Second Letter to the Minister of Health: Access to Sexual and Reproductive Health

 In Member statements

9 June 2020

Dear Minister Mkhize,


1. The above and our letter dated 17 April 2020 refer. A copy of this letter is attached forease of reference. To date, we have not received a response.

2. As previously stated, the Regulations Made under the Disaster Management Act (‘the Regulations’) as at 17 April 2020 provided that medical or health services are considered ‘essential services’ for the purposes of the Regulations and the lockdown.

3. We note that on 29 April 2020 Regulations were issued in terms of Section 27(2) of the Disaster Management Act relating to Level 4 of the Lockdown. In terms of Annexure D, essential services include “medical, health (including mental health), Laboratory and Medical services and the National Institute for Communicable Diseases”. Our understanding is that these Regulations have expanded the definition of available medical services from “essential, life-saving or chronic medical attention” available under Level 5, to the availability of all medical services under Level 4.

4. During the Presidential address on Sunday 24 May 2020, President Ramaphosa indicated that on 1 June 2020 the country would be moving into Level 3 of the Lockdown. Of note, the President confirmed that routine health services should be fully opened:

“As we mobilise our health resources to meet the expected surge of coronavirus cases, we must make sure that we do not create the space for the emergence of other health crises… Routine health services should therefore be fully opened and continue to provide services with attention to childhood immunisation, contraceptive services, antenatal care, diagnosis and treatment of tuberculosis and HIV, management of chronic diseases and support for survivors of genderbased violence.”

5. We note that the Alert Level 3 Lockdown Regulations published on 28 May 2020 are in line with the President’s announcement and do not divert from the above position.

6. Despite the gradual lowering of lockdown levels, we are concerned by the ongoing reports from women who are denied access to contraceptives and safe abortion services at public health facilities. According to the Stop Stockouts Project, 52 contraceptive shortages have been reported at public health facilities, with the provinces most impacted being the North West, Gauteng, Eastern Cape and the Free State.

7. We are further concerned about the dramatic increase in the number of people who have not been able to adhere to their HIV and TB treatment. A recent NICD report1 states that restrictions which limit the movement of people has resulted in a 48% weekly decrease in TB testing volumes. In Gauteng, 1 090 patients failed to collect their TB medication and 10 950 patients failed to collect their antiretroviral medication. This is particularly alarming as treatment interruption may lead to patients’ increased susceptibility to opportunistic diseases, including SARS CoV-2.

8. As we move into the phased easing of lockdown restrictions, we are aware of the fact that movement of people will increase. This, undoubtedly, will see an increase in the number of Covid-19 infections. It remains necessary to put in place clear measures related to access of health services beyond Covid-19, and specifically sexual and reproductive health services. Such measures would include directions to allow general practitioners and medical practitioners at primary health care level to prescribe treatment related to sexual and reproductive health services virtually.

9. We once more bring to your attention the advisory issued by the Health Professions Council of South Africa on 26 March 2020 relating to the use of Telemedicine during the Covid-19 pandemic which allows medical practitioners to diagnose, treat and dispense medical advice and treatment using virtual or telephonic platforms. We encourage the Department of Health to utilise this opportunity and allow for the virtual prescription of contraceptives and self-managed medical abortion pills, in line with international practices as per WHO clinical guidelines.

10. We urge the NDOH to communicate with SAPHRA regarding the fast tracking status of the registration of generic medical abortion drugs and to partner with the World Health Organisation and explore additional supplies through parallel imports from regional countries or offices who have registered these products.

11. In light of the Contraception and Fertility Planning Guidelines and updated tenders regarding the range of new contraception options available, we also encourage the Department to consider increasing availability of alternative contraceptive methods, in particular the hormonal IUCD.

12. We welcome Notice No. R 481 which was issued on 30 April 2020 by the Ministry of
Health which excluded Schedule 2, 3 and 4 substances in the Medicines and Related
Substances Act from the requirement that such substances be dispensed for no longer
than six months. The extended prescription period for antiretroviral treatment and
contraceptives will certainly assist with reducing the need for physical interaction with
health facilities.

In light of the above, we request the following:

13. An unequivocal undertaking that sexual and reproductive health services are available
and accessible at public health facilities, including:

13.1. Access to safe and legal abortion services, both medical and surgical;
13.2. Access to contraceptives, which includes emergency contraceptives;
13.3. Access to anti-retroviral treatment;
13.4. Access to post-exposure prophylaxis treatment and pre-exposure prophylaxis
13.5. Access to screening and treatment of sexually transmitted infections;
13.6. Continued supply of gender affirming care (hormones);
13.7. Screening, testing and treatment of reproductive cancers; and
13.8. Expansion of the female (internal) and male (external) condom distribution

14. The above undertaking be communicated to all health facilities and the public in the form of a directive or other official communique;

15. Confirmation that medical practitioners may provide access to contraception options and medical abortion services directly and via telemedicine, allowing for prescriptions to be issued for medical abortion drugs in South Africa;

16. Public health messaging noting as per the Abortion Clinical Guidelines that abortion services are available as an essential service at all health facilities, including publication of a list of public health facilities in each province where women may access abortion services;

17. Indicate what plans the Department has to explore parallel import licencing agreements for reproductive health commodities;

18. Indicate what the Department’s plans are to track and trace persons who have defaulted on TB and/or HIV treatment during the lockdown period and ensuring that those persons are expeditiously provided with treatment;

19. Guidelines be put in place to ensure that the necessary care is taken during triage procedures in health facilities to protect marginalised persons when they approach facilities for sexual and reproductive health services. These marginalised persons include, but are not limited to, members of the LGBTQIA+ community, young women, sex workers, and persons with disabilities. As the number of Covid-19 cases surge throughout the country, we are mindful of the magnitude of the task which lies before the Department of Health. Despite this, we urge the
Department to consider the equally urgent and ongoing health concerns relating to sexual and reproductive health. We trust that any measures to address Covid-19 will be taken with these considerations in mind.

We look forward to receiving a response from you on or before 16 June 2020.

Yours sincerely,
Women’s Legal Centre
Sexual and Reproductive Justice Coalition
Treatment Action Campaign
MSF South Africa
Public Service Accountability Monitor
Rural Health Advocacy Project
Asijiki Coalition
People’s Health Movement SA
TB Proof
One to One Africa
Studies in Poverty and Inequality Studies
Lawyers for Human Rights

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