I often read, and at times hear, that many lessons were learned during the COVID-19 pandemic. It has been said by some that these can be used to determine the future direction of health care. I have been reflecting on whether there were lessons to be learned and, if so, to what extent they provide insights into the future of healthcare in South Africa.
From the position now as an outsider to the mainstream of healthcare policy and management I am aware that the efforts of many in the health sector across the globe went far beyond what was normally in their job descriptions. Health professionals faced with the uncertainties of a previously unknown disease did their best, often heroically, to meet the challenges that it brought. Where families and loved ones were denied access to those hospitalised with COVID-19 infections due to the real and perceived risk of a contagious disease, caring health professionals provided support to those alone in distress. We learned that there were health professionals, even when not supported as they should have been by the organisations in which they worked, who did their best and in many instances found ways to achieve excellence.
We learned that the World was woefully unprepared for the impact of a global pandemic despite the presence of a global health organisation, the World Health Organisation (WHO). Actions in response to the pandemic by most governments resulted in various degrees of “lockdowns” which limited individual freedom but in retrospect underestimated the disastrous consequences of these lockdowns, prolonged as they were, on economies and the livelihoods of especially the poor. Nationalism prevailed across across the globe with respect to the development, production and availability of COVID-19 vaccines. Whether this resulted in a greater impact of the pandemic in the countries of Africa remains a moot point as in many countries reliable data was and remains lacking. It seems however that the rapid spread of COVID-19 infections amongst the populations of these countries both of the initial and subsequent strains beneficially increased natural population immunity. Additionally the fact that most countries in Africa have younger populations where the impact of the pandemic was less than those in Europe and North America reduced the morbidity and mortality from COVID-19 in these communities. A lesson from this experience is that despite the noble intentions of policy makers at an international level, faced by the existential threat of a global pandemic, a pragmatic nationalism will prevail. Further it became apparent that solutions developed in the affluent north of Europe and North America are not always applicable in the less affluent countries of the South.
In South Africa, draconian limitation of personal freedom occurred during an initial “hard” lockdown when almost the whole population was supposed to be confined to their homes although for many this was an impossibility. Subsequent curfews were implemented to limit the rise the numbers of people acquiring the disease and “prevent healthcare facilities being overwhelmed”. Despite studies that have been published to date, whether this in the long term had a significant impact on the overall burden of disease in South Africa during this period remains uncertain. Restrictions, many of which were illogical, on the purchase of certain items, even clothing, apart from the total ban on the purchase and distribution of alcohol and tobacco products were less successful although the numbers of those presenting to hospitals as a result of alcohol-related trauma did decrease during these periods. What was learned from this was that restrictions of this nature lead to a flourishing black market for alcohol and tobacco products similar to that which existed during the period of prohibition in the United States.
Heavy handed actions by the police exemplified by a father being arrested when his toddler strayed onto a beach and the spectacle of the Minister of Police with a posse of policemen arresting a foreign national for kitesurfing when access to beaches was banned apparently to restrict the spread of COVID-19 amongst people in the African sunshine and outdoors increased public resentment. We learned from this that it takes relatively little for those in authority to overstep the mark emboldened by the desire to exert control and that the prolonged imposition of restrictions reduced initial cooperation with government initiatives to address the pandemic.
The COVID-19 pandemic in South Africa was characterised by fraud and corruption with government funding wasted both on unnecessary activities such as the fumigation of offices and other public areas and the purchase of personal protective equipment, much of it again unnecessary, from unscrupulous individuals who either inflated prices or provided substandard products. Even at the highest level there were instances of funds allocated to deal with the pandemic being diverted by people for their own benefit. There were instances where people, who had no need of such funding, fraudulently claimed state grants and benefits aimed at the poorest in our society. We learned that moral decay runs deep in our society and that there is no limit to the nefarious actions of some even when faced with a global epidemic. We also learned that there are those, often a minority and at great personal cost, who are prepared to stand their ground and resist wrongdoing.
While plans to build or refurbish facilities, both permanent and temporary, to accommodate the burden on the health services were successfully implemented in some provinces, in others these facilities had not been completed even as the pressure on health facilities resulting from the pandemic began to subside. While fraud and corruption again occurred, long and arduous regulatory processes were often blamed for the delays. However, there were examples of dedicated and cohesive teams achieving a great deal within a short time when provided with sufficient support and an enabling environment. The relaxation of certain prescripts and rules, while risky as this creates opportunities to subvert the system, did allow those with honest intent to achieve a great deal in a short time. An example of this was the opening of a field hospital in the Cape Town International Conference Center within a period of six weeks and subsequently the opening in record time of a further facility in what was previously a large commercial warehouse to meet the need to hospitalise patients with more serious COVID-19 infections. From these experiences the lesson to be learned was that while bureaucracy can be a limiting factor, if managed effectively and judiciously relaxed where necessary particularly at a local level, much can be achieved by the concerted efforts of those with the skills and will succeed.
Medical and health experts became media personalities both here in South Africa. At times experts differed with one another leading to confusion. We learned that communication is not necessarily improved by an overload of facts and figures. The impact of social media was significant with the dissemination of spurious claims of drugs and treatments effective against the COVID-19 virus that later proved to be false. The majority of the South African population while initially keen to receive vaccination against COVID-19 grew increasingly sceptical encouraged by prominent individuals amongst the anti-vaccination lobby. The fact that vaccines which were initially advocated as prevention for infection proved at best to reduce the severity of infection, the need for hospitalisation and as a result COVID-19 related deaths added to a growing number of “vaccine sceptics”. The rigid central control of the COVID-19 vaccination program which was slow to gain momentum due initially to limited vaccine supply, later limited local initiative. As the pandemic waned government was faced with the need to destroy unused doses of COVID-19 vaccine that reached their expiry date due to poor uptake of the vaccine.
From what I have described I think that it is clear that there are lessons to be learned from the experiences of the COVID-19 pandemic. Whether these lessons were indeed learned is however another question. What seems clear to me is that the almost irresistible desire to apply a central command and control approach when faced by a crisis lead to many of the errors made during the pandemic. Clearly a degree of command and control was required, but the evidence when evaluating what occurred in retrospect was that this went too far. While the health imperative was overwhelming initially, this remained paramount for too long driven by the influence of those with a sole focus on the public health aspects of the pandemic. The result was that the wider aspects of what was done were ignored until it was too late and almost irreparable damage was wrought on the lives and livelihoods of many people.
Another recurrent and less attractive aspect of South African society that emerged during the pandemic was the lack of moral leadership, the moral compass if you will, that allowed millions of rands of government funding focused on the health sector to be wasted either by fraud, corruption or incompetence. While this tendency has been mirrored in other areas of our society (see Days of Zondo1), it becomes more reprehensible when the impact is felt most severely by those in need of healthcare who have so little. If there is a single lesson to be learned form the COVID-19 pandemic let it be that as a country South Africa finds a way to restore its moral compass to lead the way to a better future.
Finally, while it may be too late and deemed by some as politically incorrect, let me reflect on what is intended by the current draft National Health Insurance legislation in the light of what occurred during the COVID-19 pandemic. Many have stated that what occurred during the COVID-19 pandemic when decisions and actions were centralised strengthened the case for a centrally driven National Health Insurance. I would respectfully disagree and argue that to the contrary much of the experience during the pandemic supports a more decentralised approach. The cooperation between the private and public health sectors, while limited in real terms, that occurred during the pandemic it is argued similarly supports the establishment of NHI which in effect would end private healthcare as we know it in South Africa. I find it difficult, after a realistic assessment of private sector engagement during this period, to understand how what occurred during the pandemic supports this view. Universal Health Coverage is a noble goal that I fully support, but the lesson that should be learned from experiences in South Africa during the COVID-19 pandemic is that the centralisation of healthcare provided solely through a NHI public entity in the current South African context is not how this can be achieved for the foreseeable future.
