My Cabinet colleagues
MECs from various provinces
Honourable Members of the House
Distinguished guests
Ladies and gentlemen
It is a great honour and privilege to present to the House the National Department of Health’s policy priorities and budget for the financial year 2011/12 for your consideration.
I am presenting this speech at a time when the healthcare system is at cross-roads. We may choose the best route or the worst one ever, which will of course worsen our situation even more than what it is. The choice lies with us as South Africans in general but as elected leaders in particular.
Last year, I signed a Performance Agreement with the President in what we call Negotiated Service Level Agreement (NSLA). According to this agreement, the health sector must provide four identifiable and measurable outputs with the ultimate objective of ensuring “A long and Healthy Life for South Africans.”
On top of these four identifiable outcomes which we have set ourselves to achieve we also have the 10 point programme which I presented to this House in 2009. This plan further guides us on how to go about achieving the outcomes.
Extensive studies commissioned by a prestigious medical journal the Lancet, these studies which were conducted by our own scientists and researchers in South Africa clearly revealed that South Africa is going through a quadruple burden of disease.
It is important for members to understand what these are and how the outcomes agreed with the President were determined.
a. The first, most severe and very expensive burden is that of HIV and AIDS and TB.
b. The second is unacceptably high and I emphasise, unacceptable high maternal and child mortality.
c. The third is an alarming and ever increasing incidence of Non-Communicable Diseases i.e. high blood pressure and other cardiovascular diseases; Diabetes Mellitus; chronic respiratory disease; the various cancers and mental health.
d. The fourth and last is violence and injury.
Having said so Honourable chairperson, it is a known fact that South Africa spends more money on health than any other country in the continent and even beyond. But our health outcomes are worse than in some of these countries. We know that this is due to the skewed healthcare resources, in favour of the rich.
Honourable chairperson, I will now go through the quadruple burden one by one because I want each member to understand fully what our country is faced with.
I. HIV and AIDS and TB
Honourable chairperson to summarise the problems of HIV and AIDS and TB in our country all I need to tell you is that we are only 0.7% of the world’s population but we are carrying 17% of the HIV and AIDS burden of the world. We have the highest TB infection rate per population and our TB and HIV co-infection rate is the highest in the world, at 73%. A total of 35% of child mortality and 43% of maternal mortality are attributable to HIV and AIDS. One in every three pregnant women presenting at our antenatal clinics is HIV positive.
Surely this needs very serious and extraordinary measures. Hence the announcement of the President on the World AIDS day in December 2009 has come as a big relief to those given the responsibility of fighting this illness. These measures, of starting ARVs when the CD4 count is 350 or less in pregnant women and HIV/TB co-infected people, of starting PMTCT at 14 rather than 28 weeks and of treating HIV positive newborns regardless of CD4 count has gone a long way in reversing the tide of HIV and AIDS. We started these measures in April 2010.
Honourable chairperson, before these new measures were implemented the scenario was as follows: as end of February 2010:
- Only 490 health centres were able to provide ARVs as accredited ART service points. I am very proud to announce that the figure has grown to 2205 health care centres providing ARV. This has increased access to treatment in a manner unimagined just over a year ago.
- Only 250 nurses were certified to provide ARVs. Once more I am proud to mention that now 2000 nurses are certified, further increasing access.
- Before the HCT campaign launched by the President on 25 April 2010 at Natalspruit Hospital, only 2 million South Africans were testing annually.
Honourable chairperson, I am once more very happy, to mention that since the launch of the campaign only a year ago already 12 million South Africans have tested and the figure is growing every month.
Many South Africans want to know their status. Hence on 12 June, we together with the House of Traditional Leaders and Congress of Traditional Leaders of South Africa (Contralesa) launched a massive HIV Counselling and Testing Campaign at village level.
The launch was at Mafefe village in Limpopo.
- Before the campaign as at end of February 2010, we had 923,000 people on ARV treatment and now due to the campaign and the increase in access made possible by the expansion programs mentioned above up to 1,4 million people are now on treatment.
- We have been able to reduce the prices of ARVs by 53% as we promised last year.
Honourable chairperson, I have time and again expressed my worry and regret at the number of newborns who are born HIV positive. It is a big strain on our emotions and the psyche of the nation and it causes untold problems with the healthcare system as I have mentioned earlier.
Honourable chairperson, I am once more extremely excited to inform you about PMTCT results released at the HIV conference in Durban by the MRC researchers. The results show that there has been a significant reduction of transmission of HIV and AIDS from mother to child measured at about 6 weeks post delivery. It reveals that a reduction of 50% transmission has been achieved. Of note is the significant reduction in KZN as a result of an effective PMTCT programme. This is to be celebrated because it is a first sign that by 2015 we may eliminate the phenomenon of mother to child transmission of HIV.
Honourable chairperson, on the 24 March 2011 World TB day, I announced our three-pronged strategy to deal with TB.
I. Firstly, we have acquired the new GeneXpert technology. This total revolution in the diagnosis of TB is the first ever breakthrough developed after more than 50 years of relying on microscopy and culture. Honourable chairperson, with the GeneXpert technology diagnosis of TB takes only two hours.
It used to take up to a week. Whilst the microscopy method served us well for the past 50 years, its sensitivity was only around 72%, meaning that 28% of people with TB could be misdiagnosed or missed. The sensitivity with GeneXpert is at 98% meaning that we may only miss two percent of the diagnosis. Moreso, it used to take us at least three months to know that a patient has multidrug resistant TB or XDR-TB. Now we are able to have this knowledge in only 2 hours.
II. The second strategy we have implemented is that of active case finding. We have put together a team of five people each, starting in February this year to trace TB contacts i.e. to visit families of patients on our database who are being treated for TB. There are 407,000 of such families in South Africa and all of them need to be screened for TB, in the light of our knowledge that every TB patient has the capacity to infect 15 others in his or her lifetime. Honourable chairperson, I am happy to announce that since we started these household visits in February this year, we have already visited 41,000 families and screened 112 000 people.
III. The third strategy against TB is that we have unveiled nine specially designed MDR hospitals using technology from the CSIR. These hospitals, at least one per province have been made possible by generous donation R100 million from the Global Fund. This design markedly reduces the chances of health care workers, particularly nurses, from being infected by their MDR-TB patients.
High maternal and child mortality
A lot has been said about the high maternal and child mortality in our country. You have noted Honourable members, that most of our interventions in HIV and AIDS are directed at pregnant women and children.
We will work hard to reduce the mortalities of these targeted groups. Remember that maternal mortality is not just death of a woman; it is death of a woman, because she dare fell pregnant! We know that even the mortality brought upon by HIV and AIDS is disproportionally affecting young women of childbearing age more than the men.
This can’t be right. It leaves the country with lots of orphans. We now have no less than 1,3 million orphans in our country. Mostly, these are maternal orphans. This type of situation cannot be allowed to go on in our country, it has much more negative societal consequences beyond health care i.e. crime; poor educational outcomes; teenage pregnancies and abortions total social disorientation of young husbands. It is a well known fact that young husbands lose direction in life if they lose their partners so early.
Female partners are known to have a stabilising influence on a young man’s life. South Africa is fast losing this social stability due to the high maternal mortality, which according to evidence at our disposal affects more the young women than the older ones.
Non-Communicable Diseases (NCDs)
Honourable chairperson, the issue of non-communicable diseases is very less spoken about in the public arena. It is also not very clearly understood even though it preceded HIV and AIDS by several decades. This is because HIV and AIDS came as such a shock to the world that many strong civil society groups were formed to deal with it.
In our country, we all know how strong civil society and NGOs dealing with HIV and AIDS are. This has put the issue on the public agenda more than on any other disease.
A few weeks ago, I tried to bring this issue of non-communicable diseases to the Health Portfolio Committee but unfortunately the media got excited because they thought I was specifically raising the issue of dietary behaviour of members of parliament. It is therefore very important for me to explain this matter clearly for parliament to understand.
Non-communicable diseases, referred to as NCDs are diseases that are not propagated by germs from one person to another. In fact, it is also safe to say that the germ that propagates NCDs is the human being!
I am saying so, because NCDs are not only biomedical, but they are largely diseases of life-style. These are divided roughly into four categories namely:
- High blood pressure and other diseases of the heart and blood vessels
- Diabetes mellitus and a few other metabolic disorders
- Chronic respiratory diseases and asthma
- The cancers
Added to these Honourable chairperson is the ever increasing incidence of mental ill health. These diseases are driven mainly by four identifiable risk factors viz:
- smoking
- harmful use of alcohol
- unhealthy eating behaviour (Diet)
- lack of physical exercise
Honourable chairperson, once the four risk factors and related unhealthy behaviours are removed, the world would be a much safer place to live in.
The question is, just how serious is this problem of non communicable diseases? Is it a global phenomenon or is it only in a few countries? Well the answer is it is a fast growing global phenomenon and becoming more devastating in Sub-Saharan Africa because it is adding on problems of communicable diseases or infectious diseases that have been plaguing Africa for centuries.
So serious is the issue of NCDs that the World Health Organisation (WHO) and the United Nations (UN) have called all Ministers of Health to Moscow on the 28 to 29 April 2011 in what was called the First Global Ministerial Conference on Healthy Lifestyles and Non-Communicable Disease Conference.
In summary, the Moscow Declaration addresses the following pertinent issues:
a. Countries must develop and rapidly implement policies that address behavioural, social, economic and environmental factors associated with NCDs
b. Effective NCD prevention and control require a concerted leadership and the whole of government at all levels (National, Sub-National and local) and across a number of sectors such as health, education, energy, agriculture, sports, transport and urban planning, environment, labour, trade and industry, finance and economic development.
It is with this background that a couple of weeks back I said that members of parliament should take the lead in this issue of healthy lifestyles, diet and exercise. Unfortunately, some excitement in the media was generated whereby it was thought that the whole issue is being debated because there is a “gravy train” in parliament. Please South Africans, this matter is serious for it to be turned into a circus.
Sometime in 2009 in this very parliament, members asked me a lot of questions about our policy on renal dialysis for people with kidney failure. A totally wrong debate was entered into i.e. why government does not increase and invest more on dialysis machines within public hospitals. It is said the private sector is superb because those who are failed by the state in terms of dialysis are always saved by the private sector. This is a wrong debate altogether.
It is no different from encouraging the state to put up more mortuaries because the demand for mortuaries is increasing. The intelligent question to ask is why so many people are having failing kidneys such that they need this dialysis. In the Gauteng province alone the total number of patients on chronic dialysis both haemodialysis and peritoneal dialysis is 561. Those on the waiting list for an opportunity to avail itself the total number is 238.
These figures are just for one comparatively well equipped province. What happens when one adds the other poorly resourced provinces? To put a single patient on dialysis costs R150, 000 per patient per annum in the public sector and about R300,000 in the private sector. Moreso, these patients have to be in hospital for 3 times a week for a minimum of 4hours a day, whether they are employed or not.
What causes this? We know that 40-60% of people with end stage renal failure is due to high blood pressure at an average age of 39 years. What is the main risk factor for high blood pressure? It is smoking, lack of exercise and high salt intake. So, instead of demanding more dialysis machines and subsequently demanding new kidneys to an extent where the rich are trying to concoct schemes to steal kidneys from the poor as it happened recently in our country, we must reduce the prevalence of hypertension by eliminating the risk factors.
The need for targeting tobacco and alcohol has already been outlined and no matter how many financially powerful people and institutions make noise about it. I can stake my life on it, we are going to fight with our bare knuckles to achieve this, particularly a ban on advertising of tobacco and alcohol. It is a point of no return and the sooner the tobacco and alcohol industry understand this, the better.
I am going to ask parliament and this house very soon, to process legislation to reduce the salt content of our foodstuffs. South African diet has been shown to be very high in salt. The desired amount of salt for your body is known to be four to six grams per day. But in our country it is up to 9,8 grams per day i.e. more than 2 times the physiologically required amount. More salt is already found in food rather than individuals adding it on the table.
Britain has taken a lead in this case, since 2006, they have agreed to reduce salt intake by 40% within five years. In South Africa, studies show that reducing salt intake just on bread only will save close to 6 500 lives per annum. In Britain studies show that just in the second year of reduction in salt intake by 10%, 6000 deaths were averted and a saving of 1,5 billion British Pounds was achieved.
Honourable chairperson, another issue which is extremely important, is excess body weight. It is also a fast growing phenomenon among school children. According to research findings, 23% of school children can be classified as either obese or overweight.
Honourable chairperson, this is fast approaching a quarter of the school going population. The consequences to both individual and society are devastating. In the general population the national income dynamic study shows that 60% of women and 31% of men are either obese or overweight.
If you consider women over 37 years the figure rises to a tremendous 70% classified as either overweight or obese. This is why the Moscow declaration is so important. Here in South Africa, I can assure you the ban on misleading adverts on unhealthy dietary products is on the cards. The so-called freedom of expression on adverts notwithstanding.
Other countries have begun to introduce measures to deal with the impeding obesity epidemic among young people. Australia for example, has come up with a policy of regulating advertising of junk food during children’s programme where there are specific bans on junk food adverts related to the peak period when children are watching TV. We will observe what other countries are doing and collect evidence to inform our policy.
Violence and injury
The last of the quadruple burden of disease Honourable chairperson that of violence and injury, a lot is known about it because it is spoken about daily as I have said. On the arrive alive campaign; the emphasis is always on the fatalities on our roads because this is very painful.
However, for the healthcare system I have to inform you that a study by UNISA in collaboration with the MRC shows that for every person killed by injury, 30 times as many are hospitalised and 300 times as many are treated for less serious injuries and discharged. It further states that depending on the cause, severity and circumstances of the injury, many of these results in varying degrees of physical, psychological, educational social and economic disadvantages for the affected individuals and families.
National Health Insurance (NHI)
Honourable chairperson, I am painfully aware that for some people in this country what I have said up to now amounts to nothing if I don’t say anything about NHI. There are two different groups of people in this case. Those who correctly and legitimately hope that NHI will bring relief in their everyday hardships as far as their health care is concerned. And they are of course very right. However, the other group eagerly waiting are those consumed by self interest and greed that will shame even the devil.
They are waiting for any development and vowed to do anything in their power to stop NHI dead in its tracks. To both groups, the legitimate expectation group and the greedy lot, I am appealing for their patience. We are working around the clock everyday around this issue of NHI. The problem is that many believe that NHI is just the release of a document.
For us in health, we know that it also involves an extensive preparation of the healthcare system while at the same time preparing a policy document. In this case Honourable chairperson the reengineering of the Health Care System is very vital. Under the present health care system whether public or private, no national health insurance can ever survive. I know that at face value problems in the health system are said to be existing only in the public sector and the private sector must be left alone to some wayward phenomena called market forces, even though these market forces dismally failed to stop or more appropriately caused the most recent global economic collapse. Logically it means not doing anything we are preparing for the collapse of the health care system.
While it is very true that the public healthcare system is bedevilled by very poor management leading to poor quality of care adding to the very low resources available in the public health sector, I wish to categorically state that the present overall health care system both public and private will be completely re-engineered. If I have to define the present healthcare system I will say it is characterised by four very clearly identified negatives:
- firstly, it is unsustainable
- secondly, it is very destructive
- thirdly, it is extremely costly
- fourth and last it is very hospicentric or curative in nature
For any intervention dealing with the cost of healthcare like the NHI to make any sense, a complete re-engineering is essential and it is an obligation placed upon our shoulders.
The re-engineering of the Health Care System will be according to three main streams.
I. The first stream will be a district based model. In this model a team of five specialist or clinicians shall be deployed in each district. These teams will specifically focus on maternal and child mortality. This will help us arrive at our Millennium Development Goals.
These teams will consist of:
- Principal obstetrician
- Principal paediatrician
- Principal Family Physician
- Advanced Midwife
- Senior Primary Care Nurse
In this case Honourable chairperson, I have consulted all the Deans of the 8 medical schools in our country, the Professional associations of paediatricians, Obstetricians, Family Physicians, the Colleges of Medicines of South Africa responsible for specialist training and the nursing fraternity at the recently held and successful nursing summit.
I am happy to announce that there is overwhelming support from the above mentioned stakeholders. It is my intention that by the end of this calendar year, we should be far ahead in implementing this initiative. The innovation in this initiative is the creation of posts at district level.
The posts have never existed before and are totally new in the public service. We are absolutely determined to make sure that this model is implemented. Once appointed, these teams will deal with guidelines and protocols at our Antenatal Care Clinics, Labour wards, Post natal Health Care and Paediatrics and Child Health Clinics. They will follow up on every case of mortality to make sure that mortality meeting are held for every single incident, to deal with the cause at hospital level immediately rather than waiting for research studies and results later.
The specialist teams will deal with training of interns, as well as community service doctors and medical officers. Additionally, they will focus on midwives and their practice in helping to bring down maternal mortality. They will also assist primary health care nurses on following up on patients in their communities, especially for post natal care. Overall there will be a link between prevention of disease and the management and cure of diseases.
II. The second stream of re-engineering PHC Honourable chairperson is a School Health programme which will be launched with the Ministers of Basic Education and Social Development. A task team has been established about 8 weeks ago and is working around the clock to deal with these issues. This stream of PHC will deal with basic health issue like eye care problems, dental problems, hearing problems, as well as immunisation programmes in our school.
It will move further on to deal with more complex problems like contraceptive health rights that will include issues such as teenage pregnancy and abortions, as well as HIV and AIDS programs among learners. Added to this will be interventions dealing with drugs and alcohol in school.
III. The last stream will be a ward based PHC model which will deploy at least 10 well trained PHC workers per ward. This method is being put to good use in Brazil where 30 000 of such people called Community Health Care Agents have been deployed to various communities. I was also highly encouraged when the Minister of Health in India announced during the Moscow gathering in April that in his country they are deploying 800 000 such cadres and they call them Health Care Activists.
Honourable chairperson, the reengineering of our PHC system into these three streams will consolidate PHC as our primary mode of healthcare delivery. It will encourage prevention of disease and promotion of health in contrast to the present obsession with treatment of individual disease when it is already too late for many individuals and at great cost to the fiscus and the GDP of our country. It is because of this hugely curative and costly health care system that some so-called experts believe NHI is an impossible dream.
Quality Improvement Plans
I have spoken a lot about the Office of Health Standards Compliance which will consist of three units namely: inspectorate, accreditation and the ombudsperson. I have spoken at length about it that I do not want to repeat anything here save to say the Bill is ready to be sent to Parliament for members to engage towards enactment of legislation through which the office will be established. This is work in progress- it needs no further details.
Health Workforce Development and Human Resource
Honourable chairperson, our Human Resource strategy in accordance with the 10 point programme will be completed by August this year.
We need to increase the number of Health Care Workers produced in our country. We cannot keep on producing 1 200 doctors per annum as we have done in the past decades. In this case a 2-pronged strategy is already in motion; the first one is a temporary measure where we have asked the Deans of our medical schools to find an innovative way of increasing the intake of medical students even under the current circumstances of restricted space they find themselves in.
At the beginning of this year, the University of the Witwatersrand (Wits) was able to work with us and consequently have accepted 40 extra students for first year training. This they have never done before and it happened because we worked hard together. Of course this needed additional funding and the department was very pleased to oblige. We are eagerly waiting for the other seven medical schools to produce similar plans for implementation next year.
You may remember Honourable chairperson that the President announced the establishment of a ninth medical school in Limpopo. Furthermore, an announcement was made about our intention to put up new infrastructure at four other tertiary hospital and their medical schools in addition to this development in Limpopo.
These are George Mukhari Hospital; Chris Hani Baragwanath Hospital; King Edward VIII in DBN and Nelson Mandela Academic Hospital in Mthatha. Our aim in this case is to increase the number of medical students produced in our country at least three fold. We are also doing this in preparation for NHI to ensure that there is a smooth referral to institution of high quality infrastructure and equipment. The announcement by the Minister of Higher education recently about the rebuilding and expansion of Medunsa as a standalone institution is part of this agenda.
Honourable Chairperson, we have had a very successful nursing summit in April this year which dealt with HR issues of nurses. The success of this summit can be seen in the compact that has been produced. To increase awareness for the members of the public with regard to the nursing compact we have published it on many newspapers on the day commemorating the “international day of nurses” last month.
The budget of the Health Sector 2011/12 to 2013/14 financial years
Honourable Chairperson, please allow me to now focus on the budget of the National Department of Health for the FY 2011/12. The budget of the department has grown by 15,3 % from 21,7 billion in 2010/11 to 25.7 billion n in 2011/12.
At national level an additional amount of R442 million was allocated for FY 2011/12 and R692 million for FY 2012/13 and R2,276 billion for FY 2013/14. This is mainly to improve quality, to strengthen PHC teams to upgrade and maintain nursing colleges, to improve maternal and child health, for universal coverage of HIV at 350-threshold.
Additional earmarked funding has been allocated at provincial level for preparatory work for the National Health Insurance which amounts to R16,1 billion over a three-year period. This will be mainly for registrar posts, specialist posts at district level, for family health teams and for helping hospitals comply with norms and standards.
Conclusion
In conclusion, Honourable chairperson - I wish to thank numerous people that I have worked with during the last year on their contribution towards overhauling the health system. Starting with the President of our country, the Deputy President who is also the Chairperson of the South African National AIDS Council (SANAC) and the Minister of Finance as well as the whole Cabinet have been extremely understanding and sympathetic to the issues the health system is facing and I wish to express my sincere gratitude.
This support was very evident when we had to raise and extra R3 billion to fund the new treatment protocols of HIV and AIDS. It is still evident in this budget as it has been increased by 15% to assist us to overhaul the healthcare system and to aid us to prepare for NHI.
My colleague the Deputy Minister of Health Honourable Dr Gwen Ramokgopa, we have complemented each other so much that one can only wish this will go on forever and ever. The MECs for Health through the National Health Council have ensured that the department’s policies are implemented by the provinces. I would also like to take this opportunity to express my gratitude to the Portfolio Committee on Health through its Chairperson Honourable Dr Goqwana.
The Director-General of Health Ms Precious Matsoso and her management team have held strong despite numerous and competing challenges. I need to thank them for standing strong and together for the sake of the health of the nation.
Honourable chairperson, I now wish to request this house to adopt the Department’s budget for the financial year 2011/12 amounting to R25 731 554 billion.
I thank you.
