BUSINESS GUIDE TO QUALITY HEALTHCARE 2021 by 3S Media

BUSINESS GUIDE TO

QUALITY HEALTHCARE

MARCH 2021

Enhancing Covid-19 research – the road to finding a vaccine Even in this state of flux, the SAMRC remains responsive to change, continuing its journey of growth and innovation.

Overview

Over 100 million COVID-19 cases across the world

> R110 million invested into COVID-19 research and innovation

R10 million funding into the first South African Covid-19 vaccine trial

> 50 whole genome experiments have been conducted

Established in 1969, the South African Medical Research Council (SAMRC) has for the past five decades been at the forefront of responsive research, medical innovations and transformative science – the organisation conducts and funds health research, health innovation, development and research translation. Through laboratory investigations, preclinical and clinical research, and public health studies, the SAMRC has been examining the top ten causes of mortality, disability and associated risk factors against the backdrop of South Africa’s colliding epidemics of maternal, new-born and child health, tuberculosis and HIV/AIDS, non-communicable diseases (NCDs), injury and violence.

Research and innovation in a time of covid-19 Humanity lives in a constant state of flux with the COVID-19 epidemic as a stark reminder of threats to human health, with more than 102 million cases across the world. The SARS-CoV-2 (Covid-19) was first identified in Wuhan, China and since then South Africa remains one of the severely affected countries by the pandemic. The SAMRC has been responsive to change, leading research and dialogue on COVID-19 and investing over R110 million, with the South African Department of Science and Innovation (DSI), into COVID-19 research and innovation. As the fight against COVID-19 intensifies, the SAMRC continues to play an instrumental role when it comes to public-health research. Through its intramural research units, the SAMRC is engaged in a broad spectrum of studies looking into health impacts of COVID-19 across research streams, from gender-based violence (GBV), COVID-19 and the

impact on substance use, to prevalence, clinical characteristics, and immunologic responses and outcomes of children with suspected or confirmed COVID-19, among other public-health studies. On the diagnostics front, funds pooled from the SAMRC, the DSI and Technology Innovation Agency have been applied towards supporting the development of local capacity to supply reagents for existing gold standard COVID-19 testing, and offer rapid alternatives for the direct detection of the virus.

Covid-19 vaccines finding solutions to save lives Since the advent of the pandemic, there has been tremendous global efforts to find multiple vaccine candidates to protect against infection and subsequent development of COVID-19 disease. Now the biggest vaccination campaign in history is underway – millions of doses around the world have been administered to date including South Africa where the SAMRC and its collaborating centres have been intensely involved. Even if early results have found some vaccines to be safe and effective, continuing to conduct trials may bring further benefits for society. The SAMRC and DSI provided R10 million funding into the first South African Covid-19 vaccine trial. The South African Ox1Cov-19 Vaccine VIDA-Trial was announced in June 2020. SAMRC President and CEO, Prof Glenda Gray led the Johnson and Johnson Vaccine Trial which in the end produced efficacy rate of 57% protection against moderate to severe infections and is also able to handle the 501Y.V2 variant, which first emerged in SA. The vaccine is currently being rolled out, with the focus on frontline healthcare workers.

While rapid rollout of COVID-19 vaccination will fast-track the return to normality, and South Africa is making every effort to secure enough vaccines to attain herd immunity in the country. However, vaccine hesitancy poses a real challenge to the country’s vaccination efforts. That is why the SAMRC is investigating the scale and determinants of vaccine hesitancy in South Africa, so that tailored and targeted strategies can be developed to address it. This would eventually enhance confidence in, and increase demand for, COVID-19 vaccination

in South Africa. The SAMRC partnered with the DSI and the African Alliance to implement a communications and public engagement strategy to counter vaccine misinformation.

Genomics and personalised medicine Genomic research offers a unique opportunity to leapfrog technologies for a better understanding of factors that impact on the health of South Africans and inform strategies to improve their response to diseases.

SAMRC President and CEO, Prof Glenda Gray takes COVID-19 vaccine trial shot to prove safety. Gray says participating in vaccine efficacy trials ligitimizes and endorses the safety and importance of science and people taking part in vaccine trials.

The country can finally conduct whole genome sequencing on home soil – until recently, samples had to be sent overseas and the reference point for diseases was based only on sequencing of people of European descent. In July 2019, we launched the SAMRC Genomics Centre in partnership with the Beijing Genomics Institute – the first on the African continent. The Centre conducts genomic research to address the growing disease burden of South Africa and builds towards a future where 4IR is a major component in African healthcare. Since then, more than 50 whole genome experiments have been conducted, and the SAMRC – together with the DSI have made a number of funding awards to address the topics of understanding the basis of treatment failure for non-communicable disease treatments in Africa; and setting up a pilot project around HIV elite controllers, where genetics are believed to be a major contributing factor in disease management.

Having a large local sequencer that can “sequence large genomes like the human genome” evades the intensive process, criss-crossed with red tape, of sending samples away. It also unlocks the gene pool of our own continent and it is important for us to generate and analyse our own data on South African soil and the Centre now gives researchers the opportunity to do that. This is particularly important for Africa which is one of the most genetically diverse continents in the world. To prove the accuracy of the technology and analysis being applied at the Centre, Professor Craig Kinnear, who heads up the Genomics Centre, and a team of scientists, recently published a paper in Scientific Reports, a journal of the prestigious Nature Publishing Group.

www.samrc.ac.za

CONTRIBUTORS

CREDITS PUBLISHER Jacques Breytenbach EDITOR Chris Bateman (www.thrive2write.co.za) SUB EDITOR Tristan Snijders HEAD OF DESIGN Beren Bauermeister DESIGNER Jaclyn Dollenberg PRODUCTION & CLIENT LIAISON MANAGER Antois-Leigh Nepgen GROUP SALES MANAGER Chilomia Van Wijk KEY ACCOUNTS MANAGER Amanda De Beer DISTRIBUTION MANAGER Nomsa Masina

Chris Bateman Former News Editor, Izindaba, SA Medical Journal (2000-2016), Freelance Healthcare Writer

Prof. Keertan Dheda Head of Pulmonology at University of Cape Town and Groote Schuur Hospital

Dr Boitumelo Semete-Makokotlela CEO at the South African Health Products Regulator (SAHPRA)

DISTRIBUTION COORDINATOR Asha Pursotham RESEARCHER Margaret Callado BOOKKEEPER Tonya Hebenton

PUBLISHED BY

46 Milkyway Avenue, Frankenwald, 2090 PO Box 92026, Norwood 2117 Tel: +27 (0)11 233 2600 www.3smedia.co.za

NOTICE OF RIGHTS AND DISCLAIMER Prof. Jack Moodley Veteran Former Chairperson at the National Committee for Confidential Enquiry into Maternal Deaths (NCCEMD)

Prof. Glenda Gray President and CEO at the South African Medical Research Council (SAMRC)

Dr Morne Mostert Director at the Institute for Futures Research at Stellenbosch University

BUSINESS GUIDE TO QUALITY HEALTHCARE information and statistics have been taken from publicly available documents, research as well as interviews that may or may not reflect the absolute correct numbers and statistics applicable at the time of going to print. All rights reserved. This publication, its form and contents vest in Novus Print (Pty) Ltd t/a 3S Media. Reg. No. 2003/021005/07. No part of this publication, including cover and interior designs, may be reproduced or transmitted in ny form or by any means, without permission in writing from the publisher, nor be otherwise circulated in any form other than that in which it is published. The publisher obtained permission for the use of images that are protected by copyright.

Dr Gerhard Ferreira CEO at LTE Medical Solutions

Ingra du Buisson-Narsai Co-founder and Director at NeuroCapital Coaching and Consulting

Madelaine Page Freelance Writer, Editor and Proofreader

The views contained herein may not necessarily reflect those of the publisher. The local as well as International healthcare sectors are changing at a very fast pace, more so now than ever given the continuous impact of Covid-19. While every precaution has been taken in the preparation and compilation of this publication, the publisher, editors and editorial contributors accept no responsibility for errors, omissions, completeness or accuracy of its contents, or for damages resulting from the use of the information contained herein. While every effort has been taken to ensure that no copyright or copyright issues is/are infringed, Novus Print (Pty) Ltd t/a 3S Media, its directors, publisher, officers and employees cannot be held responsible and consequently disclaim any liability for any loss, liability damage, direct or consequential of whatsoever nature and howsoever arising.

Jamaine Krige Author, Freelance Writer and Medic

Jahni de Villiers Director at Labour Amplified

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Dr Tony Moll Veteran Chief Medical Officer at Church of Scotland Hospital, Tugela Ferry, and Extreme Drug-resistant TB Pioneer

CONTENTS 10

42 C OMPLIANCE Change, rethink, survive and stay safe 44 T HE ROLE OF THPs DURING COVID-19 Traditional healers

NHI

46 R EINVENTING THE RECOVERY MODEL FOR TIMES OF CRISES Looking to the future: letting go of the past 50 WORKING FROM HOME The ‘new normal’ 53 T UBERCULOSIS SA’s dangerous underdog disease GETTING HEALTHCARE MOBILE IN AFRICA

05 FOREWORD Applying the Ubuntu principle to survive 06 O VERVIEW Calling for a future-orientated, strategic and integrated health system 10 N ATIONAL HEALTH INSURANCE Navigating a route up the NHI mountain 15 INNOVATION IN THE HEALTHCARE SECTOR SA's challenges give birth to world-class innovation 19 C OVID-19 Countering the viral threat to SA’s future

58 H IV/AIDS A tale of tragedy and hope 66 I NNOVATION One man’s entrepreneurial healthcare journey 70 M ALARIA Malaria elimination in SADC finally ‘possible’ 75 C ERVICAL CANCER Guidance for HPV screening initiatives in Africa 79 M OTHER & INFANT HEALTHCARE Improved outlook for South African mothers and children 85 M ENTAL HEALTH Focus and flourish while adapting to the ‘new normal’

28 R EGULATION Expediting approval for Covid-19 vaccines 32 REGULATION The Ivermectin debate 35 S AHPRA Dynamic health regulation in the face of change

B USI NESS GUI DE TO QUALI TY HEALTHCARE 2021

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FOREWORD

APPLYING THE

Ubuntu principle to survive

uality healthcare for all” is a noble objective, challenged by each country’s unique demographics, history, GDP and ability to adapt and innovate. Besides being the ethical goal to aim for, it is an essential business survival tool, especially in this time of Covid-19 which collapsed 42.7% of small South African businesses by early December 2020 – almost exactly 10 months since the virus landed in KwaZulu-Natal in a returning traveller. This book impartially reviews where we are at in the main healthcare spheres in our country, where Covid has impacted and how we have defied the odds, time and again. One cannot help but stand in awe of how creative and innovative our researchers, clinicians, epidemiologists, healthcare workers – and business entrepreneurs – have become. The healthcare gauntlet has been well and truly thrown down, and how we respond

to it will define the quality of children’s future. We dare not fail. South Africa faces a globally unparalleled quadruple burden of disease; communicable ones such as HIV/AIDS and TB, (and now Covid-19); Non-Communicable ones such as hypertension and cardiovascular disease, diabetes, cancer, mental illness and chronic lung sicknesses like asthma; maternal and child mortality; as well as a near pandemic of injury and trauma. All this in a country run by a ruling party with just 27 years of experience in government, a society with a vivid array of cultures and religions – and an apartheid legacy that includes the largest Gini co-efficient in the world. That is not a mixture for the faint-hearted. Yet we have made stellar progress when you look at the sweep of our recent history. It is easy to be critical and focus on the frustrations of our somewhat dysfunctional public healthcare system,

the clumsiness of learning, the madness of ideology. We have no choice; health is our daily business, we must face up to it with optimism and a rational, considered, agile approach, or simply throw in the towel, emigrate, and bemoan the beloved country from afar with heavy hearts and a considerable dose of nostalgia. The hard yards, made from near or far, involve creating partnerships, private sector and government collaborations, lobbying, activism, diplomacy, empathy, and believing we as individuals can make a difference – in fact, all the qualities embraced by Ubuntu, (a person is a person though people). Chris Bateman, Editor

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OVERVIEW

Calling for a future-orientated, strategic and integrated health system

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ncreasing life expectancy to 66.6 years in the next five years and to 70 years by 2030 were targets set in the Department of Health’s Strategic Plan for the five years 2020/1 – 2024/5 and beyond. Although this seems like a very high target, the past has shown that health outcomes of South Africa reflect positively on the health system. Today life expectancy stands at 64.7 against the 64.2 that was set five years ago. This is the highest it has ever been. Empirical evidence shows that life expectancy continues the upward trajectory. “This increase is due to the expansion of the HIV programme, as well as reductions in maternal, infant and child mortalities,” Dr A Pillay, Acting DirectorGeneral says in a statement as part of the DoH Strategic Plan 2020/1 – 2024/5.

OVERVIEW

He is, however, concerned about the neonatal mortality, which has not changed in the last five years. Premature mortality due to non-communicable diseases, trauma, violence and injuries that are on the rise will require additional attention over the next five years. He says more than 25 years into the democracy the health system in South Africa remains divided, maintaining its 2-tier status. It is with this in mind, after several reports cited challenges and recommendations to improve the quality of healthcare in South Africa, that the National Health Insurance policy came to life. The aim is to dismantle the present system and introduce several structural reforms; achieving universal health coverage. Health promotion (nonpersonal), prevention and treatment

We will also collaborate with other government departments to reduce the impact of social determinants of health, and forge strong partnerships with social partners to improve community participation to ensure that the health system is responsive to their needs.” (personal) services for the population are prioritised. The aim is to progressively achieve universal health coverage coupled with financial risk protection for all citizens seeking healthcare. This will be done through application of the principles of social solidarity, crosssubsidisation and equity. “These targets are consistent with the United Nation’s sustainable development goals to which South Africa subscribes, and Vision 2030, described by the National Development Plan, that was adopted by government in 2012,” he says. The Department’s

Strategic Plan 2020/21-2024/25 is firmly grounded in strengthening the health system, and improved quality of care will be fundamental to achieve these impacts. Dr Pillay says twelve of the 18 outcomes prioritise by the department are to strengthen the health system and improve quality of care. The quadruple burden of disease is addressed by the remaining outcomes. They will join hands with provincial departments of health to achieve these outcomes. “We will also collaborate

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OVERVIEW

with other government departments to reduce the impact of social determinants of health, and forge strong partnerships with social partners to improve community participation to ensure that the health system is responsive to their needs.” To view the governments Health Strategic Plan for 2020/21 – 2024/25 go to: http://www.health.gov.za/ strategic-plans/

Future-orientated, strategic and integrated health system Many failed strategies are based on an attempt to respond to the challenges from the past. Although this may offer some insights, this is not where the healthcare system should be going. Closing the gaps in the current system is not the solution, says Dr Morne Mostert, Director at the Institute for Futures Research at the Stellenbosch University Business School. He says that even if one would be successful at such an endeavour, that it would not generate the healthcare system the country needs. He suggests a future-orientated, strategic and integrated health system that would be superior to a fragmented and reactive system.The Institute for Futures Research offers strategic advisory and research services to large organisations to improve their long-range decision-

We simply cannot afford to go back to the way things were before; we do not have the luxury of repeating mistakes. Although we need to learn from the past, we should always look ahead.” making. This, he says, is essential for the anticipation of risk and its timeous mitigation. Strategic opportunities can also be identified earlier. When asked to explain futures thinking, systems thinking and strategic thinking, he says that as different forms of thinking, they represent distinct decision-making for senior leaders. Looking at quality healthcare for all after 2021, he says: “Futures thinking helps to explore not just the current crisis, but the implications for the longer term. As important as vaccinations are, even if we are successful, we will not have a vibrant health system. “We should decide on the preferred system of healthcare we want, and then explore the most probable strategies for achieving that.” Systems thinking, he says, offers insights on a more holistic, integrated health system. “It presents cohesive alternatives to the current fragmented

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system. Strategic thinking considers the critical role of stakeholder needs and the competitive alternatives, or lack thereof, available to those stakeholders.” According to him the poor relationship that exist between business and government is seen as one of the biggest anchors limiting the future success of South Africa. “The reality is that these two entities represent two distinct paradigms, with mutual suspicion. Small and safe experiments, in which public-private partnerships are piloted, may one way of emerging from these complexities. Asking about a “new normal” that was brought about by the Corona-virus, he declares: “If a new normal really does exist, we are certainly not there yet. We are, at best, on a bridge from a previous to a new dispensation. “The past seems intolerable, while the future remains uncertain. On the ridge we are looking around for alternatives.” This, he says, is a time of enormous potential discovery for those willing to experiment and learn.

Government and private sector must work together Jahni de Villiers, Director at Labour Amplified, says that it is not possible for healthcare in South Africa to be unilaterally pivoted by government without business, as a social partner.

OVERVIEW

“Business has access to strategists that can complement and challenge government’s strategists. It’s the only way to come up with sustainable solutions for all South Africans.” She says labour relations in South Africa is built on social dialogue, echoing good practice internationally. “Nedlac is used by government to ensure participation and buy-in into new legal frameworks and policy in general.” One positive outcome of the pandemic is that social partners have been forced together into a (virtual) room until a solution is found, she says. “I hope this momentum is kept up as we need this sense of urgency and cooperation in policy development in general.” The pandemic, she says, has forced everybody in the workplace to realise that health and safety is a shared responsibility and concern and not just that of the safety manager. “I believe that the companies who will be most successful post pandemic are the ones not clamouring to return to “normal”, that same, ineffective way people have worked since forever. This is a real-time change to an interesting future of work.” She believes that no one body, even experts in their fields, has all the answers. “Magic happens when people from different backgrounds and fields get together to brainstorm solutions.” This can be in an organised way or informally, she says, with teams and businesses start talking to each other; working together – teamwork. According to Jahni unemployment will still pose the biggest problem in South Africa post 2021. While the pandemic should be seen as a catalyst for change, a system overhaul is desperately needed. “We simply cannot afford to go back to the way things were before; we do not have the luxury of repeating mistakes. Although we need to learn from the past, we should always look ahead. “If we want a country where available resources are shared in an equitable way by the majority of South Africans, we need to become serious about changing existing systems that are not serving us anymore (or never did).”

The ‘new normal’ Jahni says when she hears the term “the new normal”, she hears someone trying

I believe that the companies who will be most successful post pandemic are the ones not clamouring to return to “normal”, that same, ineffective way people have worked since forever. This is a real-time change to an interesting future of work.”

valiantly to control the uncontrollable. “What we had before wasn’t normal, it was terrible in many cases. It was a ‘normal’ that might have been safe, but wasn’t necessarily healthy. It was a ‘normal’ where childcare responsibilities meant that women had real issues with career progression, as raising children and working from 8-5, many kilometres and hours of commuting from home, was causing incredible stress and conflict. With all of us thrust into the unknown, at least there is no ‘right’ answer as to what is ‘normal, we’re all building a future in the dark.” She suggests that companies strengthen communication with employees and really listen. There might be some seriously innovative thinking around changes to be made to ensure a new “normal”.

Health in the workplace post 2021? Many big companies are selling their buildings, keeping core staff in the workplace while encouraging workers to work from home. Jahni says with this new way of doing business employees will have to set boundaries between work and private life. “Make sure there is rest-time as being online 24/7 leads to overwork and unhealthy working conditions. No employer has the right to expect people online all day, every day”. She believes communication has got to

become the buzz word. “It is incredibly important to be sensitive to the fact that people have in some cases been in lockdown alone, which could definitely lead to loneliness and isolation, which is not safe or healthy.” She suggests a mental health checkin with team members and says that there is no shame in consulting a mental health professional to work out a strategy to look after the mental health of employees. “These services are available and should be utilised.” When employers and employees despair when the world feel upside down, she advises that they breathe deeply and only handle what is right in front of them. “Tomorrow you do the same and add a bit more. You will feel your confidence being gradually restored, and soon you will be able to dream again. Never allow yourself to get isolated, there is always a lifeline out there.”

It is important to be kind to yourself, your employees and your business will understand that almost everyone is in the same boat and we (the world) will get through this, she says. “Guard your and your employees’ health, that’s the most important thing right now.”

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NATIONAL HEALTH INSURANCE

Navigating a route up the NHI mountain

niversal healthcare in South Africa is a natural extension of incremental legislation aimed at meeting the government’s constitutional obligation to create equitable access to healthcare for all – currently available at nowhere near the scale required. Intense debate roils around the government’s healthcare track record, high medical inflation, profit-oriented private medical aids and private sector over-servicing. Whether South Africa can afford an estimated R500 billion, phasedin National Health Insurance, NHI, in the current parlous economy – recently degraded by institutional corruption and Covid-19, is also hotly contested. As with all redistributive moves, those who stand to lose the most complain the loudest, whether they be healthcare businesses or higher-income taxpayers. Many problems in the South African healthcare system can be traced back to the apartheid era (1948-1993) when the healthcare system was highly fragmented, discriminating between four different racial groups (black, mixed race, Indian and white). To worsen the situation, the apartheid government developed 10 Bantustans (the so-called ethnic homelands) into which Africans were unwillingly segregated, each with their own departments of health. It’s been 27 years since the first democratic elections allowed racial and geographical integration to begin addressing gaping inequities in resource

distribution and delivery. The NHI is an attempt to comprehensively deal with this legacy, making it a steep mountain to climb – and the air seems to have got thinner half-way up. Most rational protagonists agree that it’s a moral imperative to create equal healthcare in a country with the world’s worst Gini co-efficient and such severe structural imbalances. Where it gets really interesting is in the ‘yes, but how?”

Government’s answer The government’s answer is a health financing system designed to pool funds and actively purchase services

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more cost-effectively to provide universal access to quality health services for all South Africans based on their health needs – irrespective of their socio-economic status. All NHI services will be provided free at point of care. At present the money South Africa uses to buy healthcare sits in several different pockets or “pools” – across dozens of individual medical schemes – and in the public purse. When money is split like this over many, smaller pools – which in the case of medical schemes are accessible only to a privileged few – it limits any

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one pool’s ability to enable crosssubsidisation based on income or risk. Put another way, with so many different pots of money the country is unable to effectively use funds from the rich to help cover the poor, or payment from more healthy people to offset costs incurred by those who are sicker. A single pool obviously provides massive bargaining power when it comes to buying medicines and equipment in bulk. The NHI will be financed through mandatory pre-payment. No taxpayer will be able to opt out of an incomerelated hike, though they may choose not to use NHI healthcare services and stick with their medical aid – which will eventually be legally constrained to provide only NHI-complementary services. This is another big debate, with many in the private sector arguing that there are simply not enough resources to go around, and contending that the NHI will lead to worse, not better overall healthcare delivery. Medical aids have added their voices to the protest choir saying the envisaged NHI is unaffordable, not to mention limiting an individual’s right to purchase additional healthcare (the latter, an argument the Constitution seems to rebut). The State merely shrugs and says sorry, all healthcare providers and facilities, public and private, will be paid from an NHI pool, based on proper accreditation,

services delivered – and the quality of healthcare outcomes. Like it or not, the NHI is intended to be up and running by 2026. The public healthcare system as it currently stands serves 80% of the population and South Africa spends 9% of GDP on healthcare, or US$499.2 per capita, a relatively high figure globally – yet one that hardly matches healthcare outcomes. Of the 9% of GDP, approximately 42% is government expenditure. South Africa currently lies 48th among 93 countries in the 2021 World Healthcare Index, (Taiwan and South Korea numbers One and Two, and Bangladesh and Venezuela 92nd and 93rd.) According to World Health Organization, (WHO), 2019 statistics, South Africans have a 26% probability of dying from cardiovascular disease, cancer, diabetes or chronic respiratory disease between ages 30 and 70. That’s just the non-communicable diseases. The others making up our quadruple burden are communicable diseases (e.g HIV/TB), maternal and child mortality, and injury and trauma. More than 28% of adults are obese – the highest rate among sub-Saharan African countries.

Human resource inequities An estimated 79% of doctors work in the private sector with an overall

80% The public healthcare system as it currently stands serves 80% of the population and South Africa spends 9% of GDP on healthcare, or US$499.2 per capita, a relatively high figure globally – yet one that hardly matches healthcare outcomes. Of the 9% of GDP, approximately 42% is government expenditure.

doctor to population ratio of just under one to 1 000, well below the world average. Professional nurses in both sectors have the highest share of 50- to 65-year-olds at 40%, posing a risk to the implementation of NHI, which relies heavily on nursing staff as part of the primary healthcare re-engineering. The process of policy development began in 2012 and included piloting of health system strengthening initiatives. Activities in the initial phase were funded through a combination of sources which included National Health Conditional Grant and the Health Infrastructure Grants. Workstreams were established to further refine the policy and incorporate public input

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as well as make recommendations for phased NHI implementation. The NHI pilot phase threw up useful lessons in the implementation of integrated school health services, maternal and child health initiatives, district clinical specialist teams and primary health care outreach teams. These were integrated into the 2nd phase scale up which began in 2017 and continues to 2022 – also focusing on amendments to NHI-related legislation. Included in this phase is the establishment of institutions that will be the foundation for a fully functional NHI Fund. The current phase will also entail purchasing of personal healthcare services prioritising vulnerable groups such as children, women, people with disabilities, the elderly orphans, adolescents and underserviced rural populations. Health systems strengthening initiatives will run concurrently as the primary healthcare backbone of the NHI is strengthened. Health facilities that are compliant with the certification

requirement of the Office for Healthcare Standards Compliance and meet set criteria will be accredited by the NHI Fund as part of strategic purchasing. The Fund will contract directly with accredited public hospitals (including regional, tertiary, central and specialised hospitals). In the latter phases of implementation, the NHI will also contract with certified and accredited private providers at higher levels of care, based on need. Overseeing all this is the pragmatic Dr Nicholas Crisp, a veteran public healthcare specialist whose experience has taken him into every nook and cranny in the system.

Corruption – SA now ‘alert’ Asked about setting up a R500 billion NHI fund in the aftermath of State Capture and the mismanagement and corruption at most State-Owned Enterprises, Crisp replies confidently; “now is the best time to do it.” He explains that civil society has been rendered ‘super-observant’ and strongly believes they’ll never allow grand theft again. This, combined with state-of-theart IT systems in the NHI, will enable unprecedented fraud-proofing. He scotches any narrative depicting the private sector as angels, pointing to multiple adverse findings of the Health Market Inquiry, HMI, and talking of ‘massive, institutionalised

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organised fraud,” which the HMI diplomatically labelled as ‘supplyinduced demand,’ (aka over-servicing). In a November 2020 webinar, hosted by the SA Academy of Family Physicians, Dr Crisp paints a picture of how the new system will work for healthcare providers. “There’s no reason to change individual private practices, group practices, managed care or NGO outfits. The NHI will pay everyone via a Contracting Unit for Primary Health (adapted from the Thai model), known as CUPs – using risk-adjusted capitation,” he explains. These ‘CUPs’ will contract primary healthcare services embracing prevention, promotion, curative, rehabilitative ambulatory, home based and community care. Each health district-based CUP will have its own catchment area and population and will have to fulfil certain criteria. Patients will register with a health facility in a CUP catchment and access services within that area. The entire population will be registered using a unique identifier linked to the Department of Home Affairs’ identification system. The registration information will be from cradle to grave, encrypted and be used to access services at different levels of the health system. Also in November 2020, Health Minister, Dr Zweli Mkhize reported to parliament that a total of 3,059, (of 4 200), public healthcare facilities had implemented the Health Patient Registration System (HPRS) and that registered NHI beneficiaries had reached a total of 45,286,288. (The estimated population of South Africa in 2021 is

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60,041,994, a 1.24% increase from 2020).

“Digital first” approach Dr Mkhize said that the HPRS would act as the ‘backbone of an electronic health patient record’. Ironically, South Africa’s current pre-eminent healthcare challenge – Covid-19 – has boosted efficient healthcare referral pathways and brought digital devices that support this (like the Vula cellphone app) and those addressing other dire needs, to the fore, smoothing the path for the NHI. Multiple papers on human resources for healthcare have stressed that without a “digital first’ and agile, innovative task-shifting approach, the current medical campus’s and nursing colleges will never be able to produce enough healthcare professionals to keep up with population growth – or lower the dismal healthcare worker to patient ratio. Covid-19 has concentrated the minds of the country’s top healthcare strategists around planning, supply chain management and the efficient use of resources, proving that a crisis can provide huge opportunity besides, and perhaps because of, the danger it poses. The coronavirus battleground has prompted unheard-of teamwork between NGOs, overseas agencies, the public and private healthcare sector, laboratories, epidemiologists, health economists, researchers and clinicians, even outstripping the chronic HIV/ Aids pandemic at it’s peak, though that left stakeholders more robust than before, gaining South Africa as many bouquets as the corruption and dysfunctional management have since

earned brickbats. According to Paul Cox, Managing Director at the Essential Group of Companies, South Africa has been forced to make a digital shift in the wake of the pandemic. “Traditional paper records could potentially transmit the virus among healthcare workers. In turn, this led to the adoption of new technologies which have made data collection and analysis far easier and faster,” he says. Cox believes that data extracted could potentially transform healthcare and deliver better outcomes for patients. “When health practitioners have access to a patient’s complete health data, they can offer more efficient, more personalised care. Additionally, health data used in scientific research could potentially accelerate the development of new medical products and treatments for those who need them.”

patients have greater insight into their own health and are able to make lifestyle changes accordingly, which can further augment their care outcomes and positively impact their quality of life.” Also, with the increased uptake in personal health monitoring apps and devices, “patients have greater insight into their own health and are able to make lifestyle changes accordingly, which can further augment their care outcomes and positively impact their quality of life.” The MD says better health data will speed up diagnoses, prevent disease by identifying transmission pathways, and increase the effectiveness, quality and safety of treatments. “Moreover, it could

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enable better coordination of care amongst health providers to ensure that a patient’s health conditions are managed appropriately.” He adds that advantages for the NHI include the ability to design better care pathways, insights for strategic planning, and consequently using healthcare resources more efficiently.

Crisp low down continues. Dr Crisp told NHI-curious clinicians that in rural areas where staff were only available at hospitals, the accredited health providers would have to associate with the District Hospital to constitute a CUP. “The amount of money available for patients you look after will be decided by the number of people living in your particular area – and obviously multidisciplinary practices that cover the specific disease profile in that area will

prove the most viable,” he said. He said the outcomes-based capitation model would be risk adjusted (higher payment if a practice was seen to be referring less stroke or diabetes patients to hospitals or wwas treating more women of childbearing age.) “If you’re contributing to the primary healthcare system working, then you should be rewarded for that with an outcomes-based adjustment,” he explained, adding that the entire remuneration system remained a work-in-progress, though the

If you’re contributing to the primary healthcare system working, then you should be rewarded for that with an outcomesbased adjustment.”

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broad principles were set. The risk adjustment capitation model would thus encourage gatekeepers like GP’s or multi-disciplinary practices to tailor their services to the specific healthcare needs of the community. “If you can show that your outcomes are good, for example on diabetes or kids that are hard of hearing in your community, you’ll get more money. That’s a far cry from just spending money on curative care – preventative care is fundamental to your outcomes,” he stressed. He said the quicker the fund paid providers (probably weekly), the less chance there’d be for corruption, and stressed that a stack of unwieldy legislation blocking better healthcare delivery would be scrapped as soon as possible. The air might be thin, but the peak of the NHI mountain is finally visible.

INNOVATION

SA’s challenges give birth to

world-class innovation Pliny the Elder, a Roman naturalist and philosopher, wrote in his multivolume “Natural History”: “Ex Africa semper aliquid novi,” – meaning in Latin; “There is always something new out of Africa.”

hat somewhat understates the observed reality in South Africa today. For when it comes to healthcare innovation and problem-solving technology Pliny, (had he lived today), would probably talk about the ‘global alchemy’ of Africa’s most southern developed economy. Most satisfyingly, many of the greatest beneficiaries of our stellar advances have been fellow African and other third world countries battling similar Gini co-efficients and daunting disease profiles. From TB and HIV drug research/ treatment to plastic soft-drink bottles converted to inhalants to enable low-

income asthma-afflicted children to inhale medication, to drones delivering blood supplies in remote areas, to CAT scans and heart transplants, SA’s multiple challenges have inspired us to come up with globally admired, ubiquitous solutions. And when the machinery of State proves too slow or cumbersome, the private sector and NGO’s pick up the innovation slack, often partnering with government to achieve scale and improve equity. Putting the dynamic shift to digital technology to one side for a second, imagine an inhaler spacer using an adapted plastic Coke bottle costing just R1,00 to manufacture,

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being every bit as effective as commercial spacers – costing R160. That was a University of Cape Town/Red Cross Children’s Hospital innovation designed to help up to 15% of children in South Africa suffering from asthma – 21 years ago. Today the inhalers are being distributed free of charge across the country, with global adaptation of the idea.

Blood from the skies The supply of blood, it’s various types, cold storage and sufficient quantities, is a volatile, life-giving challenge in South Africa. If it can’t be safely and quickly transported to where it is needed, it can’t be used. Enter the drone. The South African National Blood Service (SANBS) is now using drones widely to cheaply collect and deliver blood for transfusions across the country, solving what was a major problem in helping patients in remote, less accessible hospitals and clinics. The world’s first digital laser was invented by doctoral candidate and CSIR, (Council for Scientific and Industrial Research), researcher Sandile Ngcobo, enhancing the treatment of cancer, especially in the removal of tumours of vocal cords, brain surgery, plastic surgery and in gynaecology. The CSIR also made lithium batteries a reality, while it’s Gene Expression and Biophysics group designed the first induced pluripotent stem cells in Africa, helping researchers probe various diseases and cures. Stem cells are used to restore sight or repair cells affected by heart disease and can be frozen. Stem cell transplantation represents a

critical approach for the treatment of many malignant and non-malignant diseases. The foundation for these approaches is the ability to freeze marrow cells for future use.

Giving sight to millions A new cataract surgery method was created at the Baragwanath hospital in Soweto in the mid-seventies by a specialist in retinal diseases, Selig Percy Amoils. He received the Queen’s Award for Technological Innovation, and his cryoprobe was later displayed in London’s prestigious Kensington Museum. In 1999, doctors and students at the Vaal University of Technology, came up with the smart lock, single-use safety syringe in response to needle stick injuries, saving countless lives and addressing the ever-present threat to healthcare workers posed by HIV, Hepatitis, and Ebola.

A healthcare ‘diamond’ device Mining, often blamed for causing and accelerating lung-related diseases among deep level miners, ironically gifted global healthcare with the full body X-ray Lodox Systems scanner. Designed to help detect stolen diamonds, it was, from 1999 adapted for its’ ability to obtain full body images in a matter of seconds. It’s especially valuable in assessing trauma victims with only minimal manipulation of the patient required, treating multiple gunshot injuries, peripheral skeletal injuries or finding the precise location of any foreign objects. Its ‘cousin on steroids,” is the CAT scan or Computed Axial Tomography scan,

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which has revolutionised diagnostics, especially in cancer, stroke, problems with blood flow, injuries to internal organs and damage to bones. It was invented in 1972 by South African physicist Allan Cormack and British engineer Godfrey Hounsfield. An X-ray source and electronic detectors rotate around the patient and collect all the data needed to produce a crosssectional view of the body. Both scanners are now in everyday hospital use across the world. In the social sciences, an excellent example of modern-day technical innovation is the KidzAlive Talk tool, an app for combating HIV stigma, greatly enhancing the chances of treatment. The app helps healthcare professionals provide HIV/Aids education to children and reduce stigma through better understanding, using animation and games in an ageappropriate way.

Adapt digitally – or die The shift to digital technology is revolutionising modern day South African healthcare, with application in diagnostics, treatment, referrals, education, telehealth, plus data management and healthcare administration. It will prove central to the success of an incipient NHI, with national Health Minister, Dr Zweli Mkhize, speaking of a ‘digital first’ approach requiring agile task shifting in order to address SA’s human resources crisis. Software designer, human health resources fundi and social entrepreneur, Saul Kornik, says this will become especially true when the NHI purchases services from public and private to provide a basic basket of services to all South

INNOVATION

Africans – particularly in locations where there is a chronic shortage of health care workers. “Trained doctors can deal expertly with patients, but they ultimately land up in leadership positions without understanding how the different pieces of the healthcare system puzzle come together,” he stressed. The company he founded three years ago, Healthforce, provides a video telemedicine system for 440 nurse-run clinics countrywide. A team of GPs provide care and advice to patients remotely, with the support of a nurse physically with the patient. They work in partnership with Dis-Chem, Medicare

Pharmacies, and several independent pharmacies, while several major medical schemes, including Discovery, cover their service. As for overall skills, the training of healthcare professionals fails to equip them to manage and administer healthcare facilities, let alone understand the data needed to run any system efficiently. This has resulted in clinically qualified doctors being illequipped to run hospitals and clinics – or understand systemic healthcare delivery. Says Dr Jasper Westerlink, CEO of Philips Africa, “We need to embrace technology and young professionals enthusiastic about using it.” He pertinently asks, “With admin, how do we work fast and efficiently using technology to better diagnose and increase time with our patients?”

Dr Westerlink believes the only way to drive scale at affordable cost in healthcare is to rethink its management and delivery, how insurers are reimbursed and how patients get the best outcomes. He says South Africa needs a new healthcare ecosystem enabling cheaper universal access to healthcare using forward thinking, tech-friendly young people. Epitomizing this approach is Dr William Mapham, 44, an ophthalmologist and creator of the “Vula” app which is revolutionising appropriate patient treatment and referrals between primary care facilities and tertiary hospitals, providing timely, accurate and

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detailed information to help save more lives. The dynamic Mapham showed his passion for solutions during his community service and medical officer stints in the deep rural Eastern Cape, showcasing the coastal country recreational lifestyle and stellar hands-on learning opportunities via slide presentations at health conferences nationally. Neighbouring district hospitals Madwaleni and Zithulele, some 100km from Umtata, benefitted greatly as young graduates signed up to serve, alleviating their staffing crises. Primary care doctors and nurses also use the Vula digital information network on their cell phones to get fast and efficient expert consultant input. They can now far more accurately and appropriately refer patients upwards in the healthcare system, sharing X-rays, pictures, history, path lab records and presenting symptoms via their secure confidential healthcare practitioner profiles. Dr Hennie Lategan, Operational Manager at Tygerberg Hospital’s Trauma Unit, says that before Vula, the unit’s phone literally rang off the hook ‘around the clock’, tying up medical officers for hours in jotting down referral data and/ or sourcing the correct advice. Beds were taken up by patients inappropriately referred, triage was cumbersome and time

consuming, and the entire patient sorting and treatment process was fraught, sometimes costing lives through sheer patient burden. Since Vula was introduced in July last year (2020), the unit’s ‘referral’ phone had fallen almost silent, enabling those among the 14-strong medical officer corps to get on with urgent triaging and treatment of patients under the guidance of the attending consultants. Dr Tamsin Lovelock, an Internal Medicine specialist and lead clinician at the 336-bed-capacity Brackengate Covid-19 facility in Cape Town’s northern suburbs said the Vula app was proving invaluable. “It’s not only convenient for the person who needs to refer but for the person receiving – it’s so organised, the fields are all there to fill in, you don’t have to remember everything, you just push a button and have a look,” she enthused. Another example of digital technology at the core of large scale healthcare innovation and disruption is the SA Doctors App, developed to almost instantly connect the user with his/her nearest medical practice, hospital, pharmacy or vet. The digital platform enables the scheduling of consultations with doctors, including a map to find the fastest route. Since its

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inception, partnerships with software services and products have expanded to include big business players like Solidariteit, MediFin and pharmacy groups Arrie Nel, Spar, Pick ‘n Pay and Link. The creators of the app recently linked up with the Intercare Group to expand virtual or in-practice medical consultations and now boast more than 1,2 million users since the 2016 launch. We all know Astra Zeneca via South Africa’s ill-fated January 2021 purchase of one million of their anti-Covid vaccines, (subsequently shown to be less effective than the Johnson and Johnson one). Well, they have been in partnership locally with multiple stakeholders for years through the aptly named ‘Phakamisa’ (‘to lift up’) programme – an access to healthcare initiative. Aimed at reducing the burden of non-communicable diseases, (NCD’s), it targets early detection of disease and promotes primary prevention and access to care. This is done via capacity building trainings for healthcare workers, (from primary to tertiary level), NCD awareness campaigning, and clearing referral pathways to prevent disease progression.

COVID-19

Countering the viral threat to SA’s future

n a primal human survival level, Covid-19, with its super-infectious variants, has triggered grief, uncertainty, loneliness and fear – and a major drop in most people’s sustainable income. Yet, when we get a rational grip on these emotions, they can be mutated into courage, empathy, innovation, and resilience. The responses by the world’s political leaders span the full spectrum, with societies suffering, rebelling, or complying, as existing stresses on social structures are amplified by the uniquely infectious pandemic. Whatever cracks there were in our healthcare and other systems, (preventative planning and budgeting being obvious), the edges have now shifted so far apart that we’re in danger of falling into the crevasse. Many already have. Like some of history’s previous pandemics, this one is tectonic and has shaken the entire planet, painfully demonstrating how our interconnected

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global economy helps spread new infectious diseases – and, with its long supply chains, is uniquely vulnerable to the disruption they cause. The ability to get to nearly any spot in the world in 20 hours or less, and carry a virus with our cabin baggage, allows new diseases to emerge and grow when they might have died out before. While Covid-19 fatalities are tens of millions less than those of previous pandemics, it has reached into every country in the world, (except Antarctica). The most valid fear is that if we don’t collectively get it under control, third, fourth and fifth waves will send the world into an economic tailspin, let alone cost more and more lives in nature’s inexorable march to herd immunity – which will hopefully be boosted by vaccines evolving apace with the constantly emerging and vexing variants. The global Coronavirus-attributed death tally on February 1st, 2021 stood at 2,4 million, with 104 million cases and 75,2 million recoveries. Wikipedia

and JHU CSSE Covid-19 Data. That’s 13 months since January 4th, 2020, when the Wuhan Municipal Health Commission in China first issued a notice to various medical institutions about “the treatment of pneumonia of unknown cause,” reporting 27 cases, and prompting an investigation. By comparison, the 6th Century plague of Justinian alone killed up to 50 million people, perhaps half the global population at the time. The HIV pandemic is still with us and lacks a vaccine. It has killed an estimated 32 million people and infected 75 million, with more every day. The SA comparative death toll by February 1st , 2021, was 45 605, with 110 000 active cases and 1,5 million recoveries. ( Wikipedia and JHU CSSE

Covid-19 Data.) As of February 1st, the USA had the highest collective number of cases at 26.77 million, followed by India at 10,75m, Brazil at 9,2m, and Russia at 3,7m, with South Africa ranked 15th at 1 453 761 cases (total infection tallies). (see https://www.worldometers. info/coronavirus/countries-wherecoronavirus-has-spread/). Shortly before going to press (March 2nd, 2021), South Africa’s confirmed infections stood at 1 513 959 cases, with 50 077 deaths, 32 546 active cases and an overall recovery rate of 94,5% (1,4 million people having recuperated). You can see why “Fever,” so scarily depicted in

Shortly before going to press (March 2nd, 2021), South Africa’s confirmed infections stood at 1 513 959 cases, with 50 077 deaths, 32 546 active cases and an overall recovery rate of 94,5% (1,4 million people having recuperated).”

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Deon Meyer’s eponymous fictional novel of survival and alienation in a postapocalyptic South Africa, (published in 2016), gets the hairs on the back or your neck standing up. That’s because something as poorly understood as this Coronavirus elicits the basic human reptilian-brain responses of ”flight, fight or freeze.” Of the three, perhaps freeze is the most appropriate. It’s taken a long time for our brain’s more rational pre-frontal cortex to kick in – and in the interim scare mongers have flooded the internet and social media with false news, rumours and conspiracy theories as people drift into pro and anti-vax, and pro and anti-lockdown camps. If you’re proeconomy, you’re anti-Covid-mitigation, and vice versa. It has become a black and white; an “us and them” situation,

with everyone forgetting that we’re part of an indivisible whole. Tanzanian President John Magufuli described vaccinations as ‘dangerous’, telling his people that, ”if the white man was able to come up with (C-19) vaccinations, he should have found a vaccination for AIDS, for TB, Malaria, for cancer, by now.” Just months before succumbing to the disease, he declared Tanzania “Covid-free” and spurned sciencebased prevention, including curfews or confinements, relying instead on prayer and decrying the virus as ”the work of Satan.” With perhaps the exception of Madagascar’s president, Andry Rajoelina, who claimed to have an organic cure for Covid-19, (the Artemisia plant), the response to the coronavirus from Southern African Development Community, (SADC), members has been rational, drawing on their previous experiences of pandemics and epidemics. Besides South Africa, other SADC countries that have had relatively high case numbers

include Mozambique, Madagascar, Namibia, the Democratic Republic of the Congo (DRC) and Angola. However, due to the limited infection numbers compared to other regions of the world, and a low death toll, SADC states are in a position to reopen the regional economy. Some countries, such as Lesotho, went into lockdown even before their first cases of coronavirus were detected. Elsewhere in the world, New Zealand’s prime minister, Jacinda Ardern, literally halted community C-19 spread in its tracks by taking expert advice to “go hard and go early”, with one of the world’s earliest and toughest bans on international and internal travel and locking down her country for a month from midnight on 25th March 2020. On February 4th 2021, New Zealand had just 62 active cases and a total of 2 315 “confirmed and probable” (accumulated) infections – and 25 deaths. Demonstrating empathy, she and her cabinet took a 20% cut

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Tax relief measures included a delay of remittances of “Pay As Your Earn” (PAYE), without triggering penalties or interest, a delay in the remittances of provisional payments of income tax without triggering penalties or interest, and an acceleration of certain employment tax incentives.”

in salary for six months in solidarity with those whose income has been affected by coronavirus. However, for many First World Countries, fear bred vaccine nationalism and hoarding as developing nations warned them that if the vaccine response was not tailored to all, it would end up serving no one. The fundamental message of Ubuntu which South Africa made famous, is now being naturally amplified as a global survival tool. The obvious question is, how bad must it get for all of us recognise this?

Here’s how the virus landed – and how South Africa responded On Thursday March 5, 2020, the National Institute for Communicable

Diseases, NICD, confirmed South Africa’s first Covid-19 positive case. Health Minister, Dr Zweli Mkhize identified the infected person as a 38-year-old man from Hilton, KwaZulu-Natal. Together with his wife and 10 others, he’d travelled to Italy and arrived back on March 1st, 2020. He showed symptoms of fever, headache, malaise, a sore throat and a cough. Contact tracing began immediately. The first Covid-19 fatality followed just weeks later. On March 15th, President, Cyril Ramaphosa, upon learning of the coronavirus patient overwhelm of healthcare facilities in Wuhan Province, China, Thailand, Italy and Portugal, declared a national state of disaster, imposing immediate travel restrictions. Three days later, he closed all schools. Advised by his carefully formed National Coronavirus Command Council, he announced a nationwide lockdown from midnight on March 26th, just as the number of confirmed cases increased six-fold over eight days (from 61 to 402), a frightening catalyst and a portent of things to come. On the 21st of April, he announced

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a R500 billion stimulus package to counter the inevitable economic downturn. The lockdown was progressively eased after a month, on the following dates: from 1 May 2020, from 1 June 2020 and 18 August 2020, and from 21 September 2020. The restrictions finally eased to Level One on February 28th, 2021. In terms of the moderated lockdown regulations, most economic activity and movement of people was conditionally and slowly resumed. International travel was re-opened on 1 October 2020, but the list of countries from which leisure travellers could visit South Africa was reduced, (from 60 to 22), and reviewed every subsequent fortnight. Special exceptions were made for visitors conducting business, critical skills visa holders and investors, among others. Clearances were granted to visitors intending to stay in South Africa for three-months or longer, subject to strict Covid-19 protocols. Travellers from African countries were also allowed to visit on the same basis. However, suddenly, at the end of October, a new, 50% more contagious variant of the virus surfaced in Nelson Mandela Bay. Upon hearing of this, several countries immediately banned travel to and from South Africa. The accelerating SA variant quickly surpassed the heights of the first infection surge, peaking near the end of January 2021, after which it slowly waned. The government response was to tighten restrictions over the festive season, including limited days and hours for alcohol trade, and controversially closing parks and beaches across three provinces. On February 1st, President Ramaphosa re-opened beaches and parks,

COVID-19

allowed weekday liquor sales and relaxed the curfew by several hours. He also allowed 50-person indoor and 100-person outdoor gatherings, (funerals, ironically a top spreader), more than doubling this attendance concession at the end of February. Wearing of masks remained obligatory. By this time South Africa had the highest number of confirmed Covid-19 cases in Africa and the fifteenth highest number of confirmed infections worldwide – but with a relatively low death rate, indicating that the tough measures had mitigated the local pandemic. A historically unprecedented vaccine roll-out, surpassing even our worldbeating ARV roll-out for HIV, aimed at reaching 40 million of South Africa’s estimated 59 million population by year’s end, (feasibility under serious question), to achieve herd immunity, began mid-February, 2021. The somewhat dysfunctional and underequipped public sector, (with islands of excellence), and a historically youth and child-oriented immunisation program, would need everything money, the private and NGO sectors can throw at it to protect and care for all. (80% of South Africans rely on public sector healthcare). The first tranche of one million vaccines was due to go to the

exhausted and threatened front-line healthcare cadre, a pragmatic bid to maintain treatment capacity. However, they were forced to wait another two weeks once researchers testing the vaccine on the new variant found the Astra Zeneca version to be less protective than the subsequently ordered Johnson and Johnson vaccine.

Covid-19 financial relief On 24 June 2020, the Disaster Management Tax Relief Bill, 2020 and Disaster Management Tax Relief Administration Bill, 2020 were tabled in parliament. These were aimed at easing cash flow burdens on tax-compliant small to medium sized businesses as a result of the Covid-19 pandemic and lockdown. Tax relief measures included a delay of remittances of “Pay As Your Earn” (PAYE), without triggering penalties or interest, a delay in the remittances of provisional payments of income tax without triggering penalties or interest, and an acceleration of certain employment tax incentives. President Ramaphosa also announced a temporary top-up of existing basic income grants by up to R300, including a R350 unemployment grant from late March 2020. He said the relief measures amounted to about 10% of South Africa’s GDP, describing this as

“considerable for a small economy like ours.”

Health system response For healthcare facilities, access protocols, infection control measures, triaging and the separate streaming of Covid and non-Covid patients became top priorities – especially after the red flag raised by a tragedy at St Augustine’s private hospital in Durban early in March 2020. A visit to the emergency unit for a Covid check-up by a young man recently returned from Europe, led to 15 deaths within eight weeks, with 39 patients and 80 staff linked to the hospital infected. The death toll was fully half the Covid-19 death toll in KwaZulu-Natal at the time. In the Western Cape, the epicentre of the pandemic, where the first surge peaked early, (mid-July 2020), Disaster Management authorities converted community halls and erected large marquee tent field hospitals to prevent hospital

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Sudden, unexpected costs for the private healthcare sector included indefinitely deferred elective surgeries and outpatient services, PPE, isolation and respiratory equipment, and downgraded or cancelled patient insurance coverage.”

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overwhelm. The International Convention Centre on Cape Town’s Foreshore was converted into an emergency interim treatment facility – but closed after the first surge waned. When the variant emerged, a large new interim facility was hastily erected at Brackengate near the Tygerberg Tertiary hospital. This adaptive pattern was repeated across the country, as dedicated and exclusively staffed ICU’s and wards in both public and private sectors ran at full capacity. All elective surgery was cancelled. Task shifting and snaptraining became the norm with many healthcare staff suffering moral injury in having to decide who lived and who died, too often due to the lack of basic equipment such as ventilators, oxygen points or due to oxygen supply disruptions. Burnout among an already severely understaffed healthcare workforce (pre-Covid), became commonplace. Health Minister Dr Zweli Mkhize revealed that 340 state healthcare workers died of Covid-19related illnesses between March and November 2020 alone, this number having increased significantly by early February, (the time of writing). Dr Mkhize also disclosed that as early as October 31st, 2020, there were 35 145 confirmed Covid-19 cases among public sector healthcare workers, (6,8% of the total healthcare workforce, double the community infections). To somewhat offset this formidable loss of available staff, the state employed 2 926 citizen doctors and 14 232 nurses, while ‘boosting’ education, training, social and psychological support. The arrival of the virus prompted an initial scramble to source personal protective equipment, PPE, for vulnerable healthcare workers. South Africa joined the unseemly global

COVID-19

scramble. Several local factories retooled assembly lines to produce ventilators, masks, gloves, and aprons. PPE distribution saw widespread tender corruption, with the Special Investigating Unit, (SIU), estimating up to R2 billion in irregular PPE expenditure in Gauteng alone. By July 2020, public outrage at sub-standard and initially short-supplied PPE led to a presidential proclamation to enable the SIU to probe all aspects of Covid-19 corruption. The SIU soon announced that it was investigating potentially dodgy C-19 contracts amounting to R13 billion. This concentrated the minds of the national health leadership on the first batch of a million vaccines for healthcare workers which arrived on February 1st, 2021. Stringent security was arranged, and a sophisticated electronic vaccine data system set up to protect and audit what one health official described as ‘liquid gold’.

Crushing impact on private healthcare According to reputable surveys, the overall ability of the private sector to contribute to healthcare is fast corroding. Ironically this comes just as the government pushes for centrally funded universal healthcare, citing the current pandemic as evidence of the need for, and a dry-run in advance of, a unitary healthcare system. The initial lockdown to “flatten the curve” of infections created the near-perfect storm – as evidenced by a survey of 1 489 businesses across every major sector. A survey by Finfind, the Department of Small Business Development and several business groupings, revealed the forced closure of 42.7% of small businesses by early December 2020. Sudden, unexpected costs for the private healthcare sector included

indefinitely deferred elective surgeries and outpatient services, PPE, isolation and respiratory equipment, and downgraded or cancelled patient insurance coverage. Concurrently, patient healthcare avoidance led to serious progression of illnesses such as TB, HIV/AIDS, cancer, mother and child-care, diabetes; basically, any ailment that requires chronic medication or outpatient care. Fearing contagion, people stayed home and/or failed to renew drug scripts and/or seek care. Smaller healthcare providers across the entire supply chain scaled back and laid off workers. Conversely, cash reserves of medical aids grew, (a temporary phenomenon). The stress remains acute for small healthcare enterprises, solo practitioners, labs and pharmacies, an ever-increasing percentage of whom are in danger of closing without loans, guarantees or grants. The survey data show that in the first five months of lockdown, 76.2% of businesses experienced a significant decrease in revenue. Some 35% had cash reserves saved. Of these, 62.6% thought their cash reserves would last between one and three months. Only 29.2% of businesses were confident they could pay expenses the following month. Existing debt, lack of cash reserves, outdated financials, no access to relief funding, and an inability to operate during lockdown were the chief reasons cited. Surprisingly, only 47.9% of businesses that closed had applied for Covid-19 relief funding. However, virtually all (99.9%) funding applications were rejected, the Finfind survey revealed. Only 32% of respondents believe they will be

able to create new jobs – a significant alarm bell during the country’s unprecedented unemployment crisis. The government ambitiously approached the country’s medical aids in a bid to get them to pay half of the nation’s vaccination roll-out bill via their nine million members. However, Profmed CEO Craig Comrie described this funding model as “inherently unfair, unethical and illegal.” Fedhealth‘s Principal Officer, Jeremy Yatt, also objected, saying that, contrary to what was being punted in the media, “it’s by no means a done deal”. He added testily, “Aside from Discovery, I don’t know of a single scheme that is buying into a proposal that is damaging to the interests of members and will weaken the schemes financially.”

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owner’s personal credit record, to determine the business’ credit worthiness.”

Go digital or go broke. Meanwhile, access to funding remains the top challenge reported by small medium and micro enterprise, SMMEs. Poor consumer credit scores were cited as one of the primary reasons cited by banks for rejecting Covid-19 relief funding applications. Says Finfind; “Banks urgently need to develop new credit assessment models centred on the repayment history of the business itself, rather than focusing on the business

The common thread among the businesses surveyed was that sourcing funding and ‘going digital’ were major priorities. Speaking in June 2020, Sean Kelly, the co-founder and CEO of the USA-based Snack Nation, (healthy foods and beverages to workplaces and home-based teams) said; “We are in the midst of the greatest work-from-home experiment in history.” In the United States, the pandemic sees more than 88% of organizations with employees working remotely from home, (or in satellite hubs) – a 20% increase from 2019.

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Adjusting human capital management strategies to keep employee experience, morale and productivity as high as possible is the name of the new game. The McKinsey Institute recommends crafting a talent strategy that develops employees’ critical, digital and cognitive abilities, their social and emotional skills and their adaptability and resilience. ‘Doubling-down’ on learning budgets and committing to reskilling were vital for survival and success, they said. Studies have shown that companies who adopt a human bonding approach are more successful, both internally and externally. Combining this quality with ‘tech-smart’ people in building a workforce is the new imperative.

PROFILE | SAMRC

Using wastewater to detect the presence of COVID-19 Since the advent of the COVID-19 pandemic, health authorities have stressed the importance of rapidly detecting a rise in infections in communities.

s a result, the South African Medical Research Council (SAMRC), late last year, established and launched the wastewater-based early warning system for COVID-19 – the SARS-CoV-2 Wastewater Surveillance Dashboard. Tracking of wastewater plays a key role in the development of early warning systems (EWS) for various enteric viruses – SARSCoV-2 RNA had been successfully isolated, and the viral load was quantified in the wastewater of a growing number of countries. The SAMRC has been using this surveillance mechanism to help guide the country’s response to the pandemic. The system, although currently focused on COVID-19, has broader applications to develop an early warning system for diseases such hepatitis A, measles and norovirus. Soon after the start of the pandemic, the SAMRC brought together five of its research units – the Environment and Health Research Unit (EHRU), the Biomedical Research and Innovation Platform (BRIP), the Tuberculosis Platform, the Genomics Centre and the Biostatistics Unit – to design and coordinate the project. The team completed laboratory and field proof of concept studies and this detection mechanism is currently being rolled out in high-risk settings, including the City of Cape Town Municipality, Breede River Municipality, Theewaterskloof Municipality in the Western Cape, the Mopani and Vhembe Districts in Limpopo, the O.R. Tambo and Amathole Districts in the Eastern Cape, as well as in the Gauteng province.

Professor Glenda Gray, President and CEO, SAMRC, said by monitoring wastewater they can predict a rise in COVID-19 cases within a week or more before it is usually detectable through human testing. “We are excited about the prospect of curbing COVID-19 transmission and saving lives using this technology, especially when undertaken in partnership with public health officials,” Gray said.

How does it work? The process is that raw wastewater is collected at the inlet of the wastewater treatment works where a sampling device is used to scoop the wastewater and pour it into a 500 ml sample collection bottle and sent to the SAMRC’s or partner universitybased laboratories for subsequent analyses. During this process, COVID-19 viral load is determined by extracting and quantifying RNA using the reverse transcription polymerase chain reaction (RT-PCR). Data is then sent to the EHRU for spatial mapping – this is where data provided about the viral load is converted to the actual population number per wastewater site and that produces maps, which can be used to monitor whether the virus is increasing or decreasing. Through this project, the SAMRC has already alerted public health officials in the City of Cape Town and the Breede River of

spikes in SARS-CoV-2 RNA levels, allowing them valuable time to prepare for increases in COVID-19 cases and to intervene wherever possible. Another major advantage of wastewater monitoring is that it can be used to detect the presence or absence of viral RNA in wastewater from both symptomatic and asymptomatic cases and to identify hotspots. Wastewater-based epidemiology (WBE) can also be used to track the pandemic as it is unfolding and to understand trends over time. More importantly, SARS-CoV-2 viral titres can be used to monitor schools, frail care centres and university residences. In future, it can be used to detect a resurgence or identify any new local outbreak.

What’s next? This type of epidemiology does assume that people are connected to well-running sewerage infrastructure, which isn’t the case for a significant number of South Africans. The SAMRC is thinking about the communities without sewerage pipes and plans to investigate that space next.

www.samrc.ac.za

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REGULATION

EXPEDITING APPROVAL FOR

Covid-19 vaccines

Approval of vaccines or medical products can take months and even years. Covid-19 applications for approval, however, enjoy priority review without changing or lowering the standards of the review process.

cknowledging the critical need for vaccine development, SAHPRA (South African Health Products Regulatory Authority) established the Covid-19 Vaccine Registration Working Group with experts in the areas of vaccinology, manufacturing, clinical trials, epidemiology and vigilance; also informing quality, safety and efficacy. A “reliance mechanism” to expedite the approval process was also introduced. When another trustworthy regulatory body, like FDA in the US, approves a vaccine, SAHPRA may use their review documents to shorten its review time.

How could the vaccination be administered to healthcare workers before being registered by SAHPRA?

out. The real-life implementation of medical interventions is studied while SAHPRA works through the data to certify that it is safe and effective. In line with World Health Organization’s standards for Covid vaccines, SAHPRA is working on a threshold of 50% efficacy. You can view the standards for Covid vaccines here: https:// www.who.int/medicines/regulation/ prequalification/prequal-vaccines/ WHO_Evaluation_Covid_Vaccine. pdf?ua=1 Although the protocol only allows for health workers to be vaccinated, SAHPRA widened the scope so that President Cyril Ramaphosa and Deputy President David Mabuza (who chairs the inter-ministerial committee on vaccines) could be vaccinated to “encourage vaccine uptake and reduce vaccine hesitancy”. The government will pay for the additional nine million doses for a general roll-out later this year. It will be registered differently and subjected to different rules. According to Prof. Glenda Gray, President and CEO of the South African Medical

The first 500 000 doses of the Johnson & Johnson (J&J) vaccine were provided for the Sisonke Phase 3B Study and so would not be used for wider roll-

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Prof. Glenda Gray, President and CEO of the South African Medical Council

REGULATION

Research Council (SAMRC), the vaccine could be registered for use in March. She commended SAHPRA’S rigour, saying that they are following the correct processes independently, no matter the pressure. She is confident about the roll-out process, saying that the number of sites for the Sisonke Study has been expanded from 17 to 47, with imminent further expansion into 12 more sites. This includes sites in rural areas to improve access to rural healthcare workers.

Confusion over regulations It became clear that confusion still reigns about the difference between a clinical trial and a roll-out when the Department of Health came under fire in Parliament over the J&J vaccine being administered to healthcare workers. They were accused of “unethical conduct” for conducting human trials on healthcare workers who believed that they were getting a

roll-out first to protect them. Deputy Health Minister Dr Joe Phaahla had to explain that the vaccine was not yet registered for a general roll-out. It was, however, technically and legally registered as an expanded study while waiting for registration from SAHPRA, using the remaining doses from human trials all over the world. South Africa was part of the J&J trial of 43 000 volunteers across eight countries (Phase 3) in November and December 2020. The expanded study became necessary because South Africa was eager to start with the programme to protect its healthcare workers.

Why the J&J vaccine? The J&J vaccine offers 64% protection against moderate to severe Covid-19 infections in South Africa (72% the US). It is also effective against the new dominant local 501Y.V2 variant and 100% effective in preventing hospitalisation or even death from

severe Covid infection. After 49 days, no Covid-19 cases were reported in patients who'd been vaccinated. The vaccine is delivered by a replication-incompetent adenovirus. This modified version of the virus carries a gene from the coronavirus into the human cell where it produces coronavirus proteins in the cell. The immune system is thus primed to attack the coronavirus when it enters the body. Most other vaccines use molecules of synthetic RNA. The vaccine only requires one dose, doesn’t demand a deep freezer (only regular refrigeration) and keeps for up to three months. J&J has undertaken to provide a new batch of vaccine doses to South Africa every 14 days, for up to 500 000 healthcare workers. South Africa has also secured 20 million doses from Pfizer and 12 million through the Covax initiative, supported by the World Health Organization.

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EDUCATING EXCELLENT HEALTHCARE PROFESSIONALS The University of Pretoria’s Faculty of Health Sciences encompasses all facets of modern medicine. Students are trained by 600 academic staff members in the Faculty’s four schools: • The School of Dentistry • The School of Healthcare Sciences • The School of Health Systems and Public Health • The School of Medicine

CAREER PATHS COVERED THROUGH THESE SCHOOLS INCLUDE: • Medical doctor • Dentist • Oral hygienist • Dental pathology, prosthodontic and orthodontic specialist • Nurse • Occupational therapist • Physiotherapist • Nutritionist • Radiographer • Healthcare facility manager • Research scientist • Nuclear medicine • Sports medicine UP’s researchers are ranked in the top 1% internationally in Clinical Medicine, Immunology and Microbiology

FACULTY OF HEALTH SCIENCES UNIVERSITY OF PRETORIA www.up.ac.za/faculty-of-health-sciences

REGULATION

THE IVERMECTIN

debate Hailed as a ‘wonder drug’, Ivermectin is widely used by people to treat, and some say even to prevent, Covid-19, despite it not being registered for human consumption. Experts, however, warn that it can be dangerous if used unregulated.

vermectin is a drug that is registered in South Africa for the treatment of parasites in animals under the Fertilizers, Farm Feeds, Agricultural Remedies and Stock Remedies Act. This is also the drug that is now widely hailed as the “wonder drug” in Covid-19 treatment. The government website, at the beginning of March, still warned that it is dangerous to market Ivermectin as a treatment against Covid-19 as it has not been property tested for human consumption. It can be harmful to human life when used unregulated. Furthermore, no Ivermectin–containing medicines are registered for human use in the country and therefore the efficacy, safety and appropriate dosage for its use are uncertain. All these warnings, however, do not prevent people from using Ivermectin, often bought in litres at cooperative shops for farm products, on a daily basis or when they get Covid-19.

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Ivermectin for human use has led to a point where there is now a world shortage of this product, costing 2 000% more than pre-Covid. The pro-camp argues that it is cheap to make; therefore pharma companies won’t pursue it as it is not profitable. They believe that it is safe as it has been administered billions of times to humans and animals since the 80s. It works by blocking the entry of a protein into a cell’s nuclei, thus limiting the replication capacity of the virus. Gaining momentum, it is already being used widely by doctors or without medical supervision. And that is the problem. Although some healthcare workers believe the drug is safe as it is not an experimental drug, the danger lies in people abusing or overdosing on it. But, says the other camp, there is not enough data on this drug, as it had not been assessed properly. The full extent of its efficacy was therefore not know. Oxford University is now planning a trial to assess Ivermectin in the hope of finding a drug

REGULATION

that will work soon after Covid symptoms appear; to be most effective during the primary stages of the illness. Prof Chris Butler, professor of primary care at Oxford University says that although it has potential antiviral- and anti-inflammatory properties, there is a gap in the data as there has never been a rigorous trial. Smaller trials have found that it speeds recovery, reduces inflammation and reduces hospitalisation. The co-chairperson of the ministerial advisory committee, Prof Salim Abdool Karim warns that research on ivermectin to cure Covid was flawed due to the small sample size and lack of clear recommended dosages. He does not believe ivermectin can kill the virus at dosages humans can tolerate as it would be toxic to humans. The country’s top experts caution against the irresponsible social hype around this drug and ask people to wait until it was officially approved for human use.

SAHPRA steps in Although not registered for human use in South Africa, SAHPRA has approved a programme of controlled compassionate use of Ivermectin. Says Dr Boitumelo Semete-Makokotlela: SAPHRA had several meetings and consultations with the scientific and medical community to explore options for controlled, monitored access to reliable quality ivermectin-containing products for human use coupled with simple but essential reporting requirements. Only quality-assured ivermectin products intended for human use will be made accessible, and these will be controlled as prescription-only Schedule 3 medicines. Under the compassionate access programme a tiered mechanism will be followed. This will ensure access, monitored use and stringent reporting. Only a registered medical practitioner may apply for

permission to prescribe ivermectin to a patient with an obligation to report on patient outcomes. At the time of print, with reports that SAHPRA may approve a wider use of Ivermectin, its spokesperson declined to comment citing the court case at the end of March. Its website, however, still says that no other regulatory authority with which SAHPRA is aligned, neither the World Health Organization, has recommended the use of Ivermectin in the management of Covid-19. SAHPRA will continue to review all new evidence on the safety and efficacy of this product.

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PROFILE | DNN TECHNOLOGIES

MULTISECTORAL

ICT EXPERTISE

DNN Technologies is an ICT (information and communications technology) company specialising in consulting, IT infrastructure, enterprise services, new age technology, security services, fire services, biosecurity, as well as the supply of hardware and software.

fficially established in 2013, wholly South African owned business DNN Technologies provides value-added information and communications technology solutions and services. The company has delivered many successful projects over the years and continues to grow together alongside its customers. DNN Biosecurity is a business unit (BU) within DNN Technologies that focuses on Covid-19 decontamination, infrared

solution details

screening technologies, and equipment for disinfections. As a BBBEE Level 1 company, DNN Solutions is 100% black owned, with 51% ownership by black women.

Striving to be a market leader DNN Technologies aims to be the market leader in providing comprehensive integrated solutions tailored to the needs of specific industries on existing technologies. In order to do this, the company plans to continue growing its business within the SMME, large enterprise and public sector by formulating strategic alliances with technology vendors. The company offers comprehensive solutions within an array of sectors and industries, which include government, mining, healthcare and life science, telecommunications, construction, manufacturing and security.

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Biosecurity services DNN Technology’s Biosecurity BU employs a dual-phased approach to mitigating possible exposure to SARSCoV-2 and the spread of Covid-19, especially for businesses who wish to comply with government regulations and ensure the safety and well-being of their employees. Its phased approach is as follows: • Phase 1 – Decontamination of living and work space to reduce the risk • Phase 2 – Implementation of fever screening systems: - Infrared fever screening thermometer - Infrared fever screening cameras - Infrared fever screening commercial drones - Infrared fever recognition terminals - Infrared fever screening complete system.

www.dnntech.co.za

SAHPRA

Dynamic health regulating in the

FACE OF CHANGE When Boitumelo Semete-Makokotlela accepted the position as CEO of the South African Health Products Regulator (SAHPRA), she knew she was in for a challenge. With the regulator in a space of transition, she was thus tasked with innovating a turnover strategy to reposition SAHPRA as a continental and global leader. As then the global Covid-19 pandemic arrived on South Africa’s shores just three months after she assumed her new position. She spoke to Jamaine Krige.

hen I started in January 2020, I had all these plans about how we would turn things around. I had no idea of what I was letting myself in for or what was to come,” she says with a laugh. “There was no way that we could anticipate so much disruption to our business processes, or how busy we would be, because we really are at the heart of this pandemic response.”

Boitumelo Semete-Makokotlela, CEO, South African Health Products Regulator (SAHPRA)

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SAHPRA

Three months into her new role, all work was suddenly done remotely. “I had not even met all my staff members nor had the opportunity to really start building relationships.” SAHPRA was also undergoing a large-scale recruitment drive. “Job interviews were done online, and most of my executives were appointed by means of virtual interviews.”

SAHPRA has taken centre stage in recent months, specifically around the efficacy and approval of Covid-19 vaccines. But, as Semete-Makokotlela highlights, the job of the regulator is much broader than just the registration and regulation of vaccines. “The Covid-19 vaccines make up a fraction of the vaccines we regulate, and vaccines are only a small portion of what we do,” she explains. SAHPRA regulates all medicines, as well as biological material products, such as those used in oncological treatments. Complementary medicines, in addition to medical devices and in vitro diagnostic (IVD) products are also regulated. “The IVDs are interesting,” she explains, referring to diagnostic tests done on blood, tissue or other samples taken from a patient. “So right at the beginning of the pandemic and with tests not being available, we had to work very closely with the National Health Laboratory Service (NHLS) around the regulation of the molecular tests, the antigen tests, the antibody tests… And then we were still charged with regulating medical devices like ventilators, as well as all personal protective equipment (PPE), used in our healthcare and high risk facilities.” The list does not end. From sanitisers in health facilities to masks like the N95 respirator mask, and medical devices need to be

regulated, including thermometers. The challenge of transforming and repositioning the regulator grew with each new report of the novel coronavirus sweeping the world. “I was always cognisant that I would be coming into an entity that is repositioning, transitioning, transforming… from the former Medicines Control Council (MCC) to the now-SAHPRA.” She never expected the task to be an easy one. “I knew we would need to focus on change management, and on building a cohesive team. That is what I expected,” she smiles. “But then with the Covid-19 pandemic… it made a challenging task a lot more complex.”

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There was no way that we could anticipate so much disruption to our business processes, or how busy we would be, because we really are at the heart of this pandemic response.”

SAHPRA

Challenges and opportunities “The benefit of the pandemic was that it accelerated some of our plans.” When she joined the regulator, many of the functions and systems were still being operated manually. “We had to urgently digitise those systems, and even though it wasn’t necessarily the full digitisation that we wanted, we did make good progress, and fast.” Externally, the establishment of ties and relationships with local, national and global stakeholders, as well as with international regulators, had to be accelerated. There was no time for introductions – we just had to get on with it.” What was disrupted, however, was a number of the regulator’s change management initiatives. SemeteMokokotlela found that in some areas she needed to take a more hands-on approach than would traditionally be called for from a CEO. “I had to, because we really needed to do things differently. In other areas, however, my role was more traditional – providing leadership and guidance

and push, and to employ on the team that this wasn’t business as usual.” Responsiveness became an important part of her strategy. “We had to find ways to stay on track and get ahead of this pandemic; be responsive to how the sector needed to address new situations as they arise – both locally and internationally.” She needed to set the pace, the direction… and lead from the front, while ensuring the physical and mental well-being of her more than 270 staff members. “It’s so easy to get overwhelmed, so a big part of my job was to create a sense of calmness.” Around 80% of the SAHPRA staff execute a regulatory function. The other 20% are support staff. And those support staff are critical. “From a wellness perspective, we had people who became infected and who got sick, and our HR had to get involved. In the same breath, finances remain critical and operations within the regulator must continue while we work towards responding to what is happening in the outside world.”

Turning point “We really needed to rethink how things were done, and we had to rely on others a lot more. The pandemic response is a

80%

Around 80% of the SAHPRA staff execute a regulatory function. The other 20% are support staff. And those support staff are critical. “From a wellness perspective, we had people who became infected and who got sick, and our HR had to get involved. In the same breath, finances remain critical and operations within the regulator must continue while we work towards responding to what is happening in the outside world.”

collaborative one and doesn’t happen in isolation. “We relied heavily on the decisions made by others, but they also relied on us.” These decisions affected not only the health sector, but had a ripple effect through every other sector and industry and impacted on the everyday lives of all South Africans. “We also had to assume a leadership role regionally,” she says.

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SAHPRA

The novel nature of the virus underlying the pandemic also meant that decisions had to be made fast; the regulator had to adapt to the daily influx of new research and new information. “With so much that is unknown about this virus, our risk tolerance was constantly tested. With Covid-19 there is literally something new every day, calling for adaptability, but also for balance. “We needed to be agile and flexible, while making sound science-based decisions.” Making decisions in this way, however, takes time, and doesn’t always marry with the urgency that the situation on the ground requires. Fortunately, this flexibility is where Semete-Makokotlela and her background in health innovation technologies shines. “I come from an environment of innovation, and in a research and

Diversity is something I’m very intentional about, because a diverse environment with diverse voices is how new ideas are born, and how we learn to do things differently. And I know that for us to turn the regulator around, we’re going to have to do many things differently, in many different ways.”

development space you take risks. You become comfortable with taking risks,” she laughs, adding that some staff had been with the regulator for more than two decades. “And regulators aren’t always known as risk-takers.” These different approaches forced both Semete-Makokotlela and her team out of their comfort zones. She admits to meeting some resistance… But, as the world realised, what had worked in the past was not necessarily sufficient in the face of the Covid-19 outbreak. A new culture – communication and innovation, debate and discourse – was

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thus implemented. “I know it will take time for us to all be on the same page; to find a balance of risk culture within the regulator. We’re pushing innovation, not just with how we interact with the world, but also internally; not just from an IT perspective, but in how we work within SAHPRA.”

SAHPRA

By facilitating these discussions and encouraging staff to speak out, SemeteMakokotlela is building a culture that enables innovation, new ways of thinking and new ways of operating. She says she’s made an active effort to include people from all sectors and walks of life in her core team. “Diversity is something I’m very intentional about, because a diverse environment with diverse voices is how new ideas are born, and how we learn to do things differently. And I know that for us to turn the regulator around, we’re going to have to do many things differently, in many different ways.” Diversity is critical, she says, especially in the health sector, where advances are being made at warp speed and innovation means the industry landscape is changing daily. “The world outside the regulator is moving at a fast pace; you only have to look at the medicines, products and devices that we regulate to know this. We can’t afford to have a homogeneous regulator, where everyone within the organisation thinks the same, or we will get left behind.” The evolution of healthcare also means that the

I know it will take time for us to all be on the same page; to find a balance of risk culture within the regulator. We’re pushing innovation, not just with how we interact with the world, but also internally; not just from an IT perspective, but in how we work within SAHPRA.” regulator needs to be forward-thinking. “Typically, at SAHPRA, we’ve largely regulated medicines so we’ve employed pharmacists and medical doctors. Now our mandate includes medical devices & IVDs, and we will have to employ engineers, radiologists, nuclear physicist etc, which is very different!” She says it is important to appreciate the external context and how dynamic and everchanging the landscape is. “And once we have that appreciation, it’s about realising that we cannot be rigid internally.” Her R&D background has allowed her to keep her finger on the pulse of health innovation, and start to implement some of the forward-thinking that will be necessary for the regulator to thrive. “We don’t, for example, have guidelines around nanotechnology-based systems or stem cell technologies, which is something I know we will have to develop going forward,” she says. “So what my research background has done is, apart from giving me vast experience and vast exposure, also given me a good

overview of and an appreciation for the diverse range of innovations taking place in the health space, and of trends to come.” For this SAHPRA must start preparing. Despite not having regulatory experience, Semete-Mokokotletla brings a can-do attitude and a collaborative, interactive leadership style to the organisation. “I have a very high standard of delivery that I hold myself and my team to – and that is something I do not compromise on.” This, she laughs wryly, did not make her very popular among colleagues. “In the beginning not everyone is happy that you’re pushing them or expect them to deliver over weekends, or work on a Friday evening.” She shrugs. “But I’m the type who says if things need to be done then they need to be done. But I always make an effort to lead by example, because I can’t expect people to work crazy hours when I don’t.

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SAHPRA

So we can have the most beautiful strategies but if we don’t have the right culture… Organisational culture is what will make or break us.”

So I’ve found myself having to roll up my sleeves and support them in the process.”

‘Culture eats strategy for lunch’ A big part of the transformation she envisions for the regulator is a change in culture. “It’s often said that culture can eat strategy for lunch,” she laughs. “So we can have the most beautiful strategies but if we don’t have the right culture… Organisational culture is what will make or break us.” One of her greatest organisational strengths, says Semete-Makokotlela, is her ability to pull individuals together into cohesive teams who rally behind a shared goal. “At the moment we’re still in a storming phase; not norming yet. But with time I do find that my vision becomes clear and the people around me buy into that vision and commit to it, and we work together towards that vision as a team.” Her lack of regulatory experience has been a blessing, in certain instances. “I’m very open to consulting and learning from others, and I don’t hold my own views so firmly that I can’t be swayed by others.” This collaborative approach to management has enabled her to excel. “This is true even in an environment where I may not have the technical expertise, because I don’t shy away from picking up the phone and admitting that I’m not sure about something and allowing myself to be educated.” The fact that she is surrounded by a strong team of competent industry professionals makes all the difference. “As CEO, I don’t have to be the expert, especially if I’ve got a good team that I can leverage. Asking out-of-the-box questions have been helpful, especially in a time of Covid, because I’m asking how we can do things differently.” SAHPRA’s culture should be one of innovation. “That’s the culture I’m from – one where we debate and challenge ourselves and others, where new ideas are constantly flowing.” But virtual platforms,

she says, are not always conducive to organisational culture shifts. It’s been a steep learning curve, she admits, and the climb is not yet over. “Part of my vision is that we will assume a leadership role, nationally, regionally and on the continent. We’ve got all the elements to do that,” she says. “And not just SAHPRA; also our South African health sector and research community.” South Africa has been involved in a number of Covid-19 vaccine and medication trials, when very few other countries have been able to do so. “That really talks to our scientific strength as a country, and that is something I plan to leverage.” While she has excelled in a variety of fields, her real passion lies in health, especially access to health innovation – a new drug, device, delivery system or vaccine. She realised early how research and development could change someone’s life. “It’s been an unintentional journey, but access to health products is really at the heart of it.” And as a health regulator, SAHPRA is at the heart of access. She does, however, know that her life is more than just the regulator. “At the end of the day you’ve got to be a whole person; be a mom, to run around and play and get on a bike

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with the kids,” she smiles. Her children – a boy and girl – are six and ten years old respectively. “I’m a mom, a wife, a daughter and a sister, and I need to acknowledge all those parts of myself in order to also be the CEO that I’m needed to be.”

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COMPLIANCE

Change, rethink, survive Covid-19 has triggered a substantial shift in business operations, accelerating the need for digitisation, automation and organisational culture adjustments. Working from home has become a method of survival and even the South African Health Products Regulatory had to accelerate its plans; to rethink how things were done. 42

AND STAY SAFE

ll Covid-19 health and safety protocols must be followed at all times. This include observance of guidelines for social distancing, sanitation and hygiene, and use of appropriate personal protective equipment, like cloth face masks, as determined by the National Department of Health. People may travel to perform and acquire services only where such services cannot be provided from the safety of one’s home. A reference to a permitted level of employment must take into

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account the necessary social distancing guidelines as per the National Department of Health. All businesses must follow the directives issued under South Africa’s occupational health and safety act. This means that every employer has to adhere to stringent Covid-19 health and safety protocols. Protocols such as social distancing, the wearing of masks, sanitising and the adhering of government guidelines should be enforced by a health and safety committee after developing

COMPLIANCE

can be done at any labour department centre across the country. Every province has designated inspectors tasked with monitoring the compliancy of business with the rules.

What happens to noncompliant businesses?

a Covid-19 health protocol for the business.

Report businesses that flout Covid rules Failure to do so could result in a company being shut down or taken to the labour court. Many government offices have already been shut down, but the biggest culprits are still the private sector companies, Musa Zondi, acting labour department spokesperson, revealed in an interview with Business Insider SA. To the detriment of themselves, their workers and patrons, many workplaces are showing poor compliance with the Covid health and safety rules. That is why workers and the public can lay complaints against businesses who fails to adhere to the Covid-19 rules. This

For minor transgressions, an improvement notice will be given, which can be seen as a warning to fix what is defective, like workers not wearing face masks. Such a notice usually flags an issue within the workplace that has to potential to be dangerous. For many employers these new rules and regulations are full of grey areas. That is why it may be necessary to call in an expert to help sort out potential problems. Jahni de Villiers, Director at Labour Amplified, suggests that such company gets help. “A good labour relations strategist sees and develops methods for addressing risk in the human component of your business, which is arguably the most important part of your business.” She says an investigation may be necessary to see what went wrong where, as well as where a potential risk may lie and what solution could be offered. She suggests an occupational health and safety risk assessment, improving communication with teams working remotely and any

other aspect relating to the human beings in a business.

What if a company still not comply? The next step is a prohibition notice, which means the company is shut down and cannot operate until those regulations are adhere to. Inspectors will be sent out to check on these businesses to make sure that red flags have been sorted out. If not, a contravention notice is issued and the business owner taken to the labour court. Then it is in the hands of the court. For complaints, chief inspector Tibor Szana can be reached on Tibor.Szana@labour.gov.za, alternatively on 012 3094389.

Jahni de Villiers

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THPS

TRADITIONAL

HEALERS Traditional healthcare practices are largely informal and unregulated, despite the fact that approximately 80% of South Africans consulting the more than 200 000 traditional healers in the country who are mostly based in rural areas.

raditional medicine is used for primary healthcare needs because it is more accessible and affordable. This raises questions around accessibility and the patient’s safety, not to talk about the accountability of healers. Although the Traditional Health Practitioners Act was promulgated in 2007 to recognise this practise, many healers still work from home where there is little privacy for patients or their loved ones who are exposed to sick people. They can treat up to twenty people a day, while operating with little guidelines and while poorly regulated.

They want to be included in the development to treat Covid-19 patients; to identify symptoms and also to keep themselves and their clients safe.

So how have traditional healers cope with Covid-19 up till now? Traditional healers, in the last year, were forced to adapt, cope with losing work and learn how to perform rituals online (Mail & Guardian, 2021) Some of these healers had to move their place of work outdoors so that social distancing could be kept. Others now work in their gardens, saying that

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being so close to nature has brought a different dimension to their spiritual consultations. They may continue like this going forward. Like many other businesses they had to close their practices during lockdown, which brought about a loss of income and interaction with their patients. The Traditional Healers’ Organisation says the pandemic hit their members hard. Wearing a mask and sanitise may not sound like a big problem to most people, but some rural places don’t have enough water to drink and cook, let alone wash their hands. It was difficult to acquire herbs for

THPS

remedies during lockdown as markets were closed and people could not move around freely. Luckily they found that they could courier remedies to clients. Respiratory teas especially were sought after. Although group sessions are usually in high demand, these were discouraged. The emphasis is on emergency sessions, one person at a time. But even those sessions are scheduled so that surfaces can be sanitised in between. Health protocols are followed to keep healer and patient safe. Where possible sessions are held online; telephonic and online consultations forced many healers to learn new and technical skills. One way to ensure a connection between client and healer is by lighting candles on either side depending on whether the ancestors are happy with such arrangement. Many healers say that this digital move has had a positive effect on their businesses as they now can consult with many more clients and also further afield. Another solution to rituals is to teach the client how to conduct cleansing ceremonies and prayer sessions on their own. Some clients, however, are stuck in the old ways and they will only be reached once the lockdown is over.

The performing of rituals, however, especially the slaughtering of animals or group visits to mountains or rivers, had been effected most. This is a problem, one healer says, because if the ancestors’ wishes are not appeased, it can lead to problems for the client. One of the biggest problems for traditional healers is that new healers cannot be initiated. A database for traditional healers, GogoOnline was launched a while ago to advertise their services, but it was found that healers were held back from joining by a historical lack of recognition.

Covid-19 guidelines for traditional healers Traditional healers, classified as essential workers, want to be included in the development of new guidelines to treat Covid-19 patients. They feel they should be trained to identify symptoms of the virus while keeping themselves and their clients safe. Although their roles are listed, like triaging and referral of patients as well as public health messaging, they complain that the guidelines

are not always clear and also difficult to enforce. Phase one of the vaccine roll-out will include everybody at a healthcare facility in the public and private sector. This includes traditional healers and funeral sector workers. For more information on the guidelines for traditional health practitioners in dealing with Covid-19 and lockdown, please visit: http://www.health.gov.za/ covid19/assets/downloads/ policies/Traditional%20Health%20 Practitioners%20in%20dealing%20 with%20COVID-19%20and%20 lockdown.pdf

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REINVENTING THE RECOVERY MODEL FOR TIMES OF CRISIS

Looking to the future letting go of the past

A crisis should be seen as an invitation to reimagine the preferred futures and not as a desperate clamour for the romanticised certainty of the past. Madelaine Page and Jamaine Krige discuss Dr Morne Mostert’s Pro-silience model to take South Africa into the future. Dr Mostert is Director for Futures Research at Stellenbosch University and also used this model to score South Africa’s response to the Covid-19 outbreak.

anguage, he argues, is the audit of knowledge. And as knowledge evolves and changes, so must the language to communicate this. “Insights expire,” he explains. “And to the extent that language reflects the thinking that produced the insights, language that describes strategies for general success also appears to have a limited shelf-life.” This, he says, is rather easy to prove. “If the general tenet of

continuous change is embraced, then it cannot be argued that language, derived of a time and a place never to be revisited, is somehow immune to similar evolution.” In times of general success, it’s easy for individuals, organisations and societies to overcome minor disruptions and return quickly to the status quo. “The need to bounce back to a time of prosperity makes intuitive sense under pressure,” he

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explains. This, however, was not the case with Covid-19. “When the negative disruption is nothing short of tectonic, and the status quo was already severely undesirable, a meek attempt to return to a previous normal appears deeply misplaced,” he says. Even if successful, resilience under these conditions would not produce a satisfactory future. Dr Mostert warns that the reality of Covid-19 with its deadly impact and

REINVENTING THE RECOVERY MODEL FOR TIMES OF CRISIS

Dr Morne Mostert, Director of the Institute for Futures Research at Stellenbosch University, is also a member of the Club of Rome

accompanying lockdowns has not yet brought about a ‘new normal’. There is also no reason to yearn for the ‘old normal’ because this normal was actually not working very well. Resilience entails the ability to recover quickly from difficulties and toughness. This is no longer good enough. Resilience and recovery suggest a similar goal – to return to times of prosperity. But, as Dr Mostert points out, we need to move forward, not backwards, if we are to truly step into the tomorrow we deserve. No matter how daunting the prospect of alternative preferable futures may seem, rapid or dramatic innovation now holds the key. “An active citizenry cannot allow its government to revert to the defence of outdated patterns of thought and practice, or the lowering of ambition

to levels of a time gone by.” Instead, he says, what is required now is a futureconscious system actor who recognises the irrefutable reality of futures with low recognisability. Instead of just bouncing back, successful systems of tomorrow must transcend resilience as ‘re’ implies a repetition of the past. This is instead replaced by ’pro’ (pro-silience) to suggest a creative design towards preferred futures. Within the context of this Pro-silience model, Dr Mostert defines a crisis as “a sudden and surprising event or realisation, which causes significant interruption, disturbs the systemic balance, and presents an appreciable threat, especially for the current future.” He uses his Disruption Satisfaction Matrix to illustrate the limited options of traditional resilience and explains how

traditional thinking cannot deliver the desired results for an uncertain future. “In fact, traditional thinking is what has produced traditional problems,” he explains, “and a back-to-basics approach, embraced for its apparent certainty, can only repeat yesterday’s challenges.” That is why one must look at innovative, alternative futures, he says. When redesigning a business, family or society the focus should be on being successful in a “considered and dynamic future landscape” without yearning for the past, as the past will not bring about innovation and alternatives. Dr Mostert says his Pro-silience Model embodies a future-conscious design of complex adaptive systems. He uses a diagram to propose the ten point process for achieving pro-silience, starting with Distance.

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REINVENTING THE RECOVERY MODEL FOR TIMES OF CRISIS

10 POINT PROCESS FOR ACHIEVING PRO-SILIENCE

Distance

As a first step, the valued asset is removed from the immediate threat and in extreme cases drastic action may be necessary, like killing parts of the self (he uses the examples of cannibalism or self-amputation). This may be because the asset has expired or may have been rendered useless, possibly due to the crisis itself or because of a more attractive offering. • South Africa scores 8/10 on this this step as Dr Mostert lauds President Ramaphosa, saying the country did “exceptionally well to design and communicate the first hard lockdown”. Only a long-term vision could have bettered the score.

Conscious Care

The severity of the disruption in a time of crisis, he says, makes it essential to allow the system to “stop and rest” to make sure that it is secure and not injured further, either externally or due to its own dysfunctional momentum. • South African score: 6/10. Despite fairly rapid early responses, especially by the business community, and social grant measures, most businesses and vulnerable citizens remained at the mercy of the crisis.

Pro-generation, Pro-habilitation, Repair & Pro-construction

Pro-synthesis, Coalescence & Homeostasis

Scarring & Trauma Treatment

Provention & (un)Learning

At this stage the system must start moving towards its preferred future. Its recovery path should now be redesigned “with the intelligence of the recent shock embedded in the intelligence of its new DNA” and not a rehabilitation to regenerate its former state. • South Africa scores 5/10, as Dr Mostert says that after more than a year, very little has been published on meaningful recovery strategies and almost no critical focus areas have been communicated publicly.

A new identity in a novel context should now emerge, with new connections being formed. • South Africa scores 3/10. The South African Cabinet has remained unchanged, despite “glaring evidence of strategic incompetence”, which makes it clear that insights for the post-Covid landscape are still lacking.

Thermo-dynamic rebalance

Dr Mostert says the overall temperature, for instance the social temperature/mood, can be controlled as soon as a form of care and security is established. “By reducing system ‘inflammation’, the system is ready to be guided towards renewal.” • South African scores 5/10 as bureaucratic incompetence, arrogance by politicians and a lack of defensible scientific acuity brought about escalating tempers.

This is not the time to stop the recovery efforts, but rather to increase and maintain them. Doing so timeously is what will prevent intractable damage in the future. One must make sure that ghosts from the past do not feature when decisions for alternative futures are made. It is, therefore, important to test the system memory to make sure it does not hinder future progress. • South Africa scores 2/10. Dr Mostert says the government has caused economic and social scarring that will be felt for a long time as little attention was paid to the damage of the draconian measures. Talking about “hermetic lockdowns”, he says, showed almost no evidence of the slightest agility in decision-making.

Pro-hydration & Diagnosis

Pro-resourcing & Prognosis

It is at this stage where the prefix “pro” is introduced as the limits of retrogression to the past have, by implication, been reached. By controlling the systemic temperature, rehydration is allowed and a prima facie diagnosis undertaken to assess the extent of the damage. Comparisons are made between the current reality and the reality just before the crisis. The current reality is also compared to where one had expected to be now; and one’s own present reality is compared to the current reality of another. • South Africa gets 4/10 with corruption even engulfing food parcels, apart from the fact that no early diagnosis was done.

Once the system has proven that it can continue its viability, resources must be allocated for it to develop further. Not lingering on traditional resourcing models, the focus must be on what is required for the preferred future. Pro-resourcing refers to “a future-informed process of decision-making and resource allocation.” It is at this stage, Dr Mostert says, that the system can start with safe experiments towards an envisaged future. • South African score: 3/10 – The outdated conversations about the rescuing of state-owned enterprises, for instance, prevent the reinventing of the economy.

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Deep learning of the new future is necessary, especially as the past may linger or even try to repeat itself. Beyond prevention, unlearning of obsolete perspectives and prevention is also needed. Dr Mostert warns that crises are part of systemic wholes and their restructure must be able to withstand similar future shocks. Early warning systems should be developed for timeous risk detection and agile system design for rapid future response. • South African score: 2/10 – The health system, divided by stark lines of inequality, showed similarly unequal responses. Referring to the varying degrees of lockdown and the debates on, for instance, open-toed shoes and the risks of rolled cigarettes (“zol” in slang language), Dr Mostert says there is little communication of the lessons learnt or a new thinking on early warning mechanisms.

New paradigm

Dr Mostert gives South Africa a score of 1/10. This, he says, is because the country’s national paradigm is one of a nation held hostage by its past. He refers to people in positions of great influence and power based on their perceived roles of the past, and adds that he does not foresee the current leadership presenting a sudden paradigmatic shift. A number of critical structures, like the independent judiciary, free media, professional business management, sophisticated financial system, constitutionally protected academic freedom and an active citizenry, however, remain beacons of hope.

REINVENTING THE RECOVERY MODEL FOR TIMES OF CRISIS

The Pro-silience Model A diagram is used to propose the 10 point process for achieving pro-silience, starting with Distance.

Autopoiesis

Distance/Removal

Teleology

Extraction/Barrier Cannibalism

New paradigm

Self-Amputation Provention

Conscious Care

Resilience

Stop & Rest

(un)Learning,

Secure

EWS dev.

Shock

Despair

Scarring

Thermo-dynamic

phantom limb

rebalance

(muscle) memory PTSD treatment

Confidence

Reduce inflammation

Hope Meaning

Pro-synthesis

Pro-hydration

Coalescence

Diagnosis

Homeostasis

Prescription Re-fueling Pro-generation

Pro-Resourcing

Pro-habilitation

Experimental

Repair

movement

Pro-construction

Prognosis

If the general tenet of continuous change is embraced, then it cannot be argued that language, derived of a time and a place never to be revisited, is somehow immune to similar evolution.”

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NEW NORMAL

Working from HOME the In an emailed response from Absa, it says that the principle remains that, if work can be done from home, it should be done from home.

ovid-19 has triggered a substantial shift in business operations both globally and within Absa, accelerating the need for digitisation, automation and organisational culture adjustments.” According to the email, they are in the process of collectively reviewing and redefining its ways of work. Jahni de Villiers, director at Labour Amplified, says the Covid-19 pandemic forced sweeping changes to the traditional ways of work. “Suddenly working from home is no longer a privilege for a select few management members. It’s now a method of survival, both for businesses and for employees who could be vulnerable to terrible outcomes, should they contract Covid.” The very strict health and safety directions, designed to prevent mass infection in a workplace, led to many businesses to rethink offices and their set-up. Many business leaders saw this as an opportunity. They realised that managers would need training to manage remote teams effectively and to build loyalty among employees with sensitive policies, which allows employees freedom

but also binds them to mutually set goals, she says. Most companies suddenly see their lives as virtual, Jahni says. “My life has changed drastically from no more person interventions and office work. You now try and figure out how to present a virtual study tour for participants from 13 countries with enough energy and oomph that they not only learn from the experience, but also enjoy it.” The advantage of this is that one has the luxury of only dressing up from the waist up while baking a bread while listening in on a meeting, avoiding traffic and rushing “like a mad woman to get to work and back after sitting for nine hours”. Jahni admits that this freedom brings about a lack of boundaries and eye contact and “complexity of managing animals, children and partners while being on work calls”. She says everybody was equally blindsided at the beginning of Covid-19. “Nobody had all the answers. We are building as we go.” Businesses had no choice but adapt to the new regulations. “Some likely had to pay someone to do a Covid-19 risk assessment for them, as is now required by law. Furthermore, some businesses had to install physical barriers where employees couldn’t be moved 1.5 meter apart. There are also relatively smaller expenses like cloth face masks and sanitiser installations.” On the bright side she declares that workplaces in general are very well regulated. Jahni believes that these public health measures will be

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NEW NORMAL

‘I refuse to take the vaccination’ – What now?

kept up, and may even affect absenteeism due to things like seasonal flu. Looking at occupational health and safety, she says: One could argue that they are regulated in such an intimidating way that many employers opt to ignore regulations, to their own detriment. The answer is not more regulation, it's strengthening the current regulations by proper communication and assistance from government in ensuring that employers and employees know and understand the regulations that are in place. “ Jahni, however, believes that things will stabilise, admitting that “chaos reigns some days.” She says the businesses who thrive are the ones who embraced the chaos, did what they could with what was in front of them, changed rapidly because they already had the buy-in of their employees before the pandemic started. “They came,

they saw and they moved on rapidly. If we learn nothing else, we should learn that employers with engaged workforces can survive anything, including global pandemics.” Absa, in their email response, also says that they are participating in discussions relating to the vaccine roll-out programme in South Africa through the Banking Association of South Africa, Business Unity SA and the Private Sector Coordinating Committee. “Absa will align with the national vaccine roll-out programme in South Africa, and we will prioritise employees most at risk, predominantly customer-facing staff.” The start of the vaccination roll-out signalled what is expected to be a turning point in the country’s fight against the Covid-19 pandemic. MidFebruary 2021 South Africa has recorded almost 50 000 deaths and more than 1.5 million infections.

But the vaccine roll-out will bring about another headache for businesses as, like some healthcare workers, employees may refuse to take the jab. The various strains of coronavirus often drive concerns. For instance, the mutation of the virus discovered in South Africa, known as 501Y.V2, is believed to be more deadly than its counterparts. And while President Cyril Ramaphosa said that no one will be obligated to take the vaccine or be given this vaccine against their will, like stated in the National Health Act, what happens to healthcare in the public interest? What could happen to an employee, like a healthcare worker, who deals with patients or clients on the frontline? Although a mandatary policy could be introduced by an employer, a labour law expert says the golden rule will be communication. Employees should be allowed to give their input and also to raise objections. It will be to the benefit of employee and employer if consensus could be reached. If an employee is dead set against the vaccination, the employer should act according to Section 189 of the Labour Relations Act. This means the employer could probably try and accommodate them in a different position. If not possible, retrenchment may be the next step. If all procedures were followed correctly, it would be difficult for an employee to prove unfair dismissal. Some workers believe the Constitution is stronger than the Labour Relations Act and that their right to refuse the inoculation will thus be protected as they have a constitutional right to refuse anything they believe is against their personal well-being. But once again the labour expert says that this may not hold water as one’s rights are limited in so far as they effect the rights of one’s colleagues and the people around you. This argument fails at an Employment Equity level, at an Occupational Health and Safety Act level, and in regard to the Protection of Personal Information Act. The latest study by Ipsos (January 2021) shows that 61% of South Africans are prepared to be vaccinated against Covid-19.

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TUBERCULOSIS

TB – SA’s

dangerous underdog disease

uberculosis cost 58 000 South African lives between 2018 and 2019 –a full 10 000 more than the Covid-19 pandemic killed over an almost identical period between its first local outbreak in March 2020 to March 2021. TB puts Covid-19 in the shade historically; similar numbers of TB patients in South Africa have been dying annually for years. TB remains the leading cause of death in SA, although mortality rates have halved in the past decade. The government’s

End TB target of a 95% reduction in TB mortality by 2035 is arguably achievable, in spite of two major amplifying pandemics (HIV and Covid-19). However, sustained effort in high-risk groups together with improved vital registration data are sorely needed to reach this target. Around one per cent of SA’s population contract TB annually. TB has been in South Africa since 1860, (probably even earlier), when the first minor outbreaks were recorded in Butterworth and Queenstown in

the Eastern Cape – or wherever military, trading or missionary outposts existed. Those early outbreaks were isolated and contained, but the disease burgeoned with industrial development, spurred on by migrant labour, poverty, malnutrition, and insufficient and crowded housing. Today South Africa carries 3% of the global TB burden. Adjusting for population size, many epidemiologists rank the country the highest in terms of TB incidence, more recently fuelled (i.e. from around 1990), by the devastating HIV epidemic.

TB/HIV – the terrible twins Today the two diseases, (HIV&TB), are so intertwined that the country has embraced both in a single counter strategy. Any clinician not up to speed with HIV can easily lose his co-infected TB patient. An HIV positive person is nine times more likely to get TB. So, it’s not surprising that a full 60% of the people surveyed in SA’s first ever national household survey (2019), and who became ill from TB, were HIV-positive, (36 000). That’s in spite of the world’s largest ante-retroviral drug roll-out, started 16 years earlier, having made a major impact on TB by strengthening HIV positive people’s immune systems and reducing their viral loads. However, just as this positive trend gained momentum, giving hundreds of

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INTERSYSTEMS | PROFILE TUBERCULOSIS

thousands more co-infected people a better chance – along came Covid-19.

The grace of adversity There’s an African proverb that says, “smooth seas do not make skilful sailors,” and it’s very apt when describing the globally admired skippers at the helm of South Africa’s HIV/TB ship. Covid has set the HIV/TB campaign back ‘by at least a decade,’ say several respected scientists and epidemiologists, inhibiting or preventing community tracing, treatment and research and aggravating symptoms as people are locked down and/or avoid treatment, unable or unwilling to continue their vital drug-treatment regimes. These fears are particularly poignant, even ironic, because the dread of Coronavirus infection seems to have gripped the collective imagination of communities far more fiercely than the much-slower acting TB ever did. This is particularly tragic because multi-drug resistant TB, the natural outflow of ‘incorrect’ or insufficient drug treatment, has become an even more silent epidemic, spreading like its less lethal milder cousin in an almost identical manner to Covid: wherever people congregate in confined spaces and at home.

subvert TB control. It’s a very worrying phenomenon – all the more reason why we need active case finding to detect minimal symptoms or asymptomatic people, not to mention drug-resistant cases. By the time people are sick and taken up in hospital they’ve infected hundreds of others – so we have to get out and into the community.” This is echoed by his peers in the field, alarmed at the numbers of “missing’ TB cases the 2018/19 national survey exposed. It also revealed that only 32% of DRTB cases were being treated. Explains HIV/Aids veteran-turned TB drugs researcher, Dr Franscesca Conradie of the clinical HIV research unit at the University of the Witwatersrand, “what we learnt from the survey is that the estimated number of (all TB) cases in the same year was much greater than then number of notified cases, (TB being a notifiable disease).” She and her colleagues now reckon that South Africa probably misses

DRTB a major threat Says TB researcher and global authority on DRTB disease, University of Cape Town-based Professor Keertan Dheda, “drug resistant TB puts an extremely high burden on SA and is very worrying and expensive, causing a lot of suffering and death with the capacity to derail, worsen and completely

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100 000 TB cases every year, a hugely sobering discovery which translated means, “we’re further away from controlling this disease than we thought. To put that visually, that is more than enough to fill the FNB stadium outside Soweto,” she says.

Case finding is key Adds Dr Conradie, “this is bad for the individual. TB is a progressive lung disease and the later we treat, the more likely they’ll suffer from ongoing pulmonary problems – and of course it’s transmissible, so we know they’ll infect others, particularly the vulnerable in their homes, such as HIV-positive people, the elderly and children under five years old.” “We need a heightened index of suspicion – these are all undetected cases not reported to the national TB program,” she stresses. A hardened lobbyist who has the ear of Dr Norbert Ndjeka, Director of DrugResistant TB, TB & HIV at the National

TUBERCULOSIS TUBERCULOSIS (TB)

Department of Health, she’s pushing for a heightened TB detection awareness campaign among healthcare workers. Dr Conradie developed treatment guidelines for bedaquiline, a gamechanging TB treatment drug introduced clinically in 2018, putting South Africa, (in her words), “at least five years ahead of anywhere else in the world”. She posts a time-based warning on the TB household survey, completed for interpretation in July 2019 but only released in early February 2021. “You have to take those numbers with pinch of salt – in the last six months alone we’ve probably missed as many cases as we’ve found,” she says.

considered one of the most effective ways of finding the huge numbers of asymptomatic and latent, (read ‘missing’), TB cases, rather than relying on treating only those who present at hospitals – either with advanced TB or active symptoms (i.e. notified cases). The grant will help buy or hire a large fleet of Toyota Avanzas, each fitted with a mobile mini-battery operated

GeneXpert machine, (molecular diagnostics), and manned by two healthcare workers and point them at communities where TB is suspected to be most underdiagnosed. “We’re aiming at really switching off the tap, instead of just constantly mopping the floor,” he enthuses, adding that to make an impact, the operation has to be scalable with “hundreds’ of vehicles and teams operating simultaneously. This will almost certainly require more funding. Prof Dedha emphasised how similar to Covid, TB was, constantly evolving against drugs used to treat it. “Like fluoroquinolone before it, also used to treat drug resistant TB, we’ve already had lots of bedaquiline, (still relatively new), resistance emerging,” he revealed.

Modest country doctor, a South African hero XDRTB was first discovered – and a strategy developed for household tracing – by Dr Tony Moll and his staff at the remote Tugela Ferry mission

Mobile tech to the rescue To this end, Professor Dheda, an A-rated scientist and head of the Division of Pulmonology at the University of Cape Town, and his team, secured a R200 million grant from the European Union and the US-based National Institutes of Health, (the world’s foremost medical research centre), in midFebruary this year (2021). Their aim is to rapidly expand household TB tracing,

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TUBERCULOSIS

Prof Keertan Dheda, Head of Pulmonology, University of Cape Town and Groote Schuur Hospital

hospital in KwaZulu-Natal in 2005, causing a world-wide sensation. Within months, his alerted peers across South Africa began finding it. The Tugela Ferry district, then a known HIV/ Aids hotspot and Dr Moll’s treatment sleuthing of co-infected HIV/TB patients failing to respond to treatment, led to the groundbreaking discovery. Professor Dedha said that TB vaccines in development were unlikely to reach approval for population inoculation anytime soon.

Vaccine hope However, there is hope. Dr Conradie says that if healthcare workers can learn to appropriately tailor and administer TB drugs, “I think we’ll be able to control the epidemic.” According to Dr Ribka Berhanu, a guest lecturer at the Boston University School of Public Health and Wits University HIV/TB researcher, the most promising TB vaccine, (M72), tested on HIV negative people with latent TB, already reduces the incidence of active disease by 50%,

with Phase 3 trials currently planned. Perhaps Shakespeare’s Hamlet sums it up best: ‘To be, or not to be, that is the question: Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous fortune, or to take arms against a sea of troubles, and by opposing, end them. To die – to sleep, no more; and by a sleep to say we end the heartache and the thousand natural shocks that flesh is heir to: 'tis a consummation…”

Sources Medztalk webinars Feb 2021 – (Dr Francesca Conradie, Dr Ribka Berhanu), Interviews, currently and historically, with Professor Keertan Dedha and Dr Tony Moll. The World Health Organization, WHO, Global Tuberculosis Programme; ‘Our response to Covid.” www.who.int › teams › covid-19 (see https://www.google.com/search?rlz=1C1SQJL_enZA854ZA854&sxsrf=ALeKk0 30BRnNtdPPxZRFTxBlZjfJQHwpZA%3A1613912810606&ei=6loyYPjMJNmg1fAP6PakyAI&q=WHO+2020+report+C19+impact+on+TB&oq=WHO+2020+report+C-19+impact+on+TB&gs_lcp=Cgdnd3Mtd2l6EAM6BwgAEEcQsANQya4iWMmuImC ZuiJoAXACeACAAdwCiAHVBJIBBTItMS4xmAEAoAECoAEBqgEHZ3dzLXdpesgBBMABAQ&sclient=gws-wiz&ved=0ahUKEwj46ZjehfvuAhVZUBUIHWg7CSkQ4dUDCA0&uact=5 -)

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PROFILE | UNIVERSITY OF PRETORIA STRAP

Educating the next generation of healthcare professionals

At the Faculty of Health Sciences at the University of Pretoria, we are committed to educating excellent healthcare professionals who will become the next generation of scientists, inventors and caregivers.

ur students receive training of the highest standard. Using the latest technology, our curricula combine modern content with interactive approaches to offer students a rich and varied hands-on clinical experience in a range of hospital, clinical and community settings. The Faculty of Health Sciences encompasses all the facets of modern medicine in its four schools. The School of Dentistry trains future dentists and oral hygienists, as well as specialists in dental pathology, prosthodontics and orthodontics. The School of Healthcare Sciences trains our future nurses, occupational therapists, physiotherapists, nutritionists and radiographers, and offers postgraduate opportunities in all these fields. The School of Health Systems and Public Health provides an extensive range of postgraduate qualifications aimed at training our future managers and research scientists. The School of Medicine offers a Bachelor of Surgery degree, with opportunities to specialise in traditional disciplines such as surgery and anatomy, as well as new fields such as nuclear and sports medicine. Our clinical graduates receive realworld, hands-on training in partnership with the Gauteng Department of Health, at Steve Biko Academic Hospital, Kalafong, Tembisa, Mamelodi, Tshwane District Hospital, Oral and Dental Hospital, Pretoria West Hospital,

1 Military Hospital and Weskoppies Hospitals, as well as Mpumalanga’s Rob Ferreira Hospital, Witbank Hospital and surrounding communities. At the Faculty of Health Sciences, we believe that innovation and relevance are maintained through research. Our researchers are ranked in the top 1% internationally in: Clinical Medicine, Immunology and Microbiology (Source: Web of Science Essential Science Indicators). The Faculty hosts various research institutes, centres and units that foster opportunities for transdisciplinary and translational research. Our research themes aim to achieve the globally relevant United Nations Sustainable Development Goals. We are passionate about improving the lives of the people

living on our doorstep and beyond, and believe that our actions, close to home, will have a far-reaching effect.

Life Changers Fund In 2020, the Faculty of Health Sciences established the Life Changers Fund to help the many students who experienced heightened challenges due to the Covid-19 pandemic. The Life Changers Fund is a student solidarity fund that supports students with the tools and subsistence required to complete their training in the current year, and provides support to help them complete their studies. The Life Changers Fund also provides bursaries for students who struggle with tuition fees. We are committed to ensuring that our students do not go hungry!

www.up.ac.za/faculty-of-health-sciences

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HIV/AIDS

HIV/AIDS IN

SOUTH AFRICA A tale of tragedy and hope

he story of HIV/Aids in South Africa is one of dark tragedy and inspirational hope. Aids denialism – official policy between 1999 and 2004, aggravated the population decimation begun two years earlier. The government’s rejection of life-saving anti-retro-viral drugs prompting a protracted and ultimately victorious healthcare rights struggle, unseen since

the protracted opposition to apartheid. Courage, sacrifice and heroism marked the lives of activists, healthcare workers and ordinary people as researchers and clinicians, first covertly, then openly, battled the pandemic, in the process becoming world authorities on HIV/AIDS. Today South Africa is regarded as a leader and beacon of hope in prevention, treatment, human rights and cutting edge medical and social science research. (Simelela, N and Francois V; S Afr Med J 2014;104(3 Suppl 1):249-251. DOI:10.7196/SAMJ.7700) And yet, and yet…How are things now? Some 7.9 million people are living with HIV (PLHIV), four times more than South Africa’s nearest global rival, (Mozambique). We have the world’s 4th-highest HIV prevalence (13,5%) – while boasting the largest-ever ARV roll-out. Though still pivotal to our economic future, HIV has been largely transformed from an immunity-lowering killer disease to a chronic condition.

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South Africa’s long-awaited ARV roll-out finally reached hospitals in April 2004 after court victories led to government capitulation, first on ARV’s, then on treatment for prevention of motherto-child infection, (PMTCT). In spite of this, provincial acolytes of then President Thabo Mbeki and his late health minister, Dr Manto TshabalalaMsimang, (in power from 1999-2004), ran interference with PMTCT programmes, slowing implementation.

Death toll The dark tragedy is the loss of an estimated 330 000 lives with some 35 000 babies being born with preventable HIV infections, both between 2000 and 2005 alone. However, clinicians and epidemiologists estimate the full loss to run into well over one million lives. https://www.hsph.harvard. edu › magazine › spr09aids. Not quite fitting the definition of genocide, but one can see why angry activists use the term. Enthusiastically led by Dr TshabalalaMsimang, whose defiant Afrocentric antics in exhibiting beetroot, lemon and garlic, and African potato at the Worlds AIDS conference in Toronto in 2006 drew scorn

330 000

The dark tragedy is the loss of an estimated 330 000 lives with some 35 000 babies being born with preventable HIV infections, both between 2000 and 2005 alone.

HIV/AIDS

and ridicule, the denialist era soon became a distant nightmare for some, but a source of life-long grief for too many. The impetus of the stellar ARV roll-out out and its associated societal support slowly bled away over the latter part of the next 14 years. A global economic downturn choked funding, especially after Covid-19 arrived in SA in March 2020, speeding up the overall drop in world growth to minus 3%. Observes Aids struggle veteran, Professor Francois Venter, a former President of the HIV Clinician’s Society; “Covid-19 has interrupted everything. Our gains when it comes to HIV and TB will sadly be reversed because of the Covid disaster and how government responded.” The most recent US-initiated, President’s Emergency Plan for Emergency Relief, (PEPFAR), assessment of South Africa’s HIV/ Aids response, reports that the country has failed to meet two of the three United Nation’s 90-90-90 targets set for 2020. (90% of population aware of their HIV status, 90% on ART and 90% virologically suppressed). The iconic UNAIDS 2014

declaration is aimed at ending the global Aids pandemic by 2030. Besides dramatically less funding, the public health system, on which 80% of South Africa’s population relies, has failed the best laid plans and collaborations of local and international HIV combating outfits. PEPFAR says the insufficient pace of the scale up of ART and the ‘insufficient quality,’ of programmes have led to high rates of loss to follow up. (https://www. unaids.org/sites/default/files/media_ asset/2019-UNAIDS-data_en.pdf.) Translated, this means people are getting tested, but fewer are returning to begin or complete treatment. A mid-term review of SA’s National Strategic Plan; 2017-2022 (HIV, TB and Sexually Transmitted Diseases, STI’s), released by the South African National Aids Council, (Sanac), shows 90,5% of PLHIV are aware of their status, but just 68,4% are on ART while 88,4% are virologically suppressed. Several countries reached the 90/90/90 goals by 2020, including Swaziland, Botswana, Switzerland and the United

decrease Pepfar made a hefty contribution to scaling up optimal HIV treatment for pregnant mothers, helping the NDOH to reduce the mother-to-child HIV rate of transmission, (MTCT), from 1,47% in 2015/16 to under 0,75% by 2021.

Kingdom, providing cold comfort to South Africa.

Got the memo, failed to act. In May 2019 the National Department of Health, (NDOH), announced a slew of policy changes in a circular distributed to all Siyenza, (We Act), sites in a bid to remove barriers to care and support accountability of health workers. However, it admits that a key directive was ignored by many sites.

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HIV/AIDS

“Despite extensive collaboration with and circular dissemination by the government, bottlenecks and inadequate policy implementation for optimal client-centred services persist at provincial, district and site levels.” With the establishment of Ritshidze (“Saving our lives” in TshiVenda) – a community-led monitoring system developed by organisations representing people living with HIV, PEPFAR began to systematically document the failures in quality HIV service delivery as well as gaps in implementation. For example, the monitoring found there was a pharmacist actively giving out medicine in 72% of facilities and a health marshal helping patients to get to where they needed to go in 47%. In another piece of healthy introspection, Pepfar reported a majority of ‘nos’ in a spreadsheet detailing compliance to Community Priority Interventions, (COP’s). https://healthgap. org/wp-content/uploads/2020/02/ Peoples-COP20-South-Africa.pdf Reflecting the global economic slump, Pepfar confessed in 2020 that it had failed to increase it’s $220 million programme to match its’ 2019 SA budget. It also failed to meet its 2018 promise to annually fund 20 000 supplemental front-line staff

and 8 000 community health workers (to reduce waiting times and ensure better re-engagement in care). The roll-out of multi-month ARV dispensing, including six-month supplies of ARV’s, did not happen by 2020, nor were support groups set up at all Pepfar sites to 2020, functional. The same held true in establishing medical and psycho-social support that could be individualised, according to the ‘distinctive needs of disengaged individuals.’ Reaching other admirable COP goals remained elusive; these included ensuring index testing, (i.e testing of at-risk family members or sexual partners), that this did not lead to intimate partner violence or forced disclosure of PLHIV status, funding a major expansion of high-quality treatment literacy, or supporting a bio-behavioural survey and a size estimate survey for key populations to improve service delivery. Significant achievements, however, include scaling up facility and community adherence clubs at all PEPFAR supported sites to ensure at least 20% of PLHIV were decanted into them. Pepfar made a hefty contribution to scaling up optimal HIV treatment for pregnant mothers, helping the NDOH to reduce the mother-to-child HIV rate of transmission, (MTCT), from 1,47% in 2015/16 to under 0,75% by

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2021. This virtual elimination of MTCT was lauded world-wide. Meanwhile female condom distribution was reported at 44% of the NDOH’s National Strategic Plan target. Preexposure prophylaxis, (PrEP), was introduced in June 2016, first for female sex workers, (FSWs), then into sites for men who have sex with men, (MSM), in April 2017, then onto university campuses in October 2017, and finally in May 2018 into general sites for young people. PEPFAR reported overall oral PrEP uptake at just 29% by 2020 – a disappointing result for a 100% successful intervention. South African women bear the brunt of the pandemic due to biological and societal factors, with females aged 15 and older accounting for 21,3% of HIV prevalence (males 13,1%), and children under 15 at 1,7%. These late-2019 figures continue to represent the current prevalence distribution. A multi-pronged approach to protecting women, including PrEP, (currently oral, but with injectables pending), ARV-infused vaginal rings, and femidoms, has since been adopted, while campaigns to conscientize men in a society where abuse of women is of near-epidemic proportions, is ongoing. (Just under 50% of South African women report having ever experienced emotional or economic abuse at the hands of their intimate partners in their lifetime.) A dapivirine-infused, (an ARV), silicone vaginal ring that can last up to three months was awaiting WHO

HIV/AIDS

It is one of the defining global issues that will affect market development and the performance of individual companies over the next half century.” pre-qualification at the time of writing, with the SA Health Product Regulatory Authority eager to appraise and hopefully approve it. This and PrEP have particular valence because the easily detected and somewhat uncomfortable femidoms are unpopular. Little has changed in the HIV prevalence among sex workers (57,7%), Men who have sex with Men (31%), transgender people (19%), Adolescent Girls and Young Women (AGYW), aged 10-24 years (11,3%), inmates (8,9%), and People with Disabilities (PWD’s) (17%).

Implications for business The productive members of SA society – aged 18 to 36 – have the highest rate of infection. This means that if the disease is not managed correctly, your customer and service provider base will narrow, not to mention losing employees through illness or death. About 23 million people work in the formal and informal sectors, most in small to medium enterprises, (SME's). A study by the University of Port Elizabeth identifies HIV/Aids as one of the three main factors that cause nearly 80% of South African start-ups to fail every year. The loss of a key employee due to AIDS can prove catastrophic, since in a small firm there may be no-one available or capable of taking on the specialised tasks of an employee too ill to work. According to the chief operational officer of the SA Coalition for Business Coalition for Health and AIDS, (SABCOHA), Ms Susan Preller, most private sector corporations initially set up health and wellness programs centred on HIV/TB and sexually transmitted diseases. However, from about 2014, SABCOHA embraced a more general health approach, leading to a dramatic boost in HIV status testing among member companies – due to the reduced stigma. Her organisation focusses mostly on men in 12 of South Africa’s health sub-districts and has screened nearly

10 000 people since April 2019, including HIV tests in the more general blood pressure, glucose, and BMI screening. Uptake of HIV and TB screening leapt from 32% to 98% once they became part of the general health package. Most large corporates also invest in actual communities, both for philanthropic and self-interest reasons. According to Asif HussainNaviati, of the United Nations’ Equal Opportunity Steering Group (EOSG), Aids is no longer just a niche issue for companies wishing to demonstrate corporate leadership to a particular group important to their business. “It is one of the defining global issues that will affect market development and the performance of individual companies over the next half century,” he stresses. At every level of business, valuable and skilled workers continue to fall sick and die, even in the ARV era. Suppliers fail to deliver on time because of a diminished workforce, now also battling Covid-19. Productivity declines and the costs of overtime, recruitment and training rise. For many companies, there are steep rises in the costs of health benefits and funerals.

A swift education and awareness campaign near the beginning of the AIDS pandemic saw Botswana’s diamond company Debswana drop the HIV prevalence rate among workers by almost a quarter – from 28.8% in 1999 to 22.6% – in 2001 already. It also introduced low-cost ART for workers living with HIV/AIDS (with workers paying 10% of the cost). The company viewed this as a “business imperative.”

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CCI | PROFILE

Communication that believes in tomorrow Centre for Communication Impact (CCI), a South African non-profit organisation, has played a key role in Covid-19 risk communication and community engagement through the Breakthrough ACTION programme.

isk communication and community engagement (RCCE) is an essential component of health emergency readiness and has a direct bearing on the success of response activities. The global Covid-19 pandemic has and will continue to challenge public health systems and their ability to effectively communicate with their populations, which is precisely where entities such as CCI intend to assist. Through the Breakthrough ACTION mechanism at the Johns Hopkins University, USAID engaged CCI in South Africa to support the National Department of Health with RCCE activities. With over 15 years of experience in implementing multimillion-dollar USAID-funded strategic communication and community responses programmes, CCI was appointed as a sub-awardee to the programme in March 2020 – with a role to support the department’s RCCE Technical Working

Group (TWG) through various activities. Its key activities as per the approved workplan entailed: risk communication systems, internal and partner coordination, public communication, community engagement, and addressing uncertainty and perceptions as well as managing misinformation. Within these activities, CCI achieved numerous project highlights, some of which are detailed below.

Risk communication systems CCI was appointed to support government in engaging with mobile service providers to disseminate key Covid-19 messaging through various platforms. With telecommunications companies using their own platforms to implement Covid-19 bulk messaging early on, CCI focused on other systems to support risk communication. With support from Breakthough ACTION, CCI contributed to this area through the development of the

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Rumour Monitoring and Tracking system and use of GeoPoll to assess the public understanding of Covid-19 messages. Additionally, CCI also monitored interactions on Covid-19 messages through the Brothers for Life and Zazi platforms, adding to the numerous risk communication systems that were developed.

Internal and partner coordination CCI became a member of the RCCE TWG in mid-March 2020, with its first engagement being to coordinate multiple efforts to communicate the repatriation of South African citizens (students) from Wuhan, China, to Polokwane, Limpopo, who arrived safely on 14 March. CCI participated in at least eight TWG meetings a month, where it provided strategic planning support to the TWG to review, adapt and update the RCCE plan, social and behaviour change communication (SBCC) strategy, and

CCI | PROFILE

related media plans, as the Covid-19 response evolved from a containment to a mitigation approach. CCI also participated in several partner-led forums that included the UN Inter-Agency Task Team on Covid-19 – coordinated by Unicef and the WHO – and the Health Implementing Partners Group, which was established in the midst of Covid-19 to ensure the protection of the gains made in other diseases (such as HIV and TB) prior to the pandemic response. In July 2020, the RCCE TWG tasked CCI with the development of a Covid-19 SBCC strategy. The strategy articulated how the RCCE TWG members would influence societal and individual behaviour change through three pillars: Mass and Social Media Campaigns, Community Action, and Enabling Environment. Following the endorsement of this strategy by the Incident Management Team, CCI led the development of an operational plan for the Community Action pillar. The strategy and operational plan helped RCCE TWG members to coordinate Covid-19 interventions at national and local levels, ensuring the harmonisation and preventing the duplication of efforts.

Public communication Under public communication, CCI actively participated in developing messages in collaboration with members of the RCCE TWG. CCI led the translation and dissemination of Covid-19 messages countrywide. CCI was requested to support the translation of Covid-19 material from English to 10 other South African languages, translating existing English versions into isiXhosa, Sepedi, Sesotho, isiZulu, Xitsonga, isiSwati, IsiNdebele, TshiVenda, Afrikaans, and SeTswana. In total, it produced 230 versions of translated material.

The project assessed CCI’s existing media assets and identified media clips/ characters that were repurposed for Covid-19 messaging. A video clip on gender-based violence prevention was also produced. CCI provided input into material development led by other partners as well. CCI developed a social media and digital plan endorsed by the RCCE TWG that outlined how key messages would be shared. Covid-19 messages were shared through CCI’s social media platforms, print, digital platforms, as well as through community radio stations. CCI partnered with TooMuchWifi in the Western Cape to disseminate Covid-19 messages and reward users with free data. It also engaged 55 community radio stations in all provinces to disseminate Covid-19 messages in their localities, including translated public service announcements, live reads, interviews with government officials and call-in sessions. Through the Knowledge Translation Unit at the University of Cape Town, CCI supported the Western Cape Department of Health with evidence-informed, trustworthy, contextually relevant and engaging information for low- and middleincome households during the pandemic.

Community engagement Prior to CCI implementing a robust community engagement strategy, the country went into a nationwide lockdown with very strict conditions. These conditions made it impossible for the RCCE TWG to implement community engagement interventions. CCI implemented the Stories of Hope initiative instead, which engaged different communities to submit inspirational stories that were collated into a book. The objective of Stories of Hope was to bring hope to the South African communities through individual stories collected from Gauteng, the Western Cape and Eastern Cape, amid proliferating misinformation and increasing numbers of new Covid-19 cases. A total of 39 stories were selected to form part of the book. CCI disseminated the Stories of Hope e-book through various platforms, including CCI’s social media outlets. The e-book was shared with participants at

the Africa Brand Summit, held in October 2020. The National Department of Health together with CCI identified a need for training funeral undertakers on handling human remains during the pandemic. A total of 141 undertakers were trained to reduce the risk of cross-infection during collection of the deceased, transportation, preparation and during the funeral proceedings. The training also aimed at strengthening the relationship between funeral undertakers and the department, as well as other relevant authorities.

Addressing uncertainty and perception and managing misinformation With support from Breakthrough ACTION, CCI developed a system for the collection and management of rumours and fake news. The District Health Information System (DHIS) 2 based system was then transitioned to the National Department of Health. Now that the USAID-funded project has ended, Unicef continues to provide technical support to the department on collecting, analysing and responding to rumours and fake news, through their social listening initiative. CCI was able to achieve so much within the programme’s eight months largely due to partnerships. The support from Breakthrough ACTION and USAID South Africa made it easier to accomplish targets, while the leadership of the National Department of Health’s Communication Cluster ensured message development stayed the course and that the communication platforms were aligned with the priorities of government.

Partnering with the private sector While CCI’s work on the Breakthrough ACTION programme has come to its conclusion, USAID support to South Africa through CCI is focusing on vaccine rollout communication. CCI is also working closely with various private sector players in furthering South Africa’s fight against the Covid-19 pandemic. Among these endeavours, CCI is working with Anglo American to galvanise the community assets, power and voice as enablers of behaviour change in support of the prevention, response and recovery from Covid-19 in these mining communities.

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INNOVATION

One man’s entrepreneurial healthcare journey

Getting healthcare mobile in Africa

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INNOVATION

The calculus of innovation is really quite simple; Knowledge drives innovation, innovation drives productivity, productivity drives economic growth.” William Brody (born 1944) – Scientist

illiam Brody could easily have been critiquing South Africa, where consumption seems to outstrip production, at least in the civil service, but for a University of Pretoria-trained doctor, that is his adopted mantra. Dr Gerhard Ferreira, now living in Perth, and his partner, Andries Vorster, have built a hugely successful company, LTE Medical Solutions, which has spread its highly mobile products and technology across Africa like a river delta in midsummer, helping deliver primary healthcare with minimal red tape and maximum efficiency. The wellspring of LTE Medical Solutions was Dr Ferreira’s share in the sale of the phenomenally successful former South African Community Hospital Group, to Netcare in 2008 – and his passion for and belief in the fundamental importance of primary healthcare. The over 1 000-bed hospital group worked closely with provincial governments to deliver care, a prime example being their (now Netcare), flagship University of Cape Town Private Academic Hospital, inside Groote Schuur Hospital with which it shares patients and equipment.

“Our mindset has always been about providing sustainable solutions. I was keen to address out of pocket costs which is such a big issue for so many South Africans needing treatment. You can do pro-bono work, but it doesn’t have the required effect, so we formed LTE,” he says. As a young doctor, he had seen mobile health clinic models fail or deliver well below par, mainly because they were European or United States designed systems with products unsuited to local conditions and populations – and lacked technical support and maintenance.

Changing into low gear LTE did not reinvent the wheel – they just added three more to create a fourwheel drive vehicle that could deliver appropriate services almost anywhere. “The key is a local solution, with the technology, the right medical equipment and proper management. We began with self-sustainable container-based trucks that could reach the most remote communities,” he said. The next step was to convince big clients with deep pockets to pay for the service. “So, we looked at funded projects: The World Bank, the Global

Fund, USAID, UNICEF and similar outfits working through African countries’ departments of health. If we could provide the solution to some of their ongoing concerns, we could put a successful business case to them.” They did. Today LTE has a footprint in more than 20 African countries, having expanded rapidly over the last five years. Asked what sets LTE apart from other medical outfits, Dr Ferreira replies; “An understanding of rural SA (and by extension, Africa). All our solutions are developed and manufactured in South Africa, all our plans, clinic layouts, types of vehicles. Our software solutions take our own healthcare system and challenges into account. Overseas outfits do not always understand the challenges of working off-line in remote areas. We

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INNOVATION

call it Africanizing the solution. Our hardware, software and radiology are all fit for local purpose – a total solution,” he adds.

Mobile tech transforming healthcare. Using mobile technology, LTE staff plus trained healthcare workers on site, capture patient details electronically, manage patient workflows and outcomes, and report back to funders. “We provide what very few others can – it’s a total in-house solution,” he says. They are perfectly positioned to help health departments gather rich and accurate data – regionally or nationally – the foundation stones of effective policy and planning. The most recent example is their securing a tender to help the National Health Department with their national TB survey, funded by the Global Fund, (to appreciate why this is so crucial see the TB chapter on page 53). GenXpert diagnostic machines, CAD and X-rays will be part of the mobile armament. With fast moving pandemics, this is literally life-saving work. They have been working with the South African Business Coalition on HIV/Aids (SABCOHA), since 2018, conducting HIV/Aids and wellness screenings for some 90 000 patients to date. A Global Fund grant project, this initiative sends teams of nurses and admin staff to erect field tents for recruiting and testing over 18 months, active case finding, and composing a vital disease overview. “While we have supplied some 150 mobile units (supplementary vehicles sourced in other countries), they are not in use on this project, but the big difference comes in the software application we use. The Lynx-HCF software

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INNOVATION

We provide what very few others can – it’s a total in-house solution.” is total unique and captures data in real time, doing away with antiquated paper-based systems. Our funders and principals can sit anywhere in the world and see exactly what is happening on the ground. Everything is fully cloud based. The questionnaires are done on tablets in the field and immediately uploaded, whether it is TB, STI screening, HIV – you name it. Funders can see the full cohort, number of positive cases, and drill down by age or any parameter they want, using a dynamic dashboard. We can identify and evaluate hotspots, monitor where a patient has sought care and refer appropriately,” he enthuses. Their latest innovation is monitoring treatment compliance, “so we can help with that last mile of care,” Dr Ferreira adds. He wants to expand into actual treatment, a hugely dynamic, fast evolving space with multiple opportunities for computeraided diagnoses and software algorithms to keep healthcare scores.

Hard early slog However, it was the first few miles of start-up where they faced their biggest challenges. “Over the early years we had to do lot of lobbying and showcasing to demonstrate to funders and recipients what our solutions and software offer. The big thing was getting people to change the way they used data and software – they are sometimes scared to go that route. Our marketing and showing proof of concept was perhaps the hardest part.” Another challenge was physical demographics, ‘in other words, what we deliver and constantly figuring out how it’s all sustainable. Most recently with Covid, we have had a better than usual year providing solutions,” he adds. Dr Ferreira says being already set up for infectious diseases, they were perfectly placed to help digitally screen and test during the Covid pandemic, not to mention provide tailored medical equipment and online training. Of the coronavirus pandemic, he has this to say; “Once its over I think it needs to be unpacked very wisely

and evaluated for what it is. We must look at the effect of the virus on healthcare, mental wellness and the economy. It’s a fine balance between mortality and morbidity, and socio-economics, but people’s health and lives must come first.” Perhaps in the final analysis, a healthy economy depends on maintaining a healthy population – and making them productive.

It’s a fine balance between mortality and morbidity, and socioeconomics, but people’s health and lives must come first.”

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OUR CAMPAIGNS Brothers For Life is a campaign that focuses on men promo�ng responsible behaviour in life, health , rela�onships, sex, our families and communi�es. We also advocate for health services for men and educate each other as brothers, men and as leaders.

CCI is a non-proﬁt organisation that aims to improve the health and well-being of all South Africans. Together with its partners and sponsors CCI aims to bring critical change underserved communities

ZAZI is a women’s empowerment movement encouraging women to know their sexual rights. Zazi is a Nguni word that means Know Yourself. The campaign aims to create a na�onal movement equipping young women and suppor�ve male counterparts with prac�cal knowledge on their rights, sexual health and general lifestyle and wellness.

OUR CORE VALUES DIVERSITY

INTEGRITY

Treats all people with dignity and respect; shows respect and sensitivity towards gender, cultural and religious differences; challenges prejudice, biases and intolerance in the workplace and communities; encourages diversity wherever possible. Maintains high ethical standards; takes clear ethical stands; keeps promises; immediately addresses untrustworthy or dishonest behavior; resists pressure in decision-making from internal and external sources; does not abuse power or authority.

Demonstrates commitment to CCI’s mission and broader development goals; demonstrates the values of COMMITMENT CCI in daily activities; seeks out new challenges, assignments and responsibilities; promotes CCI’s cause.

EXCELLENCE

Aims to achieve results through relevant and excellent, high-quality, state-of-the-art approaches that ensure work is evidence-informed, innovative and impactful.

CARING

Demonstrates compassionate support and concern for people and their communities.

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‘We Beat TB’ is a na�onal campaign supported by USAID TB CARE II South Africa Project. It aims to raise awareness and encourage early diagnosis, preven�on and treatment of TB and TB/HIV.

OUR SPONSORS

OUR PROJECTS ANGLO AMERICAN SOCIAL BEHAVIOUR CHANGE PROGRAMME In partnership with Anglo American, CCI works with the Community Oriented Primary Care (COPC) team from the University of Pretoria and other stakeholders in targeted Anglo American mining communi�es to develop and implement a capacity building plan for community stakeholders to either strengthen exis�ng or establish new pla�orms to address COVID-19.

The Woza Asibonisane Community Responses Programme is a community-based comprehensive HIV preven�on, counselling and tes�ng interven�on to reduce HIV incidence. Funded by USAID, with TVT as a sub-partner to the Centre for Communica�on Impact (CCI), the programme engages local leadership and health facili�es to improve access to HIV-related and other services in informal se�lements.

Masiphephe Network, a unique project funded by USAID designed to enable local authori�es and civil society organiza�ons to work together to reduce GBV in their areas and to improve access to jus�ce and vic�m empowerment.

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MALARIA

Malaria elimination in SADC finally ‘possible’

lobally each year, more than 400 000 people die of malaria – 94% of them in Africa where the more southern countries recently moved into what epidemiologists call the (disease) “elimination phase.” Visit https://www.who.int/news-room/factsheets/detail/malaria for more information. The Southern African Development Community, SADC, countries have made major gains in reducing their malaria burdens over the last decade, according to the WHO’s latest (2019) global assessment. Professor Lucille Blumberg, Deputy Director at the SA National Institute of Communicable Diseases, (NICD), and the founder of the Division of Public Health Surveillance and Response, says Swaziland leads the way, followed closely by South Africa, Namibia, and Botswana.

Between 2015-2019 South Africa averaged between 10 000 and 30 000 notified cases of malaria per year, and the National Department of Health plans to eliminate it (i.e. reaching no local transmission) within two years (i.e. by 2023). Locally acquired malaria occurs primarily in the three endemic provinces of Limpopo, Mpumalanga and KwaZuluNatal. This is due to the perennial presence of malaria-transmitting Anopheles mosquito populations there. Other provinces, especially Gauteng, report and treat comparatively high numbers of imported cases, mainly from Mozambique. SA’s long history of effective malaria control has led to a low incidence, making elimination a feasible prospect. The main interventions at provincial level include

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mosquito vector control by indoor residual spraying (IRS) of specially formulated insecticides, the targeted management of mosquito breeding sites, and prompt diagnosis and effective treatment of all confirmed malaria cases. While sub-Saharan case incidence was also reduced substantially over the last two decades, there was a small increase in the total number of malaria cases – from some 204 million in 2000 to 215 million in 2019 – reflecting a rapidly increasing population in the region. (The population in sub-Saharan Africa increased from 665 million in 2000 to 1.1 billion in 2019.) Malaria remains a preventable and treatable disease. Tragically, an estimated two thirds of deaths are among children under the age of five. One estimate goes so far as to say that the disease

MALARIA kills a child every two minutes in Southern Africa. The WHO says malaria killed 409 000 people in 2019 and 411 000 in 2018, most of them babies and toddlers in sub-Saharan Africa. Visit https://www.bmj.com/content/ 371/bmj.m4711 for more information.

Covid-19 – an aggravator that mimics malaria A 10% disruption in access to antimalarial treatment could lead to 19 000 additional deaths in this region this year – something Covid-19 is almost sure to do. Professor Blumberg warned that with the 2020/21 heavy Summer rains in traditional malaria regions, a higher peak malaria season was expected, meaning more infected patients were presenting with Covid-like symptoms. Visit http:// www.samj.org.za/index.php/samj/article/ view/13142/9648 for more information. With Covid ubiquitous and top of mind

for most healthcare workers, malaria could easily be misdiagnosed, leading to delays in appropriate treatment and progression to severe disease, increasing pressure on ICU’s (where beds were available). “The symptoms overlap with Covid-19, so we need to always check whether patients live in or have travelled to a malaria area within the last month – and do malaria tests. These results are usually very quick, (hours), compared to Covid tests, which can take days, meaning the opportunity to treat uncomplicated malaria can be lost,” she warned. The Covid-19 pandemic has disrupted regional, national and provincial malaria control programmes and made planning and preparation slower and more complicated. Visit https://www.who.int/ teams/global-tuberculosis-programme/ covid-19 for more information.

Between 20152019 South Africa averaged between 10 000 and 30 000 notified cases of malaria per year, and the National Department of Health plans to eliminate it (i.e. reaching no local transmission) within two years (i.e. by 2023).”

Implementing and sustaining enhanced malaria control/elimination activities during the coronavirus pandemic requires innovative measures to protect healthcare workers and the communities they serve.

Case detection and parasite surveillance The WHO says accurate current intelligence on malaria parasites and

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incidence has become even more crucial with Covid around. Any interruption in routine surveillance and control activities risks malaria rebounding with severe consequences, as seen in the recent West African Ebola outbreaks. As C-19 control measures, such as physical distancing and restricted movement of people have the potential to limit routine surveillance activities, malaria surveillance systems needed to be flexible, adopting and implementing innovative strategies to enable the continued collection and analysis of essential data. With the provincial malaria control programmes forced to downscale their active case-finding activities, community healthcare workers, particularly those in border communities frequented by mobile and migrant populations, should be supported and equipped to fill this vital surveillance gap, advises the WHO. Community healthcare workers needed to be adequately trained and equipped with the required personal protective equipment (PPE), testing devices and necessary case-reporting tools to be able to assume this responsibility. Playing a major role in innovation and enabling immediate notification are mobile applications such as MalariaConnect and the Notifiable Medical Conditions App, which are readily available – but not always used.

Climate change boosts malaria Climate change negatively impacts malaria

control efforts, and if ignored, has the potential to suppress ongoing malaria elimination efforts significantly. A study in Zambia conducted between 2000 and 2016 found climate change interfered with intervention program effectiveness and altered distribution and incidence patterns, resulting in poorer health outcomes and higher incidence rate. The direct cost of this was estimated at up to US$2.4 billion annually by 2030. Visit https://pure.ulster.ac.uk/ws/portalfiles/ portal/85956609/2020LubindaJPhD.pdf for more information. One recent collaborative trial in northern Namibia showed how malaria incidence can be reduced by up to 75% in settings where malaria transmission is mostly low but persistent – and plagued by sporadic outbreaks of higher numbers of malaria cases. Visit https://www.sciencedaily.com/ releases/2020/04/200427102546.htm for more information.

Vaccine drawing ever nearer A candidate malaria vaccine, RTS,S, has been successfully evaluated in a Phase III program conducted in eight African countries and undergone a stringent evaluation by a regulatory agency. Although its’ efficacy may be modest, the number of cases averted in settings of significant disease burden, be it clinical malaria, severe malaria or malaria hospitalizations, on the scale seen historically, would have a major public health impact. Visit https://www. sciencedirect.com/science/article/pii/ S0264410X15013377 for more information.

Business involvement While high-tech digital solutions involving malaria-control are far and few between, one public private partnership is making a major difference. Goodbye Malaria,

Globally each year, more than 400 000 people die of malaria – 94% of them in Africa where the more southern countries recently moved into what epidemiologists call the (disease) ’elimination phase’.”

launched in 2012, is an African-run initiative to eliminate malaria. It is the brainchild of passionate and concerned African entrepreneurs who believe their generation can create innovative solutions for problems that ultimately change the way the world sees Africa. They raise funds while supporting and initiating on-theground malaria elimination programs. The organization also retails causal merchandise aimed at corporations and consumers to raise awareness. Visit https:// www.theglobalfund.org/en/private-ngopartners/resource-mobilization/goodbyemalaria/ for more information. Southern African communities are employed via social entrepreneurship groups, (job creation), to produce an attractive range of Goodbye Malaria products. The initiative benefits Global Fund-supported programs in Mozambique, South Africa and Eswatini and is supported by Nando’s, an international fast-food group founded in South Africa, as well as Vodacom, Nedbank and Airports Company South Africa. Goodbye Malaria pledged US$5.5 million for the Global Fund’s Sixth Replenishment, covering 2020-2022, representing a significant increase over its previous pledge. With thanks to; Professor Lucille Blumberg, the WHO, the SA Medical Journal.

References SAMJ Malaria Covid warning (http://www.samj.org.za/index.php/samj/article/view/13142/9648), The World Health Organization, WHO, Global Tuberculosis; Programme; “Our response to Covid.” https://www.sciencedaily.com/releases/2020/04/200427102546. htm, https://www.google.com/search?rlz=1C1SQJL_enZA854ZA854&sxsrf=ALeKk030BRnNtdPPxZRFTxBlZjfJQHwpZA%3A1 613912810606&ei=6loyYPjMJNmg1fAP6PakyAI&q=WHO+2020+report+C-19+impact+on+TB&oq=WHO+2020+report+C19+impact+on+TB&gs_lcp=Cgdnd3Mtd2l6EAM6BwgAEEcQsANQya4iWMmuImCZuiJoAXACeACAAdwCiAHVBJIBBTItMS4xmAEA oAECoAEBqgEHZ3dzLXdpesgBBMABAQ&sclient=gws-wiz&ved=0ahUKEwj46ZjehfvuAhVZUBUIHWg7CSkQ4dUDCA0&uact=5 -

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Guidance for HPV screening initiatives in Africa HOW ASSAY DESIGN AND PERFORMANCE CAN IMPROVE TEST PARTICIPATION

lobally, upwards of 600 000 women are diagnosed with cervical cancer each year, resulting in more than 340 000 estimated deaths annually.1 A staggering 19 out of the 20 countries with the greatest cervical cancer burden are found in Africa,2 making it the continent’s second most prevalent cancer. These figures reflect the inequality between countries (Figure 1), depending largely on income and access to resources, but also on the age of the population and the incidence of HIV, among other factors. Africa has a young population and, because cervical cancer tends to attack this female demographic, the disease has a significant social impact on communities. The major risk factor is, of course, persistent human papillomavirus (HPV) infection, and the prevalence of this increases with HIV positivity; women living with HIV are six times more likely to develop cervical cancer compared to HIV negative women,3 largely due to their lowered immune response. Crucially, cervical cancer can be entirely preventable with proficient testing, vaccination and management but, so far, a lack of resources, funding and understanding has seen only limited and predominantly opportunistic screening in many countries and a limited introduction of HPV testing into clinical settings. In November 2020, the WHO announced its Global Strategy to Accelerate the Elimination of Cervical Cancer4 to address this situation, shining a spotlight on the

need for access to HPV testing in Africa, particularly in low- and middle-income areas, and securing funding for screening programs. Rates of cervical cancer and deaths continue to rise rapidly across Africa and the WHO warns that, without effective intervention, this will continue to escalate. Comprehensive vaccination programs, and HPV screening and treatment are now planned and aim to reduce the incidence of cervical cancer and alleviate the disease burden in Africa.

HPV testing and the WHO initiative Testing for cervical HPV helps to screen for patients who may go on to develop cervical cancer, allowing a far earlier diagnosis and effective disease management. The WHO elimination

Dr Christopher Maske, Principal Pathologist, QLAB Laboratory, South Africa

strategy targets for HPV are 90-70-90, meaning 90% vaccine coverage, 70% of women screened before the age of 35 and 90% treated, with the ultimate aim to reduce the global incidence of cervical cancer by 10% by 2030.4 Therefore, efficient strategies are needed for implementing effective screening

FIGURE 1 Global incidence rate of cervical cancer based on age, World Health Organization8,9

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programs into public and private healthcare settings. HPV testing involves the screening of cervical cells using a PCR-based molecular diagnostic that detects the presence of high-risk types of HPV and is both validated and endorsed internationally as a replacement to cytology-based screening (Pap smears). The HPV tests are designed to detect oncogenic HPV genotypes and therefore provide a binary answer with respect to cervical cancer risk. Women who are positive with oncogenic HPV have the potential for progression along the dysplasia sequence in the cervix that may progress to invasive cancer. Those who are negative with oncogenic HPV have a minimal risk of developing a high grade squamous intraepithelial lesion. However, for risk stratification purposes, current assays provide far more sophisticated information than this, particularly about specific genotypes. The majority of HPV strains are transient and most sexually active women and men will be infected at some point in their lives. In fact, 95% of invasive cervical cancer cases are caused by just 14 HPV strains and, of those, HPV 16 and HPV 18 are the highest risk and together account for 70% of invasive cancers.5 Clinicians can stratify

patients by determining both the presence and genotype of HPV and streamline them for further investigations and treatment. In a setting with limited resources, this risk stratification on the basis of genotype to prioritise the highest risk patients is essential for relieving the burden on colposcopy or ablation services. Women with HPV 16 and HPV 18 have a higher incidence of high grade dysplasia and higher incidence of progression; as such, management algorithms prioritise this subset of women for immediate treatment. The subset of patients with non-16, non-18 oncogenic HPV genotypes have a lower risk of high grade lesions and a lower risk of progression and are therefore best further evaluated with an additional triage test, most commonly cytology analysis, to determine the stage of progression of the woman down the continuum of dysplasia to stratify for referral and therapy or follow up. The extremely high negative predictive value of HPV-based testing allows for safely extending the interval between screening events in oncogenic HPV-negative women; in high resource settings the recommended screening interval is 5 years for HPV-negative women. In lower resource settings the interval that is likely to be achievable is

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a 10-year screening interval. Historically, cervical cancer screening has been performed by examining cervical cells under a microscope with morphological evaluation, and recently this evolved to using liquid-based collection methods. The cytology sample is taken directly from the cervix and requires a skilled healthcare worker in a clean setting that is well-supplied with resources such as a speculum, good light and a medium to preserve the sample. However, this laborintensive and human resource-dependent procedure has a low throughput at a high cost, hindering the scalable capacity of screening. In contrast, HPV testing is looking for a stable DNA-based virus and so there is the potential to simplify sampling and detect cells that have shed from the cervix in the vaginal canal. In addition to the benefits of sensitivity and risk stratification with genotyping described above, there is even the possibility for using self-sampling techniques if a method can be established that would give enough sensitivity, which would drastically increase the scale of testing and likely encourage more participation.6 The cost of the HPV test has also now come down to a more affordable screening price, and the technology, for the most part, is the same as HIV viral load testing, allowing access to pre-existing infrastructure across Africa.

Introducing HPV testing to clinics and laboratories So, assuming we now have a sensitive, efficient test for cervical cancer risk, how do we roll out a screening program? At this point, it is important to balance age-dependent screening intervals with access to resources and medical capacities. Guidance is usually given in a tiered system based on resources (Table 1) and highlights how many times a woman should be screened in her lifetime and over what age ranges.7 The progression to invasive cervical cancer from persistent HPV infection is time-dependent, so it is not appropriate to screen women at a young age when most HPV infections spontaneously clear, and the disease burden in terms of high grade cervical intraepithelial neoplasia (CIN) and invasive carcinoma is very low. In high resource settings, screening should start at

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25 years, and occur every five years until the patient is 65-70 years of age, provided that no high-risk HPV genotypes are detected. However, where resources are more limited, longer intervals between tests can be implemented with the goal of screening every woman three times in her lifetime, starting at the age of 30. It is only with the high sensitivity and high negative predictive value of HPV-based screening, that one can safely increase intervals across a population. ASCO recommends that even in low resource settings, if a woman receives just one single cervical screening test in her lifetime, this should be an HPV-based screening test (see Table 1).7 Those who test positive for highrisk HPV should be managed according to guidelines for the particular health system. In general, this management would include immediate referral of HPV 16 and HPV 18 positive women for colposcopy and ablation where available, or ablation where colposcopy is not available, and triage with cytology or follow up of

laboratory hardware have evolved rapidly over the past decade. The spectrum of tests now available includes assays that can be safely and effectively deployed in different resource settings. In addition, the African continent has seen a broad-based development and implementation of molecular diagnostic services to serve the needs of the HIV management program and is therefore uniquely prepared for the implementation of an HPV-based cervical screening program. The following factors, in no particular order of importance, are key considerations in selecting HPV-based screening assays for implementation in the individual health systems in the African continent: • The cervical cancer screening program should ideally integrate with existing programs, such as HIV viral load, with respect to shared hardware and laboratory capacity. • The supporting hardware for an assay should allow for appropriate scaling of

non-16, non-18 HPV positive women. With a combination of screening intervals and cytology, we can create a staging process for patients and fast track the management of patients most at risk. HPV screening tests and the associated

the program and throughput. • T he assay should at a minimum include partial genotyping for HPV 16 and HPV 18 to identify the most at-risk women and streamline subsequent management.

• HPV-based screening assays should include an internal cellular genomic control to ensure that sampling is adequate; this is particularly important looking forward to the potential of selfsampling in women. • The assay should ideally be adaptable to include self-sampling with a validated device for the future of the screening program. • The assay should have sufficient analytical and clinical validation data to support a high negative predictive value of the assay and sensitivity and specificity of oncogenic HPV detection. • The HPV-based screening program will ideally couple with a cytology service, where available, to effectively triage HPV-positive women for subsequent management.

Conclusion The WHO’s Global Strategy to Accelerate the Elimination of Cervical Cancer has highlighted the need for efficient vaccine, screening and treatment programs across Africa. HPV screening at regular intervals throughout a woman’s life is the most effective and reliable method for the detection of cervical cancer risk. The long interval between initial exposure to highrisk HPV and the development of high grade dysplasia provides a unique window to identify women at risk and effectively manage them to prevent the development of invasive cancer. Choosing the right assay, with the right workflow, design and performance criteria is essential in order to integrate HPV tests quickly and easily into African clinics and labs. Successful implementation of programs based on the right assay can help to reduce the incidence of cervical cancer and the disease burden across Africa.

References 1 Global rates of cervical cancer. https://gco.iarc.fr/today/data/factsheets/populations/900-world-fact-sheets.pdf 2 Rates of cervical cancer in Africa. https://www.afro.who.int/health-topics/cervical-cancer 3 Stelzle D et al. Estimates of the global burden of cervical cancer associated with HIV. Lancet Global Health, vol.9,2 (2020). DOI: https://doi.org/10.1016/S2214-109X(20)30459-9 4 Who Global Strategy to Accelerate the Elimination of Cervical Cancer. https://www.who.int/news/item/19-08-2020-world-healthassembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination 5 Statistics for HPV. http://www.hpvcentre.net/datastatistics 6 Racey, C.S., Withrow, D.R. & Gesink, D. Self-collected HPV Testing Improves Participation in Cervical Cancer Screening: A Systematic Review and Meta-analysis. Can J Public Health 104, e159–e166 (2013). 7 DOI: 10.1200/JCO.2016.71.6563 Journal of Clinical Oncology 35, no. 11 (April 10, 2017) 1250-1252. 8 Ferlay J et al. Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. (2020) Available from: https://gco.iarc.fr/today, accessed [10 February 2021]. 9 S ung H et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 46 cancers in 185 countries. CA Cancer J Clin. 2021 Feb 4. doi: 10.3322/caac.21660. Epub ahead of print. PMID: 33538338 B USI NESS GUI DE TO QUALI TY HEALTHCARE 2021

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Improved outlook for SA mothers and children

steady decline in the total number of maternal deaths in South Africa over the past three decades and an almost halving of the institutional mortality rate since 2009 show we are on the right track. However, from March 2020, just as women and their children were surviving the HIV pandemic far longer – due to anti-retroviral drugs – Covid-19’s sudden arrival almost derailed the train. A red flag-waving Covid-19 study among pregnant women showed a 30% increase in maternal deaths in the Cape Metropole alone, while still births and unwanted pregnancies also rose there during the first coronavirus infection surge. This was mainly because access to clinics, contraception and safe termination of pregnancies

Besides the direct impact if they’re C-19 infected (those with pre-existing obesity, high blood pressure and pregnant 45-plus-year olds being at greatest risk), there’s greatly reduced access to reproductive health services and an increase in mental health strain.”

were sharply reduced by lockdown and a general fear of becoming infected. The Cape Town study was conducted from March 2020 to July 2020, with results compared with the same period in 2019. The researchers stressed the necessity for high-risk pregnant women, (i.e, those with existing comorbidities), to get vaccinated against the coronavirus as soon as possible – and pleaded for facilities to be kept running at full capacity.

Adverse event fears drive lack of C-19 data There’s a global paucity of data on the effect of Covid-19 vaccines on pregnant women – mainly because of a global fear of litigation by major drug companies trialing coronavirus vaccines. Despite this and because the vaccines are generally safe, clinical experts were

in February 2021, urging high risk pregnant women to get vaccinated. There were no known contraindications among those vaccinated in this particular group, or any pregnant women, at the time of writing. Elaborating on her as-yet unpublished Gauteng findings, Professor Priya Soma-Pillay, head of the Department of Obstetrics and Gynecology at Steve Biko Academic Hospital, says C-19 impacts pregnant women on many different levels. “Besides the direct impact if they’re C-19 infected (those with pre-existing obesity, high blood pressure and pregnant 45-plus-year olds being at greatest risk), there’s greatly reduced access to reproductive health services and an increase in mental health strain,” she explains.

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Covid-19 life-threatening for pregnant women Professor Salome Maswime, an obstetrician/gynaecologist and head of the global surgery division at the University of Cape Town cites one of the only other studies available, (in the United States; of 400 000 pregnant women infected with Covid-19). It shows they had a 70% greater chance of death compared to non-pregnant Covid-infected women. They were also

“significantly more likely” to require ICU treatment and/or mechanical ventilation than uninfected pregnant women of the same age. Veteran former chairperson of the National Committee for Confidential Enquiry into Maternal Deaths, NCCEMD, Professor “Jack” Moodley, urged pregnant women at higher risk to vaccinate. “If you have any of those pre-existing conditions, you should be offered the

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If you have any of those preexisting conditions, you should be offered the vaccination because otherwise you’d be much more likely to get complications if infected,” the veteran clinicianscientist advised.

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vaccination because otherwise you’d be much more likely to get complications if infected,” the veteran clinician-scientist advised. Prof Moodley confirmed the paucity of data on the subject, adding that one of the main reasons for this was that drug manufacturers shied away from including pregnant women in vaccine trials because they feared legal liability if adverse events occurred. “There are plenty of published papers making a plea for Covid-19 vaccination – much of the vaccine producers’ fears are based on the thalidomide tragedy of 1961 where that medication, (for vomiting and nausea), led to the deaths of 2 000 children and serious birth defects in more than 10 000,” he explained. Professor Lynette Denny, Head of the Department of Obstetrics and Gynaecology at UCT, also encouraged pregnant women to be vaccinated, ‘certainly after the first trimester.” She explained that the first trimester was when women were most susceptible to any drug-induced birth defects.

maternal deaths over the past three decades (1990-2019). The common local causes or death are usually non-pregnancy related infections (e.g, HIV/TB), followed by obstetric haemorrhage, hypertensive disorders and medical disorders of pregnancy, a reading of the seven NCCEMD reports since 1999, shows. The committee meets every three years to unpack and report on the latest data and confidential surveys. The surveillance and its findings have enabled hugely effective interventions

in many crucial maternal health areas over the past 22 years. The committee, via an extensive network of provincial assessors, has documented the rise and fall of maternal deaths with the institutional Maternal Mortality Ratio (iMMR) reaching a peak of 189/100 000 live births in 2009 and dropping to below 100/100 000 live births in 2019 – for the first time since the start of the inquiry. All provinces have shown a decline in the iMMR, with the Free State, KwaZuluNatal, Mpumalanga, North West and Northern Cape halving their iMMR from their peaks. The enquiry saw a dramatic

Common drivers of mortality These latest developments emerged in the wider historical context of South Africa seeing a steady decline in the total number of

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rise in deaths due to non-pregnancy related infections until 2008-2010 and then noted a sharp decline from 2011-2013 onwards. Consistently more than 90% of the women who died in this category were HIV positive, and the sharp decline is associated with the widespread availability and use of antiretroviral therapy from 2004 onwards. The slow uptake and gradual ARV-induced increase of immunity among women over the ensuing seven years made the difference. The linked roll-out of prevention of mother to child transmission, (PMTCT), has since reduced HIV infection of new-born babies from 2% in 2015 to almost zero currently – another huge win, acknowledged globally.

Obstetric skills dangerously lacking Professor Moodley, (SA’s doyen of hypertensive disorders during pregnancy), identified a major challenge as getting specialists posted to understaffed rural hospitals to handle obstetric emergencies. Too many women who developed complications during birth were attended by hapless community service or inexperienced medical officers and nurses. This and poor transport

services, far worse in rural areas, contribute greatly to the maternal mortality rate, he said. Prof Moodley added that reproductive health education remained a major issue, especially around sexuality and contraception. “We need to get teenagers to delay pregnancy until at least 18 to 26 because a large percentage of adolescent pregnancies are associated with more complications,” he revealed. Adolescent pregnancy has its own unique set of problems, especially with infant mortality. Explains Prof Moodley, “Once the young woman gets pregnant, she’s often deserted by her male partner, so there’s no support, and that leads to issues of finance, stress and depression.” One of the challenges the national department of health, (NDOH), has identified and tackled is maternal healthcare operating in silos. It is also busy upgrading the Caesarean Section surgical skills of young doctors. The benefits of this have yet

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to be quantified. Says Prof Moodley, “Even in small towns and regional hospitals you just can’t get people to go and work there. You can get a medical officer but not a specialist, so it’s really about teaching medical officers, (MO’s), providing advice and being available for emergencies.” He says medical schools tend to be too theoretical but needed to change because obstetric haemorrhage continued to lead the field in all-cause maternal mortality. Meanwhile, the NDOH is looking at patient access versus safety, which means reducing the number of facilities with too few or inexperienced staff available to conduct C-sections, and accrediting appropriate facilities for specific maternal care. “We’ve been putting training, equipment and accreditation in place for several years now and things are definitely improving,” Professor Moodley adds. The remedies included using private doctors to train medical officers and community service doctors.

Early childhood development – challenges and solutions When it comes to early childhood development in South Africa, malnutrition, inadequate pre-natal care,

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incidence stood at 21,3% in 2016. Breastfeeding, heavily promoted as the most nutritious, affordable and safe feeding option, yielded good results, with close to 73% of children aged less than one year breastfed, while 32% among the same group were exclusively breastfed. In spite of this, one third of children in the Free State and Gauteng were found to be stunted due to chronic malnutrition.

Protein

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Alarming malnutrition

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and poor feeding practices contribute to unacceptably high early-childhood death rates. Nationally, the under-five mortality rate and the infant mortality rates, (last recorded in 2016), were 44 and 34 deaths per 1000 live births, respectively. Studies show that those countries who fail to invest in the well-being of women, and children in the first 1,000 days of life, lose billions of dollars to lower economic productivity and higher health costs.

First 1000 days ‘crucial’ The “First 1000 days’ (measured from conception to a child’s second birthday) are when a child’s brain begins to grow and develop and when foundations for their lifelong health are built. Many United Nations International Children's Emergency Fund, UNICEF, programs focus on this, not least in South Africa. Research in the fields of neuroscience, biology and early childhood development provide powerful insights

into how nutrition, relationships, and environments in these first 1000 days shape future outcomes. Nutrition plays a foundational role in a child’s development and ability to prosper, and a lack can cause irreversible damage to a child’s growing brain, affecting his or her ability to do well in school and earn a good living and making it harder to rise out of poverty. It can also set the stage for later obesity, diabetes and other chronic diseases which can lead to a lifetime of health problems. According to Statistics SA, based on the findings of General Household Survey data, there were 7,2 million children aged 0-6 years in South Africa in 2016. More than 60% of these were poor and only 36% among those aged 0-4 years old lived with both biological parents. Close to 35% of pregnant women stayed in households that ran out of money to buy food for five or more days out of the previous 30 days. Unsurprisingly, SA has one of the world’s highest low-birth weight rates with 13,3% of live births under 2,5kg. The underweight-for-age

In the same survey, the rate of deaths associated with severe acute malnutrition among children under five stood at an alarming eight per cent. This together with inadequate prenatal care and poor child feeding practices, helps drive unacceptably high child mortality levels. With stimulation proven to play a major role in cognitive and psychosocial development, children living in poor households without time or money to feed and educate them suffer an additional burden. The 2016 survey revealed that close to half of the children in the lower household income quintiles did not attend any education centre compared to 40% of those in the highest household income quintiles attending out-of-home early learning programs.

Business solutions for maternal/child health One of the companies with arguably the greatest influence in maternal and child-care in South Africa, is General Professor Jack Moodley

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Electric, (GE). They provide equipment, training, and entrepreneurial skills which help drive a range of high-tech products designed to help reduce maternal and infant mortality. Partnering with Santa Clara University’s Miller Centre for Social Entrepreneurship based in Silicon Valley, California, they not only train and mentor social entrepreneurs, (via the campuses Global Social Benefit Institute (GSBI®) Accelerator programs) but make products like vital signs monitors and infant warmers. This innovative partnership trains candidates in batches of some 20 people to strengthen their business models, refine business plans, reinforce organizational development, manage talent and learn how to scale sustainably. The enterprises then chosen provide infrastructure services or facilities associated with needs – from pregnancy to paediatric care.

Graduates “sell’ ideas to investors The accelerator and mentorship programme culminates in an investor showcase event in Gauteng during which the finalists pitch their respective enterprises to an audience of potential investors and supporters. UNICEF partners with a number of

major South African companies in child health and development, including Woolworths, Mango Airlines, Standard Bank, MTN, Momentum Metropolitan, Truworths, Johnson and Johnson, Louis Vuitton and BASF Chemicals. Another outfit that has helped reduce preventable maternal and child deaths by introducing and promoting lifesaving technologies and techniques is the Atlantic Philanthropies-funded, Program for Appropriate Technology in Health, or PATH. It’s helping reverse negative trends in Birth Asphyxia, (responsible for one in every three neonatal deaths in South Africa). PATH makes neonatal resuscitator devices widely available and trains healthcare workers in using these lowcost, relatively simple lifesaving devices. Their tuition integrates maternal and new-born care elements through a series of training models based on labour and delivery complications – and by providing appropriate technology. PATH vigorously promotes the use of oxytocin via the uniject® device, an evidencebased intervention that can reduce Postpartum haemorrhage (PPH) by up to 60%. Excessive vaginal bleeding after delivery (aka PPH), is responsible for 16% of all maternal deaths in South Africa. This uterotonic drug, (delivered via a preloaded syringe), stimulates contractions of the uterus and prevents excessive

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blood loss, oxytocin having been shown to halve PPH rates.

Bolstering the NHI Meanwhile, the District Clinical Specialist Team (DCST), an NDOH initiative from 2011, (laying the groundwork for universal health care), is slowly improving maternal, neonatal, child and women’s health outcomes by enhancing clinical governance. Teams consist of three doctor-nurse pairs, (obstetrician and advanced midwife, paediatrician and paediatric nurse, family physician and primary healthcare nurse), together with an anaesthetist. DCSTs are in a unique position to develop best practices and innovate – and provide a promising entry point for private sector entrepreneurs seeking opportunities. The DCST helps set up improved protocols for gestational hypertension, manages clinical risk, develops paediatric clinical skills, and probes the determinants of severe acute malnutrition. They have also dramatically improved the quality and accuracy of district health information systems as they move from facility to facility identifying problems – and are constantly on the lookout for appropriate private sector support.

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FLOURISH while adapting to the ‘new normal’

he nature of work has changed in the past year, with many employees now working remotely. What is the psychological impact of working from home on employees? How does this change impact on mental health and wellness? According to organisational psychologist and director of Neurocapital Consulting, Ingra du Buisson-Narsai, it’s important to understand how our world of business has been disrupted before we can reorient ourselves and our employees to the ‘new normal’. She is also the author of best-selling book ‘Fight, Flight or Flourish: How Neuroscience Can Unlock Human Potential’. “The Covid-19 pandemic has resulted in a shift from a high-tech, high-touch economy to a high-tech, low-touch economy, with huge ramifications for our mental health,” she explains. “We must give people back a sense of control and the sense of orientation, of clarity and commitment that comes with working in a group and having a purpose greater than oneself.” During the pandemic, companies should work at turning its challenges and disruptions into opportunities. “This is the chance to really align what individuals are doing to what the company is doing; to know what is uniquely important to people you’re working with – from the team to

The global Covid-19 pandemic has not only changed our way of life, but also the way we work. While individuals have had to adapt to the ‘new normal’, businesses have also had to rethink the way they operate, with an increasing focus on, not only physical health and safety, but also emotional and psychological well-being. Jamaine Krige reports.

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the team leader and the executives.” The pandemic, she says, has thrown people into a reactive state – fight, flight or freeze. But, she says, there is a fourth option – flourish. “We all have different combinations of these functions happening at the moment, and that’s okay.” The key to managing this in ourselves, our teams and our businesses is to understand why the pandemic has impacted individuals and groups in a certain way and work in a calculated manner to counter the chaos.

“We need to talk openly, because we still have work to do and decisions to make, but we need to know that we are not alone,” she says. “We need to talk openly about burnout, about navigating a work-life balance, or a work-life and home-life balance, and we need to be deliberate in the conversations we’re having.”

Work-life balance and the 4 Cs of optimum functioning The concept of a work-life balance is one that many people struggled to maintain even before the pandemic. “What we have learnt while working from home during the pandemic, is that it is not just this work-life balance that has been threatened; our basic needs as individuals have also been challenged.” Simply put, she says, it all boils down to four key psychological needs for optimal functioning – certainty, control, connection and consistency. When these are present, we are primed to thrive. If not, employee mental health begins to suffer. “If you look at the pandemic, these are the four key areas that are being threatened. That is where we find ourselves today – in a scramble. Our brains are in a scramble too,” she says. “We have no past to draw on or history to tell us how to handle this, and the future is also uncertain.” Employees' basic work needs have been disrupted, and if companies want to re-orientate themselves within this ‘new normal’ then an active effort must be made to address these challenges. “We need to work at giving our people certainty, control, connection and consistency, even as the world changes. It means really examining what these

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concepts mean in the world of work and what they look like in practice,” she says. “When our psychological needs are threatened, we experience uncertainty and we flip over into psychological disorientation, disorder and even dysfunction,” she cautions.

A model for stability in unstable times There is, however, a relatively uncomplicated way to counter this. “It’s a simple model that cuts across how businesses function and how employees function within businesses. Wherever we focus, that is where we end up.” To promote stability, business leaders must direct their attention to four key areas: a focus on the self, a focus on others, a focus in the business and a focus on the business. “Employers who follow this model have a nice recipe that works, for stability in your business, regardless of what is happening around you.” The first two areas, namely the self and others, focus on individuals. “It is important for leaders, managers and executives to model what we call deliberate calm and positive coping,” she explains. “If they don’t have their own calmness in place and model this calm daily, then the employees and organisation will follow. And this,” she adds, “is why it is so important for you as a leader to look

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after your own body-budget, which means ensuring you’re energised and modelling positive coping to your team.” Self-care is more important now than ever before. Next is to make sure that as a leader, you focus on others. “That means understanding that we’re dealing with a human tragedy, and working remotely is one of the challenges that we need to reshape into an opportunity.” Remote work is a relatively new concept, and not one that everybody may be familiar or comfortable with. “Working from home is unique to each person, and the quicker we can connect with people individually and understand what it means and what works for them uniquely, the better we can customise a set of practices that meet our employee needs.” But it’s not enough to just offer emotional support. If employees are to thrive, they need the physical resources to do so. “Provide tech that is reliable. If you’re using Zoom or Teams, ensuring that everyone knows how to work the platforms,” says Du Buisson-Narsai. This extends to building a virtual culture of belonging, in the same way that companies in the past had to foster an inclusive office culture. “It really is about structure and order and building practices that emphasise and foster this into each work day,” she explains.

Support beyond mental health and shared goals for social cohesion Focusing in the

business, Du Buisson-Narsai says, is vital for establishing an architecture for decision-making. It means knowing what is expected from each team member and communicating these expectations clearly. Not making a decision is also a decision, she reiterates. It is important to be clear on what the turnaround time on decision-making and other deliverables are. “And finally, when it comes to focussing on the business, it’s about giving your people a clarity of purpose,” she explains. Focus on self, focus on others, focus in the business and focus on the business – it seems simple enough. So where are businesses failing? “Leaders must always focus on vision, but vision is not enough,” she cautions. “We need to hold a space for our people, but also give clear goals and clarity about what we expect of them.” Simply feeding them the company goals and expectations is not enough either. “An internal sense of motivation comes from workers who align their own goals with those of the company.”

Relationship building and bonding While it may be easier to monitor employee wellness when they are on site, a remote work environment does not negate this need. “What we have learnt from remote working is the power of human connectivity,” says Du Buisson-Narsai. “Again, emphasising that first and foremost we are dealing with a deeply human crisis, and we need to be very deliberate in dialling up our

Ingra du Buisson-Narsai

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Certainty, control, connection and consistency – four key psychological needs for optimal functioning.”

caring.” This means going beyond the virtual meeting or webinar, and checking in with employees on a regular and individual basis. “Oneon-one interaction has always been a part of the corporate world; where we build connection and connectivity,” she explains. “It is also where we practice and become aware of micro-positive actions; those small gestures that show that we care.” Online interaction is limited, and

leaders must make an active effort to not only facilitate micropositivity, but also to avoid microaggressions. “We might exclude somebody or not greet everybody on the call, and that might be taken very personally.” When it comes to mental health, she says, it’s about addressing those four Cs in employees – certainty, choice, connectivity and consistency or fairness, which means being treated equally. Relationship building is also key. “The virtual world has taught

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us that we don’t have to see each other every day but there still needs to be trust, and an understanding of people’s unique situations and personal demands that influence how they work.” To do this, team leaders can prioritise personal interactions. “Our need for bonding and belonging remains vital. If that need is not met, we feel rejected and alone, which may flick over into disorientation and dysfunction.” The pandemic has, however, also shown us our potential for change. “When we as humanity unite for a human cause, we can change rapidly and phenomenally well,” she says. “Especially when we act coherently and constructively. The way the world has pulled together shows us that humans can adapt, and do so with great impact, if we just know what to focus on.”

Humanity’s greatest advances are not in its discoveries – but in how those discoveries are applied to reduce inequity. Whether through democracy, strong public education, quality health care, or broad economic opportunity – reducing inequity is the highest human achievement. Bill Gates

BUSINESS GUIDE TO QUALITY HEALTHCARE 2021

Articles inside

REINVENTING THE RECOVERY MODEL FOR TIMES OF CRISES Looking to the future: letting go of the past

THE ROLE OF THPs DURING COVID-19 Traditional healers

NATIONAL HEALTH INSURANCE Navigating a route up the NHI mountain