Tuesday 12 June 2001
Chairperson and honourable members
You have before you, for your consideration, the national health budget, amounting to R6,61-billion. Given the special character of this House, I expect that you will not view this budget in isolation but will assess how it interacts with and adds value to the provincial health budgets, which exceed R28-billion in total.
About 90% of the national health budget is directly allocated to provinces in the form of conditional grants:
Chairperson, I believe that we can confidently claim we are making steady progress towards fulfilling most of these goals. Our clearest gains have been in the areas of:
In addition, in most provinces long-standing patterns of over-expenditure on budgets have been reversed. This is certainly evidence of improved financial management at all levels in the provincial health services.
Against this progressive trend, however, there are a couple of features that contradict our transformation agenda.
The one is the familiar issue of quality of care in our health services - a matter that I addressed at length in the National Assembly last week. We are striving to make the Patient's Rights Charter a living reality in our services but we are still far from achieving this. I believe we should not be deterred by this fact - the problems that undermine quality of care are complex and are not amenable to instant solutions. But we also need to recognise that we will not succeed unless we provide powerful leadership to quality initiatives and infuse a measure of discipline that has been sadly lacking in recent times.
The other matter of concern is a disturbing retreat from our goal of establishing equity across provinces. We made significant gains between 1994 and 1997 in narrowing the gap in per capita health spending between urban and rural provinces. But this progress has not been sustained in recent years. With the introduction of fiscal federalism, competing provincial priorities have eroded gains in health spending particularly in the less developed provinces and equity has suffered in the process.
I want to flag this trend in this Council and appeal to the members of this chamber to consider its implications in terms of addressing the basic needs of our most disadvantaged people and breaking the cycle of poverty.
The proportion of the national health allocation that is retained for the national Department's "own" work is small but it inevitably has a wide impact. In essence, it is spent on drafting laws and policies, setting norms and standards and undertaking research and surveillance.
New policies and programmes depend largely on provincial resources for their implementation. Alignment between the two spheres of government is, therefore, critical for effective delivery. It is important to note that our intergovernmental structure, the Health Minmec, plays a central role in achieving this alignment.
The Minmec carefully scrutinises national health plans and subjects them to reality checks so that they take account of resource constraints. This process allows various elements of the health system to move largely in unison, thereby giving expression to our basic constitutional character as a unitary state. At the same time, the Minmec also recognises that provinces face different conditions and that implementation strategies may vary.
The concurrent exercise of powers by different spheres of government would be unworkable without a clear sense of priorities and shared direction among the leadership. I used the opportunity of my Budget speech in the National Assembly last week to outline some of these priorities, and would like continue the process this afternoon focusing on different areas of intervention. Unfortunately, time does not allow for a comprehensive review and I hope members will read my remarks in the National Assembly in conjunction with today's comments.
This afternoon I would like to focus on:
Firstly let's look at: Developing the district health system
There is a firm view, held across the public health system, that primary health care services should be administered and controlled at a local level. Partly, this has to do with ensuring that communities can engage the authorities directly about their service needs. But it also relates to the fact that health is an inter-sectoral endeavour and that co-operation among these various sectors works best when it is focused. The definition of local health districts provides precisely such a focus and creates the conditions for good coordination among role players.
When the restructuring of local government took place late last year, health district boundaries were redrawn to coincide with new municipal boundaries. Soon after this the Health Minmec took a policy decision that primary health care services should be delivered by local govrnment wherever this option is viable and acceptable to both the province and the municipality in question.
I would like to emphasise that the shift of primary health care services to local authorities will be an incremental process. In each locality the shift will only take place:
A service agreement between the province and the municipality will spell out the terms of transfer of primary care services. The agreement will specify the services to be delivered by the municipality and it will set out financial, human and other resources to be contributed by the province.
We welcome and support initiatives by the Minister for Public Service and Administration to incorporate local government personnel into the public service. This would certainly facilitate the personnel transfers that are critical for the building of our new health districts. It goes without saying that labour law provisions would be observed at all times in creating the new districts and that appropriate talks would be held with trade unions.
Decentralisation has many obvious benefits - but, unless it is managed carefully, it also has the potential to create or increase inequalities. Our strongest defence against this danger is the very thorough work we have done to create a standard service package for primary health care in clinics and community health centres. This not only specifies the range of services to be delivered, but also itemises the mixture of staff, the equipment and the drug supplies needed.
The package of services represents a realistic norm for primary care delivery. We believe that the vast majority of clinics and community health centres will be able to achieve this norm by the year 2004. During the course of this year we will be conducting an audit of services and resources in all health districts so that we actually know the size of the gap between what presently exists and the standard we want to achieve.
I want to make a commitment to members of this house that the transfer of primary care services to local authorities will be an exercise in development and not a dumping of responsibility. We are proud of the advances we have made in primary care - our expansion of immunisation, our improved STD management, the strengthening of TB treatment and increased access to maternity care, to name just a few achievements. We will guard these gains jealously throughout the process of restructuring.
Obviously, as local councils become major players in the public health sector it becomes necessary to create structures to give effect to co-operative government between provinces and local authorities. These Provincial Health Authorities would play a similar role as the Health Minmec currently plays.
The National Health Bill will be tabled later this year and it will provide a firm basis for the division of responsibility among spheres of government and for the consultative processes that will ensure that all elements combine to form a single national health system.
Turning to our second focus area of Human resource strategies . . .
There is more than a little truth in the commonly held view that there is a shortage of health professionals in the public sector; that the rural areas are worst off; and that the brain drain is hurting public health care. But, of course, the picture is a lot more complex than this and I can only give you a flavour of the issues relating to recruitment, redistribution and retention of personnel.
Firstly, recruitment and the related matter of training:
At the time of last year's budget vote the Department had just produced a major strategy document, entitled Human Resources for Health.
Two further human resource audits have been undertaken during the last year:
The evidence on recruitment and training points to one simple fact: Government and the institutions that train our health professionals are badly out of step. Few university medical faculties can show real results in terms of the diversity of their student bodies. A minority of clinical departments in medical schools have embraced the goals of health sector transformation. I believe this situation demands urgent remedial action.
Our medical schools represent a considerable public investment and their potential to contribute to the development of our country is enormous. But we will not reap this benefit if we do not engage each other fully and honestly. I am therefore inviting the relevant university administrations to get together with Government (that is, with the departments of Education and Health) so that we can jointly hammer out an Accord on the Transformation of Training in Health Sciences. I believe we should commit ourselves to achieving this Accord before the end of 2001.
Chairperson, as the Human Resources for Health report suggests, the so-called "shortage" of health professionals could often be more accurately described as an extremely uneven distribution of professional personnel. Our provincial health departments vary in the extent to which they experience serious shortages of health professionals. Provinces that are mainly rural are hit by shortages in almost all professional categories, while the urban provinces only experience problems filling posts in a few occupations where the private sector has great pulling power.
A compelling need to introduce doctors and other professionals into distant, dispossessed communities has driven our community service programme as well as various country-to-country agreements for the deployment of foreign doctors.
In the Northern Cape, for instance, there were only 20 full time doctors in the province in 1994. As a result of community service and the employment of Cuban doctors, the number of full-time doctors employed in 2000 was 111 -- a five-fold increase. In the Eastern Cape, community service has put pharmacists into hospitals that have been without a single pharmacist for some years.
Critics of community service refer to it disparagingly as a stop gap measure, with low retention of professionals beyond the compulsory year. For instance, in the Northern Province last year, just 20 out of 137 community service doctors stayed on after completing community service. The chances are that far fewer than 20 South Africa- trained doctors would have been recruited to the Northern Province without being introduced through community service. And, although the yearly turnover is not ideal, I have no doubt that any patient in pain and distress would rather have a "stop gap" doctor than no doctor at all.
Perhaps surprisingly, a recent feature article in the Afrikaans Sunday paper Rapport portrayed the community service initiative in a really positive light. The young professionals who were interviewed confirmed that being sent from the world of plenty and privilege to serve in an environment of need and destitution is a life-altering experience. It is an experience they will carry with them forever -- and that will continue to influence their professional practice.
I would like to pay tribute to the young doctors, dentists, pharmacists and allied health professionals who have performed their community service with commitment, often in conditions that are far from easy. For me, if you talk of patriotism -- this is the genuine article: A real contribution of service to our country at a critical time in our history.
Finally, in the area of human resource planning there is the challenge of retaining skilled professionals in the public health sector -- and, indeed, in South Africa.
When it comes to the foreign brain drain, we recognise that higher salaries in developed countries -- together with the exchange rate that favours these countries -- are inevitably going to attract a certain number of our health workers. We may regret this -- but freedom of movement and freedom to sell one's labour are basic rights that we have built our democracy on and we cannot restrict these rights.
However, any responsible Government would take steps to protect its assets and we certainly need to devise strategies that will conserve the public investment in human resources for health care.
We need to recognise that many health workers leave this country temporarily -- for instance, to gain experience abroad or to boost their earnings to repay student loans. Such international exposure generally leads to personal development and enriched knowledge -- therefore iwe should make it easy and attractive for returning professionals to reintegrate into the public sector.
It might very well be in our interests to facilitate short-term foreign contracts for public sector health workers and to offer options for continuity of pension and other service benefits. We will be exploring ways of doing this within the context of South-South cooperation -- and, more specifically, to benefit our neighbouring countries in the SADC region.
We want to state quite clearly that, although we recognise migration as a normal phenomenon in any free country, we will continue to object vigorously whenever developed countries plunder the meagre skills resources of developing countries in organised recruitment raids. Countries that systematically under-produce skilled workers because it is cheaper to poach them from poorer countries are guilty of exploitation. This is simply colonialism in a new guise -- and, in the context of knowledge-based economies, it is as destructive to our national interests as the rape of our natural resources was in the past.
As South Africans we are proud of our decision not to meet our short-term human resource needs by bleeding the health systems of our neighbouring countries.
The outflow of health professionals to the private sector probably represents a greater drain on public health services than foreign migration does. I am not arguing in any way for the demise of the private health care sector, but I do believe that it should be aligned with the overall public health goals for the country. When the private sector operates in a way that undermines national health objectives -- for instance through wasteful and irrational practices that create artificial markets -- then government is compelled to intervene.
We have already done so through a number of laws that are designed to reduce health costs in the private sector. The Medicines Control Amendment Act, for instance, outlaws kickbacks (which artificially increase demand) and compels pharmacists to offer the cheapest versions of prescribed drugs. The Pharmacy Act opens up ownership of pharmacies and therefore increases competition. The Medical Schemes Act strengthens the hand of members in relation to the schemes, and the schemes in relation to service providers.
We acknowledge that conditions in the public sector are also a significant factor when it comes to the loss of professional personnel. There are many aspects of the working environment, over-and-above salaries, that are unattractive. Poor management systems, in particular, impose additional burdens on busy professionals. We need to work constantly at improving the working environment and injecting attractive features into the public health settings.
We also need to ensure that there is representivity in all sectors of the health profession. To this end, a group of pharmaceutical companies and private health care institutions have initiated a bursary scheme, in my name, to provide financial assistance to deserving students in a variety of fields.
In concluding my review of human resource planning, I would like to mention that the Department is finalising a comprehensive gender policy and that we aim to launch this publicly before the year is over. Of course, the policy extends beyond issues of human resource development -- but gender issues are of direct concern to a huge number of our health workers and this seemed an appropriate point to share our plans.
The policy deals with issues of women's health in a comprehensive way and includes policy perspectives on violence against women and girls, safe pregnancy and motherhood, female cancers, women's mental health, tobacco control and health promotion issues, as well as ways of making the health system more responsive to women's needs.
Planning for the impact of HIV/AIDS, tuberculosis and other related diseases is my next focus area.
The specific allocation for HIV/AIDS programmes in the Budget before you is R207-million. However, this represents only a fraction of the amount actually spent on HIV/AIDS in the health sector. The bulk of spending on treatment for AIDS-related illnesses is indistinguishable from general hospital and clinic spending in all provinces.
The challenges of meeting the demand for HIV/AIDS treatment and care were at the heart of the meeting that was held in Pretoria last week between Health Ministers of the SADC region and representatives of seven of the world's largest pharmaceutical companies.
All of the countries represented at that meeting reported that the sheer size of the HIV/AIDS epidemic makes it extremely difficult to deal effectively with adequate nutrition of people living with HIV and the treatment of opportunistic infections -- let alone expand health infrastructure to the point where anti-retroviral therapy can be done in a safe and responsible way.
Furthermore, in the SADC region we have embraced the view taken at Abuja conference last month, that there is no justification for dealing with HIV/AIDS in an isolated and elevated way when other diseases like TB and malaria are having a devastating impact on our countries. These emerging and re-emerging diseases have common roots in poverty and underdevelopment. To some extent they have common solutions in poverty relief, development and the general strengthening of health systems. Therefore they demand a response that is coordinated and comprehensive.
SADC health Ministers asserted the position that -- given the incurable nature of HIV/AIDS -- prevention programmes must remain the first line of attack and should not be reduced in scope, no matter how urgent the need for expanded treatment infrastructure. And the drug company executives concurred with this view.
UNAIDS executive director Peter Piot drew the obvious conclusion that the HIV/AIDS epidemic will not be tackled effectively on the resources of the affected countries alone. A massive and sustained contribution of resources is required from the countries of the Northern hemisphere. This, of course, is what the Global Fund for HIV/AIDS and Health - initiated by UN Secretary-General Kofi Annan -- is all about. Like other developing countries South Africa has a vital interest in the success of this fund.
However, the possibility that the demand for treating AIDS-related conditions could overwhelm our health services has been apparent for some time -- and we have never believed that we can sit back and wait for an outside benefactor to solve the problem.
Last year the Government commissioned a study on the likely impact of HIV/AIDS on health services. The study was completed late in 2000. It was essentially a modelling exercise in which existing research was utilised to produce various scenarios.
The value of the impact study lies not in the exact figures produced -- in fact, there are some methodological problems that have to be sorted out and this will alter the figures. The true value of the study lies firstly in the inescapable conclusion that the demand for AIDS care will far outstrip the capacity of our health system to deliver unless we take decisive action to strengthen our health system. Secondly, and equally importantly, the study suggests areas where we could intervene most fruitfully to reduce the gap between demand and supply of health care.
The top treatment priority that emerges from the impact study is more effective control of tuberculosis. On-the-ground experience in provinces confirms this finding that effective control of TB will be the key to containing the burden of opportunistic infections. Every province has taken steps in the past year to improve TB management and all are targeting it as a priority in the year ahead.
TB cure rates have improved to about 65% in recent years thanks to widespread implementation of the DOTS community-based treatment strategy. Pilot schemes for integrating TB and HIV management have yielded promising results and will be scaled up. At the integrated sites, many HIV-positive patients can be given medication to prevent them developing active TB.
National and provincial departments have set in motion a forensic audit of SANTA, which is contracted to provide hospital care for a large number of public sector TB patients. Members of this chamber might have seen the tender for the audit advertised this week. This move follows a review of TB hospitals run by SANTA and Lifecare, that uncovered some serious problems in the management of the institutions.
The HIV/AIDS impact study also highlighted the need to build alternatives to hospital care: Our main alternative form of care is home- and community-based care which is still at an extremely early stage. This year we will focus on providing additional funding to existing projects so that they can consolidate their services. Some provinces are funding NGO-run hospice beds and in the Gauteng and Northern Cape health departments have created the first step-down facilities within public hospitals.
When we talk of strengthening the health system, we are referring to improving its overall efficiency -- for instance, by managing length of stay, ensuring care is delivered at the most appropriate level of service and pursuing the lowest possible drug prices.
The use of nevirapine to prevent mother-to-child transmission of HIV may substantially reduce pressure for paediatric AIDS care. It will only do so, however, if we can ensure that the majority of babies that are protected by nevirapine at birth are not exposed later to the risk of infection by being breast fed. 18 research sites for prevention of MTCT have been designated in order to understand the demands for a successful programme. One of the aims of the programme is to sustain the mother in good health through nutritional supplements, prompt treatment of opportunistic infections and supportive counselling. Some of the sites will also research the matter of drug resistance in mother-to-child transmission programmes. Five research sites in three provinces are already operational and others will follow soon. We are also prioritising the promotion of voluntary counselling and testing because knowledge of an indvidual's HIV status is the pre-condition for various prophylactic and and therapeutic measures. Provinces have taken up the challenge of expanding the number of facilities where this service is on offer. For instance in the North West the number of sites offering voluntary counselling and testing has been increased to 78 and 350 nurses have been trained in the use of rapid test kits for HIV.
There has been considerable progress in certain provinces in establishing AIDS Directorates where these did not exist and staffing them appropriately.
When it comes to Emergency medical services we need to remind ourselves that . . .
Emergency medical services are the single area of health care where the Constitution confers an outright guarantee of service provision. Emergency medical services are also an exclusive function of the provinces. Although they are not specifically funded by a conditional grant, I'd like to spend some time reporting on this area because it has been the focus of public debate and there have been considerable changes during the year.
Until recently most provinces depended on local authorities to deliver non-institutional emergency services on their behalf -- in other words, to staff and run their fleets of ambulances. The arrangement worked with varying degrees of success -- but overall it was unsatisfactory.
During the past year:
The final significant item on my list is Hospital Revitalisation. We have identified better management systems and skilled managers as critical factors in the programme of Hospital Revitalisation, impacting both on the dimension of quality of care and on capital works projects. All provinces confirm that they have taken this priority on board. Wherever provinces are reducing or eliminating over-spending, better financial management -- particularly by hospital managers -- has been a critical factor. Funding is available from Treasury for further development of management skills during the course of this year . Amounts totalling more than R3,5-billion have been allocated for a three-year programme to restore and replace hospital facilities. In all, 242 hospitals will benefit from this programme. To date 331 individual building projects have been completed at 86 hospitals. Provinces have also shown results in relation to improving the mobilisation of resources:
I spoke at length in the National Assembly about quality of care. I believe that it is the responsibility of every health worker to contribute directly and on a daily basis to better health care. It is a responsibility that should not have to be imposed from above, but enacted simply as part of our professional commitment and our undertaking as public servants. The Batho Pele ethos is non-negotiable.
I also indicated in the National Assembly that I believed that there should be far more serious consequences for health workers who fail in their responsibility to deliver quality care. I would like to see cases of gross negligence, fraudulent behaviour and outright abuse of patients pursued much more vigorously by the various professional councils that are charged with defending the public interest.
It is disturbing that it has taken years for anybody to lodge a complaint against Wouter Basson and to ask whether his behaviour renders him unfit to remain in the ranks of the medical profession. It seems that our moral and ethical senses have been anaesthetised and that we are in need of a real shaking up. I would like to repeat my intention to appoint a task team to look into the ability of the professional councils to deal decisively and fairly with cases of professional misconduct and malpractice.In particular the task team will be asked to consider whether we need to review the legislation that governs the councils.
Honourable chairperson, before taking my seat I would like to thank a range of individuals for the constructive role they have played during the course of the last year.
Members of the Select Committee on Social Services and the Portfolio Committee on Health have continued to play a significant role in guiding our work. We thank all of them and in particular their respective chairpersons.
I started out this speech with a reference to cooperative government and want to acknowledge the contribution of all MECs for Health and their departmental heads in making this concept a living reality.
The President, the Deputy President and colleagues in the Cabinet have taken the challenges of health care to heart and I thank them for their interest and collegial support.
Finally, my thanks go to those whose daily and unremitting task is the improvement of our health system -- the thousands of health professionals, health support staff and health service managers across the country. We are profoundly indebted to those of you who do your work with compassion and understanding, guided by your deepest personal values. I include in this group officials and managers of the Health Department, and especially the Director-General of Health whose leadership remains constant in challenging times. I am also deeply appreciative of my personal staff and particularly the support staff - Lucky Motaung, Patrick Mahlangu, Jaco Theron ahd Chris Kondowe -- who work extremely long hours and respond to many unexpected demands with great resilience and good will.
Chairperson and honorable members, I thank you for this opportunity to address you and look forward to your responses.
Dr Manto Tshabalala-Msimang
Minister for Health