My colleague the Deputy Minister of Health, Dr Joe Phaahla, MP
My colleagues Ministers present
Chairperson of the Portfolio Committee – Honourable Dunjwa
Members of the Portfolio Committee on Health
Honourable Members of the House
MECs for Health present
Ladies and Gentlemen
It is a great honour and privilege for me to present the health budget vote for 2014/15 financial year.
This Budget Policy Statement is being delivered under the guidance of imperatives, targets, pledges and obligations which are both national and international in character.
These imperatives have to be considered, the targets reached, the obligations and pledges respected by the Department of Health in particular, but by the country in general.
Firstly, we have the National Development Plan or the NDP. It implores on us to amongst others
- increase life expectancy to 70 years by 2015;
- have a generation of under 20’s free of HIV and AIDS;
- reduce maternal and child mortality;
- significantly reduce the burden of diseases both communicable and non-communicable;
- implement the National Health Insurance (NHI) in phases, complimented by relative reduction in the cost of private healthcare, supported by better human resources and systems.
Secondly, at international level, we are having the MDGs (Millennium Development Goals) which expire next year in 2015.
By and large, within the health fraternity, i.e the World Health Organisation (WHO), UNAIDS, the African Union (AU) Health Ministers’ Summit, the BRICS Ministers of Health Summit, the Commonwealth Health Ministers, the Southern African Development Community (SADC) and many others, there is broad consensus about the Post-2015 World Health Agenda.
The consensus is that the Post-2015 World Health Agenda must be characterized by three (3) goals:
- first goal is that Millennium Development Goals (MDGs) 4, 5 and 6 need to continue far beyond 2015; i.e goals on child mortality, maternal mortality and the fight against HIV/AIDS, TB and malaria should not stop at 2015;
- second goal is that the world must decisively deal with the risk factors that cause the ever exploding pandemic of non-communicable diseases (NCDs). You will recall that these risk factors are smoking, harmful use of alcohol, poor diet and lack of exercise;
- the third goal is implementation of Universal Health Coverage by every country. As you will know, we call this National Health Insurance (NHI) in our country.
Furthermore at the International level, we have the Partnership Forum housed by the World Health Organisation, and chaired by our very own, Mrs Graca Machel, which held its Summit here in our country at the end of June 2014.
The communiqué at the end of this Partnership Forum is that we need to ensure the well-being of every woman, child, newborn and adolescent.
Honourable Chairperson, these are very noble goals and there can never be any argument about them. The question we need to ask is, how?? But the answer still has to be provided by us – both individually and collectively!!
In order to avoid getting lost in this myriad of goals, targets and pledges, South Africa is always guided by the assessment of our own disease profile. Our own disease profile is characterized by four (4) colliding pandemics, or what we commonly refer to as the quadruple burden of disease. While I have mentioned this many times, I need to repeat it here today so that we are able to follow this budget debate.
- The first and biggest burden is HIV/AIDS and TB;
- The second is maternal and child mortality;
- The third are the NCDs or non-communicable diseases; and
- The fourth is Injury and Violence
Honourable Chairperson when your country is faced with such a huge burden of disease and the NDP implores us to reduce this burden, it means the healthcare system has to be directed. You cannot reduce a burden of disease through a largely curative healthcare system. A huge disease burden such as ours can only be reduced through a Primary Health Care system. Put simply, it means that a healthcare system that is directed at prevention of diseases and promotion of health.
This is what the South African healthcare system is going to look like. We have got no choice in that regard because the NDP guides us in that direction.
HIV/AIDS and TB
Honourable Chairperson, you will notice that the elimination of HIV/AIDS, TB and Malaria is MDG 6. But you will notice that under the quadruple burden of diseases Malaria is not mentioned. This is because we have already exceeded our target for malaria long before 2015.
Yes we have reduced incidence of malaria by 89% in our country long before the target date of 2015. We have achieved this through a preventative system called IRS (Indoor Residual Spray), a system whereby mosquitoes are prevented from landing on the walls of houses, so that they cannot bite human beings.
Our biggest problem remains HIV/AIDS and TB. We have made tremendous progress in the fight against these scourges in the last five (5) years. But a lot still needs to be done.
Honourable Chairperson, you and the Honourable Members must have heard about the 20th International AIDS Conference that is going on in Melbourne in Australia. Unfortunately you have heard about it in a rather tragic manner – the tragic death of citizens of many countries in a plane crash in Eastern Ukraine.
Amongst them, the outgoing President of the International AIDS Society Mr Joep Lange and other luminaries in the fight against HIV/AIDS, who were on their way to the Conference.
Yes it was very tragic and the opening ceremony of this Conference on Sunday the 20th of July did feel the tragedy in the air.
I have just arrived back a day before yesterday from this Conference. The Conference took a very far-reaching decision to add to the already existing international goals which I have mentioned earlier.
The decision is that we need to bring an end to HIV/AIDS by 2030.
Chairperson, in South Africa 2030 is very important. It is the target for all our NDP Goals. So this international target agreed to in Melbourne, coincides with this important date on our calendar. The Conference defined what is meant by bringing an end to HIV/AIDS by 2030. It means the following things:
- 90% of people know their status;
- 90% of those that are HIV positive are on treatment;
- 90% of those on treatment are virally suppressed.
In other words Honourable Chairperson, the strategy is 90% by 2030!
Discounting this year, we have 15 years to achieve these targets globally.
Now Honourable Chairperson, what will it take for South Africa to achieve these targets?
Where do we start?
- We have 52 million people in South Africa;
- Of those that are between 16 – 64 years (those considered sexually active), there are 35 million people. This number needs to be prioritized for HCT, i.e HIV Counseling and Testing;
- Of the 35 million between 8 – 9 million people are tested annually;
- Of these the prevalence rate is 17% for those between 15 – 49 years – with the prevalence of pregnant women who use public sector ante-natal clinics at 29%;
- We have 6 million people who are HIV positive;
- Of these, 2,5 million have been initiated on treatment (this constitutes 80% of eligible women, 65% of illegible children and 65% of illegible men on treatment).
This number of 2,5 million on treatment is 30% or one-third of the total global figure;
- Of these, about 50% receive viral load tests;
- Of these 75% are virally suppressed;
- At 36 months we currently have 37% loss for follow-up.
So, like elsewhere in the world, there are leakages in the HIV/AIDS cascade. This needs to be fixed to ensure that those that are prioritized for HCT are indeed tested and those eligible for treatment are initiated on treatment and stay on treatment.
Our next step is to increase coverage in the manner proposed by the 90% approach. This means testing most if not all of the population annually, initiating everyone who is positive on treatment regardless of CD-4 and supporting all those that are on treatment.
In summary, it will mean mass testing in every possible setting (schools, universities, workplaces, churches and communities).
In further chasing those goals Honourable Chairperson, I wish to announce today that in January next year we shall move all HIV positive pregnant women to the World Health Organisation’s option B+ as opposed to the current option B, that is operational in the country.
Option B+ simply means every pregnant HIV positive woman goes on a lifelong treatment regardless of their CD4 status, whereas option B is that they stay on treatment only while breastfeeding, and stop after termination of breastfeeding if their CD4 count is >350.
Option B+ is lifelong treatment regardless of CD4 status.
In addition Honourable Chairperson, it is my pleasure to announce today that as from January 2015, we shall start HIV positive patients on treatment at the CD4 count of <500, as against the present CD4 count of <350.
You will appreciate Honourable Chairperson that we come from very far in the past 5 years.
On 1 December 2009 President Jacob Zuma announced treatment at CD4 count of <350, as against the then CD4 count of <200 for special categories of patients.
In September 2011, then Deputy President Kgalema Motlanthe, expanded this to everybody to make it universal at CD4 count 350
Today it is a further milestone that we are announcing treatment for all at CD4 count of <500.
You will remember Honourable Chairperson, that treatment of as many people as possible, has been found by research to be also a form of prevention.
So this massive treatment programme will also be accompanied by a wide range of prevention techniques including massive condom distribution, HCT, prevention of mother to child transmission (PMTCT), sexually transmitted infections (STI) management, massive medical male circumcision for which we are targeting 4 million men by 2016; provision of safe blood transfusion which we have already achieved because it is very rare now in South Africa to get HIV/AIDS from blood transfusion. This did not happen on its own, we made it happen, through the state-of-the-art facility installed at our main blood transfusion centre in Roodepoort. Other methods will include information, mass education and communication, as well as social mobilization. We also know that keeping girl children at school at least until matric, protects them from pregnancy and HIV/AIDS acquisition.
Honourable Chairperson, for all these noble goals to be achieved, government and civil society, as represented by SANAC (South African National AIDS Council) must be a well-oiled machinery, which at the moment is not so really so. I am appealing to SANAC to please recharge, for the task ahead in the next 15 years is huge, and we cannot afford to be flat-footed at this period in the history of the pandemic – this is the final push!
On the TB front Honourable Chairperson, I have already announced the new measures during my speech on the debate on the President’s State of the Nation Address, i.e that we will screen all 150 000 inmates in our Correctional Services Facilities, all the 500 000 miners and the 600 000 strong peri mining communities in 6 districts that have a high level of mining activity. In addition, we are going to embark on a massive decentralization of MDR-TB, initiation, management and treatment. Presently we have got 100 such decentralized cites, and we are intending to increase them to 2 500. This will happen through a rapid establishment and scale-up of nurse-led MDR-TB treatment management teams at municipal ward level.
Maternal, child and women’s health
Honourable Chairperson, whether you talk of MDGs, Post-2015 MDG Health Agenda, NDP, the World Health Assembly or the WHO Partnership Forum, issues of Maternal, child and Woman’s Health will always come to the fore.
This is because maternal and child mortality is not only a health issue, but also an issue of development of humanity.
What really kills women in pregnancy and child birth despite our long held assertion that no woman should die giving life?
There are of course many causes, most of which are developmental. In South Africa, we already know from tri-ennial studies of the National Confidential Committee of Inquiry into Maternal Deaths, that 3 causes emerge as the most prominent. These are summarized as the 3 H’s:
- First H is HIV/AIDS which accounts for 49% of maternal mortality and 35% child mortality;
- Second H is Hypertension in pregnancy; and
- Third H is Hemorrhage – both ante and post - partum hemorrhage.
You will appreciate why we have consistently and persistently persued strong HIV/AIDS programmes for pregnant women like the PMTCT. You are aware that we have scored significant achievements in this regard. Whereas a decade ago we had 70 000 children born HIV positive in our country every year, we now have less than 8 000 annually, due to a massive and successful PMTCT programme. We are going to build up on this success until no child is born HIV positive anymore.
To deal with the other two H’s the African Union Heads of State have launched CARMMA (Campaign on the Accelerated Reduction of Maternal and Child Mortality in Africa).
During the past 18 months, 1 468 doctors and 3 625 Professional Nurses have been trained in ESMOE (Essential Steps in the Management of Obstetric Emergencies).
Our data suggest that in the districts that the training has been done, maternal deaths from bleeding after delivery is on the decline. We will continue with this programme until doctors and midwives in all districts in the country are well trained.
Honourable Chairperson, part of the agenda to reduce maternal mortality is family planning.
We know from the NCCEM’s tri-ennial studies that of the 1 million + women who fall pregnant annually, 8% are girls under the age of 18 years but they account for a whopping 36% of maternal deaths.
There have been wild claims that the key driver of teenage pregnancy is the child support grant. There is no scientific evidence to back this.
We have always argued, and United Nations Fund for Population Development (UNFP) has backed our argument, that one of the main drivers of teenage pregnancy in Sub-Saharan Africa is lack of family planning.
This has also led to exploding number of teenage abortions.
In dealing with this scourge, on the 17 February 2014 we launched a new National Family Planning Campaign in Ekurhuleni in Gauteng, under the theme “Dual Protection”, i.e. consistent use of a condom together with another form of contraception device.
On that occasion Honourable Chairperson, we launched a totally new contraceptive device called the Sub-dermal implant, which is implanted just under the skin on the inner upper arm.
This was the first time that this long acting reversible contraceptive, that remains active for a period of 3 years has been made available in the public health sector in South Africa. Whereas it will cost you up to R1 700.00, it is provided in all public health facilities free of charge to any woman regardless of their socio-economic status.
For this campaign, we have up to now trained 5 325 nurses across all public health facilities who are now able to insert the implant even in the absence of a doctor.
When we started, we agreed that we will order 80 000 units of the implant every quarter, meaning that we would insert at least 320 000 implants per annum.
Honourable Chairperson, we were pleasantly surprised, that in only 4 months, we have already inserted 362 000 implants, far exceeding what we regarded as an annual targeted 320 000. Already, 600 000 implants have been ordered and we have cause to believe that they will all be inserted by the end of the financial year.
Shouldn’t this tell us that we were right when we said that there is a serious gap in the provisioning of family planning?
We wish to appeal to Honourable Members to help popularize this very convenient method of family planning in their constituencies.
I wish to further announce to this House that in March this year, we launched together with the Department of Basic Education, the HPV (Human Papilloma Virus) vaccine programme for Grade 4 girls, to protect them against the dreadful cancer of the cervix of the uterus.
Over 2 000 vaccination teams were trained and visited over 90% of all public schools that have Grade 4 learners, during March and April this year. These teams immunized over 87% or just over 345 377 of the eligible Grade 4 girls. We are planning for a second dose in September and October 2014, and thereafter we will immunize new Grade 4 girls every year.
The girls that have not yet turned 9 years during the year that they are in Grade 4 will be vaccinated the following year even if they leave the Grade 4 class.
This nationwide initiative will have far-reaching implications for preventing cervical cancer in our future generations of women. That is why we are providing the vaccine free in all public schools whereas it would have cost you between R700-R1 000.
Honourable Chairperson, we will do everything in our power to reach or goals on maternal, woman and child health.
To this end, we shall make sure that pregnant women are not just passive recipients of healthcare but are also active participants in claiming healthcare from our public health facilities.
As I said during the debate on the State of the Nation Address, I am happy to announce that during Women’s month, we shall launch, on 21 August 2014, the MomConnect Project.
If you forgot, let me remind you:
MomConnect will seek to register by cellphone all the pregnant women in any one year in our country.
We know this to number 1 million in the public sector and 200 000 in the private sector. Through MomConnect, all the registered pregnant women will receive “sms” messages appropriate to their stage of pregnancy. These messages will advise them what to do at any stage of their pregnancy. It will encourage them to start ante-natal care early, test for hypertension, HIV/AIDS, diabetes etc very early. It will emphasize on starting PMTCT early at 14 weeks.
The woman will also be able to send us sms messages at no cost to themselves (the “Please Call Me”), to inform us of their concerns and experiences in our healthcare facilities.
Honourable Chairperson, I would like to embark on a campaign to all the districts to inform nurses about MomConnect – I don’t want them to be caught off guard, they must understand the implication of MomConnect – it would provide unprecedented power to the pregnant woman to seek health and demand good treatment.
Honourable Chairperson, last month I was phoned by a concerned husband who was not pleased about how his wife who was in labour was being treated.
I immediately sent somebody to intervene. A few hours later the husband was even more worried. The wife was ill-treated even more and was told that because you are connected to the big people – we shall show you who wields power here.
I am warning those health workers who did that that after the launch of MomConnect, they will be faced with 1 million connected women – not just the one they ill-treated – but 1 million connected women!!
After delivery of the baby, MomConnect will still continue for up to a year. Only that this time, the “sms” messages will include advice on the baby – like exclusive breastfeeding, immunization, family planning for the mother, oral rehydration during diarrhea, check-up periods at the clinic etc, etc.
I have already indicated that the NCDs are poised to be part of the Post-2015 Global Health Agenda.
The NDP also implores us to deal decisively with NCDs. We shall establish a National Health Commission, to be chaired by the Deputy President of the country, to become the vehicle through which NCDs will be dealt with. The Deputy President will be deputized by somebody from the Academia, who is very active in the fields dealing with the risk factors of NCDs.
I would then call upon the Academia to conclude their confusing debates about diet and start guiding the Nation.
Honourable Chairperson, mental health is also a very recognizable NCD which is also on the rise just like the other NCDs.
Honourable Chairperson, about 3 weeks ago one of the prominent Sunday newspapers had a screaming article about the status of mental health in South Africa.
So many people were disturbed that they started phoning me, including members of this august House. Several asked me to clarify this issue during this budget speech. I agreed – information is always power.
I am not here to argue with a newspaper about statistics. We all know too well how the argument on HIV/AIDS statistics nearly pushed the country over an abyss. So, please understand me, I am not interested in that.
What I wish to do is to place on record the situation on mental health as we understand it.
However, the first unfortunate issue is that the newspaper called what it printed an exclusive investigation.
Honourable Chairperson, my understanding of an exclusive investigation is that you investigate that which is not known, or that which is hidden – especially deliberately or perhaps that which nobody cares about.
My problem is that the issues that were then “revealed” in this “investigation” as exclusive, are actually what was publicly mentioned in a Mental Health Summit by myself and other stakeholders on 12 April 2012.
That Summit was specifically organized by the Department to provide a platform for researchers and stakeholders to openly and honestly discuss issues of mental health in our country.
We even invited the World Health Organisation to come and participate and guide us as a country. The WHO sent in Dr Sekhar Saxena, Director of the Department of Mental Health and Substance Abuse at the World Health Organisation.
Honourable Chairperson, please allow me to quote from the speech I delivered that day –
“I believe this Summit represents a significant milestone for mental health in this country. In this regard we must collectively make maximum use of this opportunity and provide both evidence-based inputs as well as personal experiences to ensure that the objectives if this Summit are realized.
This Summit must (a) review both quality and quantity of mental health services that we currently provide, (b) identify the key challenges in the mental health care system, (c) provide information on best practices that have emerged since 1994, and (d) agree on key interventions that must be prioritized and implemented as we reorganize and strengthen the health system.
Over the two days we must deliberate and propose on a need map for mental health as this area of work is central to the achievement of the outcome of a long a healthy life for all South Africans. As you know, this is a key deliverable that this government adopted in 2009”.
Of course Honourable Chairperson, this Summit as we had requested, did its work of revealing, discussing, proving and eventually came out with the country’s first ever mental health strategy. The WHO even praised us for being the only country on the continent that did so.
So when a major newspaper comes in 2 years later, and mention things that were publicly and openly discussed in that Summit as a result of exclusive investigation, it is very worrying.
If it was that newspaper that talks about “tokoloshes” and witches flying on brooms in my home province of Limpopo, I would not have even bothered. I am bothered because this is one of the flagship newspapers of the country, which should know better.
The newpaper went on to mention that the prevalence of mental disorder in South Africa is 30% - meaning that out of every 3 South Africans, 1 has a mental disorder.
It failed dismally to mention that this refers to life-long prevalence, which simply means that at some stage in our life time, 30% of us are likely to experience some form or the other of mental disturbance that may require professional help.
You may go through bereavement which you cannot handle or some other traumatic event which may have been unexpected – like if you were a Brazillian this month.
The second disturbing issue in the article is that the newspaper states that in this 30% South Africans who it claims have mental disorder, 75% of them will not receive treatment from the health system.
The newspaper again failed to or neglected to mention that this which they claim is the results of their investigation, is actually a document adopted at the World Health Assembly in Geneva last year and it states amongst other things that “Health systems have not yet adequately responded to the burden of mental disorders; as a consequence the gap between the need for treatment and its provision is large all over the world.
Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low income and middle income countries; the corresponding range for high-income countries is also high between 35% and 50%.
In omitting these facts, the newspaper unfairly confuses many South Africans.
It is also mentioned in the said article that 48% of new mothers suffer from post-natal depression – that means that nearly one out of every two new mothers - that will be absolutely scary.
What we are aware of is that a study done in KwaZulu-Natal using a fairly small sample did make this finding of 48%. But another small study done in the Western Cape made a finding of 30% and not 48% and a third one done in Soweto arrived at a finding of 16%.
Hence why choose 48% of a small sample without telling the reader that this was actually contradicted by other studies and hence cannot be regarded as conclusive.
We do not have any national study of prevalence of post-natal depression that has been authenticated in our country.
Then comes what the newspaper calls a revelation that 43% of people suffering HIV have mental disorder.
Actually, this fact appears in my speech in the Summit of 2012. It is not a revelation done by some investigation.
But it needs perspective.
The 43% comes from a study published in 2008 and based on data collected in 2006/7 – it is important to mention this because the ART Programme roll-out was very weak then and people were starring at death in the eyes. They had to be mentally disturbed then.
We do not know the situation now that South Africa has an HIV/AIDS ART Programme which is 30% of the global total.
What is more disturbing is that the newspaper seems to suggest that the answers to all these problems lie in more psychiatric hospitals.
It blames us for not putting aside enough money to build these psychiatric hospitals, and belittles our budget on mental health.
I wish to mention other statistics mentioned in the newspaper Honourable Chairperson –
- The article claims on one page that we are spending only R5 billion of our R133 billion Budget on mental health. In another page it puts the figure at R9 billion.
Honourable Chairperson, while no budget can never be deemed enough, let me quote from a presentation made Dr Shekar Saxena in the Summit I have mentioned.
He projected a slide entitled “financing mental health from total health budgets”. The slide showed four bar graphs –
- the first one indicated that low income countries spend 0,53% of their health budget on mental health;
- the second one represents lower-middle income countries at 1,9% of their health budgets;
- the third one represents upper-middle income countries at 2,38% of their health budgets;
- the fourth one represents high-income countries at 5,10% of their budgets
I do not know where the newspaper got the figures of R5 billion or R9 billion from.
But if these very figures they quoted were correct, the figure of R5 billion puts us above the upper middle income countries and the figure of R9 billion puts us even above the high income countries.
The last issue I wish to point is that the newspaper seems to suggest that the answer lies in more psychiatric hospitals.
We are being castigated first for spending less money and secondly having fewer psychiatric facilities.
Honourable Chairperson, this advice flies in the face of the WHO advice which we fully adopted at the Summit.
The WHO advice advocates for less institutionalization of psychiatric patients and more community management of mental health.
If it has to follow the logic of this newspaper, imagine the 43% of HIV positive patients which they are quoting. In South Africa it will mean about 2,5 million people having mental disorders because they are HIV positive and all the 2,5 million having to be locked in a psychiatric facility. Chairperson, if you have got massive mental problems due to HIV/AIDS, you do not solve that by putting up many psychiatric facilities. You solve that problem by dealing with HIV/AIDS, and that is exactly what we are doing.
Honourable Chairperson, the model we adopted at the Summit in 2012 is the one informed by the WHO and it is the one we shall follow.
I present to you the Health Budget for approval!
In conclusion, let me thank the Deputy Minister Dr Joe Phaahla for the sterling work we did together to prepare for this Budget Vote.
I also wish to thank the Director-General, Mme Precious Matsoso and her team for providing all the necessary support.
Lastly Honourable Chairperson, let me thank the Portfolio Committee on Health for a good working relationship, and we hope to be like this all the time.
I thank you