APPENDIX C

The findings and recommendations in this appendix are taken from the Truth and Reconciliation Commission of South Africa Report, Volume 5, Chapter 8, pages 334-40.

Findings and Recommendations
of the TRC on the Health Sector

Millions of South Africans were denied access to appropriate, affordable health care during the period under review. Health care workers, through acts of commission and omission, ignorance, fear and failure to exercise clinical independence, subjected many individuals and groups to further abuse. Fundamental reforms in the health care delivery system, legislative controls, monitoring and accountability mechanisms, and the training of health professionals are required.

Legislation

The Commission recommends that:

All legislation pertaining to health care focus on primary health.

Present health care legislation be reviewed, and future legislation developed, taking into account the need for transparency, evaluation and monitoring, the rights of service users and the primacy of confidentiality.

Professional standards of conduct

The Commission recommends that:

A uniform code of conduct for health professionals be developed, implemented, and taught in all health science faculties.

The statutory councils ensure that all health professionals registered with those councils are familiar with the professional standards to which they must adhere. Health professionals must be held accountable if they violate these standards.
Health professionals engage in "self-audits" of their professional conduct by meeting regularly in small facilitated groups to discuss ethical and human rights dilemmas.

Training

The Commission recommends that:

Health science faculties establish programs aimed at increasing the number of black under- and post-graduate students. This may require bridging programs, financial assistance, tutors, mentoring, etc.

Training in human rights be a fundamental and integral aspect of all curricula for health professionals. This training should address factors affecting human rights practice, such as knowledge, skills, attitudes, and ethical research practices. Knowledge of and competence and proficiency in the standards (both national and international) to which doctors will be held accountable should be a requirement for qualification and registration.

The content of the oaths pertaining to health care and the ethical principles embodied in them be taught as part of undergraduate training from the earliest opportunity possible. This facilitates an interaction with the principles espoused and an opportunity to question and implement them during the training period.

Continuing Medical Education programs include a review of human rights and ethical issues and developments.

Safeguards for vulnerable health professionals

In order to ensure that health professionals who work in situations in which they have dual loyalties are not complicit in committing human rights abuses, the Commission recommends that:

Appropriate ongoing training in institutional health care and human rights be mandatory for all health professionals working in public facilities.

Training be developed for non-medical prison staff, SANDF members and police, to facilitate a mutual understanding of the duties and obligations of health professionals working in those environments. This will support professional and ethical health practices.
Standards and norms that uphold human rights be developed for institutional health care. These need to be put into operation via regular independent audits.

The Department of Health assume de jure and de facto control of prison and detainee health care, military health care, state mortuaries and forensic services. (Those responsible for forensic services should not also be responsible for providing health care to prisoners and detainees, as is presently the case.) In other words, health professionals working in these environments must be employed by, report to and be professionally accountable to the Department of Health.

Health care services in prisons

The Commission recommends that:

The role, responsibilities and obligations of individuals responsible for the health care of prisoners and detainees, both in prisons and police cells, be clearly defined and accepted by all police and prison staff.

An audit of district surgeons currently employed by the Department of Health be carried out, to ensure that those who participated in or colluded with human rights violations in the past are no longer in a position to offer treatment to detainees and prisoners. (Note: this is not a recommendation that such people should no longer be allowed to practice, only that they be removed from situations in which they might be vulnerable to collusion.)

The medical records of prisoners and detainees be inaccessible to non-medical prison staff and/or police, unless the health professional in charge deems such access to be in the interests of the patient.

Medical examinations of prisoners and detainees take place in private, unless the patient or the health professional performing the examination requests otherwise.

Regular independent reviews of health care in prisons and other places of incarceration, military installations and mental institutions be conducted.

An independent line of authority be established to advise, guide and support district surgeons and other prison health care personnel facing controversial ethical decisions.

Compulsory refresher courses for prison health care workers focus on ethics, mental health issues, human rights and the specific health needs of prisoners.
The format of documentation completed by health professionals providing health care for prisoners and detainees specifically include sections on allegations of torture or abuse, evidence of such abuse and how the allegations are being investigated. All allegations of abuse must be reported to an independent monitoring body. Failure to report abuse should be a disciplinary offense.

Medico-legal services

The Commission recommends that:

There be uniform standards of training for all staff required to perform postmortems or other forensic examinations.

Custodial care and forensic services be separated. To prevent a conflict of interest, professionals who provide health care to prisoners and to others incarcerated or detained should not have forensic responsibility.

The legislation governing forensic psychiatry be revised, the secrecy clause related to forensic psychiatry be lifted, and forensic psychiatry services be reviewed.

The state fund an independent forensic service for the use of the family of anyone who dies in custody. The families be informed of their right to have an independent forensic pathologist present at a postmortem.

There be regular independent audits of the police mortuaries and forensic pathology laboratories.

Police mortuaries and forensic laboratories be adequately equipped. The absence of X-ray facilities, for instance, in the majority of mortuaries is noted with concern.

Mental health

The Commission recommends that:

Mental health be given priority as a national concern and be brought into the primary health care system.

Mental health services be accessible to all South Africans, with particular emphasis on the rural areas.
The focus of mental health services be shifted from the almost exclusively one-on-one therapy model, to become community based. Different care and therapy modalities be explored and instituted, particularly traditional and indigenous modes of treatment. Community counselors and family members be involved in care provision. Service users be included in decisions about service provision.

The quality and type of care provided in mental institutions be monitored by an independent body.

Psychometric tests which are culturally appropriate in all aspects be developed and appropriately applied.

Appropriate models for trauma counseling in the South African context be developed and implemented.

Mental health issues be taken into consideration by all appropriate ministries, for example Housing, Correctional Services, Education, and Safety and Security, in their planning processes.

Mental health services have a developmental focus.

There be increased research into the consequences of trauma related to the experience of violence. The growing body of research on post-traumatic stress disorder (PTSD) needs to be more widely shared and practically applied in social settings. Knowledge and awareness of PTSD should be encouraged in institutions, communities and the family.

The organized medical profession

The Commission recommends that:

The Statutory Councils governing the health professions be proactive in promoting human rights.

The Statutory Councils be given a proactive capacity to investigate unethical/unprofessional conduct, without having to depend on the submission of a formal complaint.

The composition of the Councils represent society in terms of gender, race, etc., and that the Councils include community representatives and members of other professions. This will ensure that the system of self-regulation, which has failed so obviously in the past, is not perpetuated.

The appointment of Council members should be a transparent process which ensures the political independence of the Councils.

The disciplinary "arms" of the Councils be bodies whose members have a core of appropriate knowledge and experience; disciplinary measures and sanctions be implemented in a consistent, fair manner; and the full Councils have the power to review outcomes of disciplinary inquiries and the sanction(s) imposed.

Political and functional autonomy and independence of statutory Councils be entrenched.

The Councils ensure that no legislation or policies violate the rights or dignity of patients, clients or health care professionals.

Health care professionals who oppose or draw attention to human rights abuses be actively supported and protected by statutory councils and professional organizations.

Checks and balances for state-run organizations

The Commission recommends that:

A body on health and human rights be established, consisting of health care professionals, human rights experts, consumer representatives and legal experts. This body could be appropriately located within the Human Rights Commission. It should be independent of government, professional organizations and statutory councils, but would obviously work in co-operation with these.

This body be responsible, among other things, for:

• implementing health sector-related recommendations adopted by Parliament as a result of this Commission's report;
• monitoring institutional health care;
• advising on curricula in health and human rights education;
• receiving and dealing with reports and complaints about human rights abuses in the health professions;
• creating the position of and overseeing the work of a "medical public protector" or ombudsperson;
• implementing an inquiry into the legal, ethical and professional position of health personnel in the military, and developing clear guidelines to avoid conflict between military law and professional ethics.

This body have a mechanism to allow for ongoing confidential reporting of human rights abuses by health professionals.

Service users

The Commission recommends that:

Current efforts to create a Patients' Rights Charter be encouraged. The Department of Health, statutory councils and professional organizations be required to engage in ongoing programs to inform users of health services of their rights and of ways in which complaints can be lodged.

State health organizations (Department of Health and South African Medical Services)

The Commission recommends that:

The disparities in health care resource allocation be redressed, with a special focus on the disparities between the urban areas and townships, as well as between urban and rural areas. This could be accomplished through a once-off tax, or slowly over time.

All employees of state-run institutions be made aware of their duties, obligations and rights.

Health care professionals exercise the privilege and responsibility of having final authority regarding decisions affecting the health of patients. This is particularly important in situations where the patient is incarcerated.

The SANDF provide appropriate mental and physical health care for those suffering from the effects of SADF actions or participation in them. Similarly, services are needed for those who participated in and suffered the results of other state-sponsored or liberation movement violence.

All health care facilities have policies that protect and promote:

• doctor-patient confidentiality
• clinical independence
• institutional independence
• patient advocacy.

Research and publications

The Commission recommends that:

The professional bodies, Statutory Councils, and the health and human rights body (referred to above) monitor research practices, especially among vulnerable populations whose members may be unaware of their rights.

There be a prohibition against research into scientific methods of interrogation and torture.

South Africa adhere rigorously to all the stipulations of the International Conventions on Chemical and Biological Weapons, particularly those pertaining to research and development.

The South African Medical Journal (SAMJ) have editorial independence from any interest group such as the state, the Medical Association of South Africa (MASA), etc.

The editorial board of the SAMJ be broadly representative and include community representatives.

Responsibility for developing and implementing these recommendations, and for monitoring their implementation, rests primarily with:

• The Department of Health--national and provincial;
• The statutory councils;
• Professional organizations;
• The SANDF;
• Health science faculties;
• The Human Rights Commission;
• NGOs involved in health.