The dire state of healthcare services and facilities in the Free State are the main reasons some residents in Mangaung are sceptical that the implementation of the National Health Insurance (NHI) Bill will positively impact their lives.

This was among a variety of views aired by residents at a public hearing on the NHI Bill that took place in Bloemfontein on Monday.

The Free State is the sixth province in which the Portfolio Committee on Health had its public hearings on the NHI Bill. In October last year the provincial Health Department in the Free State also held preliminary hearings across the province to make people aware of the Bill.

On Monday close to three hundred residents joined MPs at the Kagisanong Community Hall to give and hear input on the Bill

Many residents told the MPs there’s a need to first fix the ailing public health sector before NHI is implemented.

One resident, Sean Lakey was among those who voiced their opposition to the Bill and who said NHI must be properly managed. “The current situation, unfortunately, is one of the most degrading circumstances and sadly the staff aren’t doing their job properly,” Lakey said.

Lovely Bill on paper

“We’ve got a lovely Bill on paper but the comprehensive needs of healthcare should be thoroughly addressed. We need to change government’s formula in terms of who’s appointed and making the decisions. We can’t be putting all the power into one person or a group. The people in charge are not going to run the NHI properly.”

Two healthcare workers present at the hearing said they believe some of the challenges they’re facing at their respective healthcare facilities will be resolved once NHI is implemented.

Staff Nurse at the Nelson Mandela Clinic in Edenburg outside Bloemfontein Thato Litsesane said she was at the hearing to get a clear understanding of the Bill. “What I know about NHI is that it’s government’s structure to bring quality healthcare services to everybody.”

A Nurse at Albert Nzula District Hospital based in Trompsburg Ntebaleng Mohapi believes the Bill will not only assist health workers but the community as well. “I don’t think government is delaying implementing it,” she said. “I think people must first understand the Bill very well before government can implement it,” explained Mohapi. She also questioned how government will be funding the Bill.

However, DA ward councillor David McKay believes the hearings do not reach everyone and not all people are able to participate. McKay said there should be public participation in every single town. Citing the country’s already dire financial state, McKay said government does not have funding for the Bill.

“The proposed changes in the Bill put all the power under one Minister. He will then decide how everything is distributed, under a system that they currently can’t even control. The Bill should totally be scrapped. It doesn’t make sense,” he said. “You cannot take a system from another country and copy and paste it. It’s not feasible. As it is the current system isn’t working. They can’t possibly maintain the level of service that they’re giving now. It’s absolutely pathetic – people are dying in our hospitals. You’re not improving the system, you’re making it worse. They should focus on improving the current system and making sure that it works well.”

Funding of the Bill remains one of the main concerns raised by many who gave their input. Some predict the Bill could end up like other financially crippled State Owned Entities’ (SOEs).

DA member of the Free State Legislature Mariette Pittaway also raised her reservations. “They are still not saying who will be funding the rollout of the NHI. During the Medium-Term Budget [speech] Finance Minister Tito Mboweni said the state didn’t have funds, so where will the money come from? NHI will not bring better healthcare services, it will only cripple the private healthcare sector and the economy. This is such a good opportunity for corruption, just look at how they’ve handled the SOEs.”

Support from trade unions

Meanwhile, representatives from the Congress of South African Trade Unions (Cosatu) and the National Education, Health and Allied Workers’ Union (Nehawu) came out in support of the Bill. Cosatu’s provincial secretary Monyatso Mahlatsi however raised concern that the province has a fragmented healthcare system.

“In our view NHI is going to assist everybody to have access to quality healthcare. NHI is a healthcare system that is going to be centrally funded by government and private sector,” he said. “One of the issues we raised is about the current management in the healthcare sector. Managers can’t manage properly. They need to be properly empowered. Many managers can’t handle the little power and responsibility that they have and if that power is going to be increased, then there will be a problem. There is also a need for regulation of the pricing of medicines and pharmaceutical companies,” Mahlatsi added.

Nehawu representatives from the Free State warned they will not be distracted by those who intend to take the matter to the Constitutional Court. The DA already indicated the party will fight the Bill ‘all the way to the Constitutional Court’.

“NHI has humanity in it. Those who can, must assist those who can’t. I came to voice my support and ensure it goes through. In fact our view is that this is long overdue,” said Nehawu’s provincial Head of Organising Jabu Makhubo. “We call on government to firstly deal with a transitional period of fixing all challenges within the health sector. NHI can’t be introduced under the current state of affairs, it isn’t conducive. We’re also aware of those opposing the Bill and intending to go to the Constitutional Court. [To them] we are saying, whether or not the court rules otherwise, we want NHI and that’s the bottom line.” he said.

Mixed feelings

Meanwhile, Head of the Free State Health Department Dr David Motau said he had mixed feelings about the public hearing. He said they’ve already known about most issues raised by residents and a situational analysis has been conducted to assess all challenges. He also claimed there is a plan to deal with all issues at various health facilities across the province.

“We have embraced the NHI Bill and it is our responsibility to deal with all the issues that were raised at this meeting. There’s a bit of uncertainty on whether this will work or not and it’s up to us to tackle all the challenges and restore everyone’s faith. We’re busy ensuring that we’ll be ready once the system is being implemented,” said Motau.

Dhlomo notes concerns

Portfolio Committee Chair Dr Sibongiseni Dhlomo said he was satisfied with the hearings in Mangaung. “While they (residents) expressed support for NHI, they highlighted that government must first fix the current issues in healthcare.” Dhlomo said government can also not ignore the views of those who fear that NHI might follow the same path as that of SOEs. “It is [the]Health [department] that must indicate that the anti-corruption forum launched by the President is going to assist getting these issues out of the way. It’s not like we don’t have money. We must find money. If we’re going to have this social solidarity plan to have all South Africans taken care of then government must look for money.”

Dhlomo said he expects the Bill to be compiled into a report by May or June this year and then be submitted to the Speaker of Parliament.

The next public hearing on the NHI is scheduled for the North West province from 30 January until 1 February.

*This article was produced by Spotlight – health journalism in the public interest.

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Refilwe Mekoa for Spotlight

How teens see their family’s social status may play a part in their mental health and success at school, a new study suggests.

Social status appears to be more important than what their parents do for a living, how much money they have or how educated they are, the researchers said.

Hierarchical system

“The amount of financial resources children have access to is one of the most reliable predictors of their health and life chances,” said Candice Odgers, a professor of psychological science at the University of California, Irvine.

“But these findings show that how young people see their family’s place in a hierarchical system also matters. Their perceptions of social status were an equally good, and often stronger, indicator of how well they were going to do with respect to mental health and social outcomes,” Odgers explained in a university news release.

For the study, the researchers followed more than 2 200 twins born in England and Wales in 1994 and 1995.

The children assessed their family’s social ranking at ages 12 and 18. By late adolescence, these beliefs were linked to how well the teen was doing, independent of the family’s income, health care, adequate nutrition and education. This pattern was not seen at age 12.

Creative solutions needed

The researchers also found that the twins’ views were not always the same. At 18, the twin who said the family’s standing was higher was less likely to be convicted of a crime, and more often better educated and employed or in training. That twin also had fewer mental health problems than his or her sibling, the findings showed.

These findings need to be taken with a grain of salt, the study authors noted, because other factors can influence how children see their family.

“Targeting adolescents’ views of where they stand in society alone will never fully combat larger inequalities,” Odgers said. “But as the gap between the rich and the rest grows, creative solutions focusing on both societal and individual factors are needed to help young people to overcome unprecedented obstacles to social mobility and move their way up the social ladder.”

The report was published in the Proceedings of the National Academy of Sciences.

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The Western Cape Department of Health will get a new Head of Department (HoD) by April, but it seems there will be no radical changes to the strategic direction and work of this department.

Dr Keith Cloete who was introduced as the new HoD this week made it clear he intends to stay on course and wants to strengthen the systems already in place and deepen the gains made by his predecessor Dr Beth Engelbrech.

His appointment was officially announced during a press conference at the District Six Community Health Centre on Thursday.

Cloete is set to take over the reins on 1 April from Engelbrecht, who was in the position for the last six years (since 2014).

“I really thought hard about this, and you will hear that I am not deviating from what has gone before. I believe it’s my responsibility to deepen and to enhance what has gone before,” Cloete said. 

Universal health coverage

He made it clear that he wants his five-year term to be about fostering good relationships between stakeholders in the health sector as well as serving others. Cloete believes more collaboration between stakeholders are important to achieve universal health coverage.

“It’s about relationships, it’s about interconnection, and that everyone has a voice, he said. “That means we need to be able to listen to community voices that tell us where we should go with Universal Health Coverage.”

Cloete did not elaborate much on the province’s UHC strategy but last year during a presentation on the department’s draft UHC framework of action he advocated for a move away from multiple players towards a collaborative whole in the best interest of all patients. 

Making the link with the National Health Insurance Bill, he this week said: “We believe that is how we give effect to the intent, we (the department) believe is in the NHI Bill. We believe Universal Health Coverage is the strategy we have to take.” 

The DA-lead Western Cape government has always been clear about its support for universal healthcare for all, but is critical of the NHI Bill as the means to attain it. Western Cape MEC for Health Nomafrech Mbombo reportedly this week expressed the department’s lack of confidence in the financing system proposed in the Bill.

The public hearings on the NHI Bill in the Western Cape is scheduled for 4 to 8 February.

The collaboration Cloete refers to will include the private sector health providers, universities, other government departments and government workers in the other provinces.

Community representatives also play a crucial role in the discourse, according to Cloete, and listening to these individuals will be essential when moving forward with the Western Cape’s plan for Universal Health Coverage (UHC), he said.

No specifics on TB and HIV

Cloete’s career started as a medical doctor in the province. He then moved to various positions within the health sector and health department. According to Engelbrecht he held the position of Chief Director of the Metro for 8 years, and in 2015 was appointed Chief of Operations for the Department of Health.  

Cloete also served as the director for HIV/AIDS/STI and TB in 2003. When asked if any changes were going to be made to the Western Cape’s approach to HIV/AIDS and TB, Cloete did not provide any specifics. He did however state that the Western Cape is proud of the progress it has made in this regard.  

“We have a renewed focus to hold on to the gains we’ve had. The best thing that can happen to HIV/AIDS and TB treatment is if you strengthen your entire system. So, there is the tension between doing HIV/AIDS and TB specific things, but then the risk of not being able to maintain that if you don’t strengthen the system,” Cloete said. 

“Our strategy is more about keeping the balance. We do not want to lose the gains we’ve made with HIV/AIDS and TB, and we want to set ourselves very steep targets which is the 90/90/90 (UNAIDS target),” he added.

Health and budget cuts

Cloete may be intent on staying on course but there are several challenges he and the department will face during his term. One such challenge is the threat of potential budget cuts.

Engelbrecht said the department will only receive clarity on their budget by 6 February. 

Despite this Cloete assured those present that the department is confident in the strategy in place to deal with any potential cuts. “We remain confident that we will get a positive response to the case we have made (to the provincial Treasury on the budget),” Cloete said. “Our approach has been that we want to preserve as much of the continuity of the entire platform. Unless every single part of the system works, we won’t have a functional system,” he said.

“One of the biggest risks is to put one part of the system against other parts of the system,” he continued. “It’s rather about working differently and saying how are we going to deal with the shortfall if there is any shortfall.” 

Both Cloete and Engelbrecht flagged the increased  strain that violence, particularly among young men, places on the department’s available resources. “The impact on our system is everything from chronic diseases to child health.

“All that has an impact on our system but by far the most significant impact in the past three years has been violence. There has been a doubling in our homicide rate in the last three years,” Cloete said.“The one place where mortality has increased is among young men. That is a societal concern,” Engelbrecht said.  

Good intentions

Within the department itself, Cloete seeks to continue the culture of “trust and respect”. In this he seeks “to allow every staff member to feel valued, but ultimately be connected to their own purpose”. “We have really skilled people in our department who can go anywhere else, but there is something that keeps them (here). We have to remind ourselves what it is that keeps them.”

“The first thing for us collectively in the health sector and the health department is to remind ourselves why are we doing what we do,” Cloete explained. “To connect with a deeper purpose for all the health people who are in our system.”

Cloete is also set on investing in the department’s staff by developing their abilities. He said that making decisions within a complex health system which consists of so many stakeholders requires leadership.

“We used the example earlier today of the clinician who is in charge of 5 or 6 hospital beds and makes daily decisions, not about who gets ICU beds, but which deserving clients do not get the ICU bed. That requires leadership capabilities, the ability to be resilient and to work in the system and to understand where they’re needed,” he explained.

Cloete reminded journalists that under Engelbrecht’s leadership the department had received its first ever clean audit – a legacy he wants to continue.“It just shows the commitment to sound governance, but also ethical governance. It is really about people believing that they are here to safeguard the resources in service of the public.

“For me that is a very, very big thing that we need to continue to work on. And it’s really to continue to improve the system,” he said.  

*This article was produced by Spotlight – health journalism in the public interest.

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Elri Voigt

Medical marijuana may not provide long-term relief of sleep issues in people battling chronic pain, a new study finds, mainly because users may develop a tolerance to the drug.

The finding is important “considering the ageing of the population, the relatively high prevalence of sleep problems in this population, along with the increasing use of medicinal cannabis,” said an Israeli team led by Sharon Sznitman, from the School of Public Health at the University of Haifa.

Various sleep issues

According to the study authors, chronic pain affects between 19% to 37% of adults in the developed world, many who have sleep problems.

Some are turning to medical marijuana for help getting good shut-eye. But how well does it work?

To find out, Sznitman’s group assessed sleep and pain in 128 patients who’d had chronic pain for at least a year. All were over age 50 and about half (66) said they used medical marijuana to help manage their sleep problems.

The type of sleep issues varied: About one in four patients said they always woke up early and weren’t able to get back to sleep; one in five said they always had difficulty falling asleep, and 27% said they woke up during the night.

Of the patients who used marijuana, average duration of use was four years, using an average of 31 grams of the drug per month. Most (69%) said they smoked marijuana, and about one in five used either cannabis oil or vapour.

A downside

The study found that pot users were less likely to wake during the night, but there were no differences between users and nonusers in the time it took them get to sleep or in the frequency of early awakening.

And there seemed to be a downside: The researchers found that more frequent marijuana use was associated with greater difficulty in falling asleep, plus more frequent awakenings during the night.

“This may signal the development of tolerance,” Sznitman’s team wrote.

But the study couldn’t prove cause-and-effect, so other factors might be at play. For example, the authors said that more frequent pot use might simply be an indicator that these people were in more pain or might be depressed/anxious. That might explain these participants’ higher propensity for sleep problems.

One US sleep medicine expert said that for some patients with chronic pain, medical marijuana can offer “some hope”.

The new study is far from conclusive as to the drug’s benefits or risks, said Dr Margarita Oks, attending physician in pulmonary, critical care and sleep medicine at Lenox Hill Hospital in New York City.

Doesn’t reduce cancer pain

“There was no mention of the exclusion of sleep-related disorders, such as obstructive sleep apnoea, that can manifest with insomnia,” she said, “and this may be a huge confounder.”

And Oks said the fact that the study was done in Israel makes a difference, too.

In Israel, “cannabis is legalised and therefore concentrations of THC [the ingredient in marijuana that produces a high] can be objectively and reproducibly measured,” she explained. “In the United States this is not yet the case.”

A second study in the same issue of the journal concluded that cannabinoids (the active chemicals in medical marijuana) do not reduce cancer-related pain. This review pooled the results of five different studies involving more than 1 400 cancer patients. It was led by Dr. Jason Boland of the University of Hull in England.

Both studies were published in the journal BMJ Supportive & Palliative Care.

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Ever since Ashli Stewart was a kid, people have told her that she’s old at heart.

Raised by a single mother, Stewart often made dinner and helped her little brother with his homework. Today, as a mother of three and an executive assistant for a company in Bakersfield, California, she still considers herself a “fixer” of other people’s problems.

Burning sensation in chest

“I’m just wired that way,” Stewart said. “It’s part of my personality to stay logical, reasonable and rational.”

She took the same approach with her own health.

After years of yo-yo dieting, she stopped eating red meat and fried foods, cut down on processed carbs and started working out four times per week. The next time she stepped on a scale, she had lost 25 pounds. Within one year, she dropped nearly 25 more.

“You give up a lot, so it was really nice to see that the hard work was paying off,” Stewart said.

One day during her workout, she felt a burning sensation in her chest. Unconcerned, she pushed through it and completed her routine.

During her next workout, it happened again.

More severe symptoms

Researching her symptoms online, Stewart became increasingly worried as website after website advised her to call 911 or go straight to the emergency room. Instead, she visited urgent care, where she received a chest X-ray and an electrocardiogram. They told her everything was fine and to return if the pain got any worse.

It did get worse.

Just sitting on her sofa, her chest felt tight. Other times, pain shot down her arm. At her second visit to urgent care, they diagnosed her with exercise-induced asthma and prescribed a drug that can increase heart rate. Her symptoms only became more severe.

A few weeks later, Stewart visited a primary care physician. She urged him to consider her high blood pressure and her family history of heart disease: Her grandfather died of a heart attack at 47 and an uncle died after open-heart surgery.

A stress echocardiogram showed her heart wasn’t pumping enough blood. She would need to consult with a cardiologist within 24 hours.

“At this point, I was shaking and having a panic attack,” said Stewart, who was only 32 at the time. “How do we fix this?”

Dr Viral Mehta, an interventional cardiologist, scheduled an angiogram to get a better look at Stewart’s heart. When they began the procedure, Mehta and his team chatted jovially. The tone changed when they got a closer look at her heart.

Heart attack or sudden death

Her left anterior descending artery, the so-called “widow maker”, was 100% blocked, and she had a 70% blockage in another artery.

Mehta immediately performed a balloon angioplasty and placed two stents.

“She is extremely lucky that she did not have a very adverse outcome,” he said. “The most adverse outcomes would be heart attack or sudden death.”

Symptom-free since the procedure in 2016, Stewart has continued to eat a healthy diet and educate her family about their history of heart disease. She also reconnected and fell in love with an old childhood friend. They live together and have a two-year-old son, Jace, who has no trouble keeping up with his older brothers, 12-year-old Bradley and 11-year-old Jerry Lee.

Stewart believes her youth and gender made doctors overlook obvious symptoms of heart disease. To raise awareness that heart disease can happen to anybody, she became involved with the American Heart Association.

“I want people to know their numbers and know their bodies so they can be advocates for themselves and push through wrong diagnoses,” she said. “We have to get away from these stereotypes, because they are killing people.”

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