National Assembly, 4 June 2002
The national health budget that I have the responsibility to propose to you this afternoon amounts to a total of R7,18 billion.
This budget is not a huge amount in terms of the overall size of the national Budget. Public health services, as you are aware, are funded mainly through the equitable share allocated to provinces. But the manner in which this national budget is used has a critical impact on the entire health sector - private and public -- which spends more than R70-billion a year and affects every South African.
I intend to focus on major structural and policy issues in health - and on the international dimension that has a critical impact on our performance. Next week, in my address to the National Council of Provinces, I will look more closely at the service issues that are linked intimately to the provinces.
If you look to the numbers in the budget for indications of programme development, there are two obvious areas of expansion and one less visible area of change:
As a nation we have asserted through our Constitution a fundamental belief that health care is, in the first instance, a human right. It is not a mere commodity and we do not accept that unrestricted market forces are the best mechanism to distribute health care - certainly not in a country with the social inequality that we have, certainly not in a global economy where the divide between rich and poor countries grows ever wider.
National Health Bill
Our regulatory framework therefore embraces both the public and the private health care sectors. This year we will strengthen this framework by tabling the National Health Bill that spells out our vision of a single national health care system -- although with distinct components.
In framing this Bill, we have been guided by the broad public interest and the goal of creating and sustaining a health system that benefits all South Africans. Its drafting has involved a number of trade offs and, in seeking to balance various interests, we have kept our eyes firmly on the need to prioritise services for the poor.
The forthcoming World Summit on Sustainable Development has focused us on the relationship between poverty, development, health status and health services. South Africa and its SADC partners played a critical role earlier this year in positioning health issues high on the WSSD agenda. In January, we hosted an inter-ministerial meeting on health and development for SADC states and E9 countries. Just two weeks ago, we had the satisfaction of seeing the positions that we asserted at that meeting endorsed by the World Health Assembly in Geneva. It is certain that health will receive much greater attention at the WSSD than it did at the Earth Summit in Rio a decade ago.
The global health community has come to recognise that:
NEPAD principles
If this approach sounds familiar, it is probably because it is the thinking that underpins both our health sector transformation and the core principles of NEPAD.
We take pride as a country in the leadership we have discharged in elaborating the health component of NEPAD - a role that was recognised recently by African Health Ministers and a strategy that is fully endorsed by my SADC counterparts. We shall take this process further when African Health Ministers deliberate on the strategy at the next meeting of the WHO Afro Region a few weeks from now. Many of the bilateral agreements and relationships that we are forging in the current period are strategically geared to support the implementation of NEPAD. It should be no surprise that we count Lesotho and Angola among the newest signatories - and that Senegal and South Africa will endorse a declaration of intent this evening.
Another development that signals the possibility of pursuing a trans-national approach to combating major public health problems is the creation of the Global Fund to fight HIV/AIDS, TB and Malaria.
The Global Fund is a groundbreaking, multi-country public-private partnership. It was shaped by the Abuja Declaration on HIV andAIDS, TB and Malaria made by African Heads of State last year and called into existence by the UN Secretary-General, Kofi Annan. By April this year the Fund was making its first disbursements.
Challenges of Global Fund
South Africa is, of course, a donor to the fund - with a pledge of US$2-million -- and a major beneficiary. The Department of Health in partnership with various non-profit organisations - including the National Association of People Living with AIDS - has already been granted well over R1-billion over the next two years. When we consider that dedicated funding for HIV and AIDS for various departments in this year's budget amounts to about R1-billion, we begin to appreciate the magnitude (and the responsibility) of the Global Fund grant.
We remain concerned, however, at the Fund's weak response to the world's poorest nations. Very few benefited in the first round of allocations. And the value of the Fund will be seriously compromised unless we find ways to provide technical support to the least developed countries so that they meet the fund's fairly demanding standards.
This dilemma reflects the need for developing countries to play a stronger role in multilateral agencies. At the World Health Assembly, countries of Asia and Africa asserted a claim for increased representation of developing countries at WHO headquarters and in the expert committees and working groups of the organisation. This resolution was carried in the face of opposition from developed countries.
International differences were also apparent on a resolution in support of the basic right of access to health care for the people of Palestine - although, fortunately, the rift between the developed and developing countries was not as pronounced.
Madam Speaker, part of my intention in taking this international detour was to make the point that: We, the developing nations, have successfully argued on the international stage that health care must be seen as a weapon in the war on poverty -- and we now have a duty to live by the same rules within our borders.
We need repeatedly to interrogate whether our own health systems and policies really serve to promote the interests of the poor. And, I believe, a critical yardstick of this is how well we manage the risks to good health. Are our policies really geared to conserving health through well-tested preventive and promotive strategies? And are we conserving our health resources through good stewardship and wise use?
When it comes to preventive and promotive health interventions we, as South Africans, have a mixed report card. In relation to communicable diseases, we have learnt through experience to work in a concerted manner across sectors - and even across borders - to stem the tide of infection. And we have seen extremely positive results - for instance, in malaria control and the containment of cholera. Our national Partnership against HIV/AIDS is certainly a massive venture in containing health risks.
And our Expanded Programme of Immunisation has dramatically reduced dangerous childhood illnesses. We are proud to be moving into the final stages of achieving polio free status as a country and a region. In April, together with Swaziland and Lesotho, we launched a sub-regional Certification Committee for the Polio Free Initiative. This committee will ensure compliance with all the requirements to reach polio free status by 2005.
Trauma and chronic diseases
But our efforts and achievements are patchy when it comes to managing the risks associated with other major causes or morbidity and death: namely hunger, chronic disease and trauma.
Perhaps we mistakenly regard heart disease, hypertension, cancers and diabetes as diseases of excess that only affect an affluent minority. Nothing could be further from the truth: These diseases cut across every level of society and, in sheer numbers, take the greatest toll among poorer people.
Similarly, impaired mental health is experienced by large numbers of people living in conditions of hardship and deprivation. The old myth that the poor are resistant to psychiatric problems lay in the health establishment's refusal to acknowledge the humanity of the dispossessed. It is small wonder that emotional problems left to fester through times of violence and turmoil and economic hardship have produced such a high level of dysfunction - of suicide, alcoholism, domestic violence and sexual abuse.
Our trauma cases stretch our casualty departments to the limit as they treat the victims of criminal attacks, road accidents and shockingly casual violence. The causes are multiple - but one factor towers above the rest: the abuse of alcohol and other illegal substances. The constant rise in the proportion of gunshot wounds - which are very often fatal - tells us that easy access to firearms is fuelling the violence in our society.
Managing these major, costly risks to health requires committed inter-sectoral work and concerted action on a number of fronts.
We need the right policies and laws. I refer to measures like our Tobacco Products Control Act that is having a clear impact on limiting exposure to passive smoking and will be further strengthened through an amendment later this year. We need to carefully consider other areas where regulation might be more useful than persuasion. For example: Has the time come to set conditions and restraints on the marketing of alcohol? Are our road regulations sufficient to truly promote safety?
The new Mental Health Care Act was recently passed by the NCOP, providing a framework for more open access to services and a community-based approach that should help to reduce the stigma and fear that are associated with mental health problems.
We also need the right partners - within government and with civil society. The clustering of the social sector departments is already a powerful asset. But we need to invest more in partnerships with the NGO and private sectors. As Government we need to understand that potential partners do not lightly share resources, insights and their good name. If we want joint action, we have to work for it.
This was a key lesson that we drew from the Health Summit that took place in November last year with an attendance of more than 600 people representing a wide range of health sector interests. The Summit produced a set of very concrete actions and projects that we are now following up.
A further major factor in containing health risks is quite simply the people. Many pre-emptive measures in health are finally in the hands of individuals, groups or communities. We talk about empowering people to take control of their health, but what does that mean? In some situations - but not too many - information alone empowers people to act. Usually, we have to go further and release energy, hope and passion - so that people stand up and take action. Sometimes, we need to extend our involvement to facilitating the formation of organizations for sustained activity.
April this year was observed throughout the country as Health Month. As a first-time effort it was a considerable success, involving all spheres of government, non-governmental organizations and the private health care sector.
Health Month in action
Various MECs for Health report that the response from communities was both inspiring and humbling. Volunteer activity formed the core of events - and this ranged from cleaning and repairing hospitals, to establishing food gardens, digging toilets in cholera-prone areas and joining TB or AIDS programmes as care workers.
People commented how this shared activity bridged social divisions - between employed and unemployed, public servants and communities, rich and poor, educated and illiterate. The experience of Health Month has renewed our commitment to building "people centred" public administration.
Close to 90% of the budget before us flows through the national Department to the provinces in the form of conditional grants - grants that pay for tertiary level services, for medical training, capital projects and special programmes, like nutrition and HIV and AIDS. These grants are added to provincial health votes and 60% of this combined amount will be spent on personnel.
When we talk of managing the risks to health, therefore, a critical dimension is our ability to build and conserve our human resource assets. Indeed the successful conclusion of our transformation agenda depends on this.
The solution lies in a range of interlocking interventions to address the burning questions of:
Expanding community service
When it comes to shortages in the rural areas, the system of community service provides significant relief. It has been estimated that 26% of public sector dental posts and 31% of pharmacy posts were filled through community service in 2001. This year, the programme will put no fewer than 1 742 young doctors, dentists and pharmacists into the field.
In 2003 we shall expand community service to cover physiotherapists, radiographers, occupational therapists, speech and hearing therapists, clinical psychologists, dieticians and environmental health officers.
We are working to improve the quality of supervision for new practitioners - especially in remote country areas. With the help of telemedicine facilities and private practitioners, we are making headway.
We harvest the first crop of nine graduates in our Cuban medical training programme in September. Candidates were recruited largely from rural provinces and are contracted to work in the province that sponsored them. Presently we have 252 students in Cuba and a further 71 will depart later this year.
This year we have introduced a special development grant, that is only available to the rural provinces, to expand registrar posts at regional hospitals, thereby increasing the pool of specialists outside the major cities.
We are also addressing the supply of health workers, through the introduction or expansion of mid-level workers. We envisage that a category of assistants to professional personnel could be useful in a range of areas - including rehabilitation and pharmacy, where professionals are especially scarce.
We believe there must be more flexibility in defining "scopes of practice" which set out the functions of various health professions. We support ongoing work by the statutory councils to review these boundaries. An excess of professional territoriality may bar health workers from legally performing procedures that they are quite capable of doing - thereby denying help to patients.
There is little doubt that human resource challenges of the public health sector can only be successfully addressed if three powerful parties pull together - the training establishments, the professional councils and the government. If any one of these is half-hearted in its contribution, the project will fail.
Graduates for our times
I believe that we have made real progress towards better partnership in the past year. But there is still much room for improvement in the overall representivity of student intakes at medical schools and the support offered to students from disadvantaged circumstances.
We are also perturbed at the poor alignment between the country's health needs and the professionals we are producing. Some medical schools are turning out graduates who are so poorly equipped to deal with malaria, HIV and AIDS, STIs and TB that they require immediate retraining in these areas. Professional nurses are emerging from four-year training unqualified to perform as primary health care practitioners. This is incomprehensible -- after all, it is almost eight years since we positioned primary health care as the foundation of our national health strategy.
In the past year we have tackled the health brain drain at the highest levels - among Ministers of the Commonwealth and through the World Health Assembly. We are close to agreement on a Code of Practice for recruitment of health professionals among Commonwealth countries. This Code will not restrict international recruitment but, by setting requirements for fairness and transparency, it will make migration more predictable and therefore less destructive.
Global labour markets
If the brain drain is the downside to a global labour market, the upside lies in opportunities for training and professional exchanges. We have identified particular fields in which we lack expertise - for instance, biotechnology, pharmaceutical policy support, epidemiology - and have received training offers from several countries.
Within the context of the SADC region, we are proud that South African universities have created 100 places at medical schools - over and above the normal intake - for training students from the region. We were honoured to count the Minister of Health of Swaziland, Dr Phetsile Dlamini, among the Medunsa graduates receiving their post-graduate degrees in public health last week.
In my last Budget speech, I raised questions about the role of the health sector statutory bodies in ensuring professional accountability. I asked whether these councils - the Health Professions Councils, the Nursing Council, the Pharmacy Council, the MCC, the MRC and the Council for Medical Schemes -- were equal to protecting the interests of the public.
During the year a joint task team from the Department and various statutory councils has considered these issues and produced a preliminary report.
Further work will be done to apply the general principles adopted by the Task Team to individual councils and amendments may be made to relevant laws.
Hospitals and equity
The financing of hospitals is a fundamental aspect of our quest for equity. The national health budget impacts on this through conditional grants for tertiary level care. And this year the basis of these grants shifts fundamentally.
Until now the bulk of tertiary care funding has been targeted at 10 central academic hospitals in only four provinces. This was based on the perception that they were responsible for the country's tertiary care. However, we did an extensive survey - visiting 531 units in 62 hospitals - and found a poor relationship between where tertiary care grants were directed and where the work was carried out.
For instance, Gauteng and the Western Cape received 73% of the funds available - but were only performing 56% of the services. Conversely, certain other provinces were offering substantial tertiary care, with little or no assistance from the national budget. This meant they were funding tertiary services at the cost of investing in more basic health care - and, of course, this raises serious questions about equity.
What compounded the situation was the fact that the big teaching hospitals are not really "national referral hospitals", as we believe. We found that more than 90% of patients at six major academic hospitals came from the province where the hospital was situated. The benefit to surrounding provinces was small indeed.
As a result of this research, the Health Minmec has decided to phase in a system of "like for like" funding for tertiary health services, beginning this year. All existing tertiary level services will be fully covered by the grant - but where the grant has been subsidising lower levels of care, this will no longer be possible.
Redistribution of resources is never a comfortable process and some sacrifices are unavoidable. But let us be clear, if we lack the integrity to face these sacrifices, then it means we are prepared to simply live with the social legacy of the Bantustans; that we are comfortable to let the wretchedly poor subsidise services for the less poor and the wealthy.
Search for consensus on care
Our actions to reshape tertiary services include a broad consultative process that we call the Modernisation of Tertiary Services. A month ago we invited hospital managers, clinicians and deans of universities to join us in creating a consensus vision for tertiary care, in a process that will unfold over a year.
We need shared solutions to a variety of challenges . . .
. . . solutions that eliminate wasteful duplication, which takes the form of two or three hospitals in the same metro running similar super-specialist units - as happens in Gauteng and the Western Cape.
. . . solutions that are more affordable and therefore preserve tertiary care by making it financially viable in the long term.
. . . solutions that clarify the relationship between tertiary care hospitals and medical schools.
. . . and solutions to the technology backlog and skills shortages that undermine the quality of tertiary care.
There is certainly a tension between the strategies of extending access to primary health care to all our people and, at the same time, improving tertiary level services - which are costly and benefit limited numbers. We have no option but to wrestle with this tension - because we cannot contemplate sacrificing our tertiary hospitals. To do so would be to destroy the integrity of the public health care system, which is based on a referral chain from a network of clinics, through district and regional hospitals, to highly specialised facilities.
Turning to the subject of HIV, AIDS and tuberculosis, I wish particularly to highlight the areas of expanded activity.
The response to Cabinet's statement on April 17, following its consolidation of our HIV and AIDS Programme, has been encouraging. We will do everything possible to nourish the spirit of hope and purpose with which Cabinet has addressed the situation. Central to this endeavour will be the consolidation of our multi-sectoral response and improved implementation of all major aspects of our national five-year strategy.
Care after sexual assault
Members may be aware that we have finalised national protocols for the provision of a combination of two drugs, AZT and 3TC, at public health institutions for survivors of sexual assault. The protocols cover the type of counselling that must be provided to enable survivors to make an informed choice about the medication with a full understanding of the risks involved and require that they give written consent.
It is important that the public should appreciate that, while nobody can undo the damage of rape, a comprehensive health system response significantly limits the harm. We can prevent women becoming pregnant through emergency contraception, or - at a later stage -- termination of pregnancy. We can prevent sexually transmitted infections - which can have long-term consequences for reproductive health. We offer AZT and 3TC - in the manner described above - plus crisis counselling and referral for further counselling. The evidence that is collected during examination by the health worker may be critical in a court of law, if the survivor chooses to charge the attacker.
We are committed to steadily increasing the number of facilities where this kind of assistance is available. And we call on every member of this Assembly to help us remove the barriers of self-blame and shame that prevent survivors from seeking help.
It is difficult to predict what the uptake for AZT and 3TC will be. But we have done some cost estimates for this new intervention that is, of course, not covered by the current budget. However, in the light of Cabinet's commitment to assisting rape survivors, we feel confident that a satisfactory funding solution will be found.
Major new funds
Before I deal with the HIV and AIDS features of this budget, I would like to highlight the fact that one of the most significant innovations in AIDS funding this year falls outside this budget. It is an amount of R400-million factored into the equitable share for provinces in order to help hospitals and clinics and community programmes meet the added demand for treatment and care. We appreciate the support from Cabinet and the Finance Ministry for our endeavours to respond more effectively to HIV and AIDS.
Government and its key partners continue to assert that prevention programmes are the corner stone of our national HIV and AIDS Strategy. During the coming year the amount allocated to this Department for prevention increases from R158-million to R172-million.
South African AIDS prevention activities are varied, creative and substantial - and they extend well beyond Government initiatives. Our free condom distribution is massive. The use of the media -- and especially educational radio and television - has given prevention initiatives an enormous boost. So: "Where are the results?" we keep asking.
HIV rate stable
The bottom line in HIV and AIDS prevention is whether the HIV infection rate begins to drop. The best measure we have of this is our annual prevalence survey done at public sector ante-natal clinics. The 2001 results confirm that the HIV prevalence rate has stabilised.
But perhaps the biggest cause for optimism is the sustained drop in HIV prevalence among mothers under 20 years, making for a total drop of 5,6% since the prevalence peaked in this age group in 1998.
Improving health through behaviour change is always a slow process. We appeal to pessimists and critics not to stand on the sidelines - if you have a better idea, get involved. Our hope of defeating HIV and AIDS lies in the size, the diversity and the morale of the army we build.
When it comes to prevention of mother-to-child transmission of HIV, the clinics and hospitals grouped as 18 research sites saw more than 90 000 pregnant women during the first year. About two-thirds elected to take an HIV test and about 10 000 of those who tested positive were provided with Nevirapine.
The programme now moves into the critical stage of the one-year follow-up test on the babies who received Nevirapine. This will tell us:
Answers will inform development
We feel we have a duty to face these difficult questions. We want to be effective in saving the lives of children and we need especially to understand how the choice of feeding options impacts on the long-term outcome. The answers will enable us to fine-tune the programme at existing and future sites and will inform decisions for the general roll-out plan.
The Constitutional Court ruling on prevention of mother-to-child transmission will, of course, have a bearing on how we proceed.
Additionally, our research to establish whether a single dose of Nevirapine produces long-term resistance to the drug is proceeding under the direction of the National Institute for Communicable Diseases. The manufacturer, Boehringer Ingelheim, is co-funding this research.
We are committed to early and effective treatment of the many illnesses that people with HIV and AIDS are prone to. And we want to state unambiguously that the health services will act to root out discrimination against people living with HIV and AIDS through the refusal to treat opportunistic infections.
The effective treatment of tuberculosis and STIs is particularly critical and last year we did important groundwork to improve our responses. Technically, our public sector STI management is excellent, but we need to build a better relationship between our public services and young clients, in particular. And we need to share technical know-how with the private sector.
Refining new TB approach
In relation to TB, we have achieved the basic turnabout from a hospital-based to a community-based service over the past five years. We are now in a position to look more critically at the quality and effectiveness of this new programme. We have set targets for the next five years, successfully canvassed for major funding from the Global Fund and identified external experts who can assist us. As the country with the ninth most serious TB problem in the world, we have much to learn from others. Next week we are hosting a major Africa-region TB conference in Durban in partnership with the International Union against TB and Lung Disease.
Undoubtedly one of our greatest unmet needs is providing end of life care. It is here that the relationship between social and health services becomes critical. It is here that the gravity of poverty begins to exert a terrible pressure. It is here that the focus switches from an individual in need to a whole family in need.
We are striving to build community- and home-based care in the face of rapidly growing demand. Our allocation for home-based care is stepped up to R47-million this year and for the first time an amount - totalling R30-million -- has been earmarked for "step down" beds, providing hospice type care within hospitals.
I would like salute the women and men who have taken upon them the responsibility of caring for all terminally ill people in our communities. Many are retired nurses who feel compelled to return to their calling. We admire your courage, we recognise your compassion and, as a society, we are deeply indebted to you for bringing relief to many whose existence centres on suffering.
The health service has a vital role to play in training community health workers and supporting home-based care networks. A person who devotes herself to this work is Ms Philisiwe Magubane, a midwife working at Nkonjeni Hospital in KwaZulu-Natal and the first national winner of the Cecilia Makiwane Award for outstanding nursing practice. We are honoured to have Ms Magubane in the Public Gallery today. We also have Ms Gladness Mathebula from Ehlanzeni District in Mpumalanga, representing one of seven outstanding districts in our annual District Health Service Competition.
The challenge of improving quality of care - in the way our two special guests have done -- remains a central concern, and I will deal with this extensively in the National Council of Provinces.
Medicine costs still a priority
The quest for safe and affordable medicines remains high on the national health agenda. We realise that there are some concerns about the lack of visible progress. But, since the drama of the Medicines Control Amendment Act court case - which was resolved out of court in April 2001, we have been working on four fronts:
The diversity and complexity of health care makes it difficult to give a full account of the progress made during a single year. We tend to go down the well-travelled routes, looking at areas that are of most concern to the public and yourselves.
But work in highly specialised areas continues - and it ranges from regulating the genetic modification of foods to policy on human cloning. So does the "backroom" effort to strengthen our support services, which form a critical national and regional resource in our fight against disease. In this regard, I'd like to mention two developments.
Vaccine production
The first is an unfolding public-private initiative involving the State Vaccine Institute. The Institute has been in decline for about a decade and it needs a large injection of capital to become viable and competitive. We decided that the only way to achieve this was through public-private partnership. We now have a preferred bidder in the shape of a consortium combining South African, Cuban and British players. And we believe that this strategic asset is poised for redevelopment to the extent that it will, eventually, play a much bigger role in vaccine manufacture than it ever did.
The National Health Laboratory Service came into operation as a public entity in the middle of 2001. While the research functions of the NHLS are still largely government-funded, the laboratory services are self-sustaining as preferred provider to the provincial health services.
Appreciation of support
In closing, I would like to thank the Health Portfolio Committee of the National Assembly and the Select Committee on Health and Social Development in the NCOP for their constructive interest and particularly for the perspective that they bring through work in their constituencies. My interaction with the chairpersons, the Honorable Ngculu and the Honorable Jacobus, is especially valuable.
I would also like to express appreciation to my political colleagues: To President Mbeki who has made time to attend key health events, members of the Cabinet and - more especially - my colleagues in the Social Cluster; and to MECs for Health of the nine provinces and our counterparts in local government. It is at times like this, I that I find myself thinking of our colleague, the late Minister Steve Tshwete. His commitment to duty remains an inspiration to us all. He featured large in my political life, from our time in exile, as a comrade, an advisor and an infallible source of strength.
The Ministry enjoys a cooperative relationship with the South African Military Health Services and particularly with Surgeon-General van Rensburg. I am deeply honoured by their decision to accord me the rank of colonel in the service.
A special mention should be made of our international partners, for both financial and technical assistance - and for the spirit of solidarity. In addition to the African agreements mentioned earlier, we have also signed agreements and declarations of intent with Tunisia, Algeria, China, India and Brazil.
My thanks go also to the health statutory bodies and to officials of the of the Department, especially our Director-General Ayanda Ntsaluba. Perhaps my deepest appreciation is owed to personnel in the Ministry - and to my husband, Mendi, my family and my household support staff. I particularly miss Sonto Dlangalala, my Pretoria housekeeper, who passed away earlier this year.
And, as I take my seat I would like to say to the nation's health service providers, we - and I'm sure I speak for this Assembly - we salute you and we continue to expect only the best from you.
Dr Manto Tshabalala-Msimang
Minister of Health