Issued by the Office of the Minister of Health
13 June 2000
Chairperson
Honourable members
Over the past few years we have seen profound changes in the delivery of health care in our country. These changes have confirmed the promise that our government has made to ensure a better life for all the citizens of our land. We take pride in what we have achieved. But we also are cognisant of the many challenges ahead.
The project of a better life for all has to succeed if only to secure our ideal of a stable, democratic and non-racial society. But we want more than that. We want a society that is non-sexist, humane and caring, a society that contributes positively to the forward march of all humanity. We want to be an example of the true and full celebration of the liberation of the human spirit.
But such can never be where poverty is rife ; where disease cuts brutally short too many a lives ; where more than half of all humanity is condemned to perpetual subservience only on account of being born a woman ; where illiteracy condemns human beings into passive bystanders in a world whose rapid change carries both the potential for success as well as self-destruction.
No doubt, ours is an ambitious project !!
Let our detractors call us dreamers.
Yes, Let us dream
Like the toddler who dreams that one day he may drive a car of his own OR become the President of this Republic OR for that matter our visionary forebears who in the face of the brutality of the apartheid crime against humanity dared to proclaim that one day we too shall be free.
Let us draw our inspiration from the knowledge that it all can come true. That through our own actions it can be done. But above all , let us be driven by the same determination that has transformed us from being a pariah state to being a respected and responsible member of the international community of nations in less than a decade. That will be a fitting tribute to the many who sacrificed their lives for us to be free so that we can make these choices. It also will be a tribute to the patience and understanding of the African woman from Nquthu who continues to walk miles to fetch water or take her child to the clinic in the next village because drugs are not available in her own.
For in spite of all our achievements there are instances where we continue to fail our citizens. We can say this openly and confront the challenges this brings because we are sincere in our commitment to serve. And for those who commit themselves to the service of their country and people, no difficulty is insurmountable. In fact , true patriots only see challenges and vow to stay the course until the job is done.
Chairperson, honourable members
I wish at the outset to pay tribute to my colleagues, the 9 MECs for health and the elected representatives of local government who participate in our meetings. Without exception, we work well together. For this, I thank them most sincerely. We have held each other's hands as we navigated what at times were turbulent waters. We have been constructively critical of each others' positions at times. At times our debates have been robust. But whatever discomfort might have been caused in the process pales into insignificance when compared to the constructive outcome of our deliberations. I make this point here in order to underscore my firm conviction that our system of intergovernmental relations is functional and as a collective I believe we are equal to the task we have been mandated to perform.
A major achievement of our co-operative interaction has been the elaboration of our strategic framework ( the ten point plan ) which guides our activities for the period 1999 to 2004. This document, copies of which are available, constitutes our collective assessment of the priority areas we need to tackle in the life of this second democratic government. This assures us that as we labour in our different areas of assignment, we all move in the same direction. This is critical to ensure that none of our citizens remain perpetually disadvantaged only on account of what province they happen to be living in. After all, South Africa is a unitary state. But this framework also acknowledges that there may be real differences in the provinces that may call for different approaches for the same problem. We take the view that we should celebrate this diversity as, if properly channelled, it provides a richness of experience and lessons that could be put to good use. This perspective informs the work of our MINMECs. We use our these meetings as fora for constructive dialogue; sharing of experiences and joint monitoring of our progress.
Honourable Chairperson
One of the priority tasks we face is the need to complete the process of putting lasting building blocks for the creation of a unified health system. Two very fundamental elements have been largely executed.
1. The first has been the need to root the primary health care perspective in the South African psyche as the correct strategic approach to underpin our health sector transformation. The urgency of this task cannot be overemphasised as increasingly it becomes obvious that the narrow biomedical model is inappropriate to deal with the major global health challenges of our times. Such is the global experience for example with the twin scourges of HIV/AIDS and TB. This requires that we co-ordinate our activities across departments and other stakeholders as well as across the different spheres of government. This view was most eloquently captured by President Mbeki in his very first state of the nation address when he said " When a clinic is built, there must be a road to access it. It must be electrified and supplied with water. It must have the requisite personnel, qualified to meet the specific needs of that community".
2. The second element has been the successful construction of one national and nine provincial administrations out of the myriad of disconnected 14 entities that constituted health administrations in 1994.
The key challenges that we continue to face in the execution of this important task are;
First , the need to build on the recent advances made with the demarcation of local government to ensure the building of viable health districts as vehicles for the delivery of integrated primary health care services. This will of necessity mean a reconfiguration of the interim health districts. As honourable members would recall that in health we had already advanced and created interim health districts. But we have always indicated that we shall adjust the boundaries of these interim districts once local government demarcation was completed. We do so, so that we can align our health districts with those of other sectors. This is necessary to facilitate intersectoral co-ordination - a key element of the strategic approach of primary health care. These health districts will also be the vehicles of delivering comprehensive Primary Care Services. In this regard we are finalising a defined package of comprehensive services that will be delivered to be available incrementally to every citizen of this country by 2004.We see the health districts playing a critical role in delivering this package .
A related challenge is the need to build a seamless referral system to create the necessary incentives for the health system to be entered at the lowest possible level. We need to launch campaigns that discourage communities from flocking at the major tertiary and regional hospitals for minor ailments which can be effectively dealt with at the primary level facilities. Such an approach is not only cost-effective but more importantly facilitates better quality care throughout the health system. Success in this initiative hinges on our ability to raise the credibility of our public clinic system. This is a task in which we have to succeed. I take this opportunity to invite your active participation to ensure the requisite success.
The second important challenge in the building of a unified national health system is that of closely aligning the activities of the public, private and the NGO sectors. The challenges we face as a country require that we pool all our resources and expertise together. The Chinese wall that continues to exist between the public and the private health sectors needs to be broken. We need to promote areas of synergies both on the provision as well as on the financing of health care. We need to engage in a consultative national process to define workable strategies for a lasting partnership. In this regard we strongly support the decision of government to increasingly explore alternative service delivery models. In so doing we shall draw on our ongoing experience on the outsourcing of both clinical and non-clinical services. We also follow very closely the current initiative which is exploring options for public private partnerships in the supply of equipment for the new Inkosi Albert Luthuli Central Hospital. We shall proceed on this path not in a doctrinaire way but guided by the overall objective of extending affordable, good quality care.
As regards provision for example , we need to grasp that it is not in the interests of our country to continue to expand our physical infrastructure when there may be possibilities of entering into contractual arrangements to utilise existing resources more efficiently. To succeed , however, this approach has to be underpinned by some fundamental prerequisites. Amongst these are ; the need to improve affordable access and the need to share a common perspective on the key objectives of our health reform agenda as reflected in our white paper .
As regards health financing , we need to encourage as many of those who can afford to make some contribution towards the financing of their health care needs to do so, so that we can better target our limited fiscal allocation to more adequately assist the many in our country who remain trapped in poverty and require our assistance. This approach underpins the amendments to the Medical Schemes Act which you passed into law in 1998 and also informs our determination to work hard towards the introduction of a social health insurance as a component of an appropriate social security system in our country. Allow me at this point to briefly outline the progress we have made with implementing the Medical Schemes Act.
The Medical Schemes Act with all relevant regulations in place finally came into effect on the first of January this year. The move to enhance regulatory capacity in the Council for Medical Schemes is proceeding smoothly. A new Registrar has been appointed to spearhead the new Council's operations. We have been working with the registered schemes to ensure that their rules and constitutions are amended to comply with the law. We have focused in particular on ensuring that the amended rules allow as many people as possible to join schemes without any unfair discrimination on the basis of age and health status. A lot of work has also gone into ensuring that the schemes restructure their benefits to incorporate the legislated minimum benefits. So far approximately 150 of 170 registered medical schemes have submitted their amended rules for evaluation. We expect to finalise these re-registrations before the end of June. A considerable amount of time has also gone into putting in place mechanisms for the protection of the interests of members. We have ensured that health care brokers are accredited. These measures will over time ensure that people are protected from harmful behaviour in the market. We are also putting in place substantially enhanced complaints resolution mechanisms in the council. The intention is to resolve members' complaints as quickly as possible.
Another fundamental task facing us is the need to reorganise our support services to support a unified national health system. In this regard we shall focus on 7 areas.
THE DEVELOPMENT OF APPROPRIATE HUMAN RESOURCES CONSTITUTES ANOTHER FUNDAMENTAL CHALLENGE
Together with my colleagues the MECs for health , we have taken a firm decision to accelerate the development of a comprehensive HR plan for health. We have appointed a team led by Prof Pick and supported by WHO to assist in this task. This is going to be no easy task but we are convinced that its further postponement can only cause more harm and bring about a reversal of some of our gains. Last Thursday we had occasion to receive the preliminary report of this team. Some of the key messages are;
1. The need to move more rapidly and forcefully to ensure greater representation of the previously disadvantaged in our institutions at all levels. This should be linked to a review of admission criteria to improve the recruitment of those who will be prepared to serve in the rural areas
2. The need for the above to be supported by effective support programmes to ensure that the improvements in intakes also translate into improvements in outputs.
3. The urgent need to curtail areas of overproduction in our system.
4. Greater emphasis to be put on appropriate categories and numbers of midlevel and multiskilled health workers.
5. Curriculum reform to ensure that early on after studies, young professionals can impact positively on the drive towards universal access to good quality primary care services.
6. We need to formulate workable strategies to deal with the high levels of emigration and exodus to greener pastures of some of our key and experienced personnel thereby reducing our capacity to deliver quality care to our citizens.
Whilst all the above goes on, we shall continue to depend on the system of community service to help extend services to rural areas. So far this programme has been a success. We are extending it to include dentists beginning this July and then pharmacists in 2001.
Last November in our consultation with you, we shared some of the findings of the report on the confidential enquiries into maternal deaths. We indicated that all of us had committed to initiate the measures necessary to rectify shortcomings . That work is ongoing . So too is the work on improving access to termination of pregnancy services particularly for the rural poor. The portfolio committee hearings last week also helped to highlight a problem that strikes at the heart of the constitutional promise of the right to reproductive choice. Evidence is indeed accumulating that shows the benefits of the Choice on Termination of Pregnancy Act. Maternal mortality from complications of abortions have decreased. Of course this will be a gradual process. We continue to improve the skills of health workers to perform this procedure. We need however, to address the problem of health workers who negate the provisions of our Act thereby putting others at risk. We all have a role to play in this task. Let it be clear, that whilst we respect the views and the constitutional protection of those who themselves would not wish to render their services to perform terminations, we also unequivocally uphold the constitutional protection all women should enjoy to reproductive choice. At the same time, we regard as imperative that the right of women to have access to emergency medical services as well as the right to proper and accurate information on services available to them be protected. In this regard, I appeal to all health workers to understand their obligations and not engage in activities that will deny others their right to exercise their choices. We shall attend to this matter with a greater sense of urgency. I appeal, honourable members , for your active participation in this task. We cannot continue to betray the women of this country particularly the rural and the poor.
Honourable chairperson,
Another area that we shall be giving greater attention to is hospital development. All of us in all provinces are familiar with both the reality and the perception of serious public concern over the state of our hospitals. These concerns span the entire spectrum from levels of cleanliness, attitudes of staff, poor management, poor work ethos, physical dilapidation and concerns overall about quality. We need to deal with all these elements comprehensively and we will. A primary challenge in this regard is the need for a comprehensive national strategic plan for the hospital sector. Such a plan must build within it elements that will help create a network of facilities for the 21st century factoring in such concepts as access for people with disabilities as well as women and baby friendliness. At the same time we need a hospital plan that relates to our reality of the growing burden of HIV/AIDS. We have commenced with this task.
An important element of our hospital reform is the need to empower managers locally by decentralising management authority. We have linked this initiative with a move towards general management where it no longer is the case that only doctors stand at the head of our institutions. We hope this initiative will attract many good managers to carve for themselves a career in the health sector. Work is ongoing in this area in many provinces. The success of this initiative depends on the presence of appropriate incentives. One such incentive is revenue retention. We are encouraged by the recent moves in Gauteng and the Western Cape in this direction.
Last year you provided us with R200million for hospital rehabilitation and reconstruction. R155million of this amount has been allocated and spent with the remainder fully committed and due to be spent in this financial year. A further R400million has been allocated for this year. A major obstacle so far has been the absence of comprehensive provincial strategic plans. This is currently being addressed and should lead to an acceleration of the programme. An area of major concern for us is the continuing significant underinvestment by all provinces in capital expenditure and routine maintenance . This is a recipe for disaster. Whilst all of us can rationalise our current spending patterns on account of the crowding effect of our personnel budgets and the consequent reduction of our non-personnel expenditure, the truth however is that these perfectly rational explanations are no cause for comfort.
I wish to note the progress with two major hospital investments we are undertaking. First, the New Nelson Mandela Academic hospital in Umtata. This new hospital will have approximately 540 level 2 beds with 60 specialist spinal beds at the existing Bedford hospital. This will improve referral and specialist services for a significant part of the Eastern Cape largely rural population. In addition, this hospital will contribute to a more appropriate teaching platform for the health science faculty at Unitra. The current Umtata General hospital will be rehabilitated and remain open on the adjacent site as a level 1 facility. This new Nelson Mandela academic hospital should be completed in November 2001. A key challenge now is to ensure that appropriate human resources both clinically and managerially are available for this institution.
The second major hospital investment is Inkosi Albert Luthuli Central hospital in Durban. This will be a major central hospital providing highly specialised services for the whole of KZN and the northern part of the Eastern Cape. This major project is due for completion later this year. This facility also will contribute to the improvement of the teaching platform for the health science faculties in the greater Durban area. This will complement the major contribution made by King Edward Hospital. At this point I wish to salute the health workers of King Edward and Groote Schuur . These two state hospitals have been rated amongst the top 10 medical facilities in the country in a survey covering 100 hospitals nation-wide. This recognition should spur all of us into action to emulate these examples.
These 2 major hospital investments referred to, contribute in a very concrete way to the correction of an historical injustice perpetuated by the previous regime and are a fitting tribute to these two outstanding heroes of our liberation struggle.
A related activity is the concerted effort we are putting on the development of specialised services in the 5 relatively underdeveloped provinces namely; Mpumalanga, Eastern Cape, Northern Cape, North West and Northern Province. This initiative is important in the promotion of greater equity between different regions in our country. We all know that our major institutions are particularly concentrated in Gauteng and the Western Cape. This is not sustainable in the longer term. Whilst we recognise that there are services that it is neither cost-effective nor desirable to provide everywhere, we do however believe that there are specialist services that it is desirable for every province to be enabled to provide. This work is facilitated through the Redistribution of specialised services grant. Other critical purposes of this grant are the reduction of cross-provincial referrals as well as the building up of expertise, specialist teaching , clinical standards and the overall quality of care.
Two examples where this grant has been particularly effective are Potchefstroom in the North West and Witbank in Mpumalanga. In Potchefstroom we established a new oncology centre which is currently treating 250 patients per month whereas previously all these patients were being referred to Gauteng. Similarly the renal dialysis unit here has quadrupled its capacity thereby providing a service for people closer to their families.
Witbank has been transformed from being a level 1 hospital to being largely level 2 comprising nine specialist departments with 13 full-time and a number of sessional specialists. Other developments include the establishment of a 15 bed ICU and the equipment of a trauma unit, an important development for the N4. Early this year, I had the opportunity to visit this hospital and witness first hand some of the changes. From this platform, I wish to recognise the enthusiasm and dedication of the health workers that was in evidence.
To date R110 million has been spent on various projects under this grant. In this year's budget an additional allocation of R176 million has been allocated to advance these initiatives.
Another related initiative has been to encourage our teaching institutions to decentralise their teaching platforms also to facilities in other provinces. We do so out of a belief that this is good both for the development of our students as well as the services. It is important that our students are familiar with the reality and diversity of our country. This enables them to be better prepared for service. At the same time there is absolutely no question that when teaching takes place at peripheral institutions it helps attract human resources and results in overall improvement in the quantum and quality of care at the periphery. This has been the clear picture emerging from the partnership between Pretoria university and Witbank as well as from the partnership between the Northern Province and Medunsa through its satellite campus at Pietersburg/Mankweng. We look with interest at the partnership between the Northern Cape and the university of the Free State as well as the discussions between North West and Wits for specialist support for Klerksdorp, Potchefstroom and Mafikeng hospitals. It should of course be stressed that the decentralisation of the teaching platform referred to should also extend to other facilities at different levels within the same province. In this regard we welcome the initiative in the Free State to open a satellite campus at the Goldfields regional hospital. I wish to convey a clear message to our teaching institutions of the eagerness of my department to be partners with them in these important undertakings. I also believe that our overall funding for health personnel training should more and more explicitly incentivise these initiatives.
Chairperson, honourable members, all these activities have one fundamental objective namely to improve access to good quality services for all our citizens. An important and critical component essential for our success is the mobilisation of all our people to participate actively in their own interests. We hope that the Patient's rights Charter that we launched on the 2nd of November 1999 will become a rallying point highlighting a lot of the necessary social dimensions of quality. We shall follow this with a comprehensive policy on quality this year which we believe will guide such interventions as peer review systems, clinical audits and complaints mechanisms. I am happy to note a lot of activity driven by my colleagues , the MECs to ensure that these initiatives take root in all provinces. I appeal to you as elected representatives to put your shoulders to the wheel and mobilise for the success of these activities.
For in spite of the many examples of outstanding service alluded to, there is that minority that does so much to betray our people. They need to be exposed and rooted out. Our service for a caring nation and a humane society obliges us not to compromise on this.
Honourable members, this address would be incomplete without dealing with the twin scourges of HIV/AIDs and TB. In my address to the National Assembly, I raised a number of pertinent points in this regard. Time does not permit for me to repeat what I said then but I would like to highlight the following ;
Added to the HIV and TB burdens, our country is witnessing a significant rise in malaria cases particularly in KZN, MP and NP. We are responding to this both in our own country as well as by working with our neighbours within the structures of SADC. Recently, Cabinet resolved to lend financial support to these provinces. With our neighbours we have also decided to continue with a programme of controlled and restricted use of DDT because of the growing resistance to the pyrethroid insecticides that we are using.
Finally let me report on progress we are making with our systems of internal controls. We are happy that for two consecutive years, the Auditor General has given us a clean bill of health. We have consolidated this with the establishment of a functional internal audit unit and an audit committee in line with the PFMA. We are proceeding with the implementation of the other components of the PFMA. Similar progress is to be noted in the majority of provinces.
This address would however be incomplete without a comment on a disturbing pattern in the allocation of the budget for health in the different provinces. The poorer provinces notably Mpumalanga and Northern Province continue to have a significantly lower per capita spend on health. This has significant implications for equity - a cornerstone of our health policy. In your oversight function, this receive your attention.
Conclusion
Let me take this opportunity to sincerely thank this house for its support. Special thanks go to the social services committee and its chairperson - comrade Loretta Jacobus. I wish to confirm my willingness to work with you across the political divide. My thanks go also to my organisation - the ANC and the President for having entrusted me with this most rewarding task at this critical stage in our history.
To the many health workers at all levels the vast majority of whom are the true architects of our glorious future , I say ISIZWE SIYABONGA.
To all South Africans, together with my colleagues, we pledge our loyalty to the cause of a better life for all.
Whatever the cost to ourselves, we shall serve you.
We shall not fail you
God Bless our beautiful land
I thank you