important for a strong immune system and keeping cells healthy but often lacks in the diet of children growing up in poor households); and help families with eating healthy and getting social support. 

“Before I would just give a child deworming and check their card to see if they’ve been to the clinic. But now I can do more things, like give education on nutrition and take their blood pressure,” says Bukiwe Mpaceka, a community health worker who adopts the mentor mother model.

“If I come into a house and see that there are no vegetables, I advise [the family] on the importance of planting these for nutrition,” she adds. 

OR Tambo is especially hard hit by food insecurity. In 2022, the district had the most deaths and hospital admissions of children under five in the province because they have too little to eat in critical development periods and become very thin (a condition called severe acute malnutrition). 

Moreover, not having a good balance of nutrients such as vitamins, minerals and proteins at a young age can lead to children’s brains not developing well, which makes it hard to concentrate or do thinking tasks like understanding stepwise instructions, and can up the chance for health problems like obesity and diabetes later in life.

First-hand change

Peer support for pregnant HIV-positive women by mothers who also have HIV has been shown to work really well. 

In Nigeria, about 1.2 million women and girls older than 14 have HIV but only a third of those who are pregnant are on treatment to prevent the virus from being passed on to their babies. A study found that women from rural areas who got advice from mentor mothers were almost five times more likely to have stuck to their treatment so well that they were virally suppressed six months after giving birth than those who had help from only general community health workers.

In KwaZulu-Natal, more pregnant women who had support from mentor mothers started taking ARVs than those without such backing. Moreover, women in the programme knew more about how to prevent their babies from getting infected and were also more likely to know their CD4 count. 

But the effect of this support model doesn’t exist on paper alone; communities see the change first hand.

Says headman Sigcau of the Mankosi village: “You won’t find a child born with HIV or malnourished in this village — because of the mentor mothers.” 

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We analysed the numbers released by Health Minister Aaron Motsoaledi and the Special Investigating Unit (SIU) on 24 August at a press briefing to make it easier to understand where what kind of problem occurs — from dodgy lawyers and unethical health workers to just plain fishy cases. 

In 2017, the SIU was called in to look into what was afoot. By July 2024, they had flagged 2 830 cases out of 10 679 in total as fishy and to be investigated. 

Of these, the ones in the Northern Cape cost, on average, four times more per case than in Gauteng, even though the province’s health budget is far smaller than Gauteng’s.

Nearly one in three cases being looked at are from Mpumalanga with KwaZulu-Natal on its heels. 

The third spot is a tussle, because although Gauteng’s claims being investigated are about double that of Limpopo, the value of those in the northernmost province is about a billion rand more. 

But first, some background. 

Where things stand now  

By the end of March, provincial health departments faced about R78-billion in medical negligence cases against them, which is almost 80% of the combined budget for such departments meant to be used for treating people.

About 90% of the total budget that the treasury allocates to health each year goes towards provincial health departments, as they are the ones who roll out the policies the national department develops.

Every financial year these departments start “on the back foot”, Thabelo Musisinyani, head of the unit that takes care of the health portfolio at the auditor general’s office, told Parliament last week. This, she says, is made worse because they have to then borrow from future budgets to pay for medical negligence claims from previous years.

In a decade, from 2012 to 2022, the amount the government spent on paying out compensation for medical negligence grew tenfold — from R265-million to R2.6-billion.

In 2018, claims against the departments sat at R70-billion, which the government wanted to come down to below R18-billion by 2024.

But instead it is now four times higher.

These claims aren’t all legit, though. Because dodgy lawyers have found loopholes in the legal system and state hospitals’ record keeping is not in order, large amounts of money are unnecessarily paid out.

The result of rising claims is a crippling ripple effect: more and more of the coming years’ money is used to cover expenses from previous years, leaving less and less to fund services that people need. 

What do the numbers show? 

1. Mpumalanga, KZN, Limpopo and Gauteng

Mpumalanga has 902 cases under the magnifying glass — nearly a third of the total number being looked at — at a combined value of just over R10-billion.

KwaZulu-Natal is second, with 713 cases to the value of R8.7-billion.

Third spot is Gauteng, but only when measured by the number of cases under investigation — about double that of Limpopo. But when it comes to the monetary value of potential payouts of those claims, the cases in the northernmost province is about a billion rand more than in Gauteng. 

Payouts in medical negligence cases are generally big because they include the cost of future medical care — often in private hospitals, Health Minister Aaron Motsoaledi says — and compensation for possible income the patient would have had if negligent treatment had not disrupted their life. 

The SIU found that some of the fishy claims were from lawyers suing the state for future medical costs even though the patients had already died. 

2. Free State

In the Free State, one of the drivers behind shady claims was stolen medical records, a situation the auditor general had previously flagged as problematic when they found that state hospitals don’t have proper systems to keep track of patient files. 

This opens opportunities for records to be stolen and sold to unscrupulous lawyers, who know that without the files the state won’t be able to argue these cases. Musisinyani says this is one of the reasons why the departments end up losing in court and having to pay. 

3. Northern Cape, Eastern Cape and North West

Even though the Northern Cape only has 20 fishy cases being looked at, each costs, on average, R28-million; compare that with the roughly R7-million per case in Gauteng and North West. 

Moreover, over half the total value of claims in the Northern Cape at the moment comes from only seven cases. Four of these had a combined value of R169-million and were submitted by a single lawyer — who, patients say, they never instructed to lodge a malpractice claim. 

In order to open a case on someone’s behalf, a lawyer needs to be given power of attorney, which means they can act as the person’s legal representative in court. 

Three other claims in this province — for a total of R129-million — involved touting, which is when an unscrupulous professional like a lawyer or nurse tries to recruit patients to sue the state by offering them big payouts.

In the Eastern Cape, claims flagged for investigation are worth about R19.3-million each. The SIU’s findings showed that close to a third of the claims in the province came from a single law firm and had a total value of R600-million. 

But their methods were dodgy, because the firm “pocketed” all of the money the state paid out and the patients “never received a cent of it”, Motsoaledi said at the SIU’s press conference in August. 

4. Western Cape

The SIU confirmed that they received claims data from the Western Cape in August but are still analysing it before they’ll be able to release findings for that province.

More spend with lower budget

Of the ones being investigated, a case in the Northern Cape costs about four times what it does in Gauteng — yet the province gets only about a tenth of what Gauteng does to spend on health. 

That’s because a province’s budget from the treasury is based on their provincial equitable share, which is calculated using the size of its population. The small population in the Northern Cape — about 1.3-million people — means the province has to make do with a fairly small health budget. 

Over the next three years, this is around R20-billion. But about 3% of that would have to cover medical negligence claims up until July 2022, which makes cases filed by dodgy lawyers even more worrying. 

If claims keep on rising and the current trend of dipping into future years’ kitties to pay for these continues, it will hamstring the state’s ability to give people proper health services, says the auditor general’s unit. 

This, Musisinyani said, will mean that the health department will need to decide where they spend their money.

“Our message [to members of parliament] is that there needs to be a way of breaking the cycle, because if we don’t, it is [just] going to be continuous.”

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This comes after a joint press briefing by the health department and the Special Investigating Unit (SIU) on Saturday on the findings from the unit’s ongoing inquiry into 10 679 legal claims against the state’s health departments from 2015 to 2020, amounting to a total of R107 billion. 

This amount is close to half of what the health department’s budget was in that five-year period — about R215-billion — which should best be used for hiring health workers, buying medicine and running hospitals.

The SIU’s work has, so far, saved the health department R3 billion. But if dealing with a dispute between doctors and their patients after treatment didn’t always have to end up in court, it might not have been so easy for dodgy lawyers to exploit the system in the first place.  

An “explosion” in legal cases brought against doctors and hospitals (so-called medicolegal claims) occurred since 2015, the health department said previously, which led to President Cyril Ramaphosa ordering the SIU to look into possible fraudulent claims two years ago. 

So far, the investigators have found cases of unscrupulous lawyers getting patient records illegally, claims having been made on behalf of patients without their knowledge or patients being “tricked” into suing the state.

Turning to the court to decide on a medical negligence claim is not necessarily in patients’ best interest, said Motsoaledi.  

“Because in court, it depends [on] who has fired more bullets or who has fired the first shot that hit. So we want to change that method.”

The silicosis class action

Something that could yield a better outcome is to opt for mediation — and “we have seen it work”. This was a reference to the out-of-court settlement reached between mineworkers and mining companies in a class action on behalf of workers who had developed silicosis as a result of their labour.

Silicosis is an incurable lung disease caused by breathing in large amounts of dust from grinding or drilling into rocks, like during mining. 

Mediation is a process in which two opposing sides negotiate a settlement with the help of a qualified independent adviser so that they come to an acceptable agreement together instead of having to go to court. 

For example, in the silicosis class action, the miners’ representatives and the different mining companies decided to talk to each other rather than present their case to a judge. After three years, a settlement was reached that let the miners who developed lung disease as a result of their work get compensation payouts to cover their and their families’ costs from a trust fund set up as part of the settlement. 

Negotiating the deal meant the case didn’t need to go through the court process, which may not necessarily have ruled in the miners’ favour, and could have meant their losing out on compensation.

But mediation is not common in medical disputes — despite a 2020 rule (called R41A) that is meant to guide legal proceedings in civil matters. The rule says that negotiation must be considered as a way to resolve a dispute first, before the case is taken to court. 

If a case does end up having to go to trial, the lawyers need to show that their clients had considered mediation but that there were valid reasons why it couldn’t work and the case therefore has to be argued before a judge. 

Settling disputes faster

With R41A, the idea is that fewer cases will end up unnecessarily clogging up the courts, likely bringing down the high costs that come with lawsuits, and get disputes resolved faster.

An analysis of 19 medical lawsuits by the South African Law Reform Commission (SALRC) found that it took anything from one year and six months to as long as 16 years and one month to get to a judgment. In fact, three-quarters of the cases took longer than five years to draw to a close. 

Lengthy lawsuits make costs pile up, as applicants need to pay for the services of an attorney, travelling to court, submitting documents and hiring expert witnesses (when needed). In most cases, lawyers charge an hourly rate for their work, so the more often they have to go to court or the longer a case drags on, the more expensive a case becomes. Sometimes, depending on the outcome of the case, a court can make one party cover the legal costs of the other.  

But the Contingency Fee Act gives lawyers’ clients the option of not having to pay anything upfront or for many billable hours; instead, if the ruling is in their favour, the lawyer is entitled to up to 25% of the payout. 

Because medical malpractice cases often involve large awards as compensation for a patient’s suffering or loss in quality of life, this is an attractive option for unscrupulous lawyers.   

And, said Motsoaledi, while the cap of 25% exists in theory, “in practice we know that many take more”.

The SIU’s investigation found instances of law firms keeping most of the money that the state paid out. For example, for one case in the Eastern Cape the department paid R373 million to a single firm for 22 different claims — but “[the firm] pocketed all the money for themselves”. 

‘Creative potential to find solutions’

Mediation can save time and costs, says Shamal Ramesar, a medical doctor and qualified mediator who heads a nonprofit called Mediation in Motion Mediators (MiMM).

Advisers can charge only up to R6 000 a day as opposed to the up to R6 000 an hour a highly experienced attorney could charge.  

But the outcome of mediation doesn’t always have to be a financial reward, says Jacques Joubert, advocate of the high court and who also works as a mediator. The idea is to settle the dispute in a way that is the best for both parties, which means “there’s a creative potential to find solutions, such as, for example, the hospital or doctor offering further treatment”. 

To encourage people to choose negotiating a deal outside court as a way to settle medical disputes, the MiMM has partnered with the South African Medical Association (Sama) to offer doctors and their patients a free meeting should a conflict arise after treatment.

The MiMM drew up a clause for a pre-mediation meeting that doctors can add to their patient consent forms. If the option for such a meeting is taken up, an appointed mediator will listen to both sides to hear what the conflict is about and then advise on whether it can be solved with mediation rather than going to court. In this both parties can make an informed decision about their course of action.

A study by the United Kingdom government shows that attending a pre-mediation meeting helped people dealing with family disputes to try negotiation rather than a lawsuit.

Participants were interviewed before and after attending a session with a mediator, who gave them information on the process and also assessed whether it would be a good option for their case. Most of the participants decided to negotiate with their opponents, with clients who knew little about the idea of mediation getting the most benefit from the pre-meeting.

Although a part of rule 41A says that if one of the parties in a dispute refuses mediation and rather opts to take the case to court, they may have to foot the bill for the court application, the stipulation is rarely enforced and there are even talks about removing it in special cases. 

That’s where a pre-mediation meeting clause, like the one doctors have an opportunity for through the mediation pilot project, could come into play. 

In fact, a discussion paper by the SALRC recommends including this type of clause in patient admission forms to help people consider mediation instead of going straight to court, especially in the public sector, where negligence claims are high.

Says Ramesar: “You’ve got nothing to lose in this meeting. And as it’s free and voluntary, and able to be stopped at any stage, why not give it a try?”

 This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

The draft of South Africa’s new energy plan could throw a spanner in the works when it comes to lowering its contribution to global warming by 2050 — and in the process cause about 32 000 unnecessary deaths, says Lauri Myllyvirta, a senior analyst at the Finnish air quality nonprofit, Centre for Research on Energy and Clean Air (Crea). 

The 2015 Paris Agreement — an international commitment by member states of the United Nations to curb climate change — set as the 2050 deadline for when the world has to reach “net zero”. 

By the “net zero” stage, the amount of carbon that is released into the air from, for example, burning fossil fuels such as coal and gas should balance the amount that can be taken up by ecosystems, for instance, through plants that use carbon dioxide to grow and the gas dissolving in the oceans. 

According to one of the scenarios in the energy plan, South Africa needs to keep its coal-fired power plants running for up to 10 years longer than their shutdown date to keep the lights on in the country.

This means the country finds itself facing two seemingly irreconcilable demands. 

State-owned, national electricity provider Eskom must have about 70% of the electricity its power stations can generate available on the grid by 2030 (the energy availability factor, EAF) to ensure that there’s enough electricity to put an end to load-shedding and, in turn, help the economy grow. 

Yet over the past seven years, the EAF has steadily dropped — from 78% in 2017 to about 53% by March 2024 — meaning that every year there’s less electricity available than what is needed. 

To get to a point where the country will have enough reliable electricity available, it seems logical to extend existing power stations’ lifespan, instead of taking them out of service once they’re too old, experts argue. (On average, Eskom’s fleet of coal-fired power stations are about 45 years old, which is close to the 50 years they’re designed to run.)

Only, this doesn’t line up with South Africa’s plan, as one of the parties to the Paris Agreement to do its part in keeping global warming to below 1.5°C. This means the layer of air close to the Earth’s surface shouldn’t get more than 1.5°C warmer than it was before the start of the Industrial Revolution about 150 years ago. 

For this to happen, the government, like other countries’, will have to cut the amount of carbon released into the air by a great deal, to help the world lower emissions by 45% by 2030, says the United Nations Intergovernmental Panel on Climate Change and get to “net zero” by 2050.

Given that 70% to 80% of South Africa’s electricity comes from burning coal, lowering carbon emissions and simultaneously ramping up electricity supply seem unattainable.

But if South Africa continues to rely on coal for power, people’s health will suffer.

A tug-of-war — with no winners

Burning coal puts carbon dioxide into the air, as well as other pollutants such as sulphur dioxide, nitrogen oxides (NOx) and tiny bits of solid material or droplets of liquid (called particulate matter). When inhaled, these chemicals can damage your airways and lungs and, over time, make it difficult to breathe. 

A study by the Centre for Research on Energy and Clean Air (Crea) shows that running coal-fired power plants in South Africa for eight years more than planned will cause 15 300 people to die from air pollution health problems such as lung cancer, asthma and heart disease, with pregnant women and children being especially likely to develop these conditions. 

Given changes to the country’s air quality standards in 2020, emissions from burning coal may not contain, per cubic metre of air, more than 500mg of sulphur dioxide, 750mg NOx and 50mg of particulate matter. But Eskom has missed a 2020 deadline to meet these requirements, and was given an extension by the department of forestry, fisheries and the environment to get six of its 17 coal-fired plants up to scratch by 2025. 

Yet the tug-of-war between having a stable electricity supply and healthy citizens continues — and seems to be stalled in a stalemate. 

Although the new draft of the energy plan notes that meeting the air quality standards will make it difficult to supply enough electricity, it doesn’t offer any firm plans for how this can be solved, says Ntombi Maphosa, an attorney from the Centre for Environmental Rights, because “it doesn’t address the issue in detail, or analyse the costs of illness to the public health system [or] the economy, or the cost of lives lost”.

Clearing the air

According to Eskom’s shutdown plan, power plants that have reached the end of their lifespan should stop working and then, in time, be broken down. This is because it becomes too expensive to keep on fixing and maintaining old equipment such as boilers, pipes and turbines used to generate electricity, or update them by installing newer, modern machinery — R400-billion if all 17 coal-fired power stations have to be fitted with new equipment that reduces the amount of pollutants pushed into the air.

But cost isn’t the only problem; efficiency also comes into the mix.

Burning coal releases a lot of energy that can be turned into electricity with simple technology and in a facility that covers a fairly small area. You can’t get the same amount of electricity from solar or wind energy from the area that a coal-fired station occupies, though, nor can it run 24 hours a day. This means that even if an old plant is converted to handle renewable energy sources, it won’t be able to add the same amount of electricity to the grid as it did when it burned coal. 

For example, the Komati power station, halfway between Middelburg and Bethel in Mpumalanga, was shut down in 2021 and the site is being converted to use renewable energy sources. But it will probably add only 350 megawatts of electricity to the grid, compared with the 1 000MW it was capable of churning out when running at full steam from coal, says Thevan Pillay, general manager of the station.

The government therefore wants to hold off on shutting down all plants that were due to be put out of service after 2035 by 10 years, until 2045. The state says this route will have “the lowest new build requirements and adequately maintain security of supply”, although carbon emissions will “remain high” in this period.

Delays now will cause deaths later

Eleven of Eskom’s 17 coal-fired power plants are in Mpumalanga.  

“People living there [Mpumalanga] can feel and smell the sulphur in the air,” says Myllyvirta.

Sulphur dioxide, which smells like a match that has just been struck, causes irritation in the throat, and inhaling it for a long time can lead to permanent difficulties in breathing.

Bhekisisa previously reported on how years-long exposure to pollution in Secunda, a town in Mpumalanga with the dirtiest air in the country because of Eskom’s coal-burning plants, has affected Khehla Mahlangu, 52. Today, he struggles to breathe when he walks or when sleeping, and he had to stop working as a manual labourer 17 years ago because of his health problems.

Research shows that air pollution of the kind produced by power stations is dangerous, can lead to a loss of sense of smell and heart problems.

In 2023, Eskom emitted close to 1.5 million tonnes of sulphur dioxide and almost 130 000 tonnes of particulate matter. 

“Breathing becomes harder each day,” Mahlangu told Bhekisisa in November last year.

Why 32 000 deaths?

Delaying the shutdown of power stations that were due to start closing before 2030 by eight years, will probably push out the shutdown of other coal stations to a later date too, the  study found. In such a scenario, which is similar to the new draft energy plan, there would probably be more than 32 000 deaths. Of these, 13 000 could come from inhaling particulate matter, 6 100 because of nitrogen oxides and 13 000 because of sulphur dioxide. 

To work this out, researchers used Eskom’s emissions data for 2022 and assumed that the numbers will be the same until the plants are retired.

They then used a model of air movement to figure out where the emissions go, looked at South Africa’s health data such as asthma cases in children, strokes or deaths from lung cancer and projected what the effect of being exposed to the dirty air would be on people’s health. 

But the flip side is also true: retiring plants prevents deaths, Crea’s analysis shows.

In the three years since the Komati power station has been offline, an estimated 220 deaths from air pollution have been prevented, as well as 760 asthma emergency room visits and 360 preterm births.

Recourse 

In most countries where air pollution has been tackled successfully, curbing emissions from coal-fired plants is a large part of their strategies, says Myllyvirta. But South Africa’s regulations are weak, and so the health of people living near coal-fired power stations suffers.

For example, in China the limit for sulphur dioxide emissions is 35mg per cubic metre of air, a target they can reach because most of their coal power stations are fitted with special filters that catch sulphur dioxide and stop it from being spewed out into the air. 

In contrast, Eskom is allowed to emit 3 500mg of sulphur dioxide per cubic metre from its older plants (because it would be too expensive to install such filtering devices at these facilities) and 500mg/m³ from its newer ones.

Legally, very little will happen if South Africa doesn’t reach net zero by 2050, because the Paris Agreement asks signatories only to submit their planned targets every five years but doesn’t force member states to comply with them. 

But this doesn’t mean communities in areas with dirty air can’t take action, says Maphosa.

In 2022, the North Gauteng high court ruled that poor air quality in the part of Mpumalanga where big air-polluting industries such as Eskom and Sasol are, denied residents of a group of municipalities, including Lesedi and eMalahleni, their constitutional right to living in a healthy environment.

The court ordered the government to pass regulations that would force industries to put measures in place to lower air pollution on the Highveld and give people cleaner air to breathe. 

Maphosa concludes: “Communities can use this order to demand industries to comply with the law, and to show them that [they] are violating [people’s] constitutional rights.” 

This story was produced with support from Internews’s Earth Journalism Network.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

Unemployed doctors aren’t the health department’s only problem; those who do work in state clinics and hospitals are heavily underpaid, says the South African Medical Association (Sama).

Yet, South African government doctors earn up to three times more in a month than what some make in a year in other middle-income countries in Africa, such as Kenya and Nigeria. 

On Wednesday, Finance Minister Enoch Godongwana allocated just over R15 billion to the health department to help it deal with its staff crisis in government health facilities — and create positions for the close to 700 unemployed doctors  who have recently graduated from universities.

The department will have R848 billion to work with over the next three years. Of this, R11.6 billion will be to cover the 7.5% wage settlement from last year and an extra R3.7 billion to pay salaries in the current financial year.

But while the government is scrambling to get enough money to ensure that all 694 unemployed doctors, as well as recently graduated healthcare professionals, are employed, Sama says the country’s public sector doctors aren’t paid enough.

At a media briefing ahead of Sama’s annual conference in mid-February, Mzulungile Nodikida, CEO of the association, said that a study commissioned by them shows that those doctors who are already employed by provincial health departments “are earning 2015 salaries”.

The study found doctors are experiencing “cost-of-living pressures” but also concedes that their salaries are “above what other similar income-level countries pay their doctors”.

For example, in Kenya medical interns were paid around Ksh122 000 and Ksh145 000 per month (including risk and housing allowances) according to the 2013 Salaries and Remuneration Commission’s allowances for government employees. This works out to around R16 000 to R19 000 a month, compared with the almost R28 000 a medical intern earned monthly in South Africa that year.

Medical interns are medical students who have completed their degrees but still have to complete two practical years in a government health facility under the supervision of staff who work at a state hospital.

Similarly, an entry-level medical officer (which, in South Africa, means  you have completed two years’ internship and a year of community service) was paid Ksh250 000 (about R32 500) a month in Kenya from 2013, whereas their South African counterparts earned almost R62 000 per month.

Salaries for doctors in Nigeria — which is experiencing a large-scale exodus of doctors — are even lower.

Data from the National Salary, Income and Wages Commission in Nigeria shows that an entry-level doctor earns roughly NN1.8 million (about R22 000) per year, compared with someone in a similar post in South Africa getting more than three times that a month — in other words, South African medical officers earn 40.9 times more than Nigerian entry-level doctors (R900 000 versus R22 000 per year).

The health department says it has not yet looked at why Sama claims doctors should earn more. But, says Foster Mohale, spokesperson for the department, they have “had meetings [with Sama] and we are planning to review our salary scales”.

How are increases calculated? 

After negotiations between the government and trade unions last year, the department settled on a 7.5% annual salary increase for all its workers (as for the rest of government employees). This took a large chunk out of departments’ budgets, leading to having to cut costs elsewhere, the health department says.

Ironically, getting the money for the salary increases contributed strongly to empty doctors’ posts at state hospitals not being filled, according to the health minister Joe Phaahla. More than 70% of the health budget is spent on paying salaries, Phaahla said earlier this month in response to the South African Medical Association Trade Union, a watchdog for healthcare workers’ rights. According to the union more than 800 qualified doctors were unemployed at the time but the health department’s follow-up count was closer to 700.

In 2009, the health department implemented occupation-specific dispensation for its employees. 

This is a table that states the basic salaries for government workers across different departments given their skill level and expertise. It was set up specifically to keep skilled professionals, such as doctors, in the government service by making sure they get salary increases that align with their field of expertise and experience so that they can plot a well-paying career path working for the state. 

Each post in which doctors work has different levels, with a specific basic salary linked to it. For example, an entry-level medical officer would be on a Grade 1 salary, which sits at just over R900 000 a year. A medical officer is a doctor who has completed their mandatory two-year internship and a year of community service and works at a public sector hospital.

After five years’ experience in the position, and depending on their performance, they can move on to a Grade 2 salary in that post and earn a basic starting salary of just over R1 million. Grade 3 medical officers earn between R1.2 million and R1.5 million a year.

Keeping up with inflation? 

The Sama-commissioned study suggests that money is a big issue. Like all other public servants, doctors get a salary increase every year, yet the study notes that doctors have felt “a significant erosion in income levels” over the past few years because of small increases, particularly, they say, considering “inflation as well as cost-of-living pressures”.

Between 2013 and 2019, yearly increases were above inflation but in 2020 the government implemented a salary freeze to keep its wage bill in check. 

For two years after, increases have been below inflation: 1.5% in 2021, against an inflation rate of 4.5%, and a 3% increase in 2022, while inflation sat at 6.9%. 

“If you’re to retain the current doctors, then you need to compensate [them] appropriately,” said Mvuyisi Mzukwa, chairperson of the medical association trade union’s board.

However, money isn’t the only issue that stops doctors from working for the state. Long working hours because of too few personnel and safety concerns, both at urban and at rural facilities, were also mentioned as deterring doctors from staying in public service.

More than 70% of South Africans use government facilities, yet there are only about three doctors for every 10 000 patients in the public system. This means the doctors who do work in state hospitals have a heavy workload. 

A 2021 study showed that working almost 60 hours a week is common, contributing to more than 80% of these workers experiencing burnout. Burnout is job-related stress which can cause exhaustion and negative reactions to patients.

“Doctors in South Africa frequently contend with heavy workloads and long working hours … making maintaining a healthy work-life balance challenging,” said Mzukwa. 

Safety at state facilities is also a problem. Between 2017 and 2022, around 200 violent incidents at public hospitals were reported across four provinces — and that’s only security issues that were big enough to get noticed.
In response to this week’s budget announcements, Sama says they hope enough funds will be put towards dealing with “the shortage of doctors in hospitals and the plight faced by medical practitioners where salaries have been eroded by inflation over the years”.

The medical negligence claims of close to R900 million paid out in only one province in a recent financial year would have been enough to employ the country’s 694 unemployed doctors, Health Minister Joe Phaahla announced on Monday during a press conference.

Although Phaahla didn’t name the province, a 2023 report from the auditor general shows that in 2021, the Eastern Cape paid out almost R867 million in claims, while the salary bill for 694 newly qualified doctors (in 2023) would have been about R838 million. 

But Phaahla did admit: “It is a paradox. On the one hand, we’re dealing with amounts of money being paid out for claims, while at the same time we’re unable to employ people who help to reduce this.”

In 2024, the South African Medical Association Trade Union, the watchdog for health practitioners’ rights, told Phaahla that they had at least 800 unemployed medical doctors on their records. Phaahla said this number dropped to 694 after the list was double-checked against the state’s employee database, which showed that these doctors had completed their community service on 31 December. 

One example was Sunhera Sukdeo, who graduated cum laude from the University of KwaZulu-Natal in 2023. In early January, she wrote in the Daily Maverick: “It is now January 2024. I am a cum laude medical doctor. I am sitting at home unemployed. But I am not alone — most of my peers are in the same boat as I am.” 

To this, the deputy director for human resources in the national health department, Percy Mahlathi, responded: “The problem that primary employers, the provincial departments of health, face is the struggle to receive adequate budgets. The current financial squeeze felt by every government sector and the country impacts on the resourcing of health services.”

Phaahla says 239 medical officer positions have now been advertised and 400 more will follow in the next few months. (A medical officer is an entry-level GP who works in the public health sector). Most of the positions are in Gauteng, Mpumalanga, Free State and the Eastern Cape. 

Ironically, universities have, in less than a decade, increased the number of medical interns they’ve trained by about 60% — from 1 470 to 2 365, Phaahla said — to address the doctor shortage in government hospitals and clinics, but the treasury has not increased provincial health departments’ budgets at the same pace. As a result, they don’t have budgets to employ the increasing number of graduates, despite many vacant positions. (Medical interns are medical students who have completed their degrees but still have to complete two practical years in a government health facility under the supervision of staff who work at a state hospital.)

Provincial health departments spend 70% of their budgets on health worker salaries, but it’s not nearly enough, according to Phaahla. 

In 2021, about one in seven doctors’ positions in hospitals were unfilled, while one in five positions for doctors were vacant at clinics. Given this shortage of professionals in the public sector and that more than 70% of South Africans use government facilities, there are about three doctors for every 10 000 patients.

Because of the increase in the number of medical students universities trained from 2018 to 2023, the state had to find that money to pay 895 more interns within five years, which, according to Phaahla, amounted to just over R800 million at a salary of R900 000 per intern a year (this includes overtime). 

The number of community service doctors, who earn about R1.2 million a year (R1.3 million if they work in a rural area), grew by almost 60% too between 2020 and 2024 (from 1 340 to 2 101), which meant the government had to fork out an extra R913 million for their salaries. 

Phaahla warns that the pressure on the health department’s purse is made worse by a 7.5% increase in public health worker salaries, negotiated between the government and trade unions in 2023, which means fewer new workers can be appointed.

“We received around 65% of the additional costs [caused by the salary hike]. So it was a bit of a cushion, but we still needed to find within our budget the remaining 35%.”

Phaahla warned there’s no “automatic placement” for qualified doctors in the public sector: 

“[While] we wish that [employing newly qualified doctors] would be seamless, we must take into consideration that, once [a doctor is] out of the regulated training and community service, [they] are almost like any other profession: when [you’ve] completed all your training, you are going to [apply] where opportunities are.”

A health system in crisis? 

Pressed about whether the department’s funding woes are plunging the public health system into crisis, Phaahla said “it’s really a choice of description” as to what you call a crisis.

But in December, a committee of deans representing health sciences faculties from universities across South Africa warned that failing to fill community service posts — all health profession graduates must complete this mandatory year or two of work — could lead to exactly that in future.

Why?

Because not having enough money available for community service posts will affect the quality of care for patients, especially in rural areas — the exact communities the in-service training programme was supposed to help, they wrote in a statement.

“We already have poor provision of [these types of] services across our system and community service appointments are often the only care that our people get,” Lionel Green-Thompson, dean of health sciences at the University of Cape Town and chair of the South African Committee of Medical Deans, told Bhekisisa.

The money crunch affects staff across all health professions, not only doctors. Since 1998, newly graduated health workers such as dentists, physiotherapists, radiographers, dietitians and environmental health practitioners have been required to work at public hospitals or clinics before they’re deemed fully qualified. 

The policy was introduced to make sure that people who use state health facilities, especially those in rural areas, will also have access to specialist and rehabilitation care.

But more so, Green-Thompson explained, medical schools were concerned about posts not getting filled being a regular occurrence. Phaahla conceded at Monday’s briefing that “the pressure on the fiscus did not happen overnight”.

Treasury versus training

In their December statement, the committee of deans said they’re concerned that budget cuts will affect the quality of training for health sciences students — which will have a knock-on effect on service delivery in state facilities. Already, community service placements are determined more by the needs of the facility with less on training and improving the skills of newly graduated healthcare workers. 

Rural facilities in particular don’t have many permanent healthcare workers, because poor conditions such as equipment at hospitals or clinics not working, too few personnel and bad roads making it difficult to get supplies results in it being difficult to keep staff. Many of these facilities therefore rely on the work provided by new graduates doing their community service. 

Although universities have answered the government’s calls to increase the number of graduates in health sciences, provinces are struggling to match the supply with available posts, said Green-Thompson.

“We have called [in the past] for a clearer management of the required financial resources and the emerging numbers of graduates,” he says. 

Green-Thompson added that having graduates sitting at home while they could have been sent to areas in need will leave many patients without access to professionals like speech pathologists and occupational therapists in the public sector.

As Phaahla says: “We are not in the best of situations. We would have preferred to be in a position to employ everybody who wants to serve [in the public sector]”.

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In 2022, the treasury said it would make an extra R1.1 billion available for medical internships and community service positions this year. But now, because of the national purse asking provincial government departments — such as health — to tighten their spending, there might be even less money available to pay for these positions.

A committee of deans representing health sciences faculties from universities across South Africa are worried about how having fewer community service posts filled will affect the quality of care for patients, especially in rural areas — the exact communities the in-service training programme was supposed to help. 

But more so, Lionel Green-Thompson, dean of health sciences at the University of Cape Town and chair of the South African Committee of Medical Deans, said, they’re concerned about posts not getting filled being a regular occurrence. 

This plays off against a background of rural hospitals and clinics already being chronically understaffed. 

According to a 2018 review by the Health Systems Trust “provinces struggle to find sufficient funding to employ all new health profession graduates in CS [community service] posts”. For example, when the Rural Health Advocacy Project looked at these positions in North West and Eastern Cape, they found that posts in urban facilities were filled but those in rural hospitals remained vacant.

The treasury has cautioned previously that if the health department cannot make do with their allocations, “it will have to finance any future shortfalls within its baseline”, read: reprioritise money within the health budget. 

Although all medical interns have been placed for 2024, by December 12, 182 new radiographers, physiotherapists, dietitians, dentists and environmental health practitioners still had no position. Without placements, they won’t be allowed to practise in their fields, as they won’t be considered fully qualified. 

Foster Mohale, spokesperson for the health department, says there are fewer positions because budget cuts from the treasury have forced provinces to limit the spending of money that comes from their cost of employment budget, which pays for medical internship and community service posts.

Since 1998, newly graduated health workers such as dentists, doctors and pharmacists have been required to work at public hospitals or clinics for one or two years, depending on their field, before they’re deemed fully qualified. Doctors have to do two years of internship, while other formal health workers, including dentists and physiotherapists, need to complete one year of community service. 

The policy was introduced to make sure that people who use state health facilities, especially those in rural areas, will have access to specialist and rehabilitation care. 

Money and worries

Provinces get money from the national government’s purse, called provincial equitable shares, to run their districts. In this allocation, the amount that can be spent on employees’ salaries is capped and is called the cost of employment budget.

To help fund community service posts and clinical training for graduates, provinces also receive a conditional grant called the human resources and training grant (HRTG), which is separate from the cost of employment budget. 

Conditional grants are funds given to provinces to provide specific services that are not included in the initial money they receive from the treasury and can’t be used for any other purpose.

With the HRTG expected to reduce from around R5.48 billion to R5.3 billion at the end of 2024, deans from health sciences faculties around the country are worried that funding woes will compromise the quality of healthcare services even more.

Figures from the World Health Organisation show that there’s only about one dentist for every 10 000 people in the country, with about a quarter working in government hospitals or clinics. 

According to the South African Society of Physiotherapy, there’s only one physiotherapist for almost 7 000 South Africans. By April 2020, over 8 000 physiotherapists were registered in the country, but only around 1 500 worked in the public sector. 

Research shows that, ideally, the country needs an extra 2 267 dentists by 2030 if every South African were to have access to oral healthcare. To meet the physiotherapist needs, there would need to be three to four physiotherapists for every 10 000 people who use government hospitals and clinics. 

The decline in community service placements for clinical workers other than doctors, says Green-Thompson, could leave underserved parts of South Africa without access to healthcare that falls outside the scope of what a doctor offers. 

“We already have poor provision of [these types of] services across our system and community service appointments are often the only care that our people get.”

A place for everyone — or not

Amy Jones*, 23, is a case in point. She will graduate as a dentist this month. Yet she won’t be able to practise — because she doesn’t have a spot at a state hospital to do her community service next year, essentially extending her training and denying patients her care.

Jones, along with 10 385 other final-year health science students, applied with the national health department to do their 2024 community service. Although her classmates received SMSes in November to say that they had been placed at hospitals and clinics around the country, she got nothing.

Despite the country struggling to place graduates such as Jones, there are already too few such staff in public hospitals.

Towards the end of their final year, all health sciences students need to submit five choices, across three provinces, and including rural areas, for a facility where they’d like to do their community service or internship. The health department looks at what type of clinical staff these facilities need as well as how much money is available to fund their posts.

The department then allocates students to a hospital or clinic, followed by an offer letter from that facility’s provincial health department to confirm their position and that they’re expected from January 2024.

Announcements about allocations started going out on 23 November, but like Jones, some students didn’t get any news.

Graduates doing their internships and community service are paid by provinces through the HRTG.

In the Western Cape, expected budget cuts to the HRTG will affect the placement of more than 50 students in community service posts — including medical officer and pharmacist positions — for 2024’s mid-year placements, says Dwayne Evans, assistant director of communications for the Western Cape health department. (Students who were not placed or didn’t meet the requirements for the January intake can apply to be placed in a second round in July.)

The treasury’s cuts will also affect the training of South Africa’s future doctors, as a 10% cut for 2024 will leave more than 87 000 university students across disciplines without funding for their fees, the National Student Financial Aid Scheme (NSFAS) announced in a presentation last month.

The state-funded bursary scheme pays for students whose combined annual household income is below R350 000, and covers their university registration costs, tuition fees, study material and accommodation, as well as giving them a monthly allowance to use on food and transport to university. 

Funding challenges at NSFAS have often left students, including those from health sciences, without their food and living allowances, says the committee of deans in a statement, which could make it harder for them to focus on their studies.

At home or in the hospital?

The committee of deans is concerned that budget cuts will affect the quality of training for health sciences students — which will have a knock-on effect on service delivery in state facilities. Already, community service placements are determined more by the needs of the facility, with less of a focus on training and improving the skills of newly graduated healthcare workers. 

Rural facilities in particular don’t have many permanent healthcare workers, as it’s difficult to attract them to these hospitals, and often rely on the work provided by new graduates doing their community service — at the expense of patients’ needs in underserved communities. 

Dental diseases, for instance, are common in South Africa. Over 40% of children under the age of nine suffer from untreated cavities in their baby teeth. In young children, untreated cavities are painful and can cause infections that make it harder for them to eat, speak and learn, especially as children who don’t get the needed dental care miss school more often and get lower marks than children who don’t.

Although universities have answered the government’s calls to increase the number of graduates in health sciences, provinces are struggling to match the supply with available posts, says Green-Thompson.

“We have called [in the past] for a clearer management of the required financial resources and the emerging numbers of graduates,” he says. 

Another worry is that having no posts for graduates goes against the country’s Human Resources for Health Strategy, which is the government’s commitment to investing in the country’s health workforce to prepare for the National Health Insurance fund.

Green-Thompson adds that having graduates sitting at home while they could have been deployed to areas in need will leave many patients without access to professionals such as speech pathologists and occupational therapists in the public sector.

Budget cuts

Mohale says the health department is working with provinces to get them to create more positions by 31 December for the 182 students without posts. 

Health sciences graduates need to register with the Health Professions Council of South Africa (HPCSA) before they can begin their community service. Christopher Tsatsawane, head of corporate affairs at the council, says they receive these applications directly from universities. 

To prevent funding issues from blocking graduates from registering, universities are working with students whose fees for the 2023 academic year have not been fully paid by the state bursar through acknowledgement of debt agreements, says Green-Thompson. 

According to these agreements, students will start paying their own fees next year via debit order unless NSFAS pays their balances first. The university then sends students’ names to the HPCSA, confirming that they have completed their qualifications.

“The HPCSA can only register those confirmed eligible and will not necessarily know of graduates that may have been [financially] excluded,” says Tsatsawane.

The committee of deans is recommending that the health department finalise discussions with the treasury ‘“to protect the health sector from budget cuts”.

*Not her real name

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

The $5 billion (about R92 billion) needed every year for the next four years for tuberculosis vaccine research is the only way to give future generations a shot at ending TB, experts at the World Conference on Lung Health in Paris said on Thursday. 

United Nations member states, including South Africa, pushed for this in their declaration at the UN General Assembly in September.

And with the world having recorded the most new TB cases in almost three decades last year, according to the new Global TB report, there’s all the more reason for speeding up the quest for a new jab.

A vaccine that is even just 50% effective — such as the promising M72/AS01E candidate — can save 76 million people from getting TB in 25 years, a 2022 analysis by the World Health Organisation (WHO) showed. One that is 75% effective can push the number up to 110 million. 

At the moment, the bacille Calmette-Guérin vaccine is the only one we have. It sits in the 75% efficacy sweet spot — but the snag is that it has to be given to children who don’t have the TB germ (in South Africa all babies get the jab at birth) and lasts only for about 15 years. This means it doesn’t protect adults and teens, who make up most of the world’s TB cases. 

Earlier this year, the Bill & Melinda Gates Foundation and the Wellcome Trust announced that they will jointly give more than R10 billion to get M72/AS01E tested on thousands of people in clinical trials, a move that could get the world a step closer to a new jab. 

Having different vaccine options to choose from is important, because some may only work on a certain group of the population and so having more than one leaves a bigger number of people protected. 

A small pharmaceutical start-up in Cape Town is helping. 

In October, Petro Terblanche, head of Afrigen Biologics told Bhekisisa at the Grand Challenges Annual Meeting in Dakar, Senegal, that they and a team of South African scientists are working on a new TB shot using mRNA technology. They’re building on what they’ve learnt about making an mRNA vaccine against Covid, similar to the one developed by US-based pharma company Moderna. 

But figuring out how to make this type of vaccine from scratch isn’t an easy feat. Terblanche gave five lessons they learnt over the past two years. 

 1. Be willing to adapt your plans 

mRNA is the genetic code that tells a cell in your body how to make proteins. If used in a vaccine, it can prompt the body to make antibodies against an infection. 

Using mRNA to design a new jab against a disease makes the development process, which can usually take up to 15 years, much faster. Moreover, producing such code-based vaccines doesn’t need large labs, which makes the technology a good option to help poorer countries set up facilities for manufacturing shots themselves. 

To help with that, Afrigen was chosen to head the WHO’s mRNA vaccine tech transfer hub in mid-2021. 

But overcoming intellectual property laws is a nightmare, says Terblanche. That’s because they apply to everything that goes into producing, say, a vaccine or a medicine (like this new anti-HIV shot), not just the final product. 

Intellectual property laws govern how companies can market the goods they invent. For example, a patent can give a single company exclusive rights to make and sell a product in a country without competition for up to 20 years. To make the final product pharma companies either have to sign a voluntary licence, in which the patent holder gives them permission — at a fee — to manufacture the drug based on their method, or be sure to get all the ingredients and equipment from suppliers who aren’t bound by the patent and develop the method themselves.

Afrigen had to overcome this hurdle early on in developing their Covid vaccine candidate. They needed to order a chemical used to make lipid nanoparticles, a fatty substance in which the fragile bits of genetic code are wrapped to help to get them into the body’s cells without breaking down. 

But because another vaccine manufacturer holds the patent in South Africa for this essential material used in making this type of jab, Afrigen wasn’t allowed to buy it to make their own product, which derailed their development process, says Terblanche.

So they had to rethink their process and search for an alternative.

This led them to a Chinese supplier of the chemical needed to make the tiny fat droplets and who has freedom to operate because the patent to the Covid vaccine and the materials needed to make it doesn’t apply in China. 

The product was just as good as the one they could have bought locally — with an added bonus of being much cheaper. 

Says Terblanche: “Be prepared to find alternatives.” 

2. Tap into a network of experts

When Afrigen’s scientists started setting up their lab, they had to learn how mRNA technology works real fast. They had lots of experience in working with vaccines — but none in using mRNA to make a jab.

Having a network of experts is crucial when deciding to begin producing vaccines, says Terblanche. “If you’re a start-up company, and you don’t have an ecosystem around you, it’s very difficult.”

In Afrigen’s case, their support system is made up of contacts both in and outside the hub, such as the Medical Research Council, local vaccine manufacturer Biovac and the Medicines Patent Pool. They also work closely with research institutes such as a group at Wits University and biotech companies like Univercells in Belgium.  

By drawing on knowledge from different experts in their network, Afrigen was able to learn how to use the tech. Taking part in online webinar workshops every week, scientists at the Cape Town lab were taught how to use the mRNA platform. They also learnt how to successfully get millions of copies of short strings of mRNA by growing bacteria in a special tank, called a bioreactor. (The bacteria contain tiny rings of genetic material for making mRNA and their multiplying in the bioreactor creates something of an mRNA factory.) 

As part of a deal with Quantoom Biosciences in Belgium, Afrigen is testing a new way of getting mRNA ready for use in vaccines — at a fraction of what the method used by other manufacturers of these types of jabs cost while maintaining the same quality, says Terblanche. 

They also drew on researchers at universities, such as a group from Wits University who has worked with mRNA technology in developing gene therapy for cancer. Both experienced academics and postgraduate students in fields like biochemistry, microbiology, genetics and processing engineering were recruited from some of the local universities to be part of Afrigen’s project. 

Says Terblanche: “The fact that we [South Africa] invest in building [scientific] research and development skills at our universities, allowed us to pull people into the [vaccine manufacturing] industry.”

3. Be prepared for the unexpected

When Afrigen was awarded the bid to host the hub in June 2021, the initial plan was for them to get tech transfer from an international drugmaker who was already making mRNA Covid vaccines. This meant they would get all the tools they’d need to rapidly develop the final product, like equipment lists, instructions on how to set up a lab and the methods to make the jabs. 

But the Ikea-like flat pack didn’t materialise.

In October 2021, they were told they’d have to go it alone. “We were working under time pressure: we had to build a facility, qualify it [which means the building has to be certified to develop the product], make the vaccine and train people, all at the same time,” explains Terblanche.

This meant they had to use information like patents and research articles that were available publicly and work back to figure out their own way to make the vaccine. Despite many unexpected hiccups, they managed this in three months after opening the doors of their facility in December 2021. By February the next year, they had produced the first batch of a lab-scale vaccine (this is a small amount of the drug that can be tested in the lab to see if it works as planned).

Tests in mice show that the vaccine candidate — which they called AfriVac 2121 — stops the SARS-CoV-2 virus (the germ that causes Covid) from multiplying in lung tissue just as well as current commercial vaccines and was better at prompting the animals’ immune systems to produce antibodies (which fight infections) than the jab it was compared to. 

4. Don’t be afraid to do new things 

A Pfizer/BioNTech collab resulted in a successful mRNA Covid shot being produced in just nine months — much faster than the conventional cycle of vaccine development. Producing a shelf-ready product so quickly came off the back of about 15 years’ experience in working with mRNA technology for making cancer drugs.

Although it took Afrigen three months to develop a vaccine candidate that was worth taking further because of promising early lab results, the team were navigating uncharted territory in getting to a jab that would be ready for clinical trials in humans. 

South Africa has never had facilities that produced vaccines from development to manufacturing, so getting a licence for this from the country’s medicines regulator, the South African Health Products Regulatory Authority, was an unknown, says Terblanche.

The Medicines and Related Substances Act says that to produce vaccines for humans a manufacturer needs to have a Good Manufacturing Practice (GMP) certificate. Having these credentials means that the facility and all the processes used in making the product are of high enough quality to be sure it’s safe for human use. 

To scale up from being a lab, which can only produce proof-of-concept vaccines, to a GMP-certified facility that can make commercially shelf-ready jabs, there are more than “700 standard operating procedures, the use of 402 pieces of equipment and 270 quality control assays [checks to make sure a substance if of high quality]” that need to be developed and vetted to get the sign on the wall, says Terblanche. 

Afrigen has already started upgrading their laboratory by ordering specified pieces of equipment and installing utilities like steam gas lines, which they aim to have completed by July next year, to allow them to produce a vaccine that can be used for clinical trials in humans.

Says Terblanche: “We didn’t get the methods; we had to develop and validate them ourselves. So I said to my team: ‘Start reading and learning.’ Realising that you have to expose your team [to new things] is definitely one of the lessons we learnt.”

5. Know how to manage your money

Funding is an integral cog in the machine that is vaccine manufacturing.

In the early stages of the Covid pandemic, vaccines could be developed rapidly because there was no shortage of funding for their development.

“It’s difficult to innovate and perform without funding,” says Terblanche. And, she adds, once you’ve secured the money, things can change unexpectedly, which impacts a project’s budget. So managing finances and having security are important parts of successfully developing a vaccine. 

The hub’s initial budget from funders, including the African Union, the South African government as well as those of France and Canada, was based on their receiving full tech transfer. The money was to go towards scaling up their labs, training partners in other low-income countries and then rapidly developing the jabs.

But things changed when they didn’t get the promised package and they needed to pivot to developing the technology from scratch while sticking to the original budget. On top of that, they had to find new suppliers for raw materials or be prepared to pay more — both options that could have depleted the initial kitty of funds. For example, if Afrigen were not able to find a different supplier for the raw material needed for the lipid nanoparticle, they may have needed to pay more than planned. 

You also need to budget for upscaling your team, says Terblanche. Afrigen’s team grew more than 10-fold — from 12 people to 134 — in 18 months.

“We learned how to deliver a huge scope of work under time pressure within tight budgets,” says Terblanche.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.