South Africa: a space of many contradictions – and now Covid-19

by Marion Stevens, Director, Sexual and Reproductive Justice Coalition

South Africa is a space of many contradictions, and even more so with the Covid-19 pandemic upon us. Food insecurity is the biggest issue, followed by spatial and housing inequality – that is, in a situation where social distancing is key, some people have no protective space to surround themselves with.

Covid-19 has brought out some incredible leadership from President Ramaphosa and Health Minister Zweli Mkhize, who give regular public briefings that include technical and scientific expertise. However, as I write this, during the fourth week of lockdown, the stark realities of gross inequality have become our foremost challenge.

I live in a middle class village, 35 minutes’ drive from Cape Town. The city is the epicentre of the pandemic in South Africa. In my small village, we are already feeding 100 families. There are 12 soup kitchens in the closest township, double the usual number. The townships in South Africa today have zinc shacks where as many as ten people live in one room (though also mansions). The water situation is a real challenge, however, with people having to buy water in litre bottles to have any water at all. It took Covid-19 to finally get the government to provide water tanks in the townships, but access is still uneven. Many refugees from Congo to Malawi live in a township close by me, but they live in “reasonable” housing, 2-3 to a room, because they were employed in the informal sector and could afford it. But they’re not working at the moment.

During March 2020, news of the pandemic began to permeate our lives. The Sexual and Reproductive Justice Coalition (SRJC) had just facilitated a series of events for the annual 10 March Abortion Provider Appreciation Day in a number of provinces. Less than seven days after one major event, the Western Cape Provincial Minister of Health, NomaFrench Mbombo, revealed that she would be self-isolating as she had been in contact with the French Consul, who had tested positive for the virus. We all breathed in, as the Minister had been warm and affectionate with many people as the keynote speaker at our luncheon for over 100 abortion providers in the Western Cape. Some 14 days later, when we were heading for lockdown, we were relieved to learn that nobody who had attended the event had become ill.

International news has had a big effect on us. No one in South Africa would ever have asked if safe abortion was an essential service here, given the continuing burden of abortion morbidity and mortality. South Africa still has poor health indicators on abortion, with some 9.4% of maternal deaths resulting from unsafe abortions. But reports that several (anti-abortion) US state governments had attempted to halt abortion services because they were “routine” brought the question to national attention here. We have people who are against abortion in our health services too, and this news had an influence on the ground. However, because local journalists picked up on the issue and interviewed us, it alerted us to follow up and check what was happening across the country.

More recently, we heard on an international webinar that access to reproductive health commodities and supplies had become an important challenge for others. South Africa has never registered generic mifepristone and misoprostol. Cytotec (misoprostol) is used off label and mifepristone is registered by one supplier and very expensive. Last year, there were stockouts here of some injectables (Net-En and Depo Provera), IUCDs, implants and contraceptive pills, and we realised this may become problematic again. Other countries in our region have greater access to medical abortion pills. For example, Zambia has three generic brands of misoprostol and combi-packs of mifepristone and misoprostol registered, but we have none in South Africa.

There are more contradictions as well. Our Choice on Termination of Pregnancy Act of 1996 is well known among other progressive sexual and reproductive health policies, but in many cases there is less than satisfactory implementation. Most messaging for women in South Africa does not cover the full spectrum of sexual and reproductive health care. In relation to Covid-19, a new website called Messages for Mothers in response to Covid-19 represents the kind of siloed thinking that has re-emerged in the past 20 years. It doesn’t mention let alone address abortion, but speaks to women as mothers, not recognising that mothers also choose to have abortions.

Over the past three weeks, as testing for the virus has scaled up in South Africa and health systems has begun to carry out screening, testing and prepare for admission of people with Covid-19, the SRJC, as coordinator of a network on SRHR within a larger civil society coalition, has been doing informal monitoring of access to SRH services across the country. We’ve been checking in with providers we know in the health services and NGOs who are providing services like Médicins sans Frontières. People have multiple needs in a situation like this, from miscarriages to after-care for rape. Most of our contacts are providers of SRHR care, including abortion services. Most report that things are going on as usual. In some provinces, however, we have received feedback of stockouts of reproductive health commodities, and also reports of women being turned away from abortion services. In response, we have intervened by referring women and utilised existing relationships with health service managers to ensure people get the care they need. We received feedback last week, for example, that a woman had received a second trimester abortion in a rural province in the public sector after assuring her that her referral letter was valid and confirming which hospital she should go to for it. In another instance, Northwest Province opened abortion services in response to a personal contact.

Moreover, an unexpected and welcome policy reform has taken place. The Health Professions Council of South Africa (HPCSA) had previously prohibited telemedicine unless the provider had an established relationship with the patient. But in seeking to keep patients out of waiting rooms and clinics able to adhere to social distancing, and also to acknowledge that telemedicine is evidence-informed and safe, on 3 April 2020, the HPCSA published a Notice to Amend Telemedicine Guidelines during COVID-19. It says that while telemedicine should preferably be practised in circumstances where there is an already established practitioner-patient relationship, where such a relationship does not yet exist, practitioners may still consult using telemedicine provided the consultations are done in the best clinical interests of the patient.

In this context, the SRJC briefed the Women’s Legal Centre and Section 27, a two-partner legal group, and wrote a letter on Friday 17 April 2020 to our national Minister of Health and the nine provincial Ministers of Health regarding telemedicine and access to SRHR services.  Part of the letter says:

‘We also bring to your attention the advisory issued by the Health Professions Council of South Africa relating to the use of telemedicine during the COVID-19 pandemic. This allows for healthcare services to be dispensed in line with physical distancing guidelines during the lockdown period. The advisory notes the need for client-centred care, and for health providers to use telemedicine to act in the best interests of the client. It allows for medical practitioners to diagnose, treat and dispense medical advice and treatment using virtual or telephonic platforms. This provides a unique opportunity to allow for the virtual prescription of contraceptives and self-managed medical abortion pills, in line with international practices as per WHO clinical guidelines. The ability to access healthcare telephonically reduces the need for women to travel to clinics and the risk of exposure to COVID-19. Telephonic medicine should operate in conjunction with in-person assistance at health facilities for those who are accessing sexual and reproductive health services.

We also referred them to the Mama Network website, which can be relied upon for solid information on using telemedicine for safe abortion.

On the following Monday afternoon, 20 April 2020, we received a timeous reply from the Provincial Minister of Health of Gauteng Province, with a positive response. Noting that reproductive health supplies were available there, they stated with respect to telemedicine for abortion: “The Gauteng Department of Health is currently using SMS technology when communicating with patients and is looking at other better means of improving.”

Marie Stopes South Africa is in a position to capitalise on this opportunity by offering telemedicine services at private market prices. But it is important that the public sector steps up and does the same.

In spite of this pandemic (or perhaps because of it), moments like these of health system reform serve as an opportunity to increase access to sexual and reproductive health care in the public health system, working towards universal health coverage for all.