Budget Vote and Policy Statement delivered by Dr Zweli Mkhize, Minister of Health
Speaker of the National Assembly
Honourable Chair of the Portfolio Committee on Health and members of parliament My Colleague Deputy Minister of Health
MECS of Health
Heads of our Public Health Entities and Statutory Councils Deans of Faculties of Medical Sciences
Health professionals who have joined us today; Distinguished guests
Fellow Compatriots Ladies and gentlemen
Thank you for this opportunity to table the Health budget vote and policy statement for 2021/ 2022.
Our country is emerging from a tumultuous year of 2020, which has seen huge global devastation from COVID 19. In our country, this resulted in 1,6 million positive cases, 10,9 million tests done, 54 968 associated lives lost, though 95% of those affected have recovered. The COVID-19 positive cases have started to rise significantly and we may find ourselves in the third wave. Of concern has been the emergence of B.1.351 in our country and the importation of B1.617.2 variant from India and B.1.1.7 from the UK. We all have a responsibility to use the non-pharmaceutical interventions to protect ourselves and reduce the risk of infection.
Our country is set to begin phase 2 of the vaccination program on 17th May 2021 targeting 130 sites in the public sector to be active next week, focusing on the population aged 60 and above and vulnerable groups, using Johnson and Johnson and Pfizer vaccine; as vaccination of the remainder of health care workers is being concluded. Private sector sites will open later next week.
Over the medium term, the department’s most urgent focus is combatting the Coronavirus through our comprehensive local intervention programmes, for which R9 billion has been allocated. We continue to play our strategic roles as co-chair of the ACT-Accelerator and COVID-19 champion of the African Union, following HE President Cyril Ramaphosa’s outstanding leadership in his capacity as chair of the AU in 2020.
Globally, the lesson from the impact of COVID-19 has emphasized the necessity of investing in long term resilience and sustainability of health systems to enable us to better respond to future health emergencies and crises.
The COVID-19 pandemic caused significant health seeking deterrence and a various results have pointed to this challenge. The mandates set out in the Performance Agreement that I signed with the President for the Period of June 2019 to April 2024, indicate the need for innovation to close these service delivery gaps. Chief amongst these include the establishment of the NHI Fund, implementing the recommendations of the Health Market Inquiry Report, building human resource capacity, quality improvement, expansion of health infrastructure, risk management, uprooting corruption and ensuring clean governance as well as building partnerships through social compact.
Today I rise to table a budget of R62,5 billion for the Department of Health for 2021/22.
Allocations per Programme are as follows (000):
Programme 1: Administration
Programme 2: National Health Insurance
1 340 471
1 436 961
1 448 660
Programme 3: Communicable and Non-Communicable Diseases
32 605 402
30 674 180
27 756 632
Programme 4: Primary Health Care
Programme 5: Hospital Systems
21 372 304
22 439 906
23 064 751
Programme 6: Health Systems Governance and Human Resources
6 186 478
6 062 498
6 031 983
62 543 271
61 655 429
59 386 455
Health expenditure is expected to increase by 0,8% per year, from R58,1 billion in 2020/21 to R59,4 billion in 2023/24. An estimated 85,9 per cent (R157,7 billion) of the department’s budget over the MTEF period will be transferred to provinces through conditional grants, increasing by 0,3 per cent, from R52,1 billion in 2020/21 to R52,6 billion in 2023/24. To remain within the national aggregate expenditure ceiling, Cabinet has approved reductions on the department’s baseline amounting to R15 billion over the period ahead (R4,1 billion in 2021/22, R4,9 billion in 2022/23 and R5,1 billion in 2023/24).
Needless to state that the backlog, current and future needs for health services far exceed the current allocation of resources; and all indications point to chronic underfunding of this sector. Despite the challenging reductions to the budget, I believe we have stretched our resources through strengthened relations with multilateral organizations such as the UNAIDS and UNICEF and key investment partners, such as Global Fund, PEPFAR, the Clinton Health Access Initiative and the Solidarity Fund to ensure that health services in this country continue to advance. We appreciate this support.
National Health Insurance (NHI)
The implementation of the National Health Insurance remains one of governments main objectives. Following the introduction of the NHI Bill to Parliament in July 2019, the Portfolio Committee on Health convened public hearings in all provinces during the latter part of 2019. These public hearings provided a platform for ordinary South Africans to be heard and contribute toward the shaping of the NHI Bill. The Department of Health attended all the public hearings to process the feedback from community members on the details of the NHI Bill and took the opportunity to attend to service delivery issues that were raised by communities. The hearings were due to progress to Parliamentary submissions in 2020, however this was disrupted by the COVID-19 pandemic and are due to resume in the near future. In the MTEF period R7.5 billion has been allocated to the NHI unit, to strengthen the system and contract service providers. Dr Nicholas Crisp has been appointed as the Deputy Director General of NHI, bringing a wealth of experience and passion into the portfolio. Tremendous progress has been made in Health Patient Registration System (HPRS) with 57 million individuals registered in 3111 public health facilities. The NHI fund will be set up, as soon as the NHI Bill is passed.
We commit R20.6 billion in the MTEF, for health facility revitalization, to establish parity in the quality of public and private infrastructure through the Infrastructure Refurbishment Programme. From 2014 to Q3 of 2020/21, 10 hospitals have been completed or replaced and an additional 23 have been revitalized. A total of 151 CHC’s and clinics have been constructed and replaced and a total of 1232 facilities have been refurbished, renovated and rehabilitated. Of these, 116 facilities were maintained, repaired and/or refurbished during the 2020/21 financial year. The Health Facilities Revitalization Grant-Direct grant” (HFRG) and the National Health Insurance Indirect Grant: Health Facility Revitalization Component (also known as “In Kind”) grants have been the main financial contributors to these achievements, however we encourage public private partnerships to facilitate alternative infrastructure investment models.
Through the implementation of the Ideal Clinic Initiative, the MTSF 2024 target is to have 100% of Primary Health Care facilities maintaining their Ideal Clinic status. As at the end of December 2020, a total of 1 286 PHC facilities obtained ideal status, after conducting both peer reviews and updates. A revised Ideal Clinic Framework version is now being used which is aligned with Office of Health Standard Compliance measures developed for the Regulated Norms and Standards.
In June we will be piloting 16 Quality Learning Centres, defined as a cluster of health facilities at different levels of care servicing the same population. The pilot cluster will comprise 80 hospitals and 64 Primary Health Care facilities. After incorporating the learnings from the pilot phase, the programme will gradually expand until all facilities belong to a quality learning centre. R13,7 billion has been allocated for supporting tertiary health care services which are offered at tertiary and central hospitals to service patients from different provinces. The grant compensates the provinces that suffer inequality that results from this arrangement.
Human Resources for Health
During the 2020/ 21 financial year, a record 50 614 new posts were created, both health related and support personnel, to strengthen services in the public health sector. This significant recruitment was enabled by combining the COVID-19 earmarked budget for HR, funding from the Presidential Stimulus Package and from the Cuban Medical Brigade. This highlights the need to adopt a diversified approach for HRH going forward into NHI.
Despite disruptions to the academic year, 2 469 Medical Interns and 10 589 Community Service Personnel (including, amongst others, Medical Doctors, Nurses and Pharmacists) were placed last year. This was thanks to close collaboration between National and Provincial Department of Health officials and the Professional Councils to swiftly conclude the registration of the Medical Interns and Community Service Personnel and ensure timely remittance.
In response to COVID-19, the Department developed surge capacity guidelines for Human Resources and a Strategy to protect the health and safety of health workers in the occupational space. We salute all our health care workers for their dedication and hard work. You are the heroes that saved our nation!
A key development over the COVID-19 period was the deployment of community health workers for the community screening and testing campaign. This programme is now a seminal case study for all countries seeking to strengthen their primary health care systems. At the end of March 2021, a total of 47 630 CHWs received remuneration against the MTSF 2024 target of integrating 50 000 CHWs into the public health system. A Committee was established by the National Health Health Council to attend to the various issues around the conditions of service for CHWs. This work is still ongoing and the NHC is expected to finalize their recommendations and table these at the bargaining council.
Programmes for prevention and treatment of communicable and non-communicable disease
R82.6 billion has been allocated in the medium term to fund disease-specific programmes to prevent and treat communicable and non-communicable diseases.
HIV, TB, other communicable diseases of interest and non-communicable diseases remain great threats to overall public health in South Africa. Honourable members, I table the status of these pathologies in South Africa and our efforts to reclaim gains towards the control of these pandemics.
South Africa’s performance against the UNAIDS 90-90-90 strategy for control of the HIV pandemic is 93-70-88, meaning that as at the end of February 2021,
- 93 % of people living with HIV knew their status
- 70% of people living with HIV are on anti-retroviral treatment (ART)
- The estimated proportion of patients on ART that are virally suppressed at 12 months was 88% as of March 2021.
The public health management of HIV, as with all communicable diseases, focuses on early detection, early initiation of treatment and prevention of onward spread.
Despite a difficult year, a cumulative total of 14 685 210 HIV tests were performed during April 2020 to March 2021. The Department intensified community testing modalities to reach the untested and under-tested, including index testing in communities and facilities as well as HIV self-screening and self-testing.
As of February 2021, 5 069 398 people were on ART and in the last financial year 93.7% of antenatal HIV positive clients were initiated on ART against the 2024 MTSF target of 98%. To improve this indicator towards the 90:90:90 goal, the Department is scaling up and promoting same day initiations at every point of care including mobile clinics; intensifying the use of standard operating procedures for ART in communities (including initiation of PrEP and PEP where indicated); supporting data management in provinces; and strengthening the “Welcome Back” campaign to improve compliance and client retention.
We still promote the consistent use of condoms to prevent HIV, other STIs and unplanned pregnancies. The total number of male condoms distributed to date is 537 330 419 against a target of 850 000 000. The Department continues to explore all non-traditional platforms for condom distribution to ensure that anyone can access a condom.
The Department of Health commits to finding all persons living with active TB in our communities and to meeting the 90-90-90 targets for TB as outlined in the National Strategic Plan for HIV, TB and STIs 2017 – 2022.
Achieving this goal is ever more urgent as we noted a 50% reduction in the number of TB tests conducted during the COVID-19 period and a suboptimal TB success rate of 78,3%, against a target of 90%.
TB catch up plans have been developed in line with the recommendations of the National TB Prevalence Survey Reports and are implemented at district level, buttressed by the adoption of eHealth technologies, such as the TB self-screening mobile application that has been launched and will be available in all official languages.
The advantage we have is that we deployed Gene-Xpert tests with the mobile COVID-19 testing units. This allows us to integrate TB and COVID-19 community testing services and indeed this is being implemented.
To address the barriers to accessing health care, NDoH is developing a Social and Behavioral Change Communication strategy which aims to mitigate stigmatization and promote proactive health seeking behaviour. This will necessarily involve mobilising technical partners, civil society organizations and funding agencies.
To facilitate enhanced adherence to treatment, we intend to introduce new generation, shorter acting options such as Rifapentine and Isoniazid (3HP) and Rifampicin and Isoniazid (3RH), which are three-month treatments, as oppose to six months.
The number of malaria cases in South Africa has decreased by 32% (from 16 690 cases in 2019/2020 to 11 323 cases in 2020/21 financial years). Similarly, malaria deaths have decreased by 48.5% (from 103 deaths in 2019/2020 to 53 deaths in 2020/21 financial years.
We believe that our target of eliminating malaria in South Africa by 2023 is still attainable, but can only be achieved through a concerted cross-border effort by harmonising malaria polices, investing in thorough intervention coverage and by synchronising operations.
Non-Communicable Diseases (NCDs)
The MTSF 2024 target is to have 25 million people screened annually for high blood pressure and elevated blood glucose respectively. A total of 22 793 617 screenings for high blood pressure and 21 780 846 for blood glucose were conducted from April 2020 to February 2021.
In partnership with Astra Zeneca, the NDOH will be piloting a community level screening project- the National NCD Campaign (NNCDC). At an operational level the Ward Based Primary Health Care Outreach Teams (WBPHCOTs) will be deployed to find, screen and refer identified clients for further chronic care. The strategy is aligned with the principles of Operation Sukuma Sakhe and the District Development Model and is planned to commence in four (4) pilot districts in Kwa-Zulu Natal- that is Amajuba; uMzinyathi; uMgungundlovu, and uGu). This will subsequently be scaled up throughout the country based on the evaluation of outcomes. To date, we have received a donation of 10 000 BP monitors from Astra-Zeneca to kickstart this initiative and we have conveyed our appreciation of this donation in a public hand-over ceremony last year.
The Chronic Medicines Dispensing and Distribution (CCMDD) programme facilitates treatment adherence and saves clients valuable time. We are thrilled that this programme continues to gain strength, having registered 4 321 755 users this past financial year. This exceeds the annual target of 3 500 000.
Sexual & Reproductive Health Services
SRH services were not spared the impact of the COVID-19 pandemic and there was an overall decrease in clients accessing reproductive health services reflected by the Couple Year Protection Rate decreasing from 55% to 47.7% in the 2020/ 2021 financial year. We also recorded a drop of antenatal visits with 67,9% of pregnant women attending against the MTSF 2024 target of 75%.
In addition our ability to acquire contraceptives was severely impacted due to disruption in the global supply chain. A number of initiatives to address stock issues are currently underway including joint forecasting with suppliers, diversifying the products on tender, and training to support the increased usage of Long Acting Reversible Contraception methods.
We have disseminated the new Sexual Reproductive Health and Rights (SRHR) policy and supported capacity building through a new set of training frameworks and packages. In addition, the BWise website has been revamped to become an essential resource of information.
The protection of parents and unborn babies is a key investment into future prosperity- the Department remains committed to providing safe and compassionate sexual and reproductive services to our people.
South African peadiatrics continues to gain strength as seen in improved key health indicators as we indicated earlier. However, this specialty was also not spared the impact of COVID-19, as evidenced by decrease overall use of key child health services.
There was an overall decline in childhood vaccinations in 2020: immunisation coverage for infants (defined as children aged less than one year) was 78.5% in the months of April 2020 to March 2021, against the MTSF target of 90% by 2024.
The Department of Health is working in partnership with United Nations agencies, private health sector, non-government organisations and vaccine manufacturers to implement a catch-up drive for children who missed their vaccination schedule, even in years preceding lockdown. Demand generation strategies are also in place and implemented at all levels of health care.
The MTSF targets for under-5 indicators 2020 fell marginally short, threatening the major gains we have made in democratic South Africa. To address this the Department is implementing various strategies to improve health of children under 5 years including:
- Side-by-Side radio shows and social media campaigns to intensify communication of child health promotion and encourage demand for immunisation
- Early detection and referral of children with common childhood illnesses through improved use of the standard treatment guidelines and protocols;
- Strengthening of the implementation of standard inpatient paediatric register to improve data quality for data based response
- Collaborating with other departments and non-state players to address the socio- economics determinants that lead to poor health outcomes for children
We have appointed service providers to analyze the purported 100 million rand liability. Their analysis has reduced the contingency liabilities by 32 million rand and we believe that it could still be reduced further by conducting forensic audits into the claims; leveraging off the precedent set by the Gauteng High Court granting provision for treatment in public health facilities instead of monetary compensation; and concluding the ratification of the The State Liability Amendment Bill of 2018 towards ascension.
Collaboration with Cuba
As I approach the conclusion of this address, I wish to pay tribute to the Cuban Medical Brigade worldwide and reiterate the call to consider their brave contribution worthy of recognition through the awarding of the Nobel Peace Prize. When other countries were seeking to retain their resources, Cuba went all out to share their human resources for the good of all mankind- this is no small gesture of love and solidarity, advancing an agenda of peace and health security. We also commend the continued collaboration between Cuba and South African medicine, which has seen us graduate 1 841 doctors through the Nelson Mandela Fidel Castro Medical Training Programme to date, of which 669 graduated in the past financial year alone. Our collaboration also extends to knowledge sharing, tech transfer and health systems strengthening, particularly in the primary health care space.
I wish to close this address by inspiring confidence in our ability to build local manufacturing capability. The government has undertaken some key collaborative initiatives and investments to ensure that South Africa can independently meet its own biotech needs: these include attracting the BRICS Vaccine Research and Development Centre for location in South Africa, fully capacitating our regulatory bodies and investing into academic and innovation institutions such as Biovac.
We believe that we have the expertise, including the precision guidance of genomic surveillance, as well as the desired global partnerships to grow our biotech capabilities.
Africa must become an independent, capable and leading continent, able to protect its people through quintessential African innovation and resilience.
I wish to thank the Director General of Health, MEC’s of Health, Statutory Entities and all health officials across the spheres of government as well as the Portfolio Committee on health and social partners for your support.
Honourable Speaker, I submit and thank you.