How we're re-engineering the health system - Motsoaledi

Health minister says under current public and private system NHI would be unable to survive

Health Budget Vote Policy Speech presented at the National Assembly by Minister of Health, Dr A Motsoaledi

31 May 2011

Mister Speaker
My fellow Cabinet colleagues
Deputy Minister of Health and other Deputy Ministers
Honourable Members of the House
Distinguished guests
Ladies and gentlemen

It is a great honour and privilege to present to the House the national Department of Health's policy priorities and budget for the financial year 2011/12 for your consideration.

I am presenting this speech at a time when the health care system is at cross-roads. We may choose the best route or the worst one ever, which will of course worsen our situation even more than what it is. The choice lies with us as South Africans in general but as elected leaders in particular.

Last year, I signed a Performance Agreement with the President in what we call Negotiated Service Level Agreement (NSLA). According to this agreement, the health sector must provide four identifiable and measurable outputs with the ultimate objective of ensuring "A long and Healthy Life for South Africans."

On top of these four identifiable outcomes which we have set ourselves to achieve we also have the 10 point programme which I presented to this House in 2009. This plan further guides us on how to go about achieving the outcomes.

Extensive studies commissioned by the prestigious British Medical Journal the Lancet but conducted by our own scientists and researchers in South Africa has clearly revealed that South Africa is going through four pandemics. Put differently the country is faced with a quadruple burden of disease. It is important for members to understand what these four pandemics are in order to understand how we arrived at the outcomes agreed with the President.

a) The first, most severe and very expensive burden or pandemic is that of HIV and AIDS and TB
b) The second is unacceptably high and I emphasise, unacceptable high maternal and child mortality
c) The third is an alarming and ever increasing incidence of non-communicable disease i.e. high blood pressure and other cardiovascular diseases; Diabetes mellitus; chronic respiratory disease; the various cancers and mental health.
d) The fourth and last one is what every South African knows and is worried about on a daily basis because the media, both print and electronic, has taken it upon themselves that they will speak about it on a daily basis. It is the pandemic of violence and injury.

Mister Speaker, if only all the four pandemics could be spoken about together on a daily basis, that will be a very good start for our country. Yes, I accept that some of the media and members of the public talk a lot about child mortality. But they do not do so with an interest to help the country solutions to the four pandemics that the country is sadly faced with. They do so as an instrument to attack individual public hospitals and individual health workers in a form of witch-hunting. Of course this is not helpful in our dailysearch for solutions for the country.

Having said so honourable speaker, this four pandemics are occurring in the face of a reasonable amount of health expenditure as a proportion of the Gross Domestic Product (GDP). Available evidence indicates that we spend 8,7 % of our GDP on health (the bulk of which, as is commonly known, is unfairly spent in the private sector). This expenditure is significantly more than any other country on the African continent and in some instances even outside our continent. A serious anomaly here is that our health outcomes are much worse than those of countries spending much less than us.

Evidently, there is a very serious underlying problem here that needs our attention. The effects of our burden of disease are clearly aggravated by inequitable distribution of human and financial resources between public and private sector whereby resources are seriously skewed in favour of the private sector, whilst it is serving only 16% of the population, in contrast the public sector which serves a whopping 84% of the population.

Honourable speaker, I will now go through the pandemics one by one because I want each and every member to understand fully what our country is faced with.

HIV and AIDS and TB

Honourable speaker to summarise the problems of HIV and AIDS and tuberculosis (TB) in our country all I need to tell you is that we are only 0.7% of the world population but we are carrying 17% of the HIV and AIDS burden of the world. We have the highest TB infection rate per population and our TB and HIV co-infection rate is the highest in the world, at 73%. A total of 35% of child mortality and 43% of maternal mortality are attributable to HIV and AIDS. One in every three pregnant women presenting at our antenatal clinics is HIV positive.

Surely this needs very serious and extraordinary measures. Hence the announcement of the President on the World AIDS day in Dec 2009 has come as a big relief to those given the responsibility of fighting this illness.

These measures, of starting antiretrovirals (ARVs) when the CD4 count is 350 or less in pregnant women and HIV and TB co-infected people, of starting Prevention of Mother to Child Transmission (PMTCT) at 14 rather than 28 weeks and of treating HIV positive newborns regardless of CD4 count has gone a long way in reversing the tide of HIV and AIDS. We started these measures in April 2010.

We are looking forward to a day, not far away whereby commencing treatment the treatment at CD4 count of 350 will be universal and not only for specific target groups. This is imperative in light of new research released recently that starting ARVs very early has given huge benefits for prevention of HIV and for protecting individuals against TB.

Honourable speaker, before these new measures were implemented the scenario was as follows: as end of February 2010 (end of financial year)

  • Only 490 health centres were able to provide ARVs as accredited ART service points. I am very proud to announce that the figure has grown to 2205 health care centres providing ARV. This has increased access to treatment in a manner unimagined just over a year ago. Our target is that all 4000 health outlets should be accredited as ARV centres by the end of the year.
  • Only 250 nurses were certified to provide ARVs. Once more I am proud to mention that now 2 000 nurses are certified, further increasing access. Our target is over 4 000 nurses to be certified by the end of the year.
  • Before the HIV Testing and Counselling (HCT) campaign launched by the President on 25 April 2010 at Natalspruit Hospital, only 2 million South Africans were testing annually.

Honourable Speaker, I am once more very happy, to mention that since the launch of the campaign only a year ago already 11,9 million South Africans have tested and the figure is growing every month.

Many South Africans want to know their status. Hence we will take the campaign further on 12 June, we shall together with the House of Traditional Leaders and centralise launch the massive HIV Counselling and Testing Campaign at village level. The launch will be at Mafefe village in Limpopo.

  • Before the campaign as at end of February 2010, we had 923,000 people on ARV treatment and now due to the campaign and the increase in access made possible by the expansion programs measure the above 1,4 million people are now on treatment.
  • We have been able to reduce the prices of ARVs by 53%. The significance of this is that as we expand coverage treatment and put more patients on treatment. As we achieve universal coverage at 350 it means further reductions in process will be necessary.

Honourable Speaker, as part of our programme to expand treatment and in an effort to reduce the burden of HIV and TB we will be providing treatment to inmates who have been diagnosed and put on treatment for both HIV and AIDS and TB. We will be working with the Department of Correctional services and have already signed an agreement with the Minister.

Honourable Speaker, I have time and again expressed my worry and regret at the number of newborns who are born HIV positive. It is a big strain on our emotions and the psyche of the nation and it causes untold problems with the healthcare system as I have mentioned earlier.

Honourable speaker, I am once more extremely, excited to inform you that next in the next few days, at the HIV conference in Durban, the Medical Research Council (MRC) researchers will release figures that show that there has been a significant reduction of transmission of HIV and AIDS from mother to child by six weeks post delivery.

It reveals that reduction of 50% transmission has been achieved. Of note is the significant reduction KwaZulu-Natal as a result of an effective Prevention of Mother to Child Transmission (PMTCT) programme. This is to be celebrated because it is a first sign that by 2015 we may eliminate the phenomenon of mother to child transmission of HIV.

Honourable Speaker, on 24 March 2011 World TB day, I announced our three-pronged strategy to deal with TB.

I. Firstly, we have acquired the new GeneXpert technology. This total revolution in the diagnosis of TB is the first ever break through developed after more than 50 years of relying on microscopy and culture. Honourable Speaker, with the GeneXpert technology diagnosis of TB takes only two hours. It used to take up to a week. Whilst the microscopy method served us well for the past 50 years, its sensitivity was only around 72%, meaning that 28% of people with TB could be misdiagnosed or missed.

The sensitivity with GeneXpert is at 98% meaning that we may only miss 2% of the diagnosis. Moreso, it used to take us at least 3 months to know that a patient has multidrug resistant TB or Multi-Drug Resistant Tuberculosis (MDR-TB). Now we are able to have this knowledge in only two hours. We have distributed 30 of these machines in districts that have high caseloads. We will be rolling these out to every district in the next six months and to every facility in the next 18 months.

II. The second strategy we have implemented is that of active case finding. We have put together a team of five people each, starting in February this year to trace TB contacts i.e. to visit families of patients on our database who are being treated for TB. There are 407,000 of such families in South Africa and all of them need to be screened for TB, in the light of our knowledge that every TB patient has the capacity to infect 15 others in his or her lifetime.

Honourable Speaker, I am happy to announce that since we started these household visits in February this year, we have already visited 41 000 families and screened 112 000 people. Our aim is that by world TB day next year at least 200,000 families should have been visited and screened. 

It is important for me to disclose that in the past before the advent of GeneXpert technology, tracing TB contact and screening them using ordinary microscopy as we have been doing forthe past 50 years, we would detect between 2-7 % of TB in the screened population. Since the introduction of GeneXpert in March this year we are now detecting 18% of TB cases. The simple fact here Honourable Speaker is that we have been under detecting TB even when it was there.

This means that we are now putting more people on treatment early on and reducing the pool of infective people. Honourable Speaker, this means we stand a better chance more than ever before to turn the tide against TB. We know that it will mean more money from the fiscus as it happened with HIV and more work for health workers in the initial stages. In the long run the amount of money needed, and the demand on health workers will be markedly reduced.

So this is the miracle brought to us by GeneXpert and house visits. May I add further Honourable Speaker, that we are the first country in the whole of Africa to have this we wish to thank the World Health Organisation (WHO) for making it available to us and for United States Agency for International Development (USAID) for helping us to acquire it.

III. The third strategy against TB, is that we have unveiled nine specially designed MDR hospitals using technology from Council for Scientific and Industrial Research (CSIR). These hospitals, at least one per province have been made possible by generous donation R100 million from the global fund. This design markedly reduces the chances of health care workers, particularly nurses, from being infected by their MDR-TB patients. Unfortunately patients have to stay for 18-months in these hospitals. Hence it is imperative that we increase our household visits so that we stop TB from spreading and prevent our people developing MDR-TB.

High Maternal and Child Mortality

A lot has been said about the high maternal and child mortality in our country. You have noted honourable members, that most of our interventions in HIV and AIDS are directed at pregnant women and children. We will work hard to reduce the mortalities of these targeted groups. Remember that maternal mortality is not just death of a woman; it is death of a woman, because she dare fell pregnant!

She becomes vulnerable to death because she is trying to bring new life to earth. We know that even the mortality brought upon by HIV and AIDS is disproportionally affecting young women of childbearing age more than the men. This can't be right. It leaves the country with lots of orphans. We now have no less than 1,3 million orphans in our country. Mostly, these are maternal orphans.

This type of situation cannot be allowed to go on in our country, it has much more negative societal consequences beyond health care i.e. crime; poor educational outcomes; teenage pregnancies and abortions total social disorientation of young husbands. It is a well known fact that young husbands lose direction in life if they lose their partners so early in life.

Female partners are known to have a stabilising influence on a young man's life. South Africa, is fast losing this social stability due to the high maternal mortality, which according to evidence at our disposal affects more the young women than the older ones.We will have to run serious campaigns in immunisations. Honourable Speaker we k now that breast feeding is a time honoured strategy in child survival, medical sciences has proven that beyond any doubt.

However in South Africa, in the advent of a heighten HIV and AIDS epidemic the issue of breastfeeding has been markedly undermined. In fact, the pattern in this area is fatal to a number of children. Studies revealed by the Human Sciences Research Council (HSRC) last year has shown that 24% of mothers are using infant formulas, only 25% are on exclusive breast feeding and a whopping 51% are on mixed feeding which the most dangerous type of feeding in a country with such a high HIV and AIDS prevalence. Many researchers and paediatricians are worried by this. It is for this reason we are calling a breast feeding summit in August this year.

Non-Communicable Diseases (NCDs)

Honourable Speaker, the issue of non-communicable diseases is very less spoken about in the public arena. It is also not very clearly understood even though it preceded HIV and AIDS by several decades. This is because HIV and AIDS came as such a shock to the world that many strong civil society groups were formed to deal with it. In our country, we all know how strong civil society and Non-Governmental Organisations (NGOs) dealing with HIV and AIDS are. This has put the issue on the public agenda more than on any other disease.

Last week, I tried to bring this issue of non-communicable diseases to the Health Portfolio committee but unfortunately the media got excited because they thought I was specifically raising the issue of dietary behaviour of members of parliament. It is therefore very important for me to explain this matter clearly for parliament to understand.

Non-communicable diseases, referred to as NCDs, are diseases that are not propagated by germs from one person to another. In fact, it is also safe to say that the germ that propagates NCDs is the human being!

I am saying so, because NCDs are not only biomedical, but they are largely diseases of life-style. These are divided roughly into four categories namely:

  • High blood pressure and other diseases of the heart and blood vessels
  • Diabetes mellitus and a few other metabolic disorders
  • Chronic respiratory diseases and asthma
  • The cancers

Added to these honourable Speaker is the ever increasing incidence of mental ill health. These diseases are driven mainly by four identifiable risk factors viz:

  • Smoking
  • Harmful use of alcohol
  • Unhealthy eating behaviour (diet)
  • Lack of physical exercise

Honourable speaker, if these four (4) risk factors and related unhealthy behaviours are removed, the world would be a much safer place to live in.

The question is, just how serious is this problem of non communicable diseases? Is it a global phenomenon or is it only in a few countries?

Well the answer is it is a fast growing global phenomenon and becoming more devastating in Sub-Saharan Africa because it is adding on problems of communicable diseases or infectious diseases that have been plaguing Africa for centuries.

So serious is the issue of NCDs that the World Health Organisation (WHO) and the United Nations (UN) have called all Ministers of Health to Moscow on 28 to 29 April 2011 in what was called the First Global Ministerial Conference on Healthy Lifestyles and Non-Communicable Disease Conference.

The outcome of this conference is a document formally referred to as the "Moscow Declaration". I have decided to make copies of the Moscow Declaration available to members in this sitting. People in the public gallery also need to get their copies.

In summary, the Moscow Declaration deals with the following issues:

  • Notes that policies that address behavioural, social, economic and environmental factors associated with NCDs should be rapidly and fully implemented to ensure the most effective responses to these diseases, while increasing the quality of life and health equity.
  • It further emphasises that prevention and control of NCDs requires leadership at all levels, to create the necessary conditions for leading healthy lives. This includes promoting and supporting healthy lifestyles and choices, relevant legislation and policies.
  • It recognises that a paradigm shift is imperative in dealing with NCD challenges as NCDs are caused not only by biomedical factors but also caused or strongly influenced by behavioural, environmental, social and economic factors.
  • The Moscow Declaration says that the Rationale for Action is that worldwide, NCDs are important causes of premature deaths, striking hard the most vulnerable and poorest populations. Subsequently they impact on lives of billions of people and can have devastating financial impact that impoverishes individuals and families, especially in low and middle income countries.
  • It goes on to state categorically that examples of cost-effective interventions to reduce the risk of NCDs which are affordable in low-income countries and could prevent millions of premature deaths every year, include measures to control tobacco, reduce salt intake and reduce harmful use of alcohol. It says particular attention should be paid to promote healthy diets i.e. low consumption of saturated fats and trans-fats, salt and sugar and high concentrations of fruits and vegetables and physical activity in all aspects of daily living.

Honourable Speaker according to the Moscow declaration, effective NCD prevention and control require leadership and concerted "whole of government" at all levels (National, Sub-National and local) and acrossa number of sectors such as health, education, energy, agriculture, sports, transport and urban planning, environment, labour, trade and industry, finance and economic development.

Lastly it states that effective NCD prevention and control require the active and unformed participation andleadership of individuals, families and communities, civil society organisations, private sector where appropriate, employers, health care providers and international community.

It is with this background that I said last week that members of parliament should take the lead in this issue of healthy lifestyles, diet and exercise. Unfortunately, some excitement in the media was generated whereby it was thought that the whole issue is being debated because there is a "gravy train" in parliament. Please South Africans, this matter is serious for it to be turned into a circus.

Let me demonstrate with a few figures to show why Ministers of Health have been called to Moscow. In South Africa, for incidence out of 100 percentage points, the following have been allocated to various risk factors to causation of diseases by the Medical Research Council.

Sometime in 2009 in this very parliament, members asked me a lot of questions about our policy on renal dialysis for people with kidney failure. A totally wrong debate was entered into i.e. why government does not increase and invest more on dialysis machines within public hospitals, which the private sector is superb because those who are failed by the state in terms of dialysis are always saved by the private sector.

This is a wrong debate altogether. It is no different from encouraging the state to put up more mortuaries because the demand for mortuaries is increasing. The intelligent question to ask is why so many people are having failing kidneys such that they need this dialysis. In the Gauteng province alone the total number of patients on chronic dialysis both haemodialysis and peritoneal dialysis is 561.

Those on the waiting list for an opportunity to avail itself the total number is 238. These figures are just for one comparatively well equipped province. What happens when one adds the other poorly resourced provinces? To put a single patient on dialysis costs R150, 000 per patient per annum in the public sector and about R300 000 in the private sector. Moreso, these patients have to be in hospital for three times a week for a minimum of 4hours a day, whether they are employed or not.

What causes this? We know that 40 to 60% of people with end stage renal failure is due to high blood pressure at an average age of 39 years. What is the main risk factor for high blood pressure? It is smoking, lack of exercise and high salt intake. So instead of demanding more dialysis machines and subsequently demanding new kidneys to an extent of the rich trying to concoct schemes to steal kidneys from the poor as it happened recently in our country, we must reduce the prevalence of hypertension by eliminating the risk factors.

The need for targeting tobacco and alcohol has already been outlined and no matter how many financially powerful people and institutions make noise about it. I can stake my life on it, we are going to fight with our bare knuckles to achieve this, particularly a ban on advertising of tobacco and alcohol. It is a point of no return and the sooner the tobacco and alcohol industry understand this, the better.

I am going to ask you in this parliament very-very soon, to process legislation to reduce salt the salt content of our foodstuffs. South African diet has been shown to be very high in salt. The desired amount of salt for your body is known to be 4-6 grams per day.

But in our country it is up to 9,8 grams per day i.e. more than two times the physiologically required amount. More salt is already found in food rather than individuals adding it on the table. Britain has taken a lead in this case, since 2006, they have agreed to reduce salt intake by 40% within five years.

In South Africa, studies show that reducing salt intake just on bread only will save close to 6 500 lives per annum. In Britain studies show that just in the second year of reduction in salt intake by 10%, 6 000 deaths were averted and a saving of 1,5 billion British Pounds was achieved.

Honourable Speaker, another issue which is extremely important which the Medical Research Council (MRC) ranks as number five risk factor after unsafe sex; injuries and violence; alcohol and tobacco is high body mass indexor excess body weight. This coupled with lack of exercise which is ranked as risk number 12 becomes very problematic. It is an international problem not confined to any specific group of people. In South Africa, it is a fast growing phenomenon among school children, increasing from 17,2% overweight in 2002 to 19,7% in2008. The figures of those who moved from overweight to obese are 4% in 2002 to 5,3% in 2008.

This means that by 2008 a total of 23% of school children can be classified as either obese or overweight. Honourable Speaker, this is fast approaching a quarter of the school going population. The consequences to both individual and society are devastating. In the general population the national income dynamic study shows that 60% of women and 31% of men are either obese or overweight.

If you consider women over 37 years the figure rises to a tremendous 70% classified as either overweight or obese. This is why the Moscow declaration is so important. Here in South Africa, I can assure you the ban on misleading adverts on unhealthy dietary products is on the cards. The so-called freedom of expression on adverts notwithstanding.

It will be befitting to quote the following article released on the 9th May this year i.e. three weeks ago by Daniella Miletic and Amy Corderoy in Australia.

"Advertisers self-regulatory codes aimed at reducing children's junk-food marketing are not working, health groupings claim. They argue that the federal government should adopt tougher measures restricting advertising, which campaigners believe is a major factor in rising childhood obesity rates. The obesity Policy coalition has developed a blueprint to be released today, to regulate this form of advertising.

"The proposal has taken years to craft and is the first comprehensive report to be endorsed by so many health groupings including the Australian Medical Association; The Australian dental Association; Cancer Council of Australia; diabetes Australia the national heart foundation. Under the plan, junk food advertising would be banned on free to air TV from 6pm to 9am and 4pm to 9am on weekdays. On weekend mornings when children tend to watch more TV, it would be banned from 6am to noon on pay TV channels, similar restrictions would apply except for channels primarily directed at children such as cartoon channels in which case junk food advertising would be banned at all times."

An impromptu poll showed that 86% of Australians support these measures. This is what nations of the world are doing to safeguard the health of the citizens. Our country cannot be allowed to lag behind.

The last pandemic Honourable Speaker that of violence and injury, a lot is known about it because it is spoken about daily as I have said. On the Arrive alive campaign, the emphasis is always on the fatalities on our roads because this is very painful.

However, for the healthcare system I have to inform you that a study by UNISA in collaboration with the MRC shows that for every person killed by injury, 30 times as many are hospitalised and 300 times as many are treated for less serious injuries and discharged. It further states that depending on the cause, severity and circumstances of the injury, many of these results in varying degrees of physical, psychological, educational social and economic disadvantages for the affected individuals and families.

National Health Insurance (NHI)

Honourable speaker, I am painfully aware that for some people in this country what I have said up to now amounts to nothing if I don't say anything about NHI. There are two different groups of people in this case. Those who correctly and legitimately hope that NHI will bring relief in their everyday hardships as far as their health care is concerned. And they are of course very right.

However, the other group eagerly waiting are those consumed by self interest and greed that will shame even the devil. They are waiting for any development and vowed to do anything in their power to stop NHI dead in its tracks. To both groups, the legitimate expectation group and the greedy lot, I am appealing for their patience. We are working around the clock everyday around this issue of NHI.

The problem is that many believe that NHI is just the release of a document. For us in health, we know that it also involves an extensive preparation of the healthcare system while at the same time preparing a policy document. In this case Honourable Speaker the reengineering of the Health Care System is very vital. Under the present healthcare system whether public or private, no national health insurance can ever survive.

I know that at face value problems in the health system are said to be existing only in the public sector and the private sector must be left alone to some wayward phenomena called market forces, even though these market forces dismally failed to stop or more appropriately caused the most recent global economic collapse.

Logically it means not doing anything we are preparing for the collapse of the health care system. While it is very true that the public health care system is bedevilled by very poor management leading to poor quality of care adding to the very low resources available in the public health sector, I wish to categorically state that the present overall health care system both public and private will be completely re-engineered. If I have to define the present health care system I will say it is characterised by four very clearly identified negatives:

  • Firstly, it is unsustainable
  • Secondly, it is very destructive
  • Thirdly, it is extremely costly
  • Fourth and last it is very hospicentric or curative in nature

For any intervention dealing with the cost of healthcare like the NHI to make any sense, a complete re-engineering is essential and it is an obligation placed upon our shoulders.

The reengineering of the Healthcare System will be according to three main streams.

I. The first stream will be a district based model. In this model a team of 5 specialist or clinicians shall be deployed in each district. These teams will specifically focus on maternal and child mortality .This will help us arrive at our Millennium Development Goals. These teams will consist of:

  • Principal obstetrician
  • Principal paediatrician
  • Principal family physician
  • Advanced midwife
  • Senior primary care nurse

In this case Honourable Speaker, I have consulted all the Deans of the eight medical schools in our country, the professional associations of paediatricians, obstetricians, family physicians, the colleges of medicines of South Africa responsible for specialist training and the nursing fraternity at the recently held and successful nursing summit.

I am happy to announce that there is overwhelming support from the above mentioned stakeholders. It is my intention that by the end of this calendar year, we should be far ahead in implementing this initiative. In this initiative, the creation of the posts at district level have never existed before and are totally new in the public service. We are absolutely determined to make sure that this model is implemented.

Once appointed, these teams will deal with guidelines and protocols at our Antenatal Care Clinics, Labour wards, Post-natal Healthcare and Paediatrics and Child Health Clinics. They will follow up on every case of mortality to make sure that mortality meeting are held for every single incident, to deal with the cause at hospital level immediately rather than waiting for research studies and results later.

The specialist teams will deal with training of interns, as well as community service doctors and medical officers. Additionally, they will focus on midwives and their practice in helping to bring down maternal mortality. They will also assist primary healthcare (PHC) nurses on following up on patients in their communities, especially for post natal care. Overall there will be a link between prevention of disease and the management and cure of diseases.

II. The second stream of re-engineering PHC, Honourable speaker, is a School Health programme which will be launched with the Ministers of Basic Education and Social Development. A task team has been established abouteight weeks ago and is working around the clock to deal with these issues.

This stream of PHC will deal with basic health issue like eye care problems, dental problems, hearing problems, as well as immunisation programmes in our school .It will move further on to deal with more complex problems like contraceptive health rights that will include issues such as teenage pregnancy and abortions, at contraception, as well as HIV and AIDS programs among learners. Added to this will be drugs and alcohol in school.

Again Honourable Speaker there has been extensive consultation on this issue and hence the task consists of all relevant stakeholders from the three departments, NGOs dealing with children, universities and individual experts who know a lot about children. When the team has completed its work, we will start implementation in the poorest schools in quintile 1 and 2, which are also far from the nearest health centres.

III. The last stream will be a ward based PHC model which will deploy at least 10 well trained PHC workers per ward. This method is being put to good use in Brazil where 30 000 of such people called community healthcare agents have been deployed to various communities. I was also highly encouraged when the Minister of Health in India announced during the Moscow gathering last month that in his country they are deploying 800,000 such cadres and they call them healthcare activists.

Honourable Speaker, I have earlier on mentioned in this speech how deploying a team of five people to deal with TB has already produced tremendous gains. A total of 251 teams have already been deployed and in just three months have reached 41,000 families and in the process discovered that 18% of the screened people had TB. As I have mentioned, in the past we would have never picked up these people and would have waited for them to show up in healthcare institutions when it is already too late.

As we can see Honourable Speaker an intervention with TB at a small scale has already produced extremely encouraging results. At a larger scale and including all the diseases the impact will be significant.

It is not a coincidence that KZN while having the highest prevalence of HIV and AIDS has achieved the lowest transmission from mother to child. I have already mentioned that the figures relating to this issue will be released at the upcoming AIDS conference. Unfortunately, I won't be able to attend this conference; I will be in New York attending a high level heads of states meeting focussing on the 30 years of HIV and AIDS on our planet. 

KZN has achieved this feat because it has got a semblance of this ward based PHC model which they achieved by simply coordinating all Home Based Care Givers, TB Directly Observed Therapy (DOTS) supporters, Masupatsela from Social Development, Community Development Workers (CDWs) from Cooperative Governance and Traditional Affairs (CoGTA), and HIV and AIDS Lay Counsellors under the Premier's Office, and made them ward based. They call them Community Care Givers. 

Honourable Speaker, the reengineering of our PHC system into these 3 streams will consolidate PHC as our primary mode of Health care delivery. It will encourage prevention of disease and promotion of health in contrast to the present obsession with treatment of individual disease when it is already too late for many individuals and at great cost to the fiscus and the GDP of our country.

It is because of this hugely curative and costly health care system that some so-called experts believe NHI is an impossible dream.

Healthcare management

There is no way Honourable Speaker that we can move forward with the reengineering of PHC without looking closely at the management of our health care institutions and health districts. We have already spent the past two years gaining an in-depth understanding of the phenomena of poor management in both individual institutions and districts as well as provincial and national departments.

We now think we know what to do. At the national and provincial level we need to align the structure with our four outcomes, the 10-point programme and the dictates of the millennium development goals (MDGs). Our structure did not necessarily speak to any of those. We need to follow a strategy that will bring a very efficient and effective management of our health institutions and districts.

The belief and the practice that anybody regardless of their training can manage a health institution is incorrect and we are definitely going to stop it.

Quality Improvement Plans

Together with the management of health care institutions and districts, the issue of quality of health care have time and again arisen in our public discourse. I have spoken a lot about the Office of Health Standards Compliance which will consist of three units of: inspectorate, accreditation and the ombudsperson.

I have spoken at length about it that I do not want to repeat anything here save to say the Bill is ready to be sent to Parliament for members to engage, towards enactment of legislation through which the office will be established. This is work in progress- it needs no further details.

Health Workforce Development and Human Resource

Honourable Speaker, our Human Resource (HR) strategy in accordance with the 10 point programme will be completed by August this year.

We need to increase the no of Health Care Workers produced in our country. We cannot keep on producing 1200 doctors per annum as we have done in the past decades. In this case a 2-pronged strategy is already in motion; the first one is a temporary measure where we have asked the Deans of our medical schools to find an innovative way of increasing the intake of medical students even under the current circumstances of restricted space they find themselves in.

At the beginning of this year, the University of the Witwatersrand (Wits) was able to work with us and consequently have accepted 40 extra students for first year training. This they have never done before and it happened because we worked hard together.Of course this needed additional funding and the department was very pleased to oblige. We are eagerly waiting for the other seven medical schools to produce similar plans for implementation next year.

You may remember Honourable Speaker that the President announced the establishment of a ninth medical school in Limpopo. Furthermore, an announcement was made about our intention to put up new infrastructure at four other tertiary hospital and their medical schools in addition to this development in Limpopo. These are George Mukhari Hospital, Chris Hani Baragwanath Hospital, King Edward VIII in Durban and Nelson Mandela Academic Hospital in Mthatha.

Our aim in this case is to increase the number of medical students produced in our country at least three fold. We are also doing this in preparation for NHI to ensure that there is a smooth referral to institution of high quality infrastructure and equipment. The announcement by the Minister of Higher education last week about the rebuilding and expansion of Medunsa as a standalone institution is part of this agenda.

Honourable Speaker, we have had a very successful nursing summit in April this year which dealt with HR issues of nurses. The success of this summit can be seen in the compact that has been produced. For members of the public to know the compact we have published it on many newspapers in the day of international day of nurses earlier this month.

The task team that organised that summit has not been disbanded and is working around the clock on ensuring that issues emanating from this compact are implemented.

The budget of the Health Sector 2011/12 to 2013/14 financial years

Honourable Speaker allow me to now focus on the budget of the National Department of Health for the financial year (FY) 2011/12. The budget of the department has grown by 15,3 % from 21,7 billion in 2010/11 to 25.7 billion n in 2011/12.

At national level and additional amount of R442 million was allocated for FY 2001/12 and R692 million for FY 2012/13 and R2,276 billion for FY 2013/14. This is mainly to improve quality, to strengthen PHC teams to upgrade and maintain nursing colleges, to improve maternal and child health, for universal coverage of HIV at 350-threshold.

Additional earmarked funding has been allocated at provincial level for preparatory work for the National Health Insurance which amount to R16,1 billion over a 3-year period. This will be mainly for registrars posts, specialists posts at district level, for family health teams and helping hospitals comply with norms and standards.


In conclusion, Honourable Speaker - I wish to thank numerous people that I have worked with during the last year on their contribution towards overhauling the health system. Starting with the President of our country, the Deputy President who is also the chairperson of the South African National AIDS Council (SANAC) and the Ministerof Finance as well as the whole Cabinet have been extremely understanding and sympathetic to the issues the health system is facing and I wish to express my sincere gratitude.

This support was very evident when we had to raise and extra R3 billion to fund the new treatment protocols of HIV and AIDS. It is still evident in this budget as it has been increased by 15% to assist us to overhaul the healthcare system and to aid us to prepare for NHI.

My colleague the Deputy Minister of Health Honourable Dr Gwen Ramokgopa, we have complemented each other so much that one can only wish this will go on forever and ever.

The MECs for Health through the National Health Council have ensured that the department's policies are implemented by the provinces. I would also like to take this opportunity to express my gratitude to the Portfolio Committee on Health through its chairperson Honourable Dr Goqwana.

The Director-General of Health Ms Precious Matsoso and her management team have held strong despite numerous and competing challenges, which at times threatened to blow them apart. I need to thank them for standing strong and together for the sake of the health of the nation.

Honourable speaker, I now wish to request this house to adopt the department's budget for the financial year 2011/12 amounting to R25 731 554 billion.

I thank you

Issued by: Department of Health, May 31 2011

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