Minister says quality of public healthcare must go up, and cost of private healthcare come down, if scheme is to work.
Health Budget speech by Dr Aaron Motsoaledi, MP, Minister of Health, National Assembly
15 May 2013
My colleague the Deputy Minister of Health
MECs for Health present
The Chairperson and members of the Health Portfolio Committee
Honourable Members of Parliament
Ladies and Gentlemen
Honourable Speaker, it is now well documented and generally understood that South Africa faces a quadruple burden of disease. Many other countries are faced only with a double burden.
These four are:
- A very high prevalence of HIV and AIDS which has now entered into a synergistic relationship with TB;
- Maternal and Child morbidity and mortality;
- Exploding prevalence of non-communicable diseases mostly driven by risk factors related to life-style; and
- Violence, injuries and trauma.
These four colliding epidemics resulted in death notification doubling between 1998 and 2008 to 700 000 per year as noted by the National Planning Commission. Life expectancy in the country also took a knock and declined to worrying levels.
We had to respond to these very urgently and very decisively.
In addition to our Ten Point Programme, the Department of Health signed the Negotiated Service Delivery Agreement with the President. We committed to four (4) objectives which we called outputs during this term of government.
- Increasing Life Expectancy;
- Reducing maternal and child mortality;
- Reducing the burden of disease from HIV and AIDS and TB;
- Improving the effectiveness of the health system
After going into a deep analysis of the problems, it became clear that unless we deal decisively with HIV and AIDS and TB, it would be foolhardy to believe that we could ever decrease the high levels of mortality and morbidity in our country. Hence our plans had to have a very strong element of a desire, commitment and passion as far as HIV/AIDS and TB are concerned.
This did not mean that the other epidemics were less important, it simply emphasised that the central driver of morbidity and mortality in South Africa was largely HIV and AIDS and TB.
Honourable Speaker, we responded comprehensively through well designed plans to deal with HIV and AIDS and TB, and the implementation of these plans was well executed.
Among others Honourable Speaker, we increased the health facilities providing antiretrovirals (ARVs) from only 490 in February 2010 to 3 540 to date. The number of nurses trained and certified to initiate ARV treatment in the absence of a doctor were increased from only 250 in February 2010 to 23 000 nurses to date. This programme is called NIMART or Nurse Initiated Management of Antiretroviral Therapy. NIMART made it possible to increase the number of people on treatment from 923 000 in February 2010 to 1,9 million to date – that is actually doubling the number on treatment.
I wish to take this opportunity to thank all the health workers for this sterling performance – especially the nurses without whom this numbers would have been impossible to achieve.
Very recently Honourable Speaker, we have introduced the ground breaking fixed dose combination (FDC) therapy which made it necessary to train 7 000 health workers for smooth implementation.
Another very important windfall from these FDCs is that by February 2010, it used to cost us R313.99 per patient per month to provide ARVs. With the FDCs, it is now costing us only R89,37 per patient per month. We are now able to treat many more people per month with the amount of money that we used to treat one person with in 2009.
The results we achieved from these endeavours are very sweet indeed.
By the end of last year, researchers, local and international started reporting a dramatic increase in life expectancy in our country. They also reported a decline in under five mortality and maternal mortality ratio. Our biggest challenge is the neonatal mortality rate. These researchers include our Medical Research Council’s Rapid Mortality Surveillance Report, the Lancet, and United Nations agencies like the UNAIDS.
All these researchers attributed the decline in mortality and the concomitant increase in life expectancy to our comprehensive response to the HIV epidemic, especially the ARV treatment programme.
The fact that we are testing large numbers of our people and large numbers are on treatment has brought much relief to individuals, families and communities.
As far as TB is concerned Honourable Speaker, we started in earnest on 24 March 2011 to introduce new programmes. We unveiled new strategies to combat TB.
(a) Firstly, we unveiled the GeneXpert technology. Honourable Speaker, the last time in the world that a new technology do diagnose TB was unveiled was more than fifty (50) years ago. The World had then thought we had defeated TB. We now know better. We are hence immensely relieved that a new, faster and very effective technology has now been unveiled by scientists commissioned to do so by the World Health Organisation’s Stop TB Partnerships.
Before GeneXpert technology, it used to take us a whole week to diagnose TB. Now it takes us only two (2) hours.
It used to take us three (3) months to conclude that a person has multi-drug resistant TB, now it takes us only two (2) hours to know that.
I am very proud that South Africa was the very first country on this continent to unveil the GeneXpert technology. Since its unveiling on 23 March 2013, we have distributed 242 GeneXpert units around the country. This 242 constitute 80% of all facilities we would like to cover. We had spent R117 million shared by the National Department of Health, the Global Fund and the Center for Disease Control in the USA to achieve this 80% coverage. We have conducted 1,3 million tests using this technology since 2011. This constitutes more than 50% of the total tests conducted in the whole world.
In five (5) months’ time, we will achieve 100% coverage of all the district hospitals with the GeneXpert technology. From there we will move to the big community health centers.
The biggest of these machines, that can diagnose forty-eight (48) patients at a time, the others can do only 4 or 16, are called GeneXpert 48. We only have two (2) in the whole country. We have placed one at the Ethekwini Municipality at Prince Mshiyeni Hospital. The second one is in the Cape Metro at Greenpoint National Health Laboratory Service (NHLS) laboratory.
We have done this because both Ethekwini and the Cape Metro are the most very heavily challenged cities as far as TB is concerned.
On World TB Day, on 24 March this year, you are aware that the Deputy President of the Republic unveiled a GeneXpert technology at Pollsmoor Prison, on behalf of all Correctional Services facilities. This was in response to a Constitutional Court ruling where an inmate took the government to court, and the State was held liable for inmates contracting TB in jail. Yes, it is now well established that the highest rate of TB in our country is in correctional service facilities. They too, will be supplied with GeneXpert units to screen all inmates on entry to facilities and also to screen them twice a year once they are inside.
We will also request for the names of those who are found by the GeneXpert to be having TB, from the Minister of Correctional Services in order to send health workers to their families so that the whole family of an inmate can be screened. One person with TB has a potential to infect 15 others in their life time.
Honourable Speaker, the second strategy we have adopted was to establish family teams. On our database, we have 405 000 families in South Africa who have a member diagnosed with TB. The family teams are visiting these families to screen all members within such a family.
About four (4) weeks ago, the Statistician-General went to Thabo Mofutsanyane Region to release StatsSA’s yearly figures on the cause of death. He released the 2010 figures and announced that TB was found to be the number one (1) killer in the country – not surprising given the synergistic relationship between TB and HIV and AIDS as I said earlier.
We are eagerly waiting for the 2011 and 2012 figures to see how effective our programmes have been. For now, we can report that in 2008 our TB cure rate was 67,5% but in 2012 it has improved to 75,9%. The target set by the World Health Organisation is 85% cure rate. We are steadily but surely moving in that direction. However Honourable Speaker, I have one very serious request to make. Having turned the corner should not be regarded as a signal for South Africans to be complacent. We still have a very long road to travel with HIV/AIDS and TB.
The National Development Plan has clearly indicated that by 2030, we must have a generation of under twenties (20) being free of HIV and AIDS and we must have a decrease in TB contact indices.
At the recent SANAC Plenary we have decided that the Presidency will we need to re-launch for us the HIV Counselling and Testing (HCT) Campaign in the country. This launch must happen at Gert Sibande District in Mpumalanga. It is now officially declared a district with the highest prevalence rate of HIV in the country.
I have a serious complaint Honourable Speaker, that since the campaign started, there is one extremely powerful place in this country were the HCT campaign was never launched. It is called the Parliament of the Republic of South Africa.
Please Honourable Speaker, may I humbly ask that you choose a date where we will come and publicly launch this campaign here in Parliament with you and the Chairperson of the National Council of Provinces (NCOP) taking the lead, followed by leaders of all political parties in this hallowed chambers. Then the provincial legislatures, District Councils and local councils will follow suite. I will then have the power and courage to ask churches, schools and all other centers of our civil life to choose their own days to do so.
I promise to supply a GeneXpert unit as well as a mobile XR unit for the benefit of Members in this Parliament because you also will need to be screened for TB as well, on top of testing for HIV and AIDS.
Honourable Speaker, let me now deal with the intractable problems that the health care system is faced with. It is output number four, i.e the efficiency and effectiveness of the healthcare system in the country.
You are well aware Honourable Speaker, that our flagship programme to change the efficiency and the effectiveness of the healthcare system in this country is the NHI – the National Health Insurance system.
While South Africans have been throwing mud at each other about NHI, I need to indicate that we need to stop wasting our time. NHI has gone global. The World Health Organisation (WHO), the United Nations (UN), the World Bank, prestigious institutions of high learning such as the Harvard University, have recently entered the fray in support of NHI and in giving well researched guidance to countries on how to get about to implement NHI – not to debate whether it is needed or not. The world has gone far beyond that stage.
Recently the World Bank and Harvard University organised a workshop of all Ministers of Finance to guide them on how their treasuries can support NHI for the benefit of economic growth.
It is of course not called NHI in every country. The World Health Organisation and all the UN agencies are calling the generic term, Universal Health Coverage. We will stick to the term NHI.
The Prestigious British medical journal, the Lancet has launched a series since late last year to allow academics, health activists and researchers to write articles to guide countries about this concept of Universal Health Coverage.
It doesn’t matter what you call it – the concept is the same i.e every citizen has a right to access to good quality, affordable health care, and that the access should not be determined by the socio-economic condition of the individual.
Hence whether you call it NHI as we are doing here in South Africa, or NHS as they do in England, or Seguro Popular as they say in Mexico or Obama Care as the Americans call theirs, the concept is the same.
In the editorial of Vol. 380 of September 8, 2012 of the Lancet it states that “certain concepts resonate so naturally with the innate sense of dignity and justice within the hearts of men and women that they seem an insuppressible right. That healthcare should be accessible to all is surely one such concept. Yet in the past, this notion has struggled against barriers of self-interest and poor understanding”.
The editorial goes further to say: Building on several previous Lancet Series that have examined health systems in Mexico, China, India, South East Asia, Brazil and Japan, today we try to challenge those barriers with a collection of papers that make the ethical political, economic and health arguments in favour of Universal Health Coverage and will be presented in New York on September 26 to coincide with the United Nations General Assembly. The series was facilitated by the Rockefeller Foundation and edited by David de Ferranti of the Results for Development Institute in Washington DC. The conclusions support the World Health Organisation (WHO) Director-General Dr Margaret Chan’s assertion that Universal Health Coverage is the single most powerful concept that public health has to offer”.
Honourable Speaker, the editorial goes on to say and I quote again: “Universal Health Coverage, like any other health system, must be accountable for the quality of its outcome and the compassion of its care. The emphasis should be on responsiveness to service users, rather than on profit for share holders”.
It is very clear Honourable Speaker and Honourable Members that the whole world, and not only our country is gearing to rid itself of archaic healthcare financing systems that cater for the privileged few, and punishes the poor, in favour of healthcare systems that will benefit all – and all citizens of a country.
This assertion, led to another article in the Lancet series I have just mentioned. It argues that Universal Health Coverage is poised to be a third global health transition.
The argument is based on the fact that since humanity came into being, there have been only two great transitions in health on this planet.
The first was the demographic transition that began in the late 18th century and changed the planet in the 20th century through public health improvements, including basic sewerage and sanitation, which helped to reduce premature deaths greatly.
The second transition was the epidemiological transition that began in the 20th century and eventually reached even the most challenged countries in the 21st century.
Communicable diseases, from smallpox to poliomyelitis were vanquished or controlled on a scale never imagined, opening the way for contemporary action to tackle non-communicable diseases.
Now a third great transition seems to be sweeping the globe, changing how healthcare is financed and how health systems are organised. For a along time, getting healthcare has meant first paying a fee to the provider – a practice that effectively burdens sick and needy people, that has meant choosing between going without needed services or facing financial ruin”.
Honourable Speaker in implementing NHI or Universal Health Coverage countries are clearly going to pay different prices for different durations in time, depending on internal objective factors and dynamics within each country. Hence a country like Qatar, is going to implement NHI starting in July this year and completing in December next year. Here in South Africa, we have given ourselves 14 years to achieve the same.
Unlike Qatar, there are two main prices we are going to have to pay for successful implementation of NHI.
The first price is that the quality of services in the public health system has to drastically undergo a metamorphosis – the quality simply has to improve and there is no running away from that.
The second price is that the cost of private healthcare has to drastically reduce. We need to firmly regulate the prices in private healthcare.
Honourable Members, as a Department of Health, we strongly welcome last week’s announcement by the Minister of Economic Development, Honourable Minister Patel, that through the amended Competition Act, the Competition Commission will launch a public market inquiry into the cost of private healthcare. We as a Department are fully behind Minister Patel and the Competition Commission on this one and we are ready to engage and offer all evidence we have at our disposal. We are eagerly waiting for the Commission to call us! For those who don’t understand where this is coming from, I wish to refer you to our National Development Plan, Vision 2030 and I quote:
“A national health insurance system needs to be implemented in phases, complemented by a reduction in the relative cost of private medical care and supported by better human capacity and systems in the public health sector”.
As to how we are going to pay the first price I have mentioned earlier, i.e on the issue of quality in the public health system, we shall outline that in the White Paper that will be released soon. We did indeed take a very long time since the Green Paper was launched. There were lots of inputs and developments that needed our very careful attention and considerations.
We will be ready very soon.
It will be released with a clear plan on how NHI is to be implemented based on the two main prices which I said the country has to pay.
Because these are elaborate plans, it will not be possible at all to outline them here. They will be made available in due course. They will include the whole concept of non-negotiables in healthcare, the delegation of powers to CEOs who are being newly appointed and trained. This will also include abolishing the dreaded depot system of drug supply to allow CEOs to get medicines directly from suppliers.
But I wish to take this opportunity to emphasize over and over again, that the NHI will be based on a preventative and not a curative healthcare system.
I will then repeat in many more occasions to come that Primary Health Care, meaning prevention of diseases and promotion of health is going to be the heartbeat of NHI in South Africa.
We will drive this healthcare system according to the dictates of the National Planning Commission which clearly states that among the important things to be done, is to reduce the burden of disease, not to allow them to flourish and then try to run helter skelter in trying to cure them, with very limited facilities, both human and financial, which is the hallmark of public health systems on the African continent.
We wish to demonstrate with a few examples on what prevention of diseases and promotion of health can do to a country’s health system.
A report compiled by the Mail & Guardian’s newly established BHEKISISA health reporting center and published on Friday last week demonstrates one of the examples
It shows how four years ago, the Department of Health introduced two very new vaccines, Prevenor, to reduce the risk of children contracting Pneumonia, and Rotarix to prevent incidences of diarrhoea in children. Remember that diarrhoea was killing 25 South African children under the age of five (5) each day.
At the time of the inception of the two vaccines, National Institute of Communicable Diseases, the NICD, was tasked with the work of monitoring and evaluating the impact of these vaccines on hospitalisations in three South African hospitals – in Cape Town, KwaZulu-Natal and Gauteng.
The findings were that at Ngwelezele Hospital in Kwa-Zulu/Natal the under five mortality rate was three times higher than in Soweto. However, the Ngwelezene Hospital ward that deals specifically with diarrhoea i.e the gastrointestinal ward, has recently been closed down as a result of the introduction of this vaccine. Around 2006, this ward used to admit close to 1 000 children annually. It is now closed down – no more need!!
On average, in all these three sites there has been a 70% reduction in admission due to diarrhoeal diseases attributable to Rotavirus.
Seeing the successes that vaccines can bring Honourable Speaker, our next target is cancer of the cervix of the uterus. One of the biggest killers of women.
According to Prof Lynette Deny, and Dr Yasmin Adam of the Department of Obstetrics and Gynaecology at Groote Schuur Hospital and Chris Hani Baragwanath Hospital respectively, cervical cancer affect 6 000 South African women annually. 80% of them are African women.
Out of these 6 000 affected, between 3 000 and 3 500 die annually as a result of this cancer.
More than 50% of women affected are between 35 and 55 years of age. Only 20% are older than 65 years of age.
HIV positive women are five times more likely to get it than HIV negative women.
This cancer is caused by another dangerous virus – the human papilloma virus. The good news is that there is now a vaccine against this virus. The very bad news is that it is available in the private sector but the costs are prohibitive between R500 and R750 a dose (3 doses are needed for protection) – even in the private sector the uptake is very slow due to this prohibitive costs.
At the moment Honourable Speaker, to make these vaccines affordable, the Bill and Melinda Gates Foundation established GAVI (Gates Action for Vaccines and Immunisation) to help poor countries.
Unfortunately, South Africa does not qualify for GAVI prices which we are made to understand, are at only $4,00 per dose.
We are also aware that the PAHO (Pan American Health Organisation) has negotiated a price of $13,00 a dose for Latin American countries.
I am extremely happy to announce that in consultation with the Minister of Finance and the Minister of Basic Education, we have decided that we shall commence to administer the HPV vaccines as part of our School Health Programme as from February next year.
We will enter negotiations in our own right to also be given a fair deal in the interest of the lives of the women of this country.
We are advised by scientists that the vaccine is only fully effective before sexual activity commences.
For this reason, we shall administer it to all 9 year and 10 year old girls in Quintiles 1, 2, 3 and 4 schools.
This will cover 385 000 of the 9 and 10 year olds. We are not unduly discriminating against Quintile 5 schools. Children from poor families who find themselves for one reason or the other in Quintile 5 schools will also be covered.
I am calling for parents of all remaining learners in that category of schools, that since they can afford, for now they must try to acquire the vaccines themselves until we are able to cover all learners in the mentioned age bracket in all the schools. I am calling on all Medical Aid Schemes in the country to pay for these vaccines to help parents in the category of learners who will not be covered when we commence the programme. The benefits far outweigh all the costs. It costs up to R100 000 per patient in the public sector to treat each of the 6 000 cervical cancer patients.
I am scared to quote you the figures for the private sector treatment.
Honourable Speaker, this week, very bad news emerged from our health facilities about an entity called RWOPS – Remunerated Work Outside the Public Service – whereby doctors fully employed by the State conduct their own private work during certain hours. RWOPS is not illegal. It was passed by the Cabinet around 1994.
The only problem is that it is being abused by some unscrupulous individuals.
I must emphasise Honourable Speaker, the overwhelming number of doctors in the public service are very decent law abiding hard working citizens who are deeply committed to their patients.
It is only a few who are tarnishing the name of the profession. I am appealing that the events that unfolded over the media this week must not be misconstrued that most doctors are involved in this practice and start regarding all doctors as some form of criminals. I want to repeat, the majority are very ethical citizens who understand their calling.
The few individuals who are involved, are not only punishing patients, they are also destroying the medical training in the country because they leave medical students to their own devices. Even specialists in training are badly affected by being abandoned by people who are supposed to guide them in every step of their training.
I have already warned the private sector, who are benefitting from this bad practice, that in the long run, they also will suffer because the country will produce poorly trained doctors.
I have given this matter to the Deans of all our medical schools where this practice seems to be very rife, to discuss the matter and come up with recommendations which will be presented to all stakeholders in health. We will call a press conference to determine the way forward. But we can’t avoid criminal charges to those who have been caught red-handed because we have their names and know their activities.
We will also refer their names to the South African Revenue Service (SARS) to see if they are paying tax in the double income they are getting.
We are also appealing to the private sector who are hell-bent on attracting this public servants with lots and lots of perverse incentives. This is going to destroy everybody in the long run.
I wish to take this opportunity to thank the Deputy Minister, the Director-General and all managers in our Head Offices and facilities. Our health workers still remain our heroes and heroines despite a few who want to tarnish their good names. I wish to thank them for the sterling work performance done under very trying circumstances.
I thank you.
Issued by the Department of Health,
May 15 2013