Issued by: Department of Health
12 June 2002
Chairperson and Honourable Members
The act of presenting the national Health Budget to this chamber of Parliament focuses our attention on the challenges of co-operative governance. We have come to appreciate that co-operative governance demands a high level of alignment in the planning of programmes and budgets - among provinces, and between provinces and the national Department. Without such an alignment, the achievement of national health goals will remain a distant dream.
The challenge of aligning our efforts becomes particularly critical as the health sector consolidates its involvement in the third sphere of government with the building of the district health system. This will significantly increase the number of points of influence over the outcome of our interventions. Clearly there are many strengths to this decentralised approach. The point being made, however, is that collaboration and commitment to common goals are absolutely necessary for the system to work.
And we cannot assume that this kind of co-operation will occur spontaneously.
Perhaps a starting point is for all of us to have a common understanding of what we hope to achieve through the many strategies aimed at reforming of our health system. Briefly:
I highlight these points to indicate that there are competing demands on our system and the relationship between different components of the system will not always be harmonious. Pain may have to be endured in one area in order to achieve substantial benefits in another.
This, I believe is the perspective that needs to inform our analysis as we examine the budget before us.
At the outset, let me state that - although we continue to make progress - we can do even better. Above all, we need to take responsibility for our actions. We cannot be indecisive and sloppy, yet expect good results. We cannot lead change without leaders. Wherever there is strong leadership, we see the reward of good results. At the same time indecision can only lead to the disappointing results we see in the Eastern Cape and - to some extent, Mpumalanga.
It is fitting therefore, as we consider the policy objectives that this budget of R7,18-billion supports, that we survey the resources and the capacity available across the country to implement the approaches we have adopted. We cannot ignore the fact that our public health system still features grave inequities among provinces.
Many of our national health goals - and the many of the UN Millennium Development Goals - relate to dealing effectively with the risks to good health. Programmes of prevention and health promotion, plus early intervention, make the most impact when it comes to improving health indicators. I spoke extensively about these in my address to the National Assembly and looked particularly at factors like tobacco use, alcohol abuse and environmental hazards.
Risk management in relation to the health of mothers and children is also critical to the achievement of our core health goals. The reduction of infant and under five mortality rates is a critical objective in our national health strategy and international programmes that we have endorsed.
Improved immunisation is a key success factor in reducing child mortality.
As a country we have succeeded in expanding the number of illnesses we immunise against, in running mass immunisation campaigns and in improving the proportion of fully immunised children. The last aspect has been won slowly and it has come about largely as a result of integrating our primary care services and running clinics as "one stop shops". Clinic workers are encouraged to use every contact with the child to catch up on missed vaccinations.
However, there are one or two provinces that lag behind. test provinces, in terms of the proportion of fully immunised children, is as much as 25%. International experience is quite clear - once immunisation levels drop below a critical point, diseases aggressively reclaim their ground. We truly need cooperation of all provinces to ensure that this does not happen here.
Another intervention that has been shown internationally to improve the survival chances of children is the Integrated Management of Childhood Illnesses. I am happy to report continued progress in expanding this approach across the country.
Last year we reflected on the challenges we face in improving the Primary School Nutrition Programme, which continues to benefit more than 4-million children. A review of the PSNP produced a series of recommendations and Cabinet has given us the green light to act on these. At the heart of the changes is improved co-operation between the departments of health and education, increased community involvement and the incorporation of national standards.
We will need support from all provinces later this year when we introduce regulations that will require manufacturers of mealie meal and wheat flour to add a range of micronutrients to their products. Although we have taken care to work with major interest groups and taken precautions to ensure that small milling companies will be able to meet the requirements, some opposition to this change is inevitable.
It is important, therefore, that we are clear about the need for this intervention. Of course, the primary evidence comes from the Food Consumption Survey that showed high levels of micronutrient deficiency and low calorie intake in children under nine years. It also revealed stunting in 22% of children in this age group.
We also need to be confident that we will achieve the desired results in terms of improving the nutritional status of children. I want to assure Honourable Members that our nutrition unit has conducted extensive research on effective and acceptable levels of supplementation. We have not only looked at the experience in other countries, but have tested responses locally with the assistance of organisations such as the CSIR.
Turning to our goals in relation to women's health, the risks that relate to pregnancy and childbirth remain a central concern.
I feel compelled to refer to the issues that have recently come to the fore in relation to implementation of the Choice on Termination of Pregnancy Act.
The message that filtered clearly through last month's Parliamentary hearings is that women seeking terminations are being denied this choice because too few health workers are prepared to perform the procedure.
We know - through our systematic monitoring of maternal deaths - that loss of life due to septic abortions has dropped during the last three years. We believe that this is due to the availability of free, safe and legal terminations. However, the decrease in deaths due to abortion is still not what we would like to see. And the public health system must take more seriously its responsibility for eliminating abortion-linked deaths - - through more accessible contraceptive programmes, in the first instance, and through a termination service that is able to respect and act on women's choices.
During the past year we have produced national guidelines on contraception and a policy on youth and adolescent health. We sincerely hope that these documents will assist provinces to extend age-appropriate reproductive health services. We need to remind ourselves that the 1998 Demographic and Health Survey found that only two out of three women in urban areas and half of those in rural areas were using contraception. In some cases women were choosing not to - but among rural African women the unmet demand for services was as high as 35%.
Chairperson and Honourable Members, we understand the causes of maternal deaths only because we have a dedicated, anonymous monitoring system. It has been operational for about four years now and I wish to acknowledge the effort that committed health professionals make to ensure its maintenance.
In some provinces there is such a shortage of gynaecologists and obstetricians that monitoring depends on better-resourced provinces "sharing" monitoring committees with their neighbours - as in the case of the Free State which has supported the Northern Cape.
Our monitoring tells us that AIDS has become the leading factor in maternal deaths and it threatens to undermine efforts to reduce maternal deaths unless it is proactively managed. We need to encourage voluntary counselling and testing generally so that women can make reproductive choices with knowledge of their HIV status before they become pregnant. In the case of those HIV-positive women who opt to have children, pregnancy and labour can be managed according to protocols that take account of the increased risks to the mother and baby.
When it comes to programme goals for HIV and AIDS, we have come to appreciate that a strong voluntary counselling and testing service is the foundation for success in many more specific interventions. This was one of the first lessons from the research sites on reducing mother-to-child transmission of HIV. The quality of the counselling and the convenience of the testing facility actually determined the uptake on the service.
For the last two years, since the introduction of the rapid HIV test, the expansion of testing sites has been a priority for which special national funding has been available. In practise, the expansion has been quite variable from province to province. Some provinces have more than 100 testing facilities, others only a handful. Undoubtedly this is an area in which we must jointly reassess our targets and tackle some of the human resource constraints that affect the creation of accessible, user-friendly testing facilities.
On the HIV prevention front, there is evidence of involvement in public events and campaigns across the country. Surveys indicate close to universal availability of condoms at clinics - and this year we will be supplying 350-million condoms for free. Members of the public cite health facilities as an important source of information on HIV and AIDS. Schools based life skills programmes are gaining ground - although at different rates in various provinces.
The major boost that we have received from the Global Fund will benefit all provinces through stronger prevention campaigns, improvement of youth-oriented services and better TB control.
I would like to recognise those provinces that are moving ahead rapidly to utilise the conditional grant for step-down care. For instance, during the April Health Month, the Free State launched step down facilities in a number of districts almost simultaneously. Gauteng and the Western Cape have also done good work in this area.
Another area in which substantial progress has been recorded in the last year is the training of health workers in various aspects of treatment for people with HIV and AIDS. Some of this training has taken place through health department training structures and some has been a product of the Diflucan Partnership with Pfizer. KwaZulu-Natal built a particularly good training programme around this. The provision of Diflucan is going well but we suspect there are pockets of unmet need. We would welcome feedback from the public and public representatives about the gaps in the service.
We have also seen a strengthening of the inter-sectoral approach at provincial and district level with the consolidation of provincial AIDS councils and the expansion of AIDS councils for municipal areas. We now have AIDS Councils in at least 55% of local government jurisdictions. The North West Province has taken the process through to all 18 sub-districts.
The importance of local-level coordination and networking cannot be over-estimated. It lays the basis for integrating prevention, treatment and care and it is our only hope of ensuring that "positive" individuals get appropriate support and treatment at every stage. The difficulty of sustaining contact between organisations in the current situation of rapid development was highlighted at the Health Summit last year. As a result, the Department has commissioned a "mapping exercise", to locate and link existing resources in particular districts in all provinces.
In recognition of the need to increase resources for treatment and care of people living with HIV and AIDS, Cabinet factored an additional R400-million into the equitable share allocated to provinces. All provinces - except the Eastern Cape - have recorded growth in their health allocations for the current year and it appears that this allocation to improve our collective response to HIV, AIDS and TB has largely reached its intended target.
However, it remains a concern that - even as the national Department is in talks with Treasury for additional funding to improve our response to HIV, AIDS, STIs and TB - there are a few pockets of money allocated for AIDS programmes that go unspent.
Improving mental health care is certainly an item on our checklist of national priorities. Just a few weeks ago this House set its stamp of approval on the Mental Health Care Bill and we now must ready ourselves to implement it. At the national level this has meant finalising the draft regulations that will deal, among other things, with the licensing of establishments for treatment of mental health problems and will set quality standards for some of the more controversial forms of treatment - such as electrotherapy and sleep therapy.
However, the weight of preparation for implementing this legislation really rests with the provinces. The law seeks to place a much greater emphasis on treating mental health conditions within the community or within general health facilities.
This requires that a large number of health workers in primary health care settings and general hospitals must be trained to manage mental health problems. I believe that the essentials are in place - the training materials and the trainers - and I trust that the President's signing of the law will be the catalyst that is evidently required to get this process moving.
The new law also states very plainly the obligations of health service providers in terms of upholding and promoting the human rights of patients.
A particular challenge is the assertion that the patients' right to dignity must be upheld at all times. The physical state of some of our psychiatric hospitals - fortunately not all that many - is truly an affront to human dignity and this must receive urgent attention. The rehabilitative element of patient care also demands greater investment.
The issue of quality of care and patients' rights is, of course, a critical issue at all our health care institutions.
The Hospital Revitalisation Programme (with a budget of some R528-million) and the Hospital Management Grant (amounting to R129-million) deal with some substantial elements of quality of care.
They focus, on the one hand, on the physical necessities for decent care - the buildings and the technology (or equipment). And they target the management systems and the skills needed by managers in order to drive a process of quality improvement.
This comprehensive approach has kicked off at one hospital in every province this year. The selected institutions - all of which have submitted detailed business cases - are:
Planning is already underway to include another three hospitals per province from next year. Eventually the bulk of the Hospital Revitalisation grant will be channelled into carefully planned initiatives to boost patient care from various angles - instead of being used only to replace or patch up buildings.
Encouraging though these developments are, a word of caution is in order.
Hospital Revitalisation is a slow process and we are tackling a huge backlog. To appreciate progress, we need to take a long-range view. We certainly will need increased resources to make a meaningful impact. And provinces, too, will have to improve their financial contribution to maintenance and capital works.
This year - in a principled move towards equity - the conditional grant for tertiary care will be shared more equally among provinces instead of being focused purely on four provinces with the major academic hospitals. Most provinces will gain from this reallocation of resources and we firmly expect a visible improvement in patient care. The Eastern Cape, for instance, in terms of the new "like for like" funding of tertiary services get R124-million this year (as against R62-million last year); KwaZulu-Natal gets R50-million more and the Northern Cape's allocation increases by 44%.
A key innovation in the National Tertiary Services Grant is the inclusion of a development component aimed at assisting poorer provinces to recruit specialists without dipping into their equitable share. Posts for registrars - that is, trainee specialists - will also be funded through this allocation. The aim is to build a strong core of skilled personnel at hospitals outside major cities.
It is almost self-evident that the availability of appropriate health technology is critical to quality of care. Until recently there was no systematic data on problems relating to technology.
In the last year, however, we have received the results of a detailed health technology audit, done on a pilot basis in two provinces - the Eastern Cape and Limpopo. These are both rural provinces with a similar socio-economic profile - and this might lead one to expect similar levels of service infrastructure. But, the audit showed, this was not the case when it came to health technology.
Despite its modest resources, Limpopo managed to come acceptably close to several international norms in terms of the age, the turnover and the maintenance of equipment. As a province, the Eastern Cape fell short on all counts - although there were individual hospitals within the province that fared better. Overall the message was clear: Money alone will not have the desired impact on improving health technology - good management is the critical ingredient. Without skilled technology management, we will have expense without good care. We will continue to replace machines that could be repaired. We will discover sophisticated equipment standing new and useless - as we did at Cofimvaba Hospital -because nobody knows how to use it.
The audit has been so useful that it will be extended to the remaining seven provinces.
Quality of care at the district level may be measured objectively against the standard package of care that has been formally adopted for national implementation. During the course of this year we got the results of an audit that measured current services against the standards set in the package. We were encouraged to find that there are clinics that are already doing more than 95% of what is expected. But there were also a substantial number trailing around the 50% mark - and we have till 2004 to get these up to standard.
The package of primary care services is also our yardstick for improved health care in the nodes of the Integrated Sustainable Rural Development Programme. In every node, a specialised worker has been appointed to guide the process of closing the gap between present levels of service and the levels set out in the package of care. These coordinators are supervised and guided by the Health Systems Trust. We are also emphasising the generation of good health information in the nodes - and, more than that, ensuring that this information is used by local communities and planners to address local needs.
Chairperson, the structural interventions and the systems that create the possibility of better care are extremely important. But equally - if not more - important is the creativeness and the dedication of hospital and clinic managers, of ward sisters and ordinary health workers who have the power to turn an ordinary or poor service into something special. There are many examples of this - and I'd like to share just a few.
A quality assurance programme has been in place at Piet Retief Hospital in Mpumalanga has reduced mortality among newborn babies simply by making relevant protocols available to their nurses, training them in the use of protocols and teaching nurses how to monitor mortality rates. It has also focused improving detection and treatment of tuberculosis and - within a year - increased the TB cure rate from 40% of cases to 80%.
In Gauteng, some of the short listed services in the annual Khanyisa Awards for Service Excellence have focused on reducing the waiting times for patients, by using various systems of booking and categorising patients. At Kagiso C Clinic , the waiting time for acute cases has been reduced to 20 minutes - in a facility where about 120 patients are seen daily by just three professional nurses, a nursing assistant, a health promoter and a clerk.
In the nation's response to HIV and AIDS there are countless projects that are born out of compassion and respect for the community. Fifty inspiring case studies are presented in a booklet called "Our young people take it on", which is a joint publication of the Departments of Education and Health.
At the district level, the incomplete merging of provincial and municipal health services continues to present problems in terms of the effective management of facilities. We view the incorporation of municipal workers into the public service - effectively creating a single public service - as the most significant contribution that could be made at this stage to the building of our district health system.
Health workers have dealt with considerable uncertainty during this protracted restructuring and have gone to lengths to make informal or "functional" integration of provincial and municipal services work. But it simply is not sustainable to have professionals who do comparable jobs in the same clinic earning different salaries, working different hours and receiving different benefits.
For some sectors, the creation of a single public service is merely an option For the health sector it is a necessity without which we cannot consolidate that primary level of service. The Ministries of Public Service and Administration and Provincial and Local Government can count on the full support of the health sector in moving this process forward.
Chairperson, the relationship between the private and public health sectors remains a challenging area of work where we have only begun to exploit the possibilities. Of course, the interaction takes many forms - from regulation to co-operation - and it occurs at all levels, right down to individual health facilities.
The interaction that claimed the headlines this year was the dispute between Discovery Health and the Council for Medical Schemes. No doubt you are aware that the parties settled their differences a few weeks ago - and I must say I am pleased that they have avoided a protracted court battle.
I am even more pleased to note that the settlement is firmly within the boundaries of the Medical Schemes Act and it affirms council's role in protecting the consumer. If we want to encourage more people to join medical schemes and assume responsibility for the costs of their own health care, we must offer potential members security and cost containment. The Act seeks to do this by ensuring that schemes meet prescribed levels of financial reserves and by limiting the exposure of schemes to the commercial environment of the insurance industry. In his handling of the Discovery matter, the Registrar of Medical Schemes has shown that we have a robust law that can be used quite effectively to protect the interests of the public.
In the year ahead, we expect to see some movement on the restructuring of medical schemes cover for public servants. Government, as the biggest single employer in the country, is responsible for no less than 12% of the total amount paid into medical schemes. But there are some obvious shortcomings about the way this cover is structured. Firstly, public servants can belong to any scheme of their choice, so Government contributions are fragmented.
Secondly, only 40% of public servants are covered because most cannot afford existing medical aid tariffs
The Ministries of Health and Finance have also resolved the question of how medical schemes brokers will be regulated. They will remain part of the medical schemes environment and a minor amendment to the Medical Schemes Act will clarify their position further.
We are currently working with the Department of Public Service and Administration on proposals to consolidate and extend medical cover for public servants.
Honourable Members, because of the grave inequities in this country between public and private health care, we are concerned to avoid irrational expansion in the private sector. We believe that expansion must be strictly needs based and result in greater access for our people. We are therefore not in favour of the mass expansion of health tourism, which has the potential to further drain personnel from the public health sector to serve foreign patients while our own people lack care in many areas.
In the arena of service delivery, public-private partnerships are beginning to register their presence. At the w Nkosi Albert Luthuli Hospital in Durban, the maintenance of the facility and all equipment has been contracted to the private sector in a bid to ensure that the hospital always has cutting edge technology available for tertiary level services.
In the Free State and Eastern Cape, excess bed capacity in hospitals has been leased to the private sector. In addition to the lease payment, the private sector puts up capital for the refurbishment of the hospitals involved.
At Johannesburg Hospital, a pilot project involving differentiated amenities for private, paying patients was launched quite recently. Differentiation only extends to the "hotel" services, while the standard of clinical care is uniform across the hospital. Kimberley Hospital has successfully implemented a similar model.
All of these initiatives aim to pump additional funds into the public sector and bring us a bit closer to our central objective of quality health care for all our people.
Chairperson, in closing, I would like to extend my sincere thanks to a whole range of individuals and structures that have assisted me fulfil my role during the past year.
Provincial MECs for Health, the heads of provincial health departments and representatives of the South African Local Government Association and the SA Military Health Services make a crucial contribution and really give meaning to the notion of co-operative governance.
Of course, this top layer of management depends on the support and expertise of a wider group of managers - including managers in the frontline, in our hospitals and district services. I would like to say very clearly: We know just how valuable you are to the public health system.
To members of the Select Committee in this council and especially the chairperson, the Honourable Jacobus, my thanks for your interest, your constructive criticism and for the perspectives you bring from your respective provinces.
Thanks al! the Portfolio Committee in the National Assembly and to Chairperson Ngculu in particular.
I am indebted to my Cabinet colleagues for their interest in matters pertaining to this portfolio and to Social Cluster Ministers for their supportive work.
I would like to recognise the Director-General of Health, Dr Ayanda Ntsaluba, for his leadership and to thank the team in the Department.
And finally, I would like to express my appreciation to those who support me most directly: my advisors and all personnel in the Ministry; my family; and my household support staff.
Dr Manto Tshabalala-Msimang
Minister of Health