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Date : 10/06/2003
Source: Ministry of Health
Title: Tshabalala-Msimang: Health Dept Budget Vote 2003/2004, NCOP


BUDGET SPEECH BY THE MINISTER OF HEALTH, MANTO TSHABALALA-MSIMANG, National Council of Provinces, Tuesday, 10 June 2003

Chairperson and Honourable Members

Occasions such as this Budget debate are a powerful reminder that the spirit of co-operative governance is the lifeblood of our national health system.

The people's contract for a better South Africa starts here. It starts with national government, provinces and local government remaining steadfast in our pledge to work together to improve the lives of all our people.

I am honoured, therefore, to present to you the budget vote on health. Of the total amount of R8,38-billion in the national health budget, no less than R7,32-billion is transferred to provinces as conditional grants.

These grants are targeted at tertiary services in central hospitals and certain regional hospitals; training for health care professionals; the HIV and AIDS Programme; revitalisation of hospitals; and the Integrated Nutrition Programme.

Honourable members, resource constraints remain an ever-present reality in the operation of our health services. We have seen respectable nominal increases in health spending for several years now. However, when these increases are adjusted for inflation and for population growth, we are spending only a little more on the health of each individual than we were in the mid-90s.

Of course, we are trying to do a great deal more with this money - including confronting the major communicable and non-communicable diseases. And some obvious pressures on resources are emerging even in our better off provinces.

We have also committed ourselves to levelling the uneven playing field that apartheid left behind.

Whilst the gap in per capita spending between the wealthier urban provinces and the poorer rural provinces continues to be narrowed - this gap has not been eradicated and it remains unacceptably wide.

This year, the budgeted per capita spending in provinces ranges from approximately R1 670, at the top of the scale, to a low of R630.

This pattern of inequity is also reflected in large disparities in the number of health professionals available in various provinces.

Therefore, Honourable Members, as you discharge your oversight responsibility and stewardship role over national resources, I am appealing to you to pay special attention to three things:

* The overall pressure on resources in the public health sector
* The manner in which resources are allocated among provinces and among districts in every province
* And the manner in which health care resources are utilized by provinces and opportunities to target services to ensure that they reach the needy and most vulnerable individuals and communities.

Chairperson, the national budget this year has some strong, positive features in the areas of capital spending, nutrition, HIV and AIDS programmes and human resources. However, we will only reap the benefit of these special allocations if provincial funding of the health system is basically adequate and sustainable.

Let me illustrate this point in relation to the area of human resources.

The budget this year includes a special allocation of R500-million in order to assist provinces to recruit and retain health professionals to serve in rural areas and to boost the levels of scarce professions in the public sector.

The R500m will introduce a system of allowances and - in a few categories - pay increases. These will "top up" the salaries already covered in provincial budgets for the year, but will not fund additional posts.

We expect that the new allowances will have a real impact in retaining skilled health workers especially in rural areas, as well as attracting additional professionals to fill vacancies and special attention will be paid to sweetening the package in the most remote areas.

Presently, we have 2 662 young professionals doing community service -- contributing critically needed service in the public sector.

For instance, 1 out of 7 doctors in the public sector is doing community service and so are about 1 out of 4 pharmacists and 1 out of 2 physiotherapists.

These figures confirm the incredible value of community service to our nation. However, it is not satisfactory for us to depend so heavily on inexperienced personnel.

By investing effort to nurture community service professionals, we can make it worth their while to spend a few more years in the public sector.

Several new categories of mid-level workers have been by the professionals councils and these will help fill some gaps in human resources.

Given the intense public debate on the international brain drain, information in the recent Intergovernmental Fiscal Review might come as a surprise to many. The Review reveals that between the end of 2001 and early 2003, provincial health departments actually recorded a 4,5% gain in doctors while the loss of professional nurses amounted to a mere 0,5%.

Of course the Review merely records the bottom line and does not tell us much about the turnover that might be happening under the surface.

Those who are familiar with the public health service will tell you that people are not only leaving the service but we are also gaining some health professionals who used to work in the private sector.

We have consistently taken the view that we would have no wish to restrict the freedom of health workers to work abroad. We are more concerned, however, about the exploitative recruiting tactics of certain international operators.

We also believe that the international movement of health workers can, to some extent, be managed to the mutual benefit of the countries and individuals involved.

Chairperson and Honourable members, I returned just a week ago from the World Health Assembly in Geneva where Commonwealth Health Ministers adopted a Code of Ethics on international recruitment of health workers, which is now binding on all Member States.

South Africa intends to build on this foundation by seeking bilateral agreements with Australia, Britain, Canada and New Zealand. We have already had extremely fruitful talks with Britain's Minister of Health and a team, led by the Director-General, will visit the United Kingdom this month to pursue discussions on this subject.

The highpoint of the Assembly this year was the unanimous adoption of the Framework Convention on Tobacco Control, which sets the scene for the global expansion of public health measures against tobacco - such as controls on advertising, sponsorship and smoking in public places.

Since returning from Geneva we have released the results of our second Youth Tobacco Survey undertaken by the MRC. This showed a very clear reduction - over a period of three years - in the number of teenagers who recalled seeing tobacco advertising and a corresponding decrease in the percentage who had ever smoked.

We feel confident in claiming that this is directly due to our laws that ban tobacco advertising and our taxes on tobacco products that make it increasingly costly to smoke.

The need for strong, multi-faceted health promotion initiatives was highlighted by another major discussion at the World Health Assembly: responding to the global epidemic of violence.

Last year, the World Health Organisation published a major study of violence as a public health issue.

The key message of the study was that we are not powerless in the face of violence. It is possible to understand the roots of violence and to take a range of actions to address the diverse causes.

Specialised centres for assisting survivors of sexual assault have been created in some provinces.

* Gauteng currently has 26 such clinics while the Northern Cape has established similar services in six towns, with outreach into surrounding communities.

* Free State, KwaZulu-Natal, Northern Cape and Western Cape have taken the lead in the training of forensic nurses.

We have donor funding to extend this training nationally and are currently creating a standard curriculum for training forensic nurses.

There is little doubt that public awareness of woman and child abuse has increased a hundredfold over the last few years and that many government sectors, including health, have played a key role in this.

But the time has come to dig deeper into the methods of prevention and to expand our conception of programmes against violence to acknowledge that adult men constitute a major category of victims.

In recent years, nearly half of all deaths among young men (in the age group15 to 29 years) are due to unnatural causes - suicide, homicide and accidents. So you can see that the problem of violence is certainly bigger than we thought five years ago.

The expansion of our mental health services, with a stronger community focus, is undoubtedly critical to tackling violence effectively.

Several provinces have made specific financial provision this year for implementing the new Mental Health Care Act by expanding community-based services and appointing boards to assist in protecting the rights of individuals admitted to psychiatric institutions.

All provinces have retained a clear focus on the objectives of our national programmes to reduce mortality and morbidity.

The Integrated Management of Childhood Illnesses was slow to get off the ground but is consolidating quite well. It has the advantage of providing nurses with a very clear framework for dealing with a whole range of childhood illnesses.

Preliminary evaluation suggests that it results in more appropriate use of medicines, appropriate referral at an earlier stage and better involvement of the caregiver.

The integrated approach will in the longer-term impact on immunisation levels. However, there are still large variations among provinces and low immunisation rates are particularly disturbing when they coincide with the re-emergence of severe malnutrition and high rates of diarrhoea disease.

Provincial plans across the board include a major focus on TB control. There has been some soul searching about how to get better TB cure rates from the Directly Observed Treatment Strategy - DOTS, and turn around the rising incidence of this disease.

The result, in a number of provinces, will be seen in greater investment in the management of the TB programme at district level and intensified recruitment of treatment supporters in communities.

We are planning much stronger public awareness and information campaigns in order to achieve earlier diagnosis of TB, a reduction in stigma and a climate more favourable for completion of treatment.

I would like all members of this council to participate actively in the TB advocacy programme.

In relation to HIV, AIDS and STIs, we can confidently say there is a steady building up of the elements of our five-year strategic plan.

For the second consecutive year, there is a major increase in the budget for this programme.

This year's allocation in the national Health Budget alone is up by more than R200-million and amounts to R666-million.

Provinces are the major beneficiaries of this increase, the bulk of which goes into a single conditional grant which can be allocated to particular services as the provinces judge most appropriate.

In 2002, the major areas of progress in most provinces were:
* Renewed strategies for preventing HIV infection among the youth;
* The expansion of the PMTCT programmes across provinces;
* The introduction of AZT and 3TC for sexual assault survivors;
* Step down facilities - an additional element in the treatment chain;
* The expansion of voluntary counselling and testing;
* Development in the area of home-based care; and
* The mass media campaigns, accompanied by targeted social mobilisation, under the slogan "Khomanani - Caring Together".

The number of facilities involved in the PMTCT programme has increased.

We are following the mother-baby pairs to determine the impact of Nevirapine when used for PMTCT. We are also committed to monitoring adverse drug events as well as resistance patterns due to a single dose of Nevirapine.

All provinces are offering AZT and 3TC to survivors of sexual assault, using the national guidelines and administering the medication as part of a comprehensive service.

The constant development of trained body of caregivers is a major feature of the HIV, AIDS and TB programmes.

These caregivers are known by various names and are skilled in different areas such as counselling, DOTS support, home nursing, outreach to families in need.

Collectively, they have become the engine for continued rollout of a range of services. I would like to recognise their singular importance here today and salute them for responding with love and dedication to the health needs of our people.

We are committed to continually review and evaluate our 5-Year Strategic Plan on HIV and AIDS.

In the year ahead, Honourable Members, further expansion of the HIV and AIDS Programme within the five-year strategic plan can be expected.

As you know, the Department of Health and National Treasury established a Joint Task Team to examine and cost various options for strengthening the National Strategic Plan on HIV and AIDS, and in particular, the treatment available to people living with HIV and AIDS.

This report will soon be dealt with by Cabinet.

Amongst other strategies, we will be strengthening the following key elements of our comprehensive national response to HIV and AIDS:

* There will be a greater focus on nutrition, food supplementation and the use of immune boosters in order to encourage positive living and delay the progression from HIV to AIDS.

* We are working with the Departments of Agriculture and Social Development to provide social support to those who are infected and affected by HIV and AIDS.

* The Medical Research Council has established - as a first step - a Unit on Indigenous Knowledge Systems to evaluate the safety and efficacy of traditional herbal remedies.

Honourable Members, turning to the area of non-communicable diseases, we have seen growth in capacity in certain specific areas.

Dedicated funding for assistive devices for people with disabilities is now routinely allocated in most provincial budgets. As a national Department, we have committed ourselves to clearing the backlog on devices by this time next year at a total cost of R30-million. This would then allow the provinces to focus on replacing devices and assisting new cases.

We need to take a careful look at the World Health Organisation's 2002 study on health risks - a study that concluded that 40% of mortality and disease burden must be laid at the door of 10 major health risks.

We have taken bold - and seemingly successful - steps to reduce the risk of tobacco. Now we need to look at some of the other major risks - such as nutrition, obesity, alcohol, unsafe water and inadequate sanitation.

Perhaps we need to recall that this year marks the 25th anniversary of the Alma Ata Declaration, the cornerstone of primary health care.

We will be commemorating this event in South Africa.

Chairperson and honourable members, the development of the health infrastructure on which these programmes depend remains a continual challenge.

As you know, the Inkosi Albert Lutuli Hospital was commissioned last year. The Nelson Mandela Complex in Umtata is due to be opened later this year. And 2004 will see the opening of the new Pretoria Academic Hospital.

In the last two years, funding for our Hospital Revitalisation Programme has taken a great leap forward. We have R717-million in the budget this year - and this increases by almost R200-million in 2004.

Presently, we have 27 hospitals on our list - and 18 of these projects involve the building of entirely new facilities, either to replace an existing hospital or to create a new service.

The Revitalisation hospitals are as follows:

* In the Eastern Cape, Frontier, St Elizabeth and Mary Theresa;
* In Free State, Boitumelo, Trompsburg and Ladybrand;
* In Gauteng, Mamelodi, Johannesburg South and Natalspruit;
* In KwaZulu-Natal, King George, KwaMashu and Empangeni;
* In Limpopo, Lebowakgomo, Jane Furse and Dilokong;
* In Mpumalanga: Piet Retief, Themba and Rob Ferreira;
* In Northern Cape, Colesburg, Calvinia and Kimberley Psychiatric Hospital;
* In North West, Vryburg, Tshwaragano and Swartruggens; and
* In the Western Cape, Eben Donges, George and Vredenburg.

Hospital Revitalisation also involves technology maintenance, replacement and innovation, as well as the development of managers and management systems and improving quality of care.

In addition to the boosted funds for the Revitalisation Programme, there has also been an increase in funding for infrastructure as part of the equitable share.

Provinces are currently using such funding to sustain the process of upgrading and expanding the network of clinics and community health centres; to increase the pace of replacing obsolete equipment; and to undertake smaller renovation projects and routine maintenance.

Systematic audits of hospital equipment revealed that shortages were often caused not by a lack of equipment but by lack of maintenance and excessive downtime on existing equipment.

We have an acute shortage of specialised engineers and technicians in our public health system to keep our equipment in good repair and we have developed a dual strategy to tackle this critical factor
* We plan to train 500 engineers and technicians over a period of 5 years, with the first 100 commencing training in the next 2 months
* As an interim measure, we have reached agreement with the Cuban Government for engineers and technicians to work in South Africa on short-term contracts and the first group will arrive shortly.

A further priority in the year ahead is the strengthening of emergency services with the eventual target of meeting a standard set of norms countrywide. We fully recognise that many other services are critically dependent on the support of an effective ambulance fleet with well-trained personnel.

Other significant measures to strengthen support services will occur in relation to laboratory services and medico-legal mortuaries.

A major pillar of our strategy to reshape the public healthcare system is the building of health districts, with strong local co-ordination of services and equally strong local accountability.

The National Health Bill, which will be tabled later this year, will recognise the constitutional reality that provinces are designated as the primary providers of public health services.

Local government will only become a significant provider of primary health care through co-operative governance arrangements.

We are exploring the use of service level agreements with local government to deliver specified services on behalf of the province with adequate resources.

Clearly this is not a simple system. It is a system that should be informed by commitment to the ideal of decentralised management to improve efficiency and effectiveness, and it should promote people centred development through greater community participation in the delivery of basic services.

There may also be significant benefits to this approach in the area of equity.

If the gap between the richest and poorest provinces is still unacceptably large, the gap between the richest and poorest municipalities is even larger and more worrying. If funds for primary health care flow through the provinces to local councils, this can help to level the playing field between municipal areas. It can also strengthen co-ordination of health services.

Chairperson, I referred in passing to the National Health Bill and am pleased to say the State Law Advisor has now certified the Bill. This means it will shortly be tabled for processing by Parliament.

We anticipate there will be high levels of interest in the Bill and we look to this Council to play an active role in channelling public input.

The Traditional Healers Bill is also likely to be of particular interest to provincial constituencies, especially where provinces already have legislation on related matters.

The increasing interface with the private health sector is another factor that is gradually having a bearing on provincial health services.

Those provinces that are using the Uniform Patient Fee Schedule quite widely and have set revenue targets, have reported achieving or exceeding their targets last year. Clearly there still is untapped opportunity for generating revenue for our public hospitals.

Changes in the medical schemes legislation, which allow schemes to designate preferred service providers, represent a significant opportunity for public hospitals to increase the proportion of paying patients. Many hospitals are preparing for such arrangements.

I can assure this Council that this new development will not compromise our responsibility to ensure care for those who cannot afford to pay their way and paying patients will not be allowed to crowd out poorer patients.

The revenue generated by fee-paying patients will benefit the service as a whole and the quality of clinical care provided in provincial hospitals will not depend on whether patients pay or not.

In closing, I would like to thank the Select Committee on Social Services and especially its chairperson, the Honourable Loretta Jacobus, for her guidance and constructive interaction with me and members of the Department of Health.

I would like to recognise Deputy Minister Schoeman, who has taken up the challenge of entering office late into the term and has strengthened the Ministry by focusing on particular aspects of our complex department.

I would like to recognise my Ministerial colleagues in the Social Cluster and in the Cabinet, and pay tribute especially to the leadership of President Mbeki.

My provincial colleagues, the MECs for Health, are partners in the exercise of concurrent powers and I am indebted to them for sharing the responsibility of decision-making.

In similar vein, I thank the Director-General of Health, Dr Ayanda Ntsaluba, and his counterparts in the provinces for their dedication and leadership.

I also wish to recognise the support received from my advisors, other members of my office and senior officials in the Department of Health.

But, when it comes down to it, the health service is run by a huge number health workers, professional and non-professional, who give it their best effort seven days a week, 52 weeks a year. On behalf of the millions who benefit from your skill and your love of your work, I thank you all.

Issued by Ministry of Health
10 June 2003

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