Cape Town, 5 June 2001
Madam Speaker and Honourable Members
In a society as unequal as our own, and particularly in one that is still deeply divided along racial, gender and class lines, a critical measure of the success of government remains the degree to which it manages to narrow the gaps between rich and poor people.
I want to say quite clearly that our government stands firmly for transformation to achieve social justice, particularly through services like health that touch the lives of those who are most deprived, predominantly the African majority.
Over the past year, we have made some significant progress and registered some clear successes in many critical areas of our work. But there are other areas of delivery where we are falling short of the results we seek.
Therefore, Madam Speaker, in accounting to this House for the proposed budget of over R6,6 billion, I intend to highlight programmes and priorities that attest to our commitment to improving the lives of the majority of our people. At the same time, I will raise some critical questions about the strategies we pursue, and whether there is a need, in some cases, to review our approach.
During my address today I will focus on six aspects of health care delivery.
Firstly, Madam Speaker and Honorable Members, the question of quality of care:
Most of the people who use our public health facilities are poor. In addition, many are unemployed and they live without adequate shelter, nutrition or clean water. Their health is undermined by their social circumstances and at the same time, social development is retarded by their ill health. Quality health care is critical in breaking this cycle.
What do we mean by quality of care? I believe that there are some key components to it. Firstly there is the area of the values and attitudes of health workers. This encompasses compassion, empathy, respect for human dignity and a general orientation towards a human rights culture. Secondly, there is the area of professional skills and clinical competency. Here we are talking about effective health care that achieves good clinical results. Thirdly, there is the area of personnel management including effective disciplinary procedures.
In terms of providing quality of care, I believe that we have made some major gains. We launched the National Patients' Rights Charter 18 months ago and since then, every province has promoted the Charter widely in its services. In addition, in order to promote a human rights ethos amongst health care workers, each province has instituted several practical quality of care initiatives. These include service excellence awards, hospital accreditation systems, the revival of peer review committees, the establishment of hospital boards and the strengthening of patient information processes.
However, despite our efforts in this regard, I am aware that many patients complain about the services that they receive in the public health system.
We get complaints of patients lying in their own soiled linen; of health workers verbally abusing and intimidating patients; of staff stealing resources at the very time when our hospitals are struggling to make ends meet; of our health workers doing additional private work during their off-duty hours and then giving very poor service in the public sector because they are exhausted.
I know that there are many health workers - professional and non-professional -- who do their work, on a daily basis, with skill, dedication and compassion, often under the most difficult or challenging circumstances. For this they have to be commended. But I would be failing in my responsibility if I did not scrutinise the conduct of all health workers and more especially that of the sub-culture where there are people who are dishonest, callous and lazy.
I also recognise the depth of the problems that undermine quality care. In some instances, resource constraints are a factor, and so is poor or ineffective management. But these constraints cannot excuse fraud, abuse or negligence. I believe that the most appropriate answer to this problem is the consistent and unhesitating application of disciplinary measures against offenders, by the employers and by the relevant professional council.
We are therefore embarking on a three-pronged approach within the public health service. Firstly, we will expand our programme of promoting the Patients Rights Charter amongst both our health workers and the people who use our services. Secondly, we will institute measures to increase the effectiveness of the management at hospitals and clinics, and to upgrade professional skills and practice. And thirdly we will scrutinise the effective use of existing disciplinary procedures and penalties for fraud, patient abuse and professional negligence.
Beyond the public sector, we will look at the functioning of the professional councils. I have already met with them and I am pleased to say that they have responded positively. They have committed themselves to a campaign to educate people on their right to complain. This is a positive step. But I do not believe that it goes far enough. We have to ask ourselves whether the professional councils are sufficiently independent to be impartial when it comes to patient complaints. To this end, I will appoint a task team to assess the present legislation that governs the professional councils and to advise me accordingly. I undertake to report back to you on this process during the coming months.
Madam Speaker, I will turn now to the matter of Hospital Revitalisation because across all provinces, hospital care claims more of our budget than any other programme:
R3,27-billion is granted to hospitals that serve as national referral centres for highly specialised treatment.
There is an urgent need to arrest the deterioration of our hospital stock. However, there is little to be gained from the physical rehabilitation of the buildings without paying equal attention to the quality of care that I have been discussing, and also to more effective management. Through the Hospitals Revitalisation Programme we aim to address all three concerns in an integrated and co-ordinated way.
Developing our management strength is the critical factor. Both the physical renewal of hospitals and the improvement of service standards demand skilled managers and appropriate management systems.
Accordingly , we invested R30-million last year to appoint chief financial officers and senior support staff in our hospitals. A further amount of R79-million has been earmarked to improve management efficiency in the coming year.
The third item on my checklist of topics, is the district health system and the consolidation of our gains in primary health care.
The recent cholera epidemic infected about 100 000 people in the last nine months and caused more than 200 deaths emphasising the crucial link between poverty, development and health. Excellent care by our health workers helped to keep the death rate down. Even so, the number of cholera cases continued to grow. Through this we became aware that long-term answers lay not in health care but in the provision of clean water and proper sanitation.
The way that we managed the cholera epidemic has been a strong vote of confidence for the primary health care approach:
Since 1994, we have brought health services within easier reach of about 6-million people by building 500 new clinics. During 2000 we turned our attention to the standard of services in our clinics through a national survey done by the Health Systems Trust. This highlighted areas of progress in our clinics and also, areas of concern.
Progress is reflected in the fact that:
On the negative side:
A critical feature of primary health care -- and a strong reason for locating these services at the local level -- is to create governance structures that can be directly influenced by people living in the communities that they serve. I would like to inform the house that I intend to address the formal re-structuring of primary health care services in my speech to the NCOP next week.
When it comes to HIV/AIDS, STDs and TB, Madam Speaker, I would like to point out that today, the 5th of June is a particularly significant date
It is exactly 20 years ago today - on the 5th June 1981 - that the Centre for Disease Control in Atlanta published its historic report recognising AIDS for the first time as a distinct syndrome. When one considers the impact of HIV/AIDS on the continent of Africa, the destruction it has wrought on families, communities and economies, it is astounding to think that the "official age" of this medical condition is just 20 years.
We are privileged to have with us today, as a visitor to Parliament, Dr Peter Piot, head of UNAIDS. Dr Piot has worked hard to promote the position that the HIV/AIDS burden in Africa and Asia must be dealt with as a global challenge. We welcome him to our country.
In the absence of a cure for AIDS, prevention and the appropriate management of those infected and affected are fundamental. Effective responses demand that we tackle the hidden and overt prejudice against people living with AIDS.
Last month I had the opportunity of addressing the World Health Assembly on behalf of the SADC region. I explained our approach to fighting HIV/AIDS through a complex set of interventions. Together these form a comprehensive, multi-sectoral approach that is fundamental for success.
The interventions that we believe are key are the following:
In terms of prevention, there are signs that safe sex messages are beginning to bear fruit among the youth. A range of youth surveys show high awareness of HIV/AIDS, good knowledge of prevention methods -- and even, in some instances, reports of increased condom use. In addition, for the last two years our ante-natal survey has shown:
During the last year we have also registered meaningful advances in relation to treatment and care.
Madam Speaker, there is tremendous public interest in the nevirapine programme to prevent mother-to-child transmission of HIV. We have invested considerable time and energy preparing the research sites for this programme.
The programme involves much more than administering a dose of nevirapine to mother and child. It has to be grounded in a research setting. It therefore involves:
The 18 sites have been set up within a research framework precisely because we want to answer several, as yet unanswered questions. These relate to drug resistance and toxicity. They also relate to the ability of HIV positive women to sustain safe infant feeding practices in a population where mixed breast-feeding is the norm. The benefits of nevirapine are more likely to be reversed where mothers mix breast milk with other foods. Furthermore, we will also have to get to grips with the costs of this integrated and comprehensive service.
In the final analysis, we will only claim that we have successfully prevented mother-to-child transmission when we have prevented sero-conversion in the infant for two full years and sustained the mother in reasonable health for that period. In this regard, I would like to mention that we are at present awaiting the final 2-year results of the SAINT study into nevirapine that was partly funded by the national department.
With regard to the use of anti-retrovirals in triple therapy for the long-term management of AIDS, our position remains the same. We have no plans to introduce the wholesale administration of these drugs in the public sector. ARVs are not a cure for HIV/AIDS. In addition, we remain concerned about aspects of toxicity, the availability of laboratory services, and infrastructural and educational constraints, particularly in the rural areas., I would however like to assure this House, that this position is not ideological. Obviously we will continue to explore all the options available to us, including the provisions of our legislation and the WHO and UNAIDS-sponsored negotiations with pharmaceutical companies.
The biggest challenges in the year ahead will certainly relate to the initiation of a national programme of community and home-based care. The model for this that has been drafted deals comprehensively with the health, as well as the psycho-social and welfare needs of families affected by HIV/AIDS. Furthermore, it integrates the care of AIDS orphans into the broad community care approach.
Madam Speaker, none of us should underestimate the challenges of getting a programme of community and home-based care off the ground. Each local care network is unique and complex and each needs strong co-ordination. We must find the means to generate hundreds of these networks in very short time.
Thinking of the task ahead from the vantage point of this historic day - the 20th anniversary of the naming of AIDS - my mind goes back to the early 1980s and the rise of the final round of mass resistance to apartheid. The price was repression on an unforeseen scale, but that repression simply generated new forms of organisation: the crisis committees, the parents support committees and the advice offices. We created communities of amazing care in the face of vicious repression.
Fellow members, many of us were architects and builders of peoples' care structures. Let us renew our commitment to people of this country by tacking up the AIDS-care challenge in a similar way.
The fifth item that I am raising concerns South Africa's involvement in the international health arena
At the heart of all our international contact is our guiding principle of meeting the day-to-day needs of the South African people.
Our success in the recent Medicines Act court case is still fresh in our minds and I'm sure this house needs little reminding of the role that local and international solidarity played in this. I would especially like to acknowledge the support of the ANC Women's League, our labour movement and PWAs. Less than a week ago we published for comment the regulations to the Medicines Act that will enable us to implement the legislation that has been delayed for three years. The regulations, like the Act itself, are fully consistent with the international trade agreements to which we are party. There will be a full three-month period for commenting on the regulations and we look forward to a robust engagement with all stakeholders.
South Africa has also done extremely valuable work at an international level in relation to tobacco control. We have made a strong contribution to the drafting of Framework Convention on Tobacco Control. We hosted the African consultative meeting on this convention in March this year where representatives from across the continent developed a unified position on international tobacco control. When the global meeting on the Convention took place in May the coherence of Africa and the strong stand that Africa was taking, were clearly evident.
Here at home, the ban on tobacco advertising and sponsorships is in full force and the control of smoking in public places is gaining ground. There are, of course, some disturbing exceptions and we will use the powers vested in us by the Tobacco Control Act to deal decisively with them.
Perhaps our most valued work across national borders is the development of health sector co-operation in the SADC region. Member countries have set clear priorities for co-operation and, with regular contact, we have developed durable joint positions on several critical issues. In particular, we have adopted a common set of principles to guide our responses to the discounted packages of AIDS care. SADC health ministers, as a group, will meet representatives of the major drug companies in Pretoria on Friday this week.
The health sector is contributing actively to the development of the Millennium African Renewal Plan, spearheaded by our own President and the heads of state of Nigeria and Algeria. Our experience in relation to TB, HIV/AIDS and the issue of affordable medicines has been critical in shaping our inputs to MAP.
We successfully hosted the health minister's meeting of the Non Aligned Movement in March in Johannesburg. The declaration produced by that meeting formed the basis for a resolution tabled at a World Health Assembly in May.
Some of our most valued international exchanges are made, not in multi-national fora, but in terms of the professional work of generous and skilled medical practitioners who come to South Africa from other countries.
Foreign doctors, serving our people in terms of a number of bilateral agreements, make an invaluable contribution to health care in our rural areas. For instance, we have a group of Tunisian doctors who have organised a number of visits to our country to help reduce the backlog in cataract surgery. A group of African-American medical practitioners, known as the Zenzele doctors, has partnered with private South African practitioners and they too use vacations and spare time to take specialist skills to outlying hospitals
Finally, in relation to our international liaison I would like to comment briefly on the many bilateral arrangements that we have with a number of countries that provide valuable technical assistance to us. It is my intention in the coming year to focus on making the most of these international partnerships in order to ensure that we derive the maximum benefit.
My sixth and final area concerns our involvement in the private sector
When it comes to private sector health care provision Government continues to play a critical role through legislation and policy development.
When the Medicines Act becomes effective, patients who pay for services out-of-pocket and medical scheme members stand to benefit hugely and rapidly from its provisions. As medicines become more affordable, the costs of health care cover will be contained, members will get better value for the cover that they buy and more people will be able to purchase health care.
The Medical Schemes Act that we passed two years ago is beginning to have the desired impact. This Act not only outlaws exclusion from schemes on the grounds of age or health status, but also guarantees minimum benefit packages and attempts to protect members through prescribing minimum reserve levels in the funds.
The Council for Medical Schemes administers the Act and - in a short period - it has tackled its regulatory role with imagination, putting a high premium on public education and effective responses to complaints. The Council is still partially funded by the Department of Health but it will in future be financed through levies on medical scheme members.
An amendment Act will be brought before this House before the end of the year to fine-tune the principal Medical Schemes Act in line with the lessons we have been learned in the first two years since this ground-breaking law was passed.
I would like to highlight the fact that the relationship between government and the private health care sector is not a one-way street. Take the contribution of the Ophthalmological Society of South Africa: no fewer than 300 ophthalmologists have pledged to contribute 60, 000 free cataract operations over the next five years to help eliminate cataract blindness. Private sector patients will pay for their own hospital costs. The Bureau for the Prevention of Blindness will sponsor low-income patients.
In Conclusion,
Madam Speaker and honourable members, I would like to end my speech with a reminder and an announcement.
The reminder is as follows: The World Health Organisation has made mental health its focal area for the year 2001. This is in recognition of the fact that mental illness takes an enormous toll of countries at all levels of development. While mental illness might not feature clearly in the mortality figures, the WHO estimates that it will be the biggest single cause of disability in the world within 50 years. In the face of this, only 16% of countries devote more than 1% of their health spending to mental health programmes.
South Africa does allocate more than 1% to mental health spending, and this year we will increase the allocated amount by re-prioritising spending in the national office. Furthermore, during this session we will table a new Mental Health Bill, the first fundamental revision of the statutory framework for mental health care in several decades.
The announcement concerns our intention to host a national Health Summit later this year. The idea is to engage a wide range of experienced individuals and critical interest groups in a constructive debate on the direction of national health care. The Health Summit has been conceived in the belief that strategic planning is a dynamic practice and that openness to new influences enriches the process.
In closing, I would like to say my thank yous, and I assure you they are not ritual thanks but are sincerely felt.
This is a rare opportunity to thank all those committed health workers throughout our country whose invaluable contribution to the nation is so seldom recognised.
Throughout the year senior officials of the Department and I have enjoyed a constructive working relationship with both the Portfolio Committee and the Select Committee, under the leadership of Honourable Members Dr Abe Nkomo and Ms Loretta Jacobus respectively. There has been a very helpful balance between constructive criticism and support, and I thank you.
On an on-going basis, we sustain and build a productive and challenging working relationship with our political colleagues including the President, members of the Cabinet and the MECs of the nine provinces. To them all I say thank you.
I would also like to place on record my thanks to the chairpersons and members - old and new - of the Medicines Control Council, the Medical Research Council, and the South African Institute for Medical Research.
Finally, my thanks go to officials of the Department, and also the staff in the Ministry, who continue collectively to support our efforts to provide a just, equitqble and humane health care system for all South Africans.
Dr Manto Tshabalala Msimang
Minister of Health