The Head of Department, Dr Sibongile Zungu
Professor CC Jinabhai
Acting Chief Financial Officer, Mr Ndoda Biyela
Senior general managers
District managers
Hospital chief executive officers
Medical managers
Chief financial officers
Community healthcare centres managers
Committed healthcare workers
Ladies and gentlemen
The public health system is also forced to carry the ever increasing burden of diseases, obviously made worse by poverty, HIV and AIDS, and other communicable diseases. However, let me accept and acknowledge upfront that some of the following factors contributing in no small measure to the problems the health system is carrying, that have also been confirmed by my visit to 17 hospitals, one community healthcare centre and two clinics since I was tasked to be MEC for Health are:
* lack of managerial skills within health institutions
* failure to cut on identified deficiencies
* delayed response to quality improvement requirements
* unsatisfactory maintenance and repair services
* poor technological management
* poor supply chain management
* inability of individuals to take responsibility for their actions
* poor disciplinary procedures and corruption
* significant problems in clinical areas related to training and poor attitude of staff
* inadequate staffing levels in all areas
* lack of financial management in institutions.
We are going to be facing all these issues head on and we will do so without fear and favour. We owe it to our country that these issues be tackled head on. The millennium development goals (MDGs) provide an international framework for measuring progress towards sustained development and elimination of poverty. Additional benchmarks were also agreed upon in 1999 at the 21st Special Session of the United Nations General Assembly for an overall review and appraisal of the implementation of the programme of action of the International Conference on Population and Development, for example: by 2015, the proportion of births assisted by skilled attendants should reach 90 percent globally and at least 60 percent in countries with high rates of maternal deaths.
We are also determined to reverse the situation and work towards the health MDG targets:
* halving the infant, child and maternal mortality rates by 2014
* ensuring effective implementation of the comprehensive plan for fighting HIV and AIDS and associated infections
* increasing the availability of anti-retroviral treatment to 80 percent by 2014
*. reduction of new HIV infections by 50 percent by 2014
*. tuberculosis (TB) cure rate of 85 percent by 2014 and
*. reducing new levels of TB by 50 percent by 2014.
Some of the issues I have mentioned as contributing factors to the problems the health system is facing are quite critical and will be dealt with urgently. Our programme of action the 10 point plan speaks to the MDGs. It has been designed to deal with the issues systematically, and in a sustainable manner. Our 2009/10 to 2009/14 will allocate resources for the ten priorities in line with the programme of action.
I intend to highlight the priorities and programmes that will attest to the commitment to improving the lives of the people of KwaZulu-Natal. At the same time critical questions will be raised about the strategies pursued, and whether there is a need, in some cases to review our approach. My address today has the 10 point plan in health (the program of government) as a point of departure.
1. Provision of strategic leadership and the creation of social compact for better health outcomes
2. Implementation of the national health insurance
3. Improving the quality of health services
4. Overhauling the healthcare system and improve its management
5. Improved human resource planning, development and management
6. Revitalisation of infrastructure
7. Accelerated implementation of the HIV and AIDS and sexually transmitted infections (STIs) national strategic plan 2007 to 2011 and increased focus on TB and other communicable diseases
8. Mass mobilisation for better health for the population
9. Review of drug policy
10. Strength research and development.
Providing strategic leadership and the creating social compact
When our organisation, the African National Congress, and government rallied our people behind the clarion call of “working together, we can do more”, we committed ourselves to exercising leadership and mobilising our people to attain better health outcomes.
Better leadership and management are critical to achieving the MDGs: they are required to demonstrate better results from existing resources and these results, in turn, make it more feasible for additional resources to be made available to health. We could call this the “virtuous circle of leadership and management strengthening”.
Reference has been made and will be made in this budget speech to the state of the nation address by his Excellency honourable Jacob Zuma. He has provided that strategic leadership on Health service delivery in our country. Some of the issues I will raise in this speech have been identified by Minister of Health, Dr Aaron Motsoaledi that is strategic leadership.
I could not have been more fortunate, to have a Premier who has such great depth of understanding of Health issues. In the ANC-National Executive Committee (NEC) he is the leader at Health and Education Committee. This 10 point plan which has been developed post Polokwane conference has been championed by the committee that honourable Premier chairs. I am expected to provide strategic leadership to my head of department, my managers, they too must do the same to the entire department.
A lot has been said about the quality and calibre of our managers at hospital and clinic levels publicly and privately. Our department has got good managers and they need to be commended and encouraged to continue to do good. We also have inefficient managers. We need to identify these and put a program to deal with the shortcomings that they have. At present, the poor leadership and management capacity is a constraint, especially at operational levels of the public health sector.
This is sobering, considering the time and money spent by this government to strengthen capacity in leadership and management. Thus it is clear that efforts have to be improved. The competencies, roles and responsibilities should be clearly defined and performance changes measured. Progress requires systematic work to determine needs and identify effective interventions, institutions to implement an overall plan for developing leadership and management capacity, and international assistance to be coherent in support of our plans.
By December this year, the department would have developed and adopted annual integrated health plan to ensure unified actions across the health sector in pursuit of stated goals. At the same timeline, we would have developed a social compact for better health outcomes following consultative health forums to be convened to adopt a social compact. We will also outline our programme that ensures that we contribute meaningfully to and continue to gain from work with and in the Southern African Development Community (SADC), Africa and the global community.
Implementation of a national health insurance (NHI)
Health systems will not automatically gravitate towards greater efficiency or greater equity in access. Unless deliberate steps are taken, steady advances in medical care will continue to benefit the privileged few. The poor will continue to be excluded from basic essential care. And the gaps in outcomes will grow wider.
This is not a healthy situation in the broadest sense. A world that is greatly out of balance in matters of health is neither stable nor secure. I was invited by our Minister of Health to his budget speech to National Council of Provinces (NCOP) and I must say it was heart warming to hear the Inkata Freedom Party (IFP) supporting NHI but quite disturbing for MEC for Health in Western Cape not accepting NHI.
The present system of healthcare financing can no longer be allowed to go on, because it is simply unsustainable. No way can we perpetuate a system whereby we spend 8.5 percent of the gross domestic product (GDP) whereas five percent caters for 14 percent of the population or seven million people, on the remaining 3.5 percent cater for a whopping 84 percent of the population or 41 million people. Nowhere in the civilised world can you find that state of affairs. The debate on NHI will be transparent and robust and will include all South Africans.
Overhauling the healthcare system and improve its management
In this regard, our department will finalise delegations for all managers at all levels of the public health system, with special attention on hospital chief executive officers (CEOs) to ensure decentralisation of management. We will also develop an accountability framework for the public and private sectors. Lastly, we will endeavour to enrol CEOs on to the Hospital Management Training programme on an annual basis.
However, this requires that we evaluate all CEOs of hospitals to ensure that they meet minimum requirements for effective management of the said facilities, and institute corrective measures where indicated, including retraining and/or deployment.
The need for sound financial management exists both in the systemic factors and the fiscal realities of the department. In the coming year the department will strongly assert its responsibilities, define and shape the trajectory of financial management through the building of strong and efficient capacity in financial management. This approach will focus on the need for organisational strengthening and effective expenditure management.
We will draft proposals for legal reforms to unify the public health service. We shall also develop a decentralised operational model including new governance arrangements. All health systems have room for improvement. All health systems have inefficiencies. In fact, some even have built-in incentives that encourage inefficiency. As famously stated, if we really want to, we can easily duplicate the huge waste and inefficiency seen in health systems that were not organised with equity and fairness as guiding values. In further overhauling the health system, we will evaluate and strengthen the district health system and primary healthcare.
Improved human resource planning, development and management
The following will be the areas of focus:
* review and refine human resources plan for health
* review all policies, legislation, regulations, and directives that lead to the closure of nursing schools and colleges
* draft plans and allocate resources for the addition of new nursing schools and colleges in the 2010 academic year
* develop norms and standards for human resource for all levels of the health system.
* finalise plans for the creation of auxiliary personnel, including a frame work for task shifting, for all categories of health professionals
* expand, within our available resources, the scope and numbers of community health workers.
Improving the quality of the health services
The core function of the Department of Health is to provide quality healthcare services to the people of KwaZulu-Natal. Quality of care has a number of key components. It encompasses effectiveness, efficiency, access, safety, equity, appropriateness, timeliness, acceptability, patient responsiveness or patient-centeredness, satisfaction, health improvement and continuity of care, Batho pele.
Quality of care is evidenced through compassion, empathy, respect for human dignity and a general orientation towards a human rights culture. Quality of care is also evidenced through a staff complement that has correct professional skills and professional competency; that is effective healthcare which meets the healthcare needs of the people and achieves good health outcomes. And finally, quality of care encompasses the desirable attributes of the settings in which care is provided.
I know that there are many healthcare workers who perform their duties with skill, dedication and compassion in challenging circumstances. For this; they have to be commended. I also recognise the depth of problems that undermine quality of care. In some instances resources are a factor, and so is poor or ineffective management. But these constraints cannot excuse fraud, abuse or negligence, I would be failing in my responsibility if I did not scrutinise the conduct of all health workers with an aim of inculcating a culture that embraces and subscribes to quality of care.
The question that we need to answer, moving forward, is this: how can the citizens of KwaZulu-Natal be assured that they will receive high quality care if they need healthcare in their communities? We know we have policies in place for the delivery of quality of healthcare, however we now must check if these policies are implemented correctly across healthcare delivery and if not, why not.
Secondly, we must also ensure quality across care, this is across all programmes. We should not have a situation where one programme and/or institution performs better than others. All patients ought to be reassured that the key elements of a high quality system are in place and the importance of continuity of care is therefore in line with the appropriate package of services at all levels of care.
We are therefore embarking on a three pronged approach within our health institutions. During the current financial year one hospital per district will be targeted for a full scale turnaround strategy from the frontline to the administrative management. Firstly, this will involve the identification and analysis of bottlenecks associated with service delivery, secondly the department will institute measures to increase the effectiveness of the management at hospitals and clinics, and to upgrade professional skills and practice.
And thirdly, we will scrutinise the use of existing procedures and systems with the aim of combating fraud, patient abuse and professional negligence. We will also refine and scale up the detailed plan on the improvement of services, including infection prevention and control plans, and direct its immediate implementation. I need to pause here and indicate that through consultation and observation, the 11 following hospitals have been identified for the pioneering of this programme:
* Benedictine Hospital, Zululand district
* Hlabisa Hospital, uMkhanyakude district
* Grey's Hospital, uMgungundlovu district
* Madadeni Hospital, Amajuba district
11
* CMJ Hospital, Umzinyathi district
* Prince Mshiyeni Hospital, eThekwini district
* Ladysmith Provincial Hospital, uThukela district
* Stanger hospital, iLembe district
* Port Shepstone Hospital, Ugu district
* Christ the King Hospital, Sisonke district
* Ngwelezane Hospital, Uthungulu district
Of the hospitals that I have visited, I have noticed some of the areas we will be looking for:
* caring security at the gate
* clean hospital premises
* caring professionals
* managing the queues professionally
* on time treatment and explanation.
* revitalisation of health infrastructure.
The hospital that seems to do most of these is Greytown and they too had an unannounced visit from MEC.
Revitalisation of health infrastructure
I will now turn to the matter of hospital revitalisation. Infrastructures are, according to the World Health Organisation, “the basic services or social capital of a country, or part of it, which make economic and social activities possible”. In public health, they are the formal and enduring structures that support public health, having both tangible and intangible aspects and existing inside and outside the government sector.
They may be directly protective of health as in sanitation systems or they may support other activities that protect and enhance health. There is an urgent need to arrest the deterioration of our hospital stock in order to “protect and enhance health”. However, there is little to be gained from the physical rehabilitation of the buildings without paying equal attention to the quality of care that I have been discussing, and also to more effective management of resources in general.
Through the Hospital Revitalisation programme we aim to address all three concerns in an integrated and coordinated fashion. Additionally, in alignment with the pronouncements of our honourable Premier the opportunities afforded by public private partnerships will be explored and leveraged to the benefit of the citizens of our province.
We are mindful of the call by the African National Congress’ 52nd Polokwane Conference resolution in this regard. We must seek new approaches and partnerships for delivery of healthcare by engaging all healthcare providers. Private public partnerships (PPPs) help ensure that healthcare delivery is in line with standards for quality care, this benefits all; the health providers, the patient, and ultimately, the public health of the entire population.
Allow me to report that a health infrastructure plan that incorporates PPPs and that is also modelled on the 2010 infrastructure delivery programme is currently being developed. We also want to urgently implement refurbishment and preventative maintenance of all health facilities. We also need to strengthen capacity to deliver and maintain health infrastructure for primary and secondary health facilities. I know that we already have a health technology plan and strategy, but we require funds to go ahead and implement it.
7. Accelerated implementation of HIV and AIDS and sexually transmitted infections national strategic plan 2007 to 2011, an increased focus on tuberculosis and other communicable diseases
The President’s state of the nation address states: “We must work together in the implementation of the comprehensive plan for the treatment, management and care of HIV and AIDS so as to reduce the rate of new HIV infections by 50 percent in the year 2011. We want to reach 80 percent of those in need of antiretroviral treatment by 2011”.
This year, on 9 June, the Human Sciences Research Council, together with its partners, the Medical Research Council, Centre for AIDS Development, Research and Evaluation and the National Institute of Communicable Diseases published a report on HIV based on interviews and testing of a random sample of the population in South Africa during 2008. The survey included people of all races, age groups, rural and urban and all provinces. The researchers concluded that:
* The epidemic is stabilising at 1 percent between 2002 and 2008
* HIV prevalence at national level decreased by nearly half among children aged two to 14 years, between 2002 and 2008
* HIV prevalence decreased slightly among youth aged 15 to 24 from 2005 to 2008
* Encouragingly there was a substantial decrease in new HIV infections in 2008, in comparison to 2002 and 2005, especially for the single age groups 15, 16, 17, 18, and 19
* What was most encouraging was the change in behaviour among South Africans. More South Africans for all age groups protected themselves against HIV infections by using condoms. More than 95 percent know where to access condoms and use has increased
* Furthermore, half of South Africans now know their HIV status, which means that the message on “know your status campaign” is being heeded
* The researchers also reported that there has been an increase in exposure to one or more HIV and AIDS communication programmes from 2005 to 2008 with 90.2 percent of youth aged 15 to 24 years being reached, followed by adults 83.6 percent of 25 to 49 years and 62.2 percent of adults 50 years and older
* However, despite these successes, there is still some unevenness in infections as well as behaviour change:
HIV prevalence is still highest in KwaZulu-Natal (15.8 percent) and Mpumalanga (15.4 percent).
It is also still highest among young women, aged 25 to 29 years, where a third of the women are HIV positive.
We take note of the recommendations made by the researchers, especially that we need to introduce targeted interventions in some provinces with high HIV prevalence. We will work in 2009/10 to ensure that 80 percent of HIV exposed infants receive ARVs for prevention of mother to child transmission (PMTCT) (based on dual therapy). This figure will increase to 95 percent over the two years of the Medium Term Strategic Framework (MTEF) 2010/11 and 2011/12.
The proportion of pregnant women who are tested for HIV will be increased from 80 percent in 2009/10 to 95 percent in 2010/11 and 2011/12. To strengthen the prevention of mother to child transmission of HIV, 80 percent of pregnant women who are eligible will be placed on ARV prophylaxis based on dual therapy in 2009/10.
This figure will increase to 95 percent in the outer two years of the MTEF period. 30 percent of eligible pregnant women will be placed on Highly Affective Antiretroviral Therapy (HAART) in 2009/10. This service will be expanded to cover 50% of pregnant women in 2010/11 and 75 percent in 2011/12. South Africans and men in particular, will be encouraged to do voluntary counselling and testing (VCT). In line with the result of the research by the Human Science Research Council (HSRC) and others, we would focus on these among other challenges
* infant mortality rate
* under 5 yr mortality rate
* maternal mortality rate
* tuberculosis
* HIV and AIDS
HIV and tuberculosis (TB) continue to be major challenges of our time. The TB crisis management plan has focused on four districts, namely eThekwini, UMgungundlovu, UThungulu and Umzinyathi, due to their high TB caseload and the existence of multiple drug resistant (MDR) and extensive drug resistant (XDR) TB within these districts. During the last year the department also registered meaningful advances in relation to TB treatment and care.
* TB case findings have been strengthened with 565/577 (98 percent) of
Primary healthcare clinics implementing the TB suspect register.
* Case retention of patients has been improved through the patient tracking System from 52 percent of TB reporting stations to 85.5 percent
* The TB Point of Service Counselling programme on disease information and treatment adherence has increased from 20 percent to 50 percent
* The TB Free DOTS project is being expanded from UMgungundlovu district to eThekwini, UThungulu and Umzinyathi
* The new smear positive pulmonary tuberculosis (PTB) cure rate is 54 percent compared to 45.2 percent in 2005, and the TB treatment interruption 7.2 percent compared to 9.2 percent in 2007/08.
Learning from previous lessons, we will spare no effort to mobilise all sectors in our communities to increase awareness about TB. We must work harder at getting the message across that this disease is treatable and curable and that treatment is free. We must also strengthen support for the frontline health workers who help people suffering from it, who play a vital role in supervising TB treatment in the community. An integrated programme involving inter departmental collaboration to create a Volunteer Corps of 4000 youth has been announced by the honourable Premier to spearhead such initiatives.
In the state of the province address our honourable Premier, Dr Zweli Mkhize, uKhabazela, had this to say about health: “We have directed that the MEC for Health leads military style interventions to reverse the rising tide of tuberculosis, treating ALL people known to have TB, ensuring strict adherence to treatment in an integrated approach”.
To this end, we have formed an inter-departmental task team of officials who will lead an integrated plan at community level working with communities to reverse the rate of infection of the twin epidemics of TB and HIV. TB can be cured even in the presence of HIV infection, but without strong management the combination has a devastating effect on patients. We have data down to the local ward level, indicating multiple deprivations of poverty, hunger and under-development which exacerbate the progression of TB to become multiple drug and extremely resistant forms. The campaign launched in July will cover areas of Nkandla (Qhudeni), Msinga (Ngome) and Inanda INK in eThekwini.
The campaign requires mobilization of grassroots cadres, community health workers, extension officers, community volunteers as well as local community leadership, supported by various government departments. That campaign will be launched in conjunction with the Food Security Campaign. For the success of this campaign, grassroots community mobilisation is essential to link food security, basic services and other forms of rural development.
This campaign will also be adapted for peri-urban settlements where extremely high levels of poverty co-exist with high levels of affluence. For the success of the campaign, primary healthcare has to be strengthened, especially health promotion and education, prevention and availability of medication. We invite communities and civil society at large to participate in these programmes to ensure their success”.
Mass mobilisation for better health for the population
These would be areas of focus:
* intensifying health promotion programmes
* strengthening programs focusing on disabled person
* intensifying implementation of program to attain the millennium development goals
* strengthening programs focusing on maternal, child and women’s health
* focusing on non-communicable disease, trauma’s, patient’s right and quality plus provide accountability
* embarking on the campaign called Siyafunda Sakha Isizwe Esinempilo.
As part of mobilisation for a better health for the population, we shall embark on a Phila MA project. With the assistance of former Minister of Health Dr Manto Tshabalala-Msimang, officials from KwaZulu-Natal Department of Health and Ethekwini municipality attended the third Stop Cervical Cancer Conference in Cape Town, 19 to 21 July 2009. Cervical cancer is the commonest cause cancer deaths among women in Africa. Cervical cancer is preventable by vaccination and curable by early screening.
With the pandemic of HIV in the Sub-Saharan countries, new cases of cervical cancer have emerged and have extended to young women, as young as 30 years old. On 11 August 2009 Department of Health in partnership with EThekwini municipality launched a Phila Ma project at Amaoti. We would like to say after few years, women in KwaZulu-Natal may die but cervical cancer is not going to be the cause of their death. We will be inviting President's Emergency Plan for AIDS Relief (PEPFAR) and other international agencies for support. This project linked with PMTCT program can actually identify women who participate both in VCT and cervical cancer screening.
Review of drug policy
The national Department of Health will be reviewing the drug policy and our department will welcome this review and will ensure that we actively participate in this review process so that the department can also find mutually beneficial solutions in the supply of drugs and the management thereof. This will include decision around establishing state owned pharmaceutical company. This may be another area of PPP.
Strengthen research and development
* Research to accurately quantify Infant mortality rate
* Research into the impact of social determinants of health and nutrition
* The national department has embarked on an initiative that will support research studies to promote indigenous knowledge system and the use of appropriate traditional medicines. Our department will actively participate in this initiative.
The department will improve our own systems for research in the province and will ensure that we allow for research that will enhance the delivery of healthcare both through conventional and traditional medicines. In all of this we will strive to ensure that the rights of our citizens are respected at all times.
Telemedicine and information technology
With the constant pressure to increase the quality of patient care and the desire to provide services, while at the same time controlling costs, healthcare providers are leveraging the power of telemedicine to link patients, specialists and clinicians, thus extending the reach of healthcare. The KwaZulu-Natal Department of Health has long been proactive in they development and establishment of telemedicine in South Africa.
There are on average 85 hours a month of video conference postgraduate teaching taking place from the Nelson R Mandela School of Medicine during the academic term. Teaching occurs in radiology, general surgery, obstetrics and gynaecology, paediatrics, paediatric surgery, genetic counselling and HIV management. The department will increase the bandwidth and connectivity in the rural areas and will develop an ongoing training programme for doctors and support staff in the correct use and maintenance of the telemedicine units.
I hope this serves as a guide to what we are aiming to achieve in this department, your support and involvement is critical.
I thank you
Issued by: Department of Health, KwaZulu-Natal Provincial Government
14 August 2009
Source: Department of Health, KwaZulu-Natal Provincial Government
(http://www.kznhealth.gov.za/)
