Date: 25/10/2003
Source: Department of Health
Title: Tshabalala-Msimang: London Solidarity Conference
SPEECH AT THE UNITED KINGDOM-SOUTH AFRICA SOLIDARITY CONFERENCE BY DR MANTO TSHABALALA-MSIMANG, MP, MINISTER OF HEALTH, 25 October 2003
Honourable Chairperson,
Ladies and gentlemen
It is indeed an honour for me to be presenting on such a wonderful occasion. The UK brings back a nostalgic feeling in me given the time that my husband and children and I spent in the UK. I fondly recall the support we enjoyed whilst my husband Mendi was the ANC's chief representative here and later when he was the first post-apartheid High Commissioner. The work that was done during this period certainly contributed in no small way to our democracy.
I wish to especially remember the friends of South Africa that involved themselves in the Anti-Apartheid Movement and without whose support we would not have been able to realise our freedom and democracy.
Legacy of the past
I am not going to go into details about the legacy of the past, as I am sure that especially this audience is familiar with what we inherited. Succinctly however, we inherited a fragmented, racially-based, hospital-centred health system.
The system benefited the white minority and the rich whilst neglecting the poor, those living in rural areas and black townships.
Children died from diseases of poverty and preventable diseases due to amongst others, poor immunisation coverage and lack of access to clean water and sanitation.
We trained health professionals in first world technology thus preparing them for work in developed countries. It is therefore not surprising that so many of our health professionals migrate to countries like the UK, Canada, Australia and Saudi Arabia. As a result of our student recruitment and training policies (largely white males trained in hospitals in urban areas) we experience great difficulty in getting health professionals to work in the public sector and greater difficulty to get them to work in rural areas.
We inherited a large, sophisticated and expensive private health care sector. This sector consumes more than half of the total health expenditure yet provides care for about 20% of the population. This in the context of large-scale poverty, unemployment and a burden of disease of both poverty and affluence. South Africa typically inherited the disease profile of a society in transition i.e., diseases of poverty, urbanisation and social instability. Our epidemiological picture is also characterised by a range of chronic and non-communicable diseases and diseases of lifestyle.
Work done pre-1994
Let me turn now to the period when the ANC prepared to govern. You will recall that even before the unbanning of the ANC numerous meetings and workshops in various parts of the world were held to consult on our policies. You will recall the meetings in such places as Sweden and Mozambique for example.
After the unbanning of the ANC we continued this work to draft post-apartheid policies. We engaged in a large scale, wide-ranging consultation process which lead to the development of the 'Ready to Govern' policies which formed the basis of the 1994 election platform of the ANC.
This consultative process resulted in the drafting of the ANC Health Plan, which formed in 1994, and continues to inform, government's health policies.
Key principles underlying our transformation process
The key principles that underlie our transformation process included: equity, quality of care, sustainability, community participation, local accountability, and intersectoral action. These principles are important to reflect on today given that this year we celebrate the 25th anniversary of the signing of the Alma Ata Declaration on Primary Health Care. These fundamental principles should be the barometer against which we measure ourselves on a continuous basis.
Achievements since 1994
When we reflect on the achievements of the past almost 10 years, it is with a lot of pride because we have achieved much in a relatively short period of time. This has been achieved not without pain. It often felt, and still feels like we have been changing all four tyres of a fully loaded car!
We have created a unified, de-racialised national health system with decentralised functions. We have created 9 provincial departments of health and are consolidating the establishment of 53 health districts.
I wish to acknowledge the role played by the Department of International Development (DFID) in supporting us to train our managers and in building systems, in particular the technical assistance provided to the district health system.
Off course, much still remains to be done in the coming years.
We implemented policies, which removed many barriers to access, especially to those that are the most vulnerable in society. Free health services for children under 6 and pregnant and lactating women was introduced in 1994, free primary health care for all in need two years later. This year we introduced free health services for people with disabilities.
We also built or extended 701 clinics, which has improved access to about 7 million people, most of whom live in rural and under-serviced areas of the country.
In 1999 we adopted a package of primary health care which we committed ourselves to ensuring is available in every health district by 2004. This was a strategy chosen to ensure, over time, equity in access of the same package of care in every health district in the country.
Given the high levels of poverty and recognising the importance of nutrition, we also instituted a primary school nutrition programme which currently provides one free meal to 4,5 learners in 15 000 schools nation-wide.
We crafted and implemented the Choice on Termination of Pregnancy Act, which was aimed at improving access to safe terminations. To ensure that women did not use terminations as a form of contraception we simultaneously improved reproductive health services. Research shows that there has been a decrease in the number of women with septicaemia.
Even though we recognise the importance of health promotion and prevention, sick people need drugs. We adopted an essential drug list and implemented strategies to increase rational drug use and improved the safety of drugs. You will recall that the big pharmaceutical companies joined together to take us to court - but we never relented because we knew that our cause was just. They relented and the consequence was a victory for developing countries around the world!
At the same time we are researching the value of traditional medicines led by the Medical Research Council. In addition, we have launched the Africa Centre, which is an African/continental project. Finally, we are piloting a Bill that will give traditional healers status within the health care system of South Africa.
Given that we inherited low immunisation rates which resulted in many preventable deaths we embarked on large-scale immunisation programmes of children, which has resulted in no deaths from measles for the past 4 years. This, Mr Chairperson, is a remarkable achievement considering ten years ago measles used to be one of the biggest killers.
We are also ready to be declared polio free and we are working with other SADC states to ensure that as a region we can be declared polio free.
We have implemented new policies to deal with a range of health problems, which I shall merely list because of lack of time. These include: direct observed treatment, short course for the treatment of TB and the introduction of electronic TB registers to better track patients and treatment outcomes; an integrated nutrition programme with other sectors; training of health workers in integrated management of childhood illnesses strategy; and we have adopted a comprehensive approach to HIV and AIDS.
Our approach to HIV and AIDS has and continues to be comprehensive. We have focused on prevention and promotion, treatment (including opportunistic infections), care and support. As has been widely publicised in the media the Cabinet has asked the Department to prepare on operational plan for the rollout of anti-retrovirals. We are almost complete with this task and we hope to present the plan to Cabinet within the next few weeks. The slowing in the infection rates in young people illustrates that our prevention programmes are beginning to bear results. In addition, UNAIDS has acclaimed our programmes as comprehensive given that it includes multiple pillars: prevention and promotion; treatment, care, support; focus on the youth; and human rights.
All pillars of the strategy have and will continue to be implemented by government.
We have implemented innovative programmes in malaria control both in South Africa and with our neighbours, Swaziland and Mozambique. The WHO has recognised these efforts by naming our programme as the best in the region. We have started to work with both Angola and Zimbabwe to assist them to strengthen their programmes as well. In addition, we recently participated in a very exciting continent-wide collaborative programme to roll back malaria - the Race Against Malaria programme.
Returning to prevention policies and legislation, we adopted arguably the most progressive tobacco legislation anywhere in the world and worked hard in the WHO to ensure the drafting of international framework agreements on tobacco control. These efforts have resulted in South Africa winning international awards for our tobacco control efforts.
Since its implementation in South Africa research reveals that the rate of smoking amongst the youth has decreased.
To further strengthen this policy we are in the process of amending the legislation to increase fines that owners of businesses face if they transgress the law.
We have crafted and implemented a large array of health legislation on a wide range of policies. These include the Choice on Termination of Pregnancy Act to provide for safe terminations, the Mental Health Care Act to improve the treatment of the mentally ill, the Medicines Act to make drugs safer and more affordable, Medical Schemes Act to stabilise the health insurance industry and to make these schemes more accessible, the NHLS Act which creates a national health laboratory service and most recently we are piloting the National Health Bill which will create overarching framework legislation for the entire health system.
Besides our efforts to transform primary health care and increase prevention activities, we have not neglected our hospitals. We inherited a large hospital stock but found that about a third by value needed replacement at between R8-10 billion (in 1996 rands). We started a hospital rehabilitation programme that focused on infrastructure development to address this problem but soon realized that we need to do more than construct new buildings. We have therefore embarked on a revitalization programme that addresses management, quality and equipment, in addition to infrastructure. We currently have 27 hospitals enrolled in this programme. The intention is to add at least 2 hospitals per province into the programme each year should funds be available.
We have created three flagship tertiary hospitals in three provinces, namely the Inkosi Albert Luthuli Hospital in Durban, the Nelson Mandela Complex in Umtata and the Pretoria Academic in Tshwane.
We recognise the potential of health tourism linked to the refurbishment of our hospitals. It is much cheaper for our neighbours and others on our continent to obtain care in our hospitals compared to the cost of care in developed countries and we have started discussions on this possibility.
Human resource development and management remains one of the most important challenges, hence the signing of the Memorandum of Agreement with the NHS yesterday. However, we have a programme that address issues such as training, retraining, and retention. We are working with our training institutions to ensure that students are trained to deal with the health problems that South Africans confront. We have several country-to-country agreements to ensure that we only recruit from countries with a surplus of health professionals. We have instituted a community service programme starting with doctors and which now requires most health professionals to do one year of community service. We have not as yet required this of nurses but plan to introduce this within the next two years. In addition we will be instituting a rural and scarce skills allowance to recruit and retain skills within the public sector.
We have also commenced the training of mid-level workers in some categories; example pharmacy assistants and we are looking to train clinical officer within the next year or two.
We recognise the need to train our health managers and provide support to them. In this regard we have established with the assistance of DFID, the Dr Arthur Letele Health Management Institute.
We realise of course that one of the critical elements of any health system is quality of care from a management, clinical and patient perspective. To this end with adopted a number of strategies to improve quality of care. These include: the government-wide Batho Pele (People First) strategy; the development and implementation of a National Patient's Rights Charter; and a national complaints system. However, let me confess that we still have a long way to go despite the fact that on average surveys show that 80% of those who use the public health service are satisfied with the service. We must also ensure that the remaining 20% are satisfied.
On the regional, continental and international fronts we have been very involved in a range of initiatives. These include the SADC health sector, the AU, NEPAD, the Non-Aligned Movement, the World Health Organization, and the Global Fund.
However, whilst we can share a large number of achievements, significant challenges remain - for which we need your assistance. In the last part of my presentation I will focus on these challenges.
Remaining challenges
I have categorised our challenges into five key areas for which we require your assistance. These are: equity; emerging and re-emerging diseases; non-communicable diseases, largely chronic diseases, mental health, trauma and diseases of lifestyle; health system strengthening; and human resources.
Equity
On the issue of equity, we need to ensure in the first instance an appropriate level of funding for the health sector. Secondly we need to find creative ways of working with the private health care sector - which I said earlier spends a large percent of the total health care budget on a small proportion of the population. Thirdly we need greater equity in the allocation of health resources between and within provinces. In terms of the former we have made some progress but the gap has not closed. And finally we need to ensure that primary health care gets an appropriate slice of the health cake.
Emerging and re-emerging diseases
Many commentators have argued that the burden of disease and infant and maternal mortality rates in South Africa will be significantly lower if we did not have diseases such as HIV and AIDS, TB and malaria. Whilst this is self-evident, it means that we have to ensure that we are able to implement a comprehensive strategy that deals with these diseases. However, this requires a strong health service delivery system. This in turn means a robust primary health care and hospital system.
The delivery of health care services is labour intensive. This means that we need sufficient quantities of appropriately skilled and motivate human resources. We are therefore very excited about the memorandum of agreement that I signed Minister Hutton yesterday. This agreement focuses on the reciprocal educational exchange of healthcare concepts and personnel between our two countries. In essence the agreement provides that both parties shall formulate an agreed plan whereby South African healthcare personnel can spend mutually agreed periods of time on education and practice periods in organisations providing NHS services and also provides for clinical staff from England to work alongside healthcare personnel in South Africa, with particular emphasis on the rural areas.
Conclusion
I would like in conclusion to say to South Africans living and working in the UK - please come home, we need your expertise.
To our friends and comrades in the UK, many thanks for your support over the years. Please continue to support us both morally and with your substantial resources.
Together we can build a better life for all.
I thank you!
Source: Department of Health (http://www.doh.gov.za)
Source: Department of Health
Title: Tshabalala-Msimang: London Solidarity Conference
SPEECH AT THE UNITED KINGDOM-SOUTH AFRICA SOLIDARITY CONFERENCE BY DR MANTO TSHABALALA-MSIMANG, MP, MINISTER OF HEALTH, 25 October 2003
Honourable Chairperson,
Ladies and gentlemen
It is indeed an honour for me to be presenting on such a wonderful occasion. The UK brings back a nostalgic feeling in me given the time that my husband and children and I spent in the UK. I fondly recall the support we enjoyed whilst my husband Mendi was the ANC's chief representative here and later when he was the first post-apartheid High Commissioner. The work that was done during this period certainly contributed in no small way to our democracy.
I wish to especially remember the friends of South Africa that involved themselves in the Anti-Apartheid Movement and without whose support we would not have been able to realise our freedom and democracy.
Legacy of the past
I am not going to go into details about the legacy of the past, as I am sure that especially this audience is familiar with what we inherited. Succinctly however, we inherited a fragmented, racially-based, hospital-centred health system.
The system benefited the white minority and the rich whilst neglecting the poor, those living in rural areas and black townships.
Children died from diseases of poverty and preventable diseases due to amongst others, poor immunisation coverage and lack of access to clean water and sanitation.
We trained health professionals in first world technology thus preparing them for work in developed countries. It is therefore not surprising that so many of our health professionals migrate to countries like the UK, Canada, Australia and Saudi Arabia. As a result of our student recruitment and training policies (largely white males trained in hospitals in urban areas) we experience great difficulty in getting health professionals to work in the public sector and greater difficulty to get them to work in rural areas.
We inherited a large, sophisticated and expensive private health care sector. This sector consumes more than half of the total health expenditure yet provides care for about 20% of the population. This in the context of large-scale poverty, unemployment and a burden of disease of both poverty and affluence. South Africa typically inherited the disease profile of a society in transition i.e., diseases of poverty, urbanisation and social instability. Our epidemiological picture is also characterised by a range of chronic and non-communicable diseases and diseases of lifestyle.
Work done pre-1994
Let me turn now to the period when the ANC prepared to govern. You will recall that even before the unbanning of the ANC numerous meetings and workshops in various parts of the world were held to consult on our policies. You will recall the meetings in such places as Sweden and Mozambique for example.
After the unbanning of the ANC we continued this work to draft post-apartheid policies. We engaged in a large scale, wide-ranging consultation process which lead to the development of the 'Ready to Govern' policies which formed the basis of the 1994 election platform of the ANC.
This consultative process resulted in the drafting of the ANC Health Plan, which formed in 1994, and continues to inform, government's health policies.
Key principles underlying our transformation process
The key principles that underlie our transformation process included: equity, quality of care, sustainability, community participation, local accountability, and intersectoral action. These principles are important to reflect on today given that this year we celebrate the 25th anniversary of the signing of the Alma Ata Declaration on Primary Health Care. These fundamental principles should be the barometer against which we measure ourselves on a continuous basis.
Achievements since 1994
When we reflect on the achievements of the past almost 10 years, it is with a lot of pride because we have achieved much in a relatively short period of time. This has been achieved not without pain. It often felt, and still feels like we have been changing all four tyres of a fully loaded car!
We have created a unified, de-racialised national health system with decentralised functions. We have created 9 provincial departments of health and are consolidating the establishment of 53 health districts.
I wish to acknowledge the role played by the Department of International Development (DFID) in supporting us to train our managers and in building systems, in particular the technical assistance provided to the district health system.
Off course, much still remains to be done in the coming years.
We implemented policies, which removed many barriers to access, especially to those that are the most vulnerable in society. Free health services for children under 6 and pregnant and lactating women was introduced in 1994, free primary health care for all in need two years later. This year we introduced free health services for people with disabilities.
We also built or extended 701 clinics, which has improved access to about 7 million people, most of whom live in rural and under-serviced areas of the country.
In 1999 we adopted a package of primary health care which we committed ourselves to ensuring is available in every health district by 2004. This was a strategy chosen to ensure, over time, equity in access of the same package of care in every health district in the country.
Given the high levels of poverty and recognising the importance of nutrition, we also instituted a primary school nutrition programme which currently provides one free meal to 4,5 learners in 15 000 schools nation-wide.
We crafted and implemented the Choice on Termination of Pregnancy Act, which was aimed at improving access to safe terminations. To ensure that women did not use terminations as a form of contraception we simultaneously improved reproductive health services. Research shows that there has been a decrease in the number of women with septicaemia.
Even though we recognise the importance of health promotion and prevention, sick people need drugs. We adopted an essential drug list and implemented strategies to increase rational drug use and improved the safety of drugs. You will recall that the big pharmaceutical companies joined together to take us to court - but we never relented because we knew that our cause was just. They relented and the consequence was a victory for developing countries around the world!
At the same time we are researching the value of traditional medicines led by the Medical Research Council. In addition, we have launched the Africa Centre, which is an African/continental project. Finally, we are piloting a Bill that will give traditional healers status within the health care system of South Africa.
Given that we inherited low immunisation rates which resulted in many preventable deaths we embarked on large-scale immunisation programmes of children, which has resulted in no deaths from measles for the past 4 years. This, Mr Chairperson, is a remarkable achievement considering ten years ago measles used to be one of the biggest killers.
We are also ready to be declared polio free and we are working with other SADC states to ensure that as a region we can be declared polio free.
We have implemented new policies to deal with a range of health problems, which I shall merely list because of lack of time. These include: direct observed treatment, short course for the treatment of TB and the introduction of electronic TB registers to better track patients and treatment outcomes; an integrated nutrition programme with other sectors; training of health workers in integrated management of childhood illnesses strategy; and we have adopted a comprehensive approach to HIV and AIDS.
Our approach to HIV and AIDS has and continues to be comprehensive. We have focused on prevention and promotion, treatment (including opportunistic infections), care and support. As has been widely publicised in the media the Cabinet has asked the Department to prepare on operational plan for the rollout of anti-retrovirals. We are almost complete with this task and we hope to present the plan to Cabinet within the next few weeks. The slowing in the infection rates in young people illustrates that our prevention programmes are beginning to bear results. In addition, UNAIDS has acclaimed our programmes as comprehensive given that it includes multiple pillars: prevention and promotion; treatment, care, support; focus on the youth; and human rights.
All pillars of the strategy have and will continue to be implemented by government.
We have implemented innovative programmes in malaria control both in South Africa and with our neighbours, Swaziland and Mozambique. The WHO has recognised these efforts by naming our programme as the best in the region. We have started to work with both Angola and Zimbabwe to assist them to strengthen their programmes as well. In addition, we recently participated in a very exciting continent-wide collaborative programme to roll back malaria - the Race Against Malaria programme.
Returning to prevention policies and legislation, we adopted arguably the most progressive tobacco legislation anywhere in the world and worked hard in the WHO to ensure the drafting of international framework agreements on tobacco control. These efforts have resulted in South Africa winning international awards for our tobacco control efforts.
Since its implementation in South Africa research reveals that the rate of smoking amongst the youth has decreased.
To further strengthen this policy we are in the process of amending the legislation to increase fines that owners of businesses face if they transgress the law.
We have crafted and implemented a large array of health legislation on a wide range of policies. These include the Choice on Termination of Pregnancy Act to provide for safe terminations, the Mental Health Care Act to improve the treatment of the mentally ill, the Medicines Act to make drugs safer and more affordable, Medical Schemes Act to stabilise the health insurance industry and to make these schemes more accessible, the NHLS Act which creates a national health laboratory service and most recently we are piloting the National Health Bill which will create overarching framework legislation for the entire health system.
Besides our efforts to transform primary health care and increase prevention activities, we have not neglected our hospitals. We inherited a large hospital stock but found that about a third by value needed replacement at between R8-10 billion (in 1996 rands). We started a hospital rehabilitation programme that focused on infrastructure development to address this problem but soon realized that we need to do more than construct new buildings. We have therefore embarked on a revitalization programme that addresses management, quality and equipment, in addition to infrastructure. We currently have 27 hospitals enrolled in this programme. The intention is to add at least 2 hospitals per province into the programme each year should funds be available.
We have created three flagship tertiary hospitals in three provinces, namely the Inkosi Albert Luthuli Hospital in Durban, the Nelson Mandela Complex in Umtata and the Pretoria Academic in Tshwane.
We recognise the potential of health tourism linked to the refurbishment of our hospitals. It is much cheaper for our neighbours and others on our continent to obtain care in our hospitals compared to the cost of care in developed countries and we have started discussions on this possibility.
Human resource development and management remains one of the most important challenges, hence the signing of the Memorandum of Agreement with the NHS yesterday. However, we have a programme that address issues such as training, retraining, and retention. We are working with our training institutions to ensure that students are trained to deal with the health problems that South Africans confront. We have several country-to-country agreements to ensure that we only recruit from countries with a surplus of health professionals. We have instituted a community service programme starting with doctors and which now requires most health professionals to do one year of community service. We have not as yet required this of nurses but plan to introduce this within the next two years. In addition we will be instituting a rural and scarce skills allowance to recruit and retain skills within the public sector.
We have also commenced the training of mid-level workers in some categories; example pharmacy assistants and we are looking to train clinical officer within the next year or two.
We recognise the need to train our health managers and provide support to them. In this regard we have established with the assistance of DFID, the Dr Arthur Letele Health Management Institute.
We realise of course that one of the critical elements of any health system is quality of care from a management, clinical and patient perspective. To this end with adopted a number of strategies to improve quality of care. These include: the government-wide Batho Pele (People First) strategy; the development and implementation of a National Patient's Rights Charter; and a national complaints system. However, let me confess that we still have a long way to go despite the fact that on average surveys show that 80% of those who use the public health service are satisfied with the service. We must also ensure that the remaining 20% are satisfied.
On the regional, continental and international fronts we have been very involved in a range of initiatives. These include the SADC health sector, the AU, NEPAD, the Non-Aligned Movement, the World Health Organization, and the Global Fund.
However, whilst we can share a large number of achievements, significant challenges remain - for which we need your assistance. In the last part of my presentation I will focus on these challenges.
Remaining challenges
I have categorised our challenges into five key areas for which we require your assistance. These are: equity; emerging and re-emerging diseases; non-communicable diseases, largely chronic diseases, mental health, trauma and diseases of lifestyle; health system strengthening; and human resources.
Equity
On the issue of equity, we need to ensure in the first instance an appropriate level of funding for the health sector. Secondly we need to find creative ways of working with the private health care sector - which I said earlier spends a large percent of the total health care budget on a small proportion of the population. Thirdly we need greater equity in the allocation of health resources between and within provinces. In terms of the former we have made some progress but the gap has not closed. And finally we need to ensure that primary health care gets an appropriate slice of the health cake.
Emerging and re-emerging diseases
Many commentators have argued that the burden of disease and infant and maternal mortality rates in South Africa will be significantly lower if we did not have diseases such as HIV and AIDS, TB and malaria. Whilst this is self-evident, it means that we have to ensure that we are able to implement a comprehensive strategy that deals with these diseases. However, this requires a strong health service delivery system. This in turn means a robust primary health care and hospital system.
The delivery of health care services is labour intensive. This means that we need sufficient quantities of appropriately skilled and motivate human resources. We are therefore very excited about the memorandum of agreement that I signed Minister Hutton yesterday. This agreement focuses on the reciprocal educational exchange of healthcare concepts and personnel between our two countries. In essence the agreement provides that both parties shall formulate an agreed plan whereby South African healthcare personnel can spend mutually agreed periods of time on education and practice periods in organisations providing NHS services and also provides for clinical staff from England to work alongside healthcare personnel in South Africa, with particular emphasis on the rural areas.
Conclusion
I would like in conclusion to say to South Africans living and working in the UK - please come home, we need your expertise.
To our friends and comrades in the UK, many thanks for your support over the years. Please continue to support us both morally and with your substantial resources.
Together we can build a better life for all.
I thank you!
Source: Department of Health (http://www.doh.gov.za)
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