Speech by Minister Manto Tshabalala-Msimang at the 2008 National Consultative Health Forum which commemorates the 30th anniversary of the signing of the Alma Ata Declaration on primary healthcare, Boksburg

Programme director
Minister of Health of Mozambique
And delegation from Southern African Development Community (SADC) member-states
Provincial MECs for health
Representatives from United Nations (UN) agencies in particular World Health Organisation (WHO) country representative, Dr Stella Anyangwe
Honoured international guests and speakers from Tanzania, Ghana and Brazil
Local government councillors present
Members of provincial consultative health fora
Experts, academics and researchers
Senior officials from the Department of Health and other government departments
Representatives of the NGOs and civil society
Member of the media
Distinguished guests
Ladies and gentlemen

Before I make my input this morning, it is important that I request all of us to take a moment and remember one of our gallant soldiers and an outstanding leader of our struggle for freedom, Chris Hani, who was assassinated on this day 15 years ago. I am certain that comrade Chris would have indeed been proud of the efforts that have been made to improve access to health for people of our Country.

Let us also use this moment to remember our colleague, Ivan Toms who contributed significantly to the progress we have made in the area of Primary Healthcare, that we are gathered here to review. I would like to request you to stand for a moment of silence to remember these two South Africans.

Programme director; let me from the outset warmly welcome Prof Garido, the Minister of Health from Mozambique. It is indeed an honour to have him present at this meeting. I also would like to welcome the delegations from SADC, particularly the delegation from Namibia led by the Director-General. Let me also welcome Dr Stella Anyangwe, the WHO representative in South Africa.

The presence of these delegations clearly demonstrates the importance that the SADC countries place on primary Healthcare and our determination to work together as a region. We are also pleased to have speakers from Tanzania, Ghana and Brazil. Again, we can see the importance of strengthening the African Union (AU) and South-South co-operation which I am committed to also as the chair of the AU Bureau of African Health Ministers.

Programme director, it is indeed a great honour for me to be part of this collective to share ideas and chart the way forward on how best to deliver accessible, affordable good quality Healthcare services with a view to improve the quality of lives of our people.

As we all know, September this year marks exactly 30 years since we adopted the Alma Ata Declaration. As part of honouring that moment in history, we took a decision to dedicate this annual National Consultative Health Forum to the subject of primary Healthcare. Our purpose is to take stock of the progress we have made in the implementation of Primary Healthcare (PHC) principles in line with the 1978 Alma Ata Declaration and to explore how we can accelerate progress in this regard.

Primary healthcare approach is central to our efforts in attaining the Millennium Development Goals and that our recommendations on how to strengthen primary Healthcare should also help us achieve the Millennium Development Goals (MDGs) by 2015. Obviously, we are not alone in doing this. A number of national and regional meetings have already taken place, for example in Argentina last year and in January in Thailand. As we deliberate over the next two days, we should also be mindful of the fact that we are also preparing for our participation in the World Health Organisation Regional Office for Africa (WHO-AFRO) conference on primary Healthcare in Ougadougou in Burkina Faso at the end of the month.

Programme director, ladies and gentlemen, allow me to provide just a brief historical background to this occasion. As we all know, it was in 1978 in the former Soviet Union town of Alma Ata when various role players in the health sector met to work out the most appropriate way of delivering healthcare services to the billions of people around the globe to achieve health for all by the year 2000. Amongst the key concerns was the provision of healthcare in an equitable manner as well as in a manner that takes seriously the social determinants of health.

One of the most important outcomes of this 1978 meeting was a decision to place particular emphasis on primary healthcare as a way of delivering health services to people of the world, particularly those living in poverty the majority of whom are in the developing countries such as ours. Sadly, the vision of 1978 was short-lived as the multilateral organisations as well as development partners moved away from an integrated comprehensive approach to what has become known as selective healthcare, which is a focus on single disease depending on the priorities on the donor. Donors argued that this approach made more sense as it was easier to monitor and see results than in a comprehensive approach.

Ten years after the adoption of the Alma Ata Declaration, at an International Meeting on Primary Healthcare held in Almaty, Kazakhstan (same city with the changed name) delegates to the meeting appeared to see the light when they recognised the historical importance of the 1978 declaration. To quote the then Director-General of WHO, Dr Gro Harlem Brundtland: "Health for All is a message for all stakeholders. Considering the forces shaping the world, with both progress in health and growing inequalities, there is a place for ‘a new universalism' in health: with universal access to quality care as the bedrock principle. Commitment to primary healthcare, still a crucial part of the health sector twenty years after Alma Ata, reduces disparity between the outcomes of poor and those better off, anchored in equity and solidarity."

However, despite this apparent acknowledgement of the importance of equity, universalism and solidarity not much happened in practice. Our assessment is that the proliferation of global health initiatives for all the good that they are doing, have in fact contributed to the strengthening of vertical programming and development of health systems that cannot deliver comprehensive health services. In addition, it must be acknowledged that not all the promises of the international community to assist developing countries have been fulfilled. It is still true today for example that a cow in the European Union (EU) enjoys a higher subsidy than the incomes of more than half the world's population at $2.20 a day!

30 years later, we have now gone full circle. The world appears to have recognised anew the importance of health systems even in the context of responses to major diseases affecting us. The establishment and the work of the Commission on the social determinants of health is just one example. The Paris declaration which has insisted that development partners work with the developing world to determine priorities and implement programmes collaboratively should, if implemented correctly, have the effect of reversing some of the losses of the past decades.

We should ensure that this does not just become mere rhetoric, but translate to tangible efforts to implement primary Healthcare using the principles adopted at Alma Ata. Coming back to our country, between 1978 and 1994 South Africa expanded little effort on trying to implement the principles of Alma Ata. In fact, the health system that we inherited in 1994 was described by many as hospicentric almost the opposite of what Alma Ata tried to achieve. Social conditions under which our people were forced to live contributed to ill-health of many kinds. This includes limited access to basic services such as water and sanitation, housing and education. It is important that we document, even if briefly, the major policy shifts that took place since 1994 and that we honestly review their implementation.

The White Paper for the Transformation of the National Health System which has as its foundation in the ANC's National Health Plan, set out very clearly how we intended to transform the health system. The preface of this document reads and I quote: "We have set ourselves the task of developing a unified health system capable of delivering quality Healthcare to all our citizens efficiently and in a caring environment. The strategic approach guiding us in this endeavour is that of Comprehensive Primary HealthCare".

The White Paper described the district health system which is the vehicle for the provision of primary healthcare as follows:
"The country will be divided into geographically coherent, functional health districts. In each health district, a team will be responsible for the planning and management of all local health services for a defined population. The team will arrange for the delivery of a comprehensive package of PHC and district hospital services (and that PHC services will be provided by a primary healthcare team which) should include community health nurses, midwives, doctors, primary healthcare nurses, enrolled nurses, nursing auxiliaries, oral hygienists/therapists, clerical and support staff and rehabilitation personnel".

In addition, the White Paper envisaged that there will be strong community participation at district level. It is clear therefore that the post 1994 policies have a strong primary healthcare thrust to them. In addition, more than five years ago government took a decision to cluster departments to facilitate greater intersectoral collaboration at both national and provincial levels.
For example, together with the Minister of Social Development, we have been responsible for chairing the Social Cluster of Ministers and the respective Directors-General of Health and Social Development did the same with respect the Social Cluster of Director Generals. At local government level the integrated development planning process was initiated to ensure intersectoral collaboration.

Programme director, we are proud to declare that we have witnessed many successes since 1994. These include the following:
(1) We have established 52 health districts with district management teams and district health plans linked to Integrated Development Plans (IDPs) in most of them.
(2) We have improved access to primary healthcare services as evidenced by the significant increase in headcounts from 67 million in 1998/99 to 101 million in 2006/07 with the PHC utilisation rate increasing to 2.5 visits per person per year. These outcomes are a consequence of building more 1 600 clinics, improving the package of care available at clinics and removing user fees.
(3) We have decreased the inequities in funding amongst health districts. The ratio between the highest and lowest per capita expenditure per district has improved from 9.3 in 2001/02 to 3.3 in 2006/07
(4) Our immunisation coverage stands at 85%
(5) In 2005 for instance the average number of new cases of diarrhoea per one thousand children under five dropped by more than half from 258 in 2005 down to 119 in 2006

This progress is related to another set of statistic that I wish to provide this morning. According to the 2007 Statistics South Africa Community Survey, we have improved access to water, sanitation and electricity.
* Over 70% of households live in formal dwellings, increasing from 64.4% in 1996
* The percentage of households where refuse is removed by a local authority at least once a week increased from 51.2% in 1996 to 60.1% in 2007.
* There has been a decline in the percentage of households having to use the bucket toilet system, from 4.1% in 2001 to 2.2% in 2007. And indeed efforts are underway to eradicate this derogatory sanitation system.
* Use of electricity as the main energy source for lighting increased substantially from 57.6% in 1996 to 80.0% in 2007.
* The percentage of households with access to piped water increased from 84.5% in 2001 to 88.6% in 2007.

While celebrating this significant progress, we acknowledge the major challenges ahead of us. Although we are making progress as a country, we need to increase our efforts towards the attainment of the Millennium Development Goals by 2015.
The areas of maternal and child health show much promise although additional efforts are needed to maximise impact on maternal, newborn and child mortality. Earlier this year, we launched three committees of experts to monitor maternal, perinatal and child health. They are expected to report and make recommendations on further action need to reduce avoidable deaths. We have to support the work of these committees and collaborate with them should the need arise.

As we await their first report, I urge all health professionals to ensure that protocols and guidelines are followed and that we take individual and collective responsibility to ensure that we do indeed reduce maternal and child mortality as quickly as possible, by for example doing audit facilities and intervening immediately where there is a necessity.

In the spirit of African solidarity and in my capacity as Chair of the African Union Bureau of Health Ministers, South Africa will, next week, host health professionals from the continent in a workshop that will develop tools to measure and monitor maternal, newborn and child mortality. For instance, no country other than United Kingdom and South Africa has a confidential system of enquiry into maternal deaths. We are hoping that this workshop will both provide a tool and encourage other countries in Africa to establish processes to reduce newborn, child and maternal deaths.

There are some promising signs with respect to both HIV and tuberculosis (TB). As you may know the 2006 antenatal survey showed for the first time a decline in HIV prevalence particularly amongst the youth. Pregnant women under the age of 20 years continue to show a significant decline from 16.1% in 2004 to 13.7% in 2006. These declines are likely to be the result of the country's sustained prevention and health promotion interventions.

Likewise, there are some indications that we are beginning to turn the corner with respect to TB. Our cure rates are improving annually and our defaulter rates are declining. The national cure rate increased from 54.9% during the first six months of 2005 to 62.9% during the same period in 2006. The same trend can be seen with the percentage of TB patients who have successfully completed their treatment. For the first six months of 2005, the successful completion rate was 68.3%. This increased to 73.6% in the first six months of 2006.

Similarly the defaulter rates have also decreased. Our latest data suggests that the national defaulter rate is 8.8% for the first two quarters of 2006 down from 9.7% for the same period in 2005. We are determined as the department to meet the target of 7% defaulter rate set by our President during this year's State of the Nation Address.

Programme director, human resource planning and development remain central to our ability to deliver adequate and quality healthcare to our people. The development and launch of Human Resources Plan for Health has been a very significant step in establishing a framework for addressing the many challenges facing us on this front. We are determined to ensure that as a country we train the numbers, the type and quality of health workers that are needed to meet the health needs of our people. We should not be limited by such concepts as right-sizing or task-shifting in our duty to develop adequate human resource capacity for our health system. Our development partners should rather support national priorities including efforts to address human resources challenges.

One of the key programmes we have launched in this area is the clinical associate programme which a mid-level medical worker. We are proud to say that we have passed the necessary regulations and in fact the programme has already commenced at one of our medical schools, the Walter Sisulu University in Eastern Cape. We believe that this is a good example of how the country can train appropriate personnel for the needs of its citizens.

Programme director, distinguished guests, health promotion has and must remain one of our priorities. The Department of Health has led, for some years now, a vibrant healthy lifestyles campaign. There has been a very positive response to this campaign and we hope to scale it up this year and make it the central element of our communication activity. While significant progress has been made in implementing the primary Healthcare approach, there are still many challenges we have to address.

I challenge all of you as delegates to honestly review both the successes and challenges and make recommendations on how we can strengthen the implementation of the principles of primary healthcare as outlined in the Alma Ata Declaration. In doing so, delegates are encouraged to think outside the box. As our President said during the State of the Nation Address, it is business unusual!

The questions we need to answer during this conference include the following:
* Have we implemented our stated PHC policies in the desired manner and what have been the results?
* What lessons are there, both positive and negative that we need to understand and share?
* What would be the best way of enhancing implementation and increasing effectiveness of this approach?

Programme director, in conclusion I wish to thank all the participants to this conference for their commitment to primary healthcare. I am sure that their deliberations and the outcomes of this conference will ensure the strengthening of primary healthcare in South Africa.

I wish to thank the delegates from the other countries represented here for making time to share with us their own experiences on primary Healthcare. I also wish to thank the team that has put together the concept paper that will lay the foundation for this important gathering. I am confident that as we go to Burkina Faso, we will do so with a clear sense of the task lying ahead and with the knowledge that what we will share with the international community reflects the collective wisdom of delegates gathered here today.

I wish you all fruitful deliberations.

Thank you very much.