EPF 23 JULY 2014
PAGE: 1 of 95
WEDNESDAY, 23 JULY 2014
____
PROCEEDINGS OF THE EXTENDED PUBLIC COMMITTEE – GOODHOPE
CHAMBER
____
Members of the Extended Public Committee met in the Good Hope
Chamber at 10:02.
Ms T C Memela, as Chairperson took the Chair and requested
members to observe a moment of silence for prayer and
meditation.
APPROPRIATION BILL
Debate on Vote No 16 – Health:
The MINISTER OF HEALTH: Hon Chairperson, my colleague the
Deputy Minister of Health, Dr Joe Phaahla, my colleagues the
Ministers present, chairperson of the portfolio committee, the
hon Dunjwa, members of the Portfolio Committee on Health, hon
members of the House, invited guests, and ladies and
gentlemen, it is a great honour and privilege for me to
present the Health Budget Vote for the 2014-15 financial year.
EPF 23 JULY 2014
PAGE: 2 of 95
This Budget Policy Statement is being delivered under the
guidance of imperatives, targets, pledges and obligations
which are both national and international in character. The
imperatives have to be considered, the targets reached, and
the obligations and pledges respected, by the Department of
Health in particular, but also by the country in general.
Firstly, we have the National Development Plan, which implores
us, amongst others: to increase life expectancy to 70 years by
2030; to have a generation of under 20s free of HIV and Aids
by 2030; to reduce maternal and child mortality; to
significantly reduce the burden of disease, both communicable
and noncommunicable; to implement the National Health
Insurance in phases and complimented by the relative reduction
in the cost of private health care, supported by better human
resources and systems.
Secondly, at the international level we have the Millennium
Development Goals, MDGs, which, as you know, expire
in 2015.
By and large within the health fraternity - that is, the World
Health Organisation, the United Nations Programme on HIV/Aids,
UNAIDS, the African Union Health Ministers’ Summit, the
Brazil, Russia, India, China and South Africa group, Brics,
the Ministers of Health summit, the Commonwealth Health
Ministers, the Southern African Development Community, and
EPF 23 JULY 2014
PAGE: 3 of 95
many others - there is broad consensus about the post-2015
world health agenda.
The consensus is that the post-2015 world health agenda must
be characterised by three goals. The first is that MDGs 4, 5
and 6 need to continue far beyond 2015, meaning that the goals
on child mortality, maternal mortality and the fight against
HIV/Aids, TB and malaria should not stop in 2015. The second
goal is to deal with the risk factors of noncommunicable
diseases by 2015. The third goal is to implement universal
health coverage by every country which, as we know, is called
the NHI in South Africa.
Furthermore, at the international level we have just witnessed
the Partnership Forum, housed by the World Health Organisation
and chaired by our very own Mrs Graça Machel, which held its
summit here in our country at the end of June 2014. The
communiqué at the end of this Partnership Forum meeting states
that we need to ensure the wellbeing of every woman, child,
newborn and teenager.
These are very noble goals and there can never be any argument
about them. The question we need to ask is: How? But the
answer still has to be provided by us, both individually and
collectively.
EPF 23 JULY 2014
PAGE: 4 of 95
In order to avoid getting lost in this myriad of goals,
targets and pledges, South Africa is always guided by the
assessment of our own disease profile. Our own disease profile
is characterised by four colliding pandemics, or what we
commonly know as the quadruple burden of disease.
I’ve mentioned this many times, but I need to remind this
House in this Budget Speech, lest some might have forgotten,
that the four pandemics are the following: the first and
biggest of them all is HIV/Aids and TB; the second is maternal
and child mortality; the third is the noncommunicable
diseases; and fourth and last is injury and violence.
When our country is faced with such a huge burden of disease
and the NDP implores us to reduce this burden, it means that
the health care system has to be directed. We cannot reduce a
burden of disease through a largely curative health care
system such as the one we have in South Africa. A huge disease
burden such as ours can only be reduced through a primary
health care system. Put simply, it means a health care system
that is directed at the prevention of diseases and the
promotion of health. This is what the South African health
care system is going to look like. We have no choice in that
regard because the NDP guides us in that direction.
EPF 23 JULY 2014
PAGE: 5 of 95
Let me start with HIV/Aids and TB. You will notice that the
elimination of HIV/Aids, TB and malaria is Millennium
Development Goal 6. However, you will also notice that under
the quadruple burden of disease in South Africa malaria is not
mentioned. This is because we have already exceeded our target
for malaria - long before 2015. Yes, we have reduced the
incidence of malaria by 89% in our country, long before the
target date of 2015. We have achieved this through a
preventative system called the IRS or indoor residual
spraying, a system whereby mosquitoes are prevented from
landing on the walls of houses and also from being in touch
with human beings.
Our biggest problem remains HIV/Aids and TB. We have made
tremendous progress in the fight against these scourges in the
last five years. However, a lot still needs to be done.
Hon Chairperson, you and the hon members of this House must
have heard about the 20th International Aids Conference that
is going on in Melbourne, Australia. Unfortunately, you have
heard about it in a tragic manner – the tragic death of
citizens of many countries in a plane crash in Eastern
Ukraine. Amongst them were the outgoing President of the
International Aids Society, Mr Joep Lange, and other
luminaries in the fight against HIV/Aids, who were on their
way to the conference. Yes, it was tragic and at the opening
EPF 23 JULY 2014
PAGE: 6 of 95
ceremony of this conference on Sunday, 20 July we felt the
tragedy in the air.
I returned from this conference the day before yesterday. The
conference took a far-reaching decision to add to the already
existing international goals which I mentioned earlier. The
decision was that we need to bring HIV/Aids to an end by 2030.
In South Africa 2030 is a very important date. It is the
target date for the NDP goals. So, the international target
agreed to in Melbourne coincides with this important date on
our calendar.
The conference defined what is meant by bringing HIV/Aids to
an end by 2030. It means the following three things: Firstly,
90% of people should know their status; secondly, 90% of all
those that are HIV-positive must be on treatment; and thirdly,
90% of those on treatment must be virally suppressed. That
means no virus can be detected in their blood. In other words,
the strategy is: “90% by 2030”. Discounting this year, we have
15 years to achieve this target globally.
Now, what will it take for South Africa to achieve these
targets? Where do we start? Let me start here.
EPF 23 JULY 2014
PAGE: 7 of 95
There are 52 million of us. Those who are between 16 and 64
years, which means those who are sexually active, number
35 million. This number needs to be prioritised for HIV
counselling and testing.
Of the 35 million, between 8 million and 9 million people are
tested annually in the Active Case Detection campaign. Of
these, the prevalence rate is 17% for those between 15 and 49
years. With the prevalence rate among pregnant women who use
public sector facilities at 29%, we have 6 million people who
are HIV-positive in this country.
Of these, 2,5 million have been initiated on treatment. This
figure constitutes 80% of eligible women, 65% of eligible
children and 65% of eligible men. The 2,5 million on treatment
are 30% or one-third of the total global figure.
Of these, about 50% undergo viral load tests, and of these 75%
are virally suppressed. I have told you that the Melbourne
conference decided that by 2030, 90% of people who are HIVpositive must have been virally suppressed.
So, like elsewhere in the world, there are leakages in the
HIV/Aids cascade. This needs to be fixed to ensure that those
that are prioritised for the Health Care Team, HCT, are indeed
tested.
EPF 23 JULY 2014
PAGE: 8 of 95
Our next step is to increase the coverage in the manner
proposed by the “90%” approach. This means testing almost all
of the population annually. In summary, it will mean mass
testing in every possible setting - schools, universities,
workplaces, churches and communities.
In further chasing those goals, I wish to announce today that
as from January next year we shall move all HIV-positive
pregnant women to the World Health Organisation’s option B+ as
opposed to the current option B that is operational in the
country. Option B+ simply means that every pregnant HIVpositive woman goes on lifelong treatment regardless of their
CD4 status, whereas option B is that they stay on treatment
only while they are breastfeeding, and stop after termination
of breastfeeding if their CD4 count is less than 350. Option
B+ is lifelong treatment regardless of the CD4 status and it
will start next year. [Applause.]
In addition, it is my pleasure to announce today that as from
January 2015 we shall start HIV-positive patients on treatment
at the CD4 count of less than 500, as against the present CD4
count of less than 350. You will appreciate, hon Chairperson,
that we have come very far in the past 5 years. On 1 December
2009 President Jacob Zuma announced treatment at a CD4 count
of less than 350, as against the then CD4 count of less than
200, for special categories of patients.
EPF 23 JULY 2014
PAGE: 9 of 95
In September 2011 the then Deputy President Kgalema Motlanthe
expanded this to everybody, to make it universal at a CD4
count of 350. Today, it is a further milestone that we are
announcing treatment for all who are at a CD4 count of less
than 500. [Applause.]
You will remember that treatment of as many people as possible
has been found by research also to be a form of prevention.
So, it is in keeping with our strategy of preventative health
care. This massive treatment programme will also be
accompanied by a wide range of prevention techniques,
including massive condom distribution; the HCT; preventing
mother-to-child transmission, PMTCT; sexually transmitted
infection management; massive medical male circumcision, for
which we are targeting 4 million men by 2016; and the
provision of safe blood transfusion, which we have already
achieved in our country because today it is very rare for
anybody to get HIV/Aids from a blood transfusion.
I want to remind you that this did not happen on its own. It
is because of the state-of-the-art facility installed about
four years ago at the transfusion centre in Roodepoort.
Other methods include information, mass education and mass
communication, as well as social mobilisation. We also know
that keeping girl children at school at least until matric
EPF 23 JULY 2014
PAGE: 10 of 95
protects them from pregnancy and HIV/Aids acquisition. This
has also been revealed by research.
For all these noble goals to be achieved, government and civil
society as represented by the SA National Aids Council, Sanac,
must be well-oiled machinery, which at the moment, I’m afraid,
is not really so. I am appealing today to Sanac to please
recharge, for the task ahead in the next 15 years is huge and
we cannot afford to be flat-footed at this period in the
history of the pandemic – it is the final push.
With regard to the TB front, I announced the new measures
during my speech on the debate in the President’s state of the
nation address. We will screen all 150 000 inmates in our
correctional services facilities, all the 500 000 miners and
all the 600 000 strong peri-mining communities in six
districts that have a high level of mining activity.
In addition, we are going to embark on a massive
decentralisation of multidrug-resistant tuberculosis
initiation, management and treatment. Presently, we have 100
such decentralised sites, and we are going to increase the
number to 2 500. This will happen through a rapid
establishment and scale up of nurse-led MDR-TB treatment
management teams at municipal ward level.
EPF 23 JULY 2014
PAGE: 11 of 95
Let me come to maternal, child and women’s health. Whether you
talk of MDGs, the post-2015 MDG health agenda, the National
Development Plan, the World Health Assembly or the World
Health Organisation Partnership Forum, issues of maternal,
child and woman’s health will always come to the fore. This is
because maternal and child mortality is not only a health
issue, but also an issue of development of humanity that
really kills women in pregnancy and child birth, despite our
long-held assertion that no woman should die giving life.
There are, of course, many causes, most of which are
developmental. In South Africa, we already know from the
triennial studies of the national confidential committee of
inquiry into maternal mortality that three causes emerge as
the most prominent.
These are summarised as the 3Hs. The first one is HIV/Aids,
which accounts for 49% of maternal mortality and 35% of child
mortality; the second one is hypertension in pregnancy; and
the last one is haemorrhage, both anti- and postpartum
haemorrhage.
You will appreciate why we have consistently and persistently
pursued strong HIV programmes for pregnant women, like the
PMTCT. We are aware that we have scored significant
achievements in this regard. Whereas a decade ago we had
EPF 23 JULY 2014
PAGE: 12 of 95
70 000 children born HIV-positive in South Africa, we now have
less than 8 000 annually, due to the massive and successful
PMTCT programme. We are going to build on this success until
no child is born HIV-positive anymore.
To deal with the other two Hs, the African Union Heads of
State have launched the Campaign on Accelerated Reduction of
Maternal and Child Mortality in Africa, Carma. During the past
18 months, 1 468 doctors and 3 625 professional nurses have
been trained in what is called Essential Steps in the
Management of Obstetric Emergencies, ESMOE. Our data suggests
that in the districts where the training has been done
maternal deaths from bleeding after delivery are on the
decline. We will continue with this programme until doctors
and midwives in all districts in the country are well trained.
Part of the agenda to reduce maternal mortality is family
planning. We know from the triennial studies of the National
Capital Conference on Emergency Medicine, NCCEM, that of the
1 million women who fall pregnant annually, 8% are girls under
the age of 18 years, but they account for a whopping 36% of
maternal deaths.
There have been wild claims that the key driver of teenage
pregnancy is the child support grant. There is no scientific
evidence to back this claim. We have always argued, and the
EPF 23 JULY 2014
PAGE: 13 of 95
United Nations Population Fund for population development,
UNFP, has backed our argument, that one of the main drivers of
teenage pregnancy in sub-Saharan Africa is the lack of family
planning. This has also led to an exploding number of teenage
pregnancies.
In dealing with this scourge, on 17 February 2014 we launched
a new National Family Planning Campaign in Ekurhuleni in
Gauteng, under the theme, “Dual Protection”, meaning the
consistent use of a condom together with another form of
contraceptive device.
On that occasion we launched a totally new contraceptive
device called the subdermal implant, which is implanted just
under the skin of the inner upper arm of the woman. This was
the first time that this long-acting contraceptive, which
remains active for three years, had been made available in the
public health sector in South Africa. Whereas it will normally
cost you up to R1 700, it is provided free in all health
facilities, regardless of their socioeconomic status.
[Applause.] For this campaign we have up to now trained 5 325
nurses across all public health facilities, who are now able
to insert the implant even in the absence of a doctor.
When we started, we agreed that we would order 80 000 units of
the implant every quarter, meaning that we would insert
EPF 23 JULY 2014
PAGE: 14 of 95
320 000 implants per annum. We were pleasantly surprised that
in only 4 months we had inserted 362 000 implants, far
exceeding what we had regarded as the annual target of 320
000. Already, 600 000 implants have been ordered and we have
cause to believe that they will all be inserted by the end of
the financial year. Does this not tell us that there has
really been a gap in the provision of family planning in this
country? We wish to appeal to hon members to help popularise
this very convenient method of family planning in their
constituencies, in their families and even among themselves.
I wish to further announce to this House that in March this
year, we together with the Department of Higher Education and
Training, launched the human papillomavirus, HPV, vaccine. I
also wish to announce to the House that we have reached a
target of 345 377 learners. We are planning a second dose in
September 2014. The girls who have not been vaccinated will
get the vaccine next year. This vaccine costs between R700 and
R1000, but we are providing it free of charge in all public
schools. [Applause.]
I’m left with 10 seconds, Chairperson. In those 10 seconds I
want to announce that on 24 August 2014 we are going to launch
the Mom Connect Project, which I have already announced, where
all the 1 million pregnant women will be connected via
EPF 23 JULY 2014
PAGE: 15 of 95
cellphones so that we can communicate directly with them.
Thank you very much. [Applause.]
Ms M L DUNJWA: Chairperson, hon Minister of Health Dr
Motsoaledi and your deputy Dr Phaahla, hon members of the
Portfolio Committee on Health, Members of Parliament, the
director-general and staff, guests, people of South Africa,
friends and fellow comrades, good morning. Today we are
debating Bugdet Vote No 16 - Health.
Firstly, I proudly stand here as a member of the ANC, and I
want to say thank you very much to the supporters and the ANC
members who again voted for it to lead this country.
[Applause.] Also we stand here as the ANC to support the
Budget Vote on Health.
At our 52nd conference in 2007 the ANC identified health as a
key priority area, and prioritisation of this area has since
remained central to the policy imperatives of the ANC
government.
Let me elaborate on what we have accomplished thus far. We
have made significant progress in regard to certain aspects of
the health system. We have developed sound and progressive
public health legislation and policy, established a unified
national health system, increased infrastructure at primary
EPF 23 JULY 2014
PAGE: 16 of 95
care level, removed user fees for maternal and child health
services, introduced a system of social support grants,
ensured the steady increase of immunisation coverage, and
supported the world’s largest HIV treatment programme.
However, there is still a long road to health recovery for
South Africans. In regard to our progress in fulfilling the
Millennium Development Goals on child health, HIV/Aids,
tuberculosis and malaria, as well as maternal health, we are
still trying our best. Coupled as this is with the quadruple
burden of disease, economic and social inequality, barriers to
accessing health services, inadequate distribution of health
resources, and continued human resource capacity needs, the
situation would appear to be a cause for major concern.
In response to these challenges and the transformation of the
sector, a diagnostic process regarding the key challenges
facing the health sector, commissioned by the Subcommittee on
Education and Health of the ANC’s national executive committee
in 2008, developed a health sector road map. You see that we
have started from 2007 because we want the people of South
Africa to understand that we as the ANC weren’t sleeping and
then woke up regarding the concern of the health sector.
The road map led to the development of the 10-point plan
intended to guide government health policy and identify
EPF 23 JULY 2014
PAGE: 17 of 95
opportunities for co-ordinating public and private health
sector efforts in order to improve access to affordable
quality health care in South Africa.
The 10-point plan, in which is located the process towards the
achievement of the MDGs, focuses on the following: providing
strategic leadership and creating a social compact for better
health outcomes; implementing the National Health Insurance;
improving health service quality; strengthening health care
system management; improving human resource development;
planning and management; revitalising infrastructure;
accelerating the implementation of strategic plans on HIV,
sexually transmitted infections and tuberculosis; intensifying
health promotion programmes and mass mobilisation; reviewing
the drug policy; and strengthening research and development.
We believe that chapter 10 of the National Development Plan
also alludes to the issues that we as the portfolio committee,
the Department of Health and the ANC think should be looked
into. Moreover, in the 2014 state of the nation address,
President Jacob Zuma also alluded to the improvement of
quality care in the public sector, under which health falls.
Primary health care will be re-engineered by increasing the
number of ward-based outreach teams, contracting general
practitioners and district specialist teams, and expanding
EPF 23 JULY 2014
PAGE: 18 of 95
school health services. The emphasis is on the delivery of
community-based services by reaching out to families more
proactively, with more focus on disease prevention, health
promotion and community participation.
These community outreach activities will be facilitated by a
primary health care outreach team consisting of both nurses
and community health workers who, in turn, are supported by
facility-based and specialist support teams of health care
professionals. District specialist teams will be deployed to
each of the 52 districts in the country to strengthen clinical
governance. The health and social policy will be strengthened,
and community health workers will be in the field to reach out
to communities.
Emphasis will be placed on quality assurance and improvement
through compliance with norms and standards for health care
delivery. The newly established Office of Health Standards
Compliance will ensure that the quality of health care is
improved by their inspecting public hospitals for six basic
health standards: cleanliness, infection control, attitude of
staff, safety and security of staff and patients, waiting
times, and drug stock-outs. Many of us have heard horror
stories of filthy wards, patients lying on dirty linen for
days, and no proper protection for patients against infectious
and contagious diseases, resulting in fatalities. The office
EPF 23 JULY 2014
PAGE: 19 of 95
will also have an ombudsman, which will make it possible for
patients to complain about health care institutions.
Government reforms will focus on a competency-based ranking
system for public hospitals, chief executive officers and
district managers and the development of a governance model
for a strengthened district health system. For us to move
forward, we must look at health workforce development and
improve the management of health care institutions and health
districts. Hospitals must function effectively. Competent and
skilled hospital managers who are able to ensure
accountability and identify weakness by management must be
appointed. The training of managers in the leadership and
management of government institutions must be prioritised.
A new public entity called the SA Health Products Regulatory
Agency will be established to manage the registration,
regulation and control of health products. The Medicines and
Related Substances Amendment Bill is before the National
Assembly and paves the way for a new regulatory body for
medicines. This will lead to more effective authority than the
slow and underresourced Medicines Control Council. The SA
Health Products Regulatory Agency will scrutinise sectors of
the market that have, until now, been unregulated, including
medical devices and diagnostics. It will also be responsible
for foodstuffs, cosmetics and complementary medicines.
EPF 23 JULY 2014
PAGE: 20 of 95
Performance management reform initiatives include the
organisational review of the national Department of Health, a
financial management improvement project, and other
initiatives such as those aimed at strengthening the provision
of quality health care by health care facilities.
The organisational review aims to improve overall
organisational effectiveness and capabilities. A thorough
diagnostic exercise has highlighted some weaknesses within the
national department relating to the ineffectiveness of the
current management infrastructure and low morale amongst
staff.
Ndicinga ukuba masiyithethe siyikomiti yezempilo ukuba kukho
inqaku ebelipapashwe ngomhla we-6 kuJulayi elithetha ngezigulo
zengqondo phantsi kweSebe lezeMpilo elikhokelwa nguMphathiswa
uMotsoaledi, kwaye liqhuba lithi asikhange senze nto
singurhulumente we-ANC. Ndifuna ukuzikhumbuza iintatheli
ezibhale eloo nqaku ukuba ngowama-2012, urhulumente we-ANC
waya kwintlanganiso yaBaphathi baMazwe [summit] wayivuma into
yokuba noko asihambi ngendlela ekhawulezayo.Iintatheli
zithatha oko ke zakwenza okwazo.
Andizi kungena kwinqaku, kodwa manditsho ukuba elaa nqaku
lithi umntu ogula ngengqondo makathathwe aye kuvalelwa, kanti
sithi siyi-ANC isigulo sengqondo sisigulo esifana nazo naziphi
EPF 23 JULY 2014
PAGE: 21 of 95
na izigulo. Sisigulo esimele ukuba abantu emakhaya bancediswe
ngoonompilo [community health workers] Sithi siyikomiti,
Mphathiswa, iSebe maliqinisekise ukuba liyancedisa ukuba
oonompilo baqeqeshwe ukuze bakwazi ukuncedisana nabantu,
bakwazi ukuba xa bengena umzi nomzi bambone umntu oza
kuhlaselwa sesi sifo.
Enye into engakhange ivezwe leli nqaku yeyokuba isiphako
[stigma] sokuba ukuba unesifo esithile sibangela ukuba
uthathwe ngokuba ugula ngengqondo kunye nosapho lwakho.
Siyacela ke ukuba iSebe lezeMpilo, phantsi kwesikhokelo sakho,
liqinisekise ukuba oonompilo, abongikazi noogqirha
bayaqeqeshwa. Xa ndigqibezela, siyacela ukuba kuqhutywe i ...
(Translation of isiXhosa paragraphs follows.)
[I think that we as the Health Committee need to refer to an
article on the state of South Africa’s mental health which was
published on 6 July and which suggests that under the ANC-led
government the Department of Health, led by Minister
Motsoaledi, has done nothing about this issue. I want to
remind the journalists behind this article that in 2012 the
ANC-led government attended a world summit and conceded that
the pace of progress in this area was slow. The journalists in
question took this concession out of context.
EPF 23 JULY 2014
PAGE: 22 of 95
I am not going to dwell on the article, except to say that it
implies that a person with a mental condition should be
institutionalised, whereas we as the ANC say that a mental
condition is a health condition like any other. It is a
condition that community health workers should help with in
the community. We as a committee, Minister, say that the
department should ensure that community health workers are
trained so that when they are doing their house-to-house
visits, they are able to help diagnose people with potential
mental conditions.
One other thing that was not raised in the article is the
effect of stigma on those with a mental condition and their
families. We appeal to the Department of Health, under your
leadership, Minister, to ensure that community health workers,
nurses and doctors are trained to deal with people with mental
conditions. In conclusion, we appeal for the ...]
... recruitment of health workers, as outlined in our
manifesto. [Interjections.] Yes, we agree. We are happy that
in your speeches you say that a number nurses will be trained,
but there is a challenge regarding how the nurses are
recruited, amongst others.
I know for a fact that in my province the recruitment of
nurses is advertised in newspapers, whereas when I had to
EPF 23 JULY 2014
PAGE: 23 of 95
apply for nursing training, I had to apply by saying that I
begged to apply, and send it to Livingstone Hospital. I did
not have to go and buy a newspaper. We are raising that
because ...
... abantwana abasemaphandleni nasezifama abakwazi ukuba
bangaxhamla.
Xa sisuka apha siye ekuqeshweni kwabancedisi ngokubanzi
[general assistants] kuba kukho into esingayaziyo singabantu
baseMzantsi Afrika yokuba ... (Translation of isiXhosa
paragraphs follows.)
[... it excludes children from rural areas and farms.
Coming to the question of general assistants, we as South
Africans miss the point that ...]
... the make-or-break person in any health services in any
country is the general assistant. You cannot give a patient
medicine on an empty stomach. You can never prepare a patient
for theatre when the theatre is dirty and the linen is dirty.
You can never!
Uyabaqeqesha abantu ekuthiwa ngoopota, oomabhalana, kuba umntu
xa engena emnyango esibhedlele ungena adibane naba bantu. Ewe,
EPF 23 JULY 2014
PAGE: 24 of 95
zine iicategories ezibalulekileyo kwezeMpilo, ngumncedisi
ngokubanzi, ngumabhalane, yipota kunye nogqirha. Kodwa zininzi
izinto ezenza umanyano lwentsebenziswano [package]. Sithi ke
kuni, Baphathiswa, xa niyijonga lo mba wezempilo, ningalibali
ukuqinisekisa ukuba ezi zinto ziyenzeka.
Xa ndisuka apha mandithi ... (Translation of isiXhosa
paragraphs follows.)
[You have porters and clerks, people who are at the coalface
of a hospital visit. Yes, there are four categories of
employees in the health sector, namely the general assistant,
the clerk, the porter and the doctor. However, co-operation
amongst them comes in the form of a package. Therefore,
Ministers, we say that when you look at the issue of health,
you should not forget to make sure that these things happen.
Let me add that ...]
... we do have a good story to tell. A good story to tell is
... [Interjections.] For your information, what worries me is
that in the last Budget Vote the ANC was perceived as being an
organisation led by people who were illiterate! Thank you.
[Time expired.] [Applause.]
EPF 23 JULY 2014
PAGE: 25 of 95
The TEMPORARY CHAIRPERSON (Ms T C Memela): The next speaker
will be the hon James, but before he takes the podium, may I
alert all hon members here to the fact that there will be a
swap between hon Carter and the hon Shaik Emam. Ms Cater will
speak before the hon Shaik Emam.
Dr W G JAMES: Hon Chair, Minister, Deputy Minister, members
and, guests present, let me start by sharing with you the
results of a paper published by Juanita Becker. The paper is
titled: “Reasons why patients with primary health care
problems access a secondary hospital emergency centre”. This
was published in the South African Medical Journal in 2012.
The researchers wanted to understand why patients went
directly to a secondary care hospital in George when they had
primary health care problems.
It is not a trivial question, as the Minister pointed out. If
community-based primary care prevents preventable diseases,
the trauma and opportunity costs of hospital care can be
avoided and physicians will be able to focus on patients with
emergency complaints.
More broadly, if primary health care, PHC, worked well to
prevent disease, our country could spend billions more rands
on treating disease, and on conducting clinical and discovery
research to find new cures in the light of our changing
EPF 23 JULY 2014
PAGE: 26 of 95
demography and the shifting complex health burden that the
Minister described.
So, what does the research say about PHC in our country? The
researchers found in George that 88% of the patients who came
for emergency care at the George Hospital were self-referred
and that 30% had complaints that had lasted for more than a
month. They established that a mere 4,7% of the self-referred
cases were, in fact, for emergency care.
The reasons why patients came for hospital emergency care were
as follows: 27% of the respondents claimed that the prescribed
clinical medicine was not helping; 23,7% said that the
treatment at the hospital was superior, or at least they
believed it to be superior; and everyone complained that there
were no after-hours primary health care services available.
Health Minister Aaron Motsoaledi is therefore entirely correct
in his desire to re-engineer PHC, as described in the various
departmental documents. So, what is the plan? The George study
researchers made some evidence-based recommendations and said
the following.
Firstly, introduce campaigns on the primary health care
services that are, in fact, available and, secondly, introduce
education campaigns to share with the public what the
EPF 23 JULY 2014
PAGE: 27 of 95
appropriate use of emergency care or hospital services, in
fact, is.
Secondly, make clinics available 24/7, which will reduce the
number of patients inappropriately ending up in emergency care
or, alternatively, specially appointed clinical nurse
practitioners could provide after-hours PHC services at
hospitals.
Finally, channel patients, using the existing triage system
better, to the appropriate level of care by ramping up the
quality of the health information and communication technology
and by introducing a standard referral letter.
Equally important to consider is the Tshwane health post
model. In a paper published in the African Journal of Primary
Health Care and Family Medicine this year, Nomonde Bam and
others recommended that primary health care teams with certain
qualities be established in the country. The following
qualities are important.
Firstly, a health post manager, which is a professional nurse,
and between 20 and 30 community health workers should be
recruited from the communities surrounding the health post.
Secondly, the health post showed serve between 2 000 and 3 000
households in a defined area within a municipal ward. Thirdly,
EPF 23 JULY 2014
PAGE: 28 of 95
the health post should be hosted by an existing communitybased nongovernmental organisation in the community. Finally,
the teams should collect digitised records, using cellular and
other modern information technology, for the entire community.
I share this sample of work with you because it comes from
medical doctors, health professionals and researchers working
in the field. These are the people who know how to get the job
done. They know how to apply expert knowledge to the task at
hand. They know what it is like to spend your life devoted to
promoting health.
We have a very large community of medical and nursing
professionals with a wealth of experience, insight and
commitment. It is government’s responsibility to take up the
recommendations of its health professionals and I believe that
Minister Motsoaledi has begun to do so.
The most recent annual performance plan of the department sets
out as a short-term goal, and I quote: “Improving access to
community-based PHC services and the quality of services at
health care facilities.” This will be achieved by having 1 500
functional ward-based primary health care outreach teams
established by 2014-15 and 3 500 by 2018-19.
EPF 23 JULY 2014
PAGE: 29 of 95
However, for the life of me, colleagues, I simply cannot find
the budget to support success in PHC. The budget seems
entirely inadequate to the task. Not only is the 2013-14
allocation of R102 million small for such a high priority
item, but it faces a budgeted decline to R93 million for this
year and next year, only to recover at an inflation-level
increase to reach R98 million by 2015-16.
The portfolio committee was alarmed by this, and I quote: “PHC
services again decline in both nominal and real terms in 201415”. The report reads: “Less than 1% of the entire budget is
allocated to this programme, which is less than it received in
the previous year, both as a percentage and in real terms.”
It is certain, of course, that some funds from other
programmes, such as the R13 billion HIV and Aids, TB and
Maternal and Child Health Programme, which is Programme 3, or
the R18,9 billion Hospitals, Tertiary Services and Human
Resource Development Programme, which is Programme 5, are
spent through the PHC system. However, I have no idea how much
of those and where.
Similarly, I am also certain that some of the modest
R621 million National Health Insurance, Health Planning and
Systems Enablement Budget, which is Programme No 3, must be
spent on PHC infrastructure and planning to progressively
EPF 23 JULY 2014
PAGE: 30 of 95
advance universal access, something which the DA
wholeheartedly supports.
The Western Cape MEC for Health, Mr Theuns Botha, asked me to
convey to this House his willingness to host more NHI projects
that advance universal access, contrary to propaganda about
what we support and what we do not support. However, again, I
have no idea how much and where that is spent. I would
therefore like to recommend that Minister Motsoaledi present
to the portfolio committee the following.
Firstly, he must have a consolidated budget for all the PHC
activities that form part of his re-engineering intention.
Secondly, he must give some idea of how he would propose to
ring-fence primary health care spending at the provincial
level and I will get back to that issue in a minute.
Thirdly, he must explain the paradox that so little is spent
on such a fundamentally important issue, which is essential to
achieving his department’s objectives.
My deputy, Dr Heinrich Volmink, and I spent this past Sunday
and Monday speaking to medical doctors, nurses and
administrators at the Pelonomi Regional Hospital and the
National Hospital in Mangaung. We were confronted with the
EPF 23 JULY 2014
PAGE: 31 of 95
stark reality of the scale of collapse of health services
there. Let me give you some examples.
Patients with bone fractures who are as old as 70 are
accommodated on stretchers in the referral ward due to a
shortage of bed space; the hospital does not have hot water,
and nursing staff and patients boil water in coffee urns;
patients bring their own blankets and pillows to the hospital,
due to medical linen shortages; and the hospital regularly
runs out of medical consumables.
According to hospital staff, there are three fully equipped
operating theatres out of operation - and we saw them - due to
a shortage of anaesthetic machines. Some patients in the
orthopaedic ward have been waiting for surgery for more than
three months. According to the medical staff at the hospital,
only four operating theatres are functional and a fifth is out
of commission, because it is not equipped with an anaesthetic
machine.
This, my friends, is a moral and constitutional failure that
goes beyond the Free State. It is for this reason that we call
on Minister Motsoaledi to intervene.
We will spare no effort in order to compel provincial
governments to uphold the constitutional requirement to make
EPF 23 JULY 2014
PAGE: 32 of 95
health care progressively available so that there is “life” in
the “better life for all”.
The Free State hospitals are examples of health institutions
that suffer from a double whammy. They receive many patients
with primary health care problems because, with some notable
exceptions, PHC does not exist in the broad swathes of this
large province, geographically speaking, and on the other hand
their hospital facilities are grossly dysfunctional.
It is government’s responsibility and duty to support the
nation’s community of professionals by ensuring that there is
adequate infrastructure; a functional work environment;
future-oriented human resource development; sympathetic,
responsive and professionally organised support services; and
properly calibrated budgets to make it all work.
I believe that Minister Motsoaledi and his Ministry are
strengths in the system. They are not weaknesses; they are
strengths in the system. However, the fact is that close to
90% of our health budget consists of transfers and subsidies
to provinces and municipalities. It is here that our weak link
in the health care chain lies.
It is the failure of municipalities to proactively and
regularly test for pathogenic bacterial, viral and parasitic
EPF 23 JULY 2014
PAGE: 33 of 95
infections when it comes to water contamination. Preventing
that would have led to the fact that the wholly preventable
and heart-rending deaths of infants from dysentery in Bloemhof
and elsewhere would not have occured.
It is the failure of most provincial governments to spend
their health funds properly, efficiently and strategically.
Regarding the audit outcomes, let me just point out to you the
following results from the Auditor-General’s reports on
viewing provincial departments of education: Limpopo has a
disclaimer with findings where they say that the root causes
to address are the slow response by political leadership, and
the lack of consequences for poor performance and
transgressions.
The same applies to the Free State, Eastern Cape, Northern
Cape, Mpumalanga, KwaZulu-Natal and Gauteng. Only the North
West and the Western Cape escaped the negative reports of the
Auditor-General. The line that runs through all of that is a
lack of consequences for failing to do the job properly.
So what is to be done? Appoint qualified and capable
individuals for the job; support them fully, but have real
consequences for failure; hold them accountable; ring-fence
EPF 23 JULY 2014
PAGE: 34 of 95
provincial budgets; be responsive to problems; and support and
value our health care professionals and the community.
I wish I had the time to develop this last point properly. I,
however, I wish to point out that the National Institute for
Communicable Diseases, which is a surveillance body, and its
parent, the National Health Laboratory Service, which is a
pathology testing body, are bankrupt. They have frozen all
their posts and they no longer have a critical mass of
epidemiologists there.
Let me just say that I want to recommend that the Minister
turns surveillance, especially with mass testing at hand, into
a fully funded programme of the department. Thank you very
much. [Time expired.] [Applause.]
Mr N S MATIASE: Madam Chairperson, we too in the EFF are
saddened by the killing of innocent people through the downing
of Malaysian Airlines Flight MH17 in the Ukraine. The loss of
life of one person in such a horrible way is one too many.
The EFF cannot endorse or support this budget presentation by
the hon Minister of Health, Aaron Motsoaledi, ...
[Interjections.] ... as it fails to address any of the causes
of the explosion in the prevalence of disease in our country,
which is escalating at an alarming rate. If this continues
EPF 23 JULY 2014
PAGE: 35 of 95
along the projected path, we will not have an economy or a
culture worth fighting for in a debate.
This budget also does not provide for any solution to
reversing the damage inflicted on our people through the:
uncontrolled proliferation of GMOs; vaccinations; hazardous
industrial toxins in foods, medicines and household products;
nutrient-deficient foods; and recklessly dangerous
agrochemicals.
Surely the focus of the department should be on the protection
of the health of the nation and, by implication, the health of
the environment upon which we all, without exception, depend
for our continued existence. The department should be at the
forefront of the battle to ensure health, and not remain
entangled in the commercial perpetuation of disease
management. We are managing diseases.
While some lip service is paid to “prevention” and to
“health”, the department’s report suffers from the same
ideological problems referred to by Commissar Floyd Shivambu
on Monday in his response to the National Treasury Budget
Vote: a misdiagnosis of the problems, leading to incorrect
remedies, and the consequent ravaging of our nation’s health
and the resultant decrease in health management to
inappropriate disease management.
EPF 23 JULY 2014
PAGE: 36 of 95
Accompanying this problem of incorrect “health” paradigms is
the planned corporate theft – as has been revealed in the Free
State and other provinces – of medicine and medicinal
products. There is also fraud and the plundering of our
financial resources through massively inflated prices on drugs
and services.
The TEMPORARY CHAIRPERSON (Ms T C Memela): Hon member, you
have two minutes left.
Mr N S MATIASE: Time is of the essence.
We call on all members of this House to oppose the Medicines
and Related Substances Amendment Bill - and it must be brought
back because it undermines section 27 of the Constitution.
This government, despite overwhelming support and successful
elections, has failed dismally to protect the health of the
people and it continues to be delusional. This government is
delusional, it has lost the sense of its historical mandate,
and it is no longer in sync with reality. [Interjections.]
Let’s remind the ruling party that it must always bear in mind
that the people are not fighting for ideas, for things in
anyone’s head. They are fighting to win material benefits, to
live better and in peace, to see their lives go forward, and
EPF 23 JULY 2014
PAGE: 37 of 95
to guarantee the future of their children. This was said by
Amilcar Cabral.
As the EFF, we refuse to endorse this budget and call upon all
concerned and affected citizens to reject it as well.
[Interjections.]
Ba nang le ditsebe ba utlwile. [Those with ears have heard.]
The TEMPORARY CHAIRPERSON (Ms T C Memela): I now call upon the
hon Oriani-Ambrosini. We as a people understand that he will
speak from where he is. Thank you.
Dr M G ORIANI-AMBROSINI: Thank you for the indulgence, Madam
Chairperson. I think that this is a committee in which we
should endeavour – more than in any other committee – to try
to create a national consensus. In order to do so, we must
accept being pragmatists, not ideologues. What is at stake is
the health of a nation, the pain and suffering of the people.
My contribution to that end is the plea for there to be a hard
look at the entire regulatory scheme. I want to be very
practical. We have adopted regulations to help people, and
many of the laws and the regulations we have adopted have the
unintended consequence of throwing the baby out with the bath
water.
EPF 23 JULY 2014
PAGE: 38 of 95
I am under the most advanced treatment in Western medicine,
targeted chemotherapy. But at the same time I am being treated
for my cancer as I would be treated if I were in Beijing or
Shanghai, with Chinese medicine. The new regulations that we
have adopted will make the Chinese treatment illegal. Why?
Because it cannot be proven to have an effective and non
harmful nature by way of a double-blind placebo-based clinical
study.
That is a problem. If we need to succeed with the enormous
challenges before us, we need to make available everything
that works, and we need to determine tests for what works and
what does not work which are adequate for the nature of what
we are testing.
In this country we may have 1 000 cases of mesothelioma. In
China they have 100 000 cases, and their effectiveness is
superior to ours regarding morbidity, the quality of life of
those who survive, and all the applicable tests.
We are part of the Brics group - that is, the Brazil, Russia,
India, China and South Africa group - and it is unusual for my
colleagues to hear me spend time advocating the benefits of
co-operation with China. But China is a great reservoir of
ancient knowledge. We are in this strategic position of being
able to have privileged exchanges with China, which ought not
EPF 23 JULY 2014
PAGE: 39 of 95
to be limited only to the trade and industry fields or the
cultural field, but should include the medical field. This is
because they treat people at a fraction of the cost of our
treatment with medicines that have thousands of years of
history behind them, and which are equally effective.
And why do we test them? We must not make the mistake of
having politicians - which we are - determining what doctors
are allowed and not allowed to do. We need to return the power
to doctors. Let them decide. And that is the nice thing about
China - the Chinese government doesn’t get into the hospitals.
They let the hospitals decide how people should be treated.
And we should not determine, by way of our laws, what doctors
can use or cannot use.
I have introduced this Bill, which I hope my colleagues will
look at seriously. It will apply only to terminal cases where
the discretion is given to doctors to go beyond the parameters
of what can be done ordinarily. I think that that discretion
should become part of the system. We have enough responsible
people to move in that direction.
There is also a need not only to treat people, but to ensure
the affordability of the system. In the end, Madam Chairperson
and hon colleagues, this is unfortunately a matter of money.
The budgetary cost of extended chemotherapy alone, in cases
EPF 23 JULY 2014
PAGE: 40 of 95
like cancer, or of some of the most expensive pharmaceutical
solutions as opposed to botanical treatments, is one that
should encourage us all to look in a different direction.
I hope that consideration is given to my Bill. We have
received 1 102 comments that are overwhelmingly favourable.
That might be the basis on which broader consideration may be
given to all the regulatory aspects of the underpinning health
system. That is how this may be achieved. Thank you, Madam
Chairman. [Applause.]
Ms D CARTER: Hon Chair, our Constitution is underpinned by the
Bill of Rights. Our Constitution requires our state to
respect, protect, promote and fulfil the rights of our
citizens - the right to human dignity, the right to life and
the right to adequate health care. Our Bill of Rights also
sets out the rights of children and of the elderly.
The question I pose, hon Minister, is simple: Is our health
care service complying with the basic responsibilities set out
in our Constitution? What is the department’s budget for
cancer research and for testing, at least at stage 1 or 2? Is
there support for entities such as the Cancer Association of
South Africa, Cansa, or the Sunflower Fund?
EPF 23 JULY 2014
PAGE: 41 of 95
When are we going to decide to establish a bone marrow bank in
this country? Currently, we are sitting with the fact that at
the Sunflower Fund there has been an increase to 65 000
donors. One out of 100 000 will be a match. Moreover, it is
costly; it is more than R2 500 to do that test.
Hon Minister, we all want HIV to end, and thank you that we
are now going to make antiretroviral drugs available to those
with a CD4 count of 500 and not only 350.
The National Development Plan states that our health care
system has been poor, despite good policy and high spending.
Page 331 speaks of the “failure of the health care system”.
Towards the end of 2012 my mother was once again admitted to
Livingstone Hospital, suffering up to five mild heart attacks
a day. Six weeks later, she was transferred to the Provincial
Hospital to undergo a second triple bypass, which we are very
grateful for at the age of 78.
At Livingstone Hospital we found compassionate and too often
sleepwalking doctors who had been on duty for up to 36 hours.
Each shift started with prayer and a song, lifting the soul,
but that is where it stopped. Patients’ food, which was next
to their beds overnight and the food of those who were too
weak to eat was returned untouched.
EPF 23 JULY 2014
PAGE: 42 of 95
Those asking for water were ignored. I eventually equipped
myself with a bottle of water and a drip line, feeding
patients water. I can and will never forget for as long as I
live how thirsty one little girl was. She had meningitis. She
could not lift her head, and was crying out, “God, take me!” I
can never forget the minute we put water to that child’s lips
and that look in her eyes. That is what she was crying for;
she was thirsty.
The stench at times was unbearable. Patients asking for
assistance to toilets or to have a bed pan were ignored, lying
in faeces for hours, with no soap to wash and no toilet paper.
Sometimes the bodies of those not so fortunate would remain in
the ward until after visiting hours, while nursing staff in
their civvies and takkies - or even slip-slops - would enjoy
their lunch.
Livingstone Hospital boasts of a state-of-the-art trauma
centre, built during the 2010 Fifa World Cup, which is now
used by outpatients. There’s a shortage of doctors and health
care staff, and patients have to wait for up to five days at
the reception to see a doctor. There is a shortage of medical
equipment, supplies, maintenance and repair of medical
equipment. Oxygen lines are regularly faulty. There’s also a
EPF 23 JULY 2014
PAGE: 43 of 95
shortage of surgeons whereby patients wait for months to have
critical operations for life-threatening problems.
Just let me add that the surgeon that did my mother’s triple
bypass had her as his last patient. He went to Canada. The
surgery was a success, but the problem was aftercare, when we
had to try to get her into a state-run facility after she got
pneumonia and infection. If we had not moved her, she would
have died. [Time expired.] [Applause.]
The DEPUTY MINISTER OF HEALTH: Hon Chairperson, hon Minister
of Health Dr Aaron Motsoaledi, other hon Ministers and Deputy
Ministers present, hon chair of the Portfolio Committee on
Health hon Dunjwa, members of the portfolio committees in the
National Assembly, hon members of this House, distinguished
guests, and ladies and gentlemen, I want to take this
opportunity to thank the hon Chair for the opportunity to
participate in this debate on the 2014-15 Budget Vote for the
Department of Health.
Our 2014-19 strategic plans and the 2014-15 annual performance
plan are firmly anchored in the implementation of the National
Development Plan. Our vision of a long and healthy life for
all South Africans speaks to both the NDP goals and also to
Outcome 2 of the government’s Medium-Term Strategic Framework.
EPF 23 JULY 2014
PAGE: 44 of 95
I will speak to the other two NDP goals, which are the
significant reduction of the prevalence of noncommunicable
diseases, and the reduction by 50% from the 2010 levels of
injuries, accidents and violence by 2030.
In addressing these two contributors to what the Minister has
already alluded to as the quadruple burden of disease facing
our country, we will be able to contribute to raising the life
expectancy of South Africans to at least 70 years by 2030, as
envisaged by the NDP. The implementation of these programmes
will also go a long way in realising the commitments we as the
ANC have made in our election manifesto.
We are all familiar, and the Minister has gone quite deeply
into this with the fact that as a country we have the
challenge of diseases such as HIV/Aids and tuberculosis, and
the high rates of maternal and child morbidity and mortality.
However, we must always be aware of the growing problem of
what is now globally known as the new emerging epidemic of
noncommunicable diseases.
Currently, in the 30-year to 70-year age group,
noncommunicable diseases account for 43% of total deaths.
Cardiovascular disease, including hypertension, cancer,
diabetes mellitus, chronic respiratory infections, mental
disorders and other diseases have been part of our health
EPF 23 JULY 2014
PAGE: 45 of 95
landscape for many years. Until recently, however, due to high
levels of infectious diseases, they have tended to play second
fiddle to communicable diseases, especially in low and middleincome countries such as South Africa.
However, noncommunicable diseases are emerging as the big
health problem of the future globally, and with our own
increased urbanisation and industrialisation we are already
seeing growing trends of these diseases in our country. These
diseases are often called, and correctly so, silent killers,
because many people that have diabetes or hypertension, for
example, are not aware of the fact that they are suffering
from these ailments.
The NDP is clear in this regard, and I quote:
South Africa’s health challenges are more than medical.
Behaviour and lifestyle also contribute to ill-health. To
become a healthy nation, South Africans need to make
informed decisions about what they eat, whether or not they
consume alcohol, ... sexual behaviour, (levels of physical
activity,) among other factors.
It goes on to say:
EPF 23 JULY 2014
PAGE: 46 of 95
Promoting health and wellness is critical to preventing and
managing lifestyle diseases, particularly the major
noncommunicable diseases among the poor, such as heart
disease, high blood pressure, cholesterol and diabetes.
These diseases are likely to be a major threat over the
next 20 to 30 years.
South Africa, together with other member states of the United
Nations, acknowledged through a General Assembly resolution in
2011 that noncommunicable diseases are not merely a health
problem, but a major development concern. NCDs are now not a
problem of the old and infirm, and of developed countries
only, but of our productive populace everywhere in the world.
They also cripple the budgets of the poorest countries.
In this regard, two weeks ago representatives from around the
world again gathered at the General Assembly in New York to
review progress made in implementing the political declaration
I referred to earlier.
I am pleased to report that South Africa was acknowledged as a
leading country in taking serious steps towards addressing the
major risk factors for NCDs, as well as in developing health
system innovations that improve health care provision. We are
recognised as a leader in areas such as tobacco control, trans
EPF 23 JULY 2014
PAGE: 47 of 95
fat and salt regulation, and also as regards our proposals to
restrict alcohol advertising and sponsorships.
Since 1995 we have brought smoking rates down by 30%,
including amongst schoolgoing children. Safeguards are needed
to ensure that this trend is strengthened rather than
reversed, and in line with the Framework Convention on Tobacco
Control. Therefore, additional regulations are being planned
in this regard.
Our salt regulations, which the industry is now beginning to
implement ahead of the compulsory targets set for 2016 and
2019, are projected to result in 7 400 fewer deaths due to
cardiovascular diseases and 4 300 fewer nonfatal strokes per
year if we implement this.
Members, what is very worrying is that alcohol consumption
amongst drinkers remains far too high, at 27 litres of pure
alcohol per annum in people 15 years and over. Consumption of
pure alcohol amongst men is even higher at 33 litres per
annum. This is significantly higher than the world average of
21 litres.
We realised that these figures would not dramatically drop
simply by our restricting advertising. However, it is also
well established from several studies that alcohol advertising
EPF 23 JULY 2014
PAGE: 48 of 95
influences behaviour. It brings about positive beliefs about
alcohol and encourages young people to start consuming alcohol
at an earlier age and in bigger quantities.
An integrated approach to managing chronic diseases, whether
they are communicable or noncommunicable, will go a long way
toward improving our effectiveness. We believe that the
establishment of the National Health Commission will also go a
long way in enhancing intersectoral collaboration.
The 10 targets we set for our strategic plan, which are to be
reached by 2020, still have some way to go, but we believe
that we are making progress with the support of organisations
such as the Noncommunicable Diseases Alliance, other civil
society organisations, and the industry.
We believe we can still reach those goals. We must reduce
premature mortality from noncommunicable diseases by 25%;
tobacco use by 20%; alcohol consumption by 20%; salt intake to
less than 5 g per day; and the percentage of overweight people
by 10%. We must also increase physical activity by 10%.
In a few weeks’ time, the department will sponsor a TV and
radio campaign that will inform the public that increased salt
intake considerably increases the risk for hypertension and
kidney disease.
EPF 23 JULY 2014
PAGE: 49 of 95
This year we will also be developing and implementing a new
strategy to combat obesity, as this continues to be a
challenge. The number of South Africans who are overweight is
still extremely high. A survey done in 2012 found that the
prevalence of obesity amongst those over 15 years old was more
than 65% in females and 31% in males.
Listen to this. Drinking just one sugar-sweetened beverage a
day increases the likelihood of being overweight by 27% for
adults and 55% for children. One 330 ml can of carbonated soft
drink contains an average of eight teaspoons of sugar, and the
same size can of sweetened fruit juice constitutes about nine
teaspoons. So, every time you guzzle 330 ml of cold drink,
know that you might as well be taking eight teaspoons of
sugar. This is another matter which is a concern to us.
The Ministerial Advisory Committee on the Prevention and
Control of Cancer has now started functioning. The
introduction of the human papillomavirus vaccine, which the
Minister touched on as well, is a critical step forward in
reducing cervical cancer. The South African cancer control
strategy will be launched this year and will be providing
additional impetus in the prevention and treatment of cancer.
We are also expanding our intervention in having cataracts
removed so that we can improve people’s eyesight.
EPF 23 JULY 2014
PAGE: 50 of 95
I would also like to touch on the areas of violence and
accidents. One of the growing public health challenges is the
road traffic crashes and injuries, which place a heavy burden
not only on the national economy, but also on household
finances, as many families are driven deep into poverty by the
loss of a breadwinner or the added burden of caring for a
member who is disabled as a result of a road accident.
The total medical costs for injuries as a result of violence
are estimated at R4,7 billion per annum according to the
Centre for the Study of Violence and Reconciliation, while the
total costs of traffic crashes and injuries are estimated at
R110 billion per annum according to the Automobile Association
of SA. The injury-related costs of alcohol alone are estimated
to be twice as much as the excise duties received from alcohol
- so, they do not balance. Road traffic crash injuries can be
prevented, and we as a government, together with other role
players in civil society, can do a lot to prevent road
crashes.
I am pleased to also announce that our Forensic Chemistry
Laboratories have appointed additional analysts and procured
additional equipment, resulting in a lot of progress. An
impact has also been made on reducing the backlog of
conducting tests for the alcohol content in blood. Our budget
for the laboratories has also increased from R78 million in
EPF 23 JULY 2014
PAGE: 51 of 95
the 2013-14 financial year to R122 million in the 2014-15
financial year. We are grateful to our National Treasury for
this assistance. This significant increase has also
contributed to the decrease in toxicology backlogs and a
decrease in the turnaround time for receiving results for
toxicology analyses in cases of unnatural deaths.
We are also taking steps to improve our emergency medical
services to make sure that we provide timeous and efficient
services to our communities. Amongst other interventions, we
are promulgating new regulations that govern emergency medical
services, which will improve efficiencies by setting high
industry standards and also providing minimum norms.
In conjunction with the Health Professions Council of South
Africa, we are developing a national policy on national
emergency care education and training in order to improve the
skills of emergency care personnel.
In order to contribute to Millennium Development Goals 4 and
5, a study is being undertaken by the department on the
efficacy of mobile obstetric units, in order to provide
quicker responses to obstetric emergencies.
With regard to malaria, and the Minister touched on that a
bit, we have made a lot of progress in reducing the rate of
EPF 23 JULY 2014
PAGE: 52 of 95
malaria quite drastically, from 86% to 78% in malaria-related
deaths between 2000 and 2013. This is a huge contribution
towards the Millennium Development Goal of reducing malaria by
50% by the year 2010. We achieved that much earlier through
various interventions.
I would just like to mention that the only challenge that
remains is what we call “malaria importation”, especially
across the Mozambique border with South Africa. We are
strengthening our partnership with Mozambique regarding crossborder initiatives, where there is a revised programme of cooperation between the two countries. This is expected to be
signed soon
The last matter that I would like to report on quickly is our
programme of co-operation with Cuba. The co-operation
agreement in the field of public health has progressed quite
significantly. This was first signed in 1995 and implemented
from 1996 on. It initially entailed the recruitment of medical
practitioners from Cuba. It later progressed to an amended
agreement which also encompassed the training of students.
This has progressed quite significantly. In 2011 it went from
a small number of trainees to an intake of 100 trainees after
the amended agreement. I can report that this is progressing
very well. As we speak there are now more than 2 700 students
studying in Cuba. In this year alone we have an intake of 607
EPF 23 JULY 2014
PAGE: 53 of 95
students. There are currently over 200 Cuban doctors here,
many of them in the Eastern Cape.
Lastly, there are a number of entities reporting to our
department and these are functioning quite efficiently.
An hon member mentioned the National Health Laboratory
Service, amongst others, and also the National Institute for
Communicable Diseases. We are aware of the issues and we are
attending to them. These entities will continue to serve the
country. Thank you very much. [Applause.]
The TEMPORARY CHAIRPERSON (Ms T C Memela): I now call on the
hon Mosala to speak. Hon members, it is his maiden speech.
Mr I MOSALA: Hon Chair, hon Minister, hon Deputy Minister, hon
members of the Portfolio Committee on Health, ladies and
gentlemen, comrades and compatriots, it is an honour and a
privilege for me to address this august House on behalf of the
ANC on a very important vote, Vote 16.
Prior to 1994 our health system was characterised by
fragmentation based on racial segregation and discrimination.
Since the advent of democracy in 1994, health provision in
South Africa has gone through several radical transformations.
These have been based on integration at primary health care
EPF 23 JULY 2014
PAGE: 54 of 95
level, respect for human rights, and an emphasis on prevention
and health promotion as envisioned by the Freedom Charter and
the strategic objectives of the National Democratic Revolution
to create a caring and loving democratic South Africa.
It is pursuant to the ideals of the Freedom Charter that our
Constitution, in section 27, entrenches the universal right of
access to health care. This section, being part of the Bill of
Rights, enjoins our government to respect, protect, promote
and fulfil the right of access to health care.
The ANC’s Mangaung national conference, the National
Development Plan and the ANC election manifesto are
reconciliatory and noncontradictory. They have the same
vision, commitment and common position in relation to the
provision of a health system that works for everyone, produces
positive health outcomes, and is accessible to all. It is apt
to remind the House that in the ANC manifesto, from 2009 to
date, our government has continued to prioritise access to
health care.
The National Health Insurance philosophy encapsulates this
position by asserting that resources should be received from
each according to their abilities, and that health care
services should be distributed to each according to their
EPF 23 JULY 2014
PAGE: 55 of 95
needs. This means that access to health care cannot, at the
same time, be a right as well as a commodity.
Hon Chair, spare me a few minutes to remind hon members of the
essence and form of primary health care. Primary health care
is the heartbeat of many sustainable health systems globally.
It is all about providing essential health care which is
universally accessible to individuals and families in the
community. Primary health care is also provided as close as
possible to where people live and work.
Primary health care remains at the core of the overhauling of
the health system and, in particular, national health
insurance in South Africa. The ANC has made progress in the
re-engineering of the primary health care system through three
streams, namely municipal ward-based primary health care
outreach teams, school health programmes, and district
specialist teams and the contracting of general practitioners
to work in pilot programmes. Therefore, you will agree with me
when I say that the ANC lives and the ANC leads. [Applause.]
Municipal ward-based health care is a system designed to have
participatory interaction amongst all relevant stakeholders in
the specific wards. Currently, the system has community care
workers and professional nurses. Furthermore, the department
has 1 500 functional ward-based outreach teams, and by 2020
EPF 23 JULY 2014
PAGE: 56 of 95
3 500 teams will be functional. Their main area of focus is
documenting the demography and epidemiology of households so
that it is known who lives in a specific ward and what the
health status of each resident who resides in the municipal
ward is.
The main strategic objective is to improve the lives of our
communities by bringing health care services closer to each
street and each household.
As we proceed into the future, the system will encourage and
stimulate active and robust participation of community
leaders, traditional leaders, church leaders, ward committees
and traditional health practitioners in ensuring the success
of this model.
The system will further benefit our communities that have
noncommunicable diseases by minimising their visits to clinics
with the sole purpose of reducing long queues at the clinics.
The churches, traditional kgotlas [residences] and farmers
should be engaged with by the department, going forward, in
order for them to enter into agreements to utilise their
venues and sites for the collection of medication.
EPF 23 JULY 2014
PAGE: 57 of 95
This strategy will further enable us to enumerate the risk
factors and improve the management of noncommunicable
diseases, for example, by identifying obesity and assisting in
reducing it by 55% in women and 21% in men by 2019 through the
establishment of community support groups and counselling
which must be intensified at this level.
Modulasetulo, ntumelle ha ke re: E a rora, e a phela, ebile e
etelletse pele! [Mahofi.] [Chairperson, allow me to say: It
roars, it is alive, and it is leading! [Applause.]]
The task team, comprised of officials of the Departments of
Education and of Health, has reviewed the School Health Policy
in order to reflect on the approach to primary health care
services at schools.
Currently, school health nurses conduct basic screening of
Grade R and Grade 1 children in poorer schools in Quintiles 1
and 2. The objective is to identify abnormalities and refer
them early to the health care facilities, which screen
abnormalities such as hearing defects and visual defects, and
the immunisation status of our children. At secondary schools,
life skills programmes are rendered, and sexual and
reproductive health education is intensified in order to curb
teenage pregnancies. Currently, 28% of the Grade 1 and 12% of
the Grade 8 learners are receiving screening, while 50% of the
EPF 23 JULY 2014
PAGE: 58 of 95
Grade 1 and 25% of the Grade 8 learners will be reached by
2019.
An other intervention by the department to improve the life
expectancy of our children is to give all Grade 4 girls who
are nine years and older the human papillomavirus vaccination
at schools to protect them from getting cervical cancer. The
target is 70%. Indeed, we would all agree that the ANC lives
and the ANC leads.
We have a good story to tell about the past 20 years of
democracy, that of eradicating anomalies in the then
fragmented health system and replacing them with an
integrated, nonracial open system. We also, on the other hand,
acknowledge that we still have some challenges in some of the
health care facilities. Allow me to mention just a few.
We are still confronted with a shortage of human resources,
especially health care workers, and this is attributed to the
unrevised staffing levels, which now need to cater for new
developments, for example, the national score standards,
primary health care re-engineering and the National Health
Insurance Programme. The lack of full staffing components
impedes the impact that could be registered, as compared to
the progress which has been registered in real terms.
EPF 23 JULY 2014
PAGE: 59 of 95
The other issue is infrastructure maintenance, which has been
varying since prior to 1994. This imposes limitations on
rendering a full package of primary health care services to
our communities.
In closing, allow me to quote Niccolò Machiavelli:
Once problems are recognised ahead of time, they can be
easily cured; but if you wait for them to present
themselves, the medicine will be too late, for the disease
will have become incurable. And what are the physicians
saying about the disease: at the beginning a disease is
easy to cure but difficult to diagnose, but as time passes,
not having been recognised or treated at the outset, it
becomes easy to diagnose but difficult to cure.
This is from The Prince.
Indeed, the department, under the leadership of the Minister,
should be commended for taking a leap in radically
transforming the health conditions of our people without
allowing the situation to deteriorate. We must further
congratulate them on moving the health care system forward in
South Africa. We are witnesses to the fact that our health
care system is much better than it was before 1994.
[Applause.]
EPF 23 JULY 2014
PAGE: 60 of 95
Therefore, this demonstrates that the ANC lives and the ANC
leads. On behalf of the organisation that lives and leads, we
support the budget unreservedly and wholeheartedly. Thank you.
Ke a leboga. Baie dankie. [Thank you.] [Applause.]
Ms C N MAJEKE: Hon Chairperson, hon Minister, hon Deputy
Minister, and hon members, the UDM commits itself to
protecting and promoting the constitutional right of all South
Africans to basic health care and to providing proper and
immediate responses to the major health risks facing the
country.
In re-engineering primary health care the department must
prioritise the access to and quality of this service, as a
lack of these continues to disadvantage poor South Africans.
In this regard, we reiterate our position that health care has
to be linked to other social cluster portfolios, further
recognising the role of social welfare, water and sanitation,
basic life skills and an awareness of improving the basic
health of the nation.
The current quality of health facilities and their
maintenance, especially hospitals in rural areas, is not of a
good standard. Hygiene at many clinics and hospitals in the
Eastern Cape needs to be addressed as a matter of urgency.
EPF 23 JULY 2014
PAGE: 61 of 95
The UDM believes that job creation can be achieved through
infrastructure maintenance and development whilst providing
quality health services.
The provision and stocking of medicines at many clinics and
hospitals still fall short of the basic requirements.
Distances travelled by communities to access the facilities
remains a challenge.
Staffing for primary health care facilities must be qualified,
trained and available at all times to give quality services to
all South Africans. In some government hospitals access to a
doctor is almost impossible, especially after hours. This is
the case at Sulenkama hospital in the Eastern Cape. Hon
Minister, it should not be a privilege for rural people to be
serviced by a qualified doctor.
We believe that diseases such as TB, cholera and malaria are
preventable and can be treated. However, unless and until we
link health with other socioeconomic factors, we will not be
able to provide a sustainable service to the nation. The
matter of additional hospitals for rural communities needs to
be prioritised to address the conditions that are always found
in health facilities. The UDM supports Budget Vote 16. I thank
you. [Applause.]
EPF 23 JULY 2014
PAGE: 62 of 95
Mr A M SHAIK EMAM: Hon Chairperson, Ministers present, Deputy
Ministers present, members of the Portfolio Committee on
Health - the chairperson and other members of the portfolio
committee - hon members, members of the media and invited
guests, let me start by advising this House that the NFP
supports this Budget Vote. [Applause.]
The approval of this Budget Vote is paramount for the purpose
of providing all South Africans with good quality health care,
health care that does not discriminate against any South
African citizen, irrespective of the socioeconomic conditions
in which they live.
Hon Chairperson, 20 years into democracy millions of our
people continue to be deprived of quality health care. The
value of the life of a poor, underprivileged citizen is no
different from that of a middle-class or rich citizen.
Much has been done to provide a quality health care service in
South Africa. However, a lot of work still has to be done. I
would be failing in my duty if I did not acknowledge and
accept that much progress has been made in 20 years in health
care in South Africa. [Applause.] Let us be honest about this,
much progress has been made. However, one cannot expect
miracles in 20 years, especially when you have gone from being
a freedom organisation to a government-in-waiting. It is not
EPF 23 JULY 2014
PAGE: 63 of 95
possible. So, let us accept that there have been challenges,
some have been met and others we will continue to meet.
Whilst the NFP supports this budget, which is in the best
interests of all the citizens of this country, let me express
my grave concern that the budget allocation for tuberculosis
is grossly inadequate. In addition to this, on the one hand we
talk about extending primary health care services in all
districts and wards, but on the other hand we decrease the
budget by 8,9%, and that is again totally inadequate. The
budget for noncommunicable diseases has also been decreased
and I think that the hon Deputy Minister alluded to the fact
that more attention needs to be paid to that.
Whilst we are building more hospitals and clinics, may I urge
and advise the Minister and all those responsible not to
forget the present hospitals and clinics that are in decline
as far as the quality of service that we provide to the people
is concerned. There are poor hospitals and I do not need to go
into that - I think we are aware of hospitals that are not
providing quality health care services for different reasons.
I urge the committee to pay attention to that.
Hon Chairperson, the National Health Insurance and its limited
progress is also a matter of concern, especially ensuring that
this pilot phase proceeds. This is another cause for concern
EPF 23 JULY 2014
PAGE: 64 of 95
in the light of the strategic plan to roll out the programme
to all districts.
The NFP welcomes the Office of Health Standards Compliance.
However, the districts are faced with human resource
shortages, especially qualified health care workers. The NFP
supports this budget. Thank you very much. [Applause.]
Mr S M JAFTA: Hon Chairperson, the AIC emerged to represent
the voiceless, poor and marginalised citizens of this country,
especially in rural areas. That is why the AIC will focus
mainly on the issues directly affecting the lives of
communities in this debate.
Hon Chair, the AIC welcomes the budget and supports it, as it
seems to be a very good plan. [Applause.] However, this party
is aware that all the departments always plan and have good
budgets each financial year, the Department of Health
included, but little is achieved. The redistribution of funds
is not a problem, but how these public funds are utilised is a
problem.
The fact that the department is still planning to improve
district governance and strengthen management and leadership
of the district health system shows that the department plans
EPF 23 JULY 2014
PAGE: 65 of 95
and constructs upon a very weak foundation. That is why the
image of the Department of Health continues to deteriorate.
Indeed, hon Chair, there is a lack of management and
leadership capacity in the public health sector in South
Africa. That is characterised by the collapsing infrastructure
of public hospitals and clinics. How can this department
expect some improvement in these health centres whilst some of
them are run without operational managers for years and some
by unpaid acting managers?
Many public hospitals and clinics, mostly in rural areas, are
ignored. They do not have water at all and nothing is done by
the department to save the situation, yet we expect them to
render quality health care to the public. It is also very
difficult to get to those public health centres because there
are no roads at all.
Mention has been made of the primary health teams deployed to
provide care to families and communities. It is really a
disgrace to the department and the government that these homebased teams and caregivers work for months, or even a year,
without being paid the stipend they are supposed to get at the
end of the month.
EPF 23 JULY 2014
PAGE: 66 of 95
The TEMPORARY CHAIRPERSON (Ms T C Memela): I now call on the
hon C N Ndaba to speak. This is her maiden speech. [Applause.]
Ms C N NDABA: Thank you, hon Chairperson. Hon Minister and
Deputy Minister, hon members, distinguished guests and ...
... bahlali baseMzantsi Afrika ndiyanibulisa, molweni. [...
South Africans, good afternoon.]
It is an honour to be afforded this opportunity to be part of
the debate on the 2014-15 Budget Vote for Health, a budget
which the ANC fully supports. [Applause.]
As the ANC, we reaffirm the Freedom Charter as the premise on
which we can discuss issues of social transformation. These
are not matters of convenience. We want to ensure that we give
serious attention to issues of health as part of the ongoing
process of looking into the capacity of the state to deliver
better services to the citizens of South Africa.
As we start in the new administration, we are humbled by the
fact that hon President Jacob Zuma, in his state of the nation
address in June 2014, noted that health was one of the
priorities of government.
EPF 23 JULY 2014
PAGE: 67 of 95
One of the issues he highlighted was that 2,4 million people
were initiated on ARVs by 2013, compared to the period 2011-12
when only 600 000 people living with HIV were initiated on the
ARV programme. Therefore our duty in this administration is to
increase the figure to 4,6 million, thereby increasing the
life expectancy of our people.
The department is also continuing to contribute to improving
the quality of life of people living with HIV and Aids by
providing an appropriate package of care, treatment and
support services. These services are available at all
government health facilities.
According to the January 8 statement of the ANC in 2014, the
mother-to-child transmission rate of HIV has decreased by 66%,
from 24 000 in 2008 to 8 200 by 2011. Asizishayeleni izandla.
[Let’s applaud ourselves]. [Applause.] For example, in Gauteng
alone only 2,4% of babies tested at the age of six weeks were
HIV-positive, compared to 3,6% in 2011. This is partly owing
to a 3% increase in pregnant women receiving long-term
antiretroviral treatment. Asizishayeleni izandla. [Lets
applaud ourselves.] It is also owing to a higher proportion of
babies receiving nevirapine within 72 hours of birth.
EPF 23 JULY 2014
PAGE: 68 of 95
By February 2012 more than 1 750 nurses had been trained in
nurse-initiated and managed ART, making it possible for
professional nurses to put people on treatment.
The SA National Aids Council, Sanac, endorsed the National
Health Council policy of initiating treatment for all those
who have been tested and have been found positive, and have a
CD4 count of 350 or less. That was also a further boost for
the treatment programme.
His Excellency President Jacob Zuma mentioned that more than
20 million South Africans had presented themselves for HIV
testing since the HIV Counselling and Testing campaign was
launched in April 2010. We have seen a positive response from
the communities to the call to undergo HIV testing, and this
is indicated by the increase in the uptake rate from the 85%
targeted by the department to 91% for the period 2011-12. We
hope that many more people who have not been tested will heed
the call and make themselves available for HIV testing. We
want to thank all South Africans who have positively
participated in this programme.
Still regarding prevention, government has continued to
provide both male and female condoms free at all health
facilities.
EPF 23 JULY 2014
PAGE: 69 of 95
Another initiative is the male circumcision programme, in
terms of which just under 350 000 medical male circumcisions
were performed in 2011-12. This reflected high levels of
performance for a newly introduced HIV-prevention service. It
is a good initiative by the department and is accessible free
in government facilities, with an emphasis on rural nodes.
We suggest that the department look at introducing compulsory
boy-child circumcision at birth, taking into cognisance the
different cultures and beliefs. This, among other measures
being taken, may reduce the high death rate at initiation
schools.
We urge the department to continue with community education
programmes through various media, school health, etc. We want
to thank all citizens who have participated and supported
government in these initiatives. The ANC supports the budget
allocation of R12 billion for the HIV and Aids subprogramme.
[Applause.]
With regard to the TB control and management programme, we
encourage South Africans to get tested at least once a year,
as outlined in the ANC manifesto for 2014. In addition to the
existing TB programme, screening and treatment will be
intensified for vulnerable groups. This will include inmates
EPF 23 JULY 2014
PAGE: 70 of 95
in all Correctional Services facilities, mineworkers and
people living in mining communities. This is important.
In order to achieve the objectives of the National Development
Plan, of initiation of all TB patients on lifelong ARV therapy
irrespective of their CD4 count, the ANC thinks that the
budget allocation for TB is still a concern. It is a concern
if we want to achieve the 85% recommended by the World Health
Organisation - unless those who present with TB symptoms
without testing are accommodated in the HIV budget, or
government forms partnerships with mining companies to
contribute to miners’ wellbeing and provides packages of
treatment services for TB and HIV for mining communities. We
suggest that the department continually educate and counsel
patients, families and communities regarding preventative
measures in TB management. In 2011 Mpumalanga was doing well
in TB control.
When it comes to women’s reproductive and maternal health, the
budget allocation, at less than 1%, remains a concern.
The ANC supports the department’s view that breast-feeding
should be encouraged in mothers. Breast-feeding is very
important for both mother and child because, among other
reasons, breast milk has all the nutrients essential for child
development; the milk is at the correct temperature at all
EPF 23 JULY 2014
PAGE: 71 of 95
times; there is less contamination of the milk compared to in
feeding bottles; breast-feeding promotes bonding between
mother and child; breast-feeding is not expensive and ...
... asikho isidingo sokukhalela ubaba wengane ukuthi akunike
imali yobisi. Awukhokhi mali, umane uncelise nje umntwana.
[... there’s no need to ask for money from the baby’s father
to buy formula milk.
You do not pay for anything; you just
breastfeed the baby.]
In the olden days breast-feeding, Minister, was used as a
family planning method.
Angazi namhlanje ukuthi singakwenza lokho futhi na. [I don’t
know if we can still do that nowadays.]
The NDP talks about reducing the under-five child mortality
rate from 56 to below 30 per 1 000 live births. The ANC has
committed itself to implementing the African Union-inspired
campaign on the accelerated reduction in maternal and child
mortality. This will place the mother and child at the centre
of our health care programmes.
The Western Cape is not doing well in this regard, despite all
the infrastructure it has. In addition, the province has lower
rates of antenatal care compared to other provinces. Antenatal
EPF 23 JULY 2014
PAGE: 72 of 95
care is very important to ensure that there is a healthy
pregnancy and that the baby is born healthy to give the child
the best possible start in life.
So, let us look at the data for Khayelitsha for the last
financial year, Khayelitsha being one of the black townships
in the Western Cape. The pneumonia rate generally for children
under five years stands at 68,7% and for measles at 59,6%,
compared to the provincial average of 71,5%. Yet, these are
the children that need these services the most.
In fact, an article in the Mail & Guardian of 2011 quoted
statistics from the City of Cape Town to the effect that in
2010 there were 58 deaths from diarrhoea of children under
five years of age. These figures are far higher than those of
any other part of the city. I quote from this article:
The city’s own health data shows clearly that Khayelitsha
has by far the highest number of diarrhoea-related infant
deaths of any district in Cape Town – its figures are double
the city average and more than 10 times worse than those of
the affluent southern suburbs.
The TEMPORARY CHAIRPERSON (Ms T C Memela): Hon member, your
time has expired. [Interjections.]
EPF 23 JULY 2014
PAGE: 73 of 95
Nk C N NDABA: Anginandaba. [I don’t care.]
The TEMPORARY CHAIRPERSON (Ms T C Memela): Thank you very
much, hon member. Your time has expired. [Interjections.]
Nk C N NDABA: Thula. Kukhuluma mina. [Can you keep quiet? I’m
the one speaking.]
I therefore support the budget.
The TEMPORARY CHAIRPERSON (Ms T C Memela): It seems to me that
the hon Tshishonga is not in the House, and I therefore call
on the hon Volmink. It is his maiden speech.
Dr H C VOLMINK: Hon Chairperson, hon Minister and Deputy
Minister, hon members, and ladies and gentlemen, today I have
the honour of addressing this esteemed House for the first
time. I was born not too far from here, in an old maternity
hospital in District Six. Over the years I have been given
many opportunities, for which I am grateful, including the
chance to study medicine.
More recently, during my experience as a registrar in
community health in Gauteng, I had the privilege of working
with those at the frontline of our health system, from
EPF 23 JULY 2014
PAGE: 74 of 95
community health workers to health care managers, and I was
humbled by their dedication to their fellow citizens.
The Minister spoke earlier about the post-2015 agenda after
the United Nations Millennium Development Goals. I would like
to pick up on that point because, as part of that, it has been
proposed that we develop sustainable development goals to
carry us into the future. Accordingly, I would like to suggest
that, in our own country, we consider the idea of a
sustainable health system.
Now we must recognise the exemplary work and efforts of our
hard-working Minister and our Director-General. Indeed, the
health sector Negotiated Service Delivery Agreement, which
aims to tackle our country’s quadruple burden of disease,
includes a focus on strengthening the health system. However,
while there has been progress, we still face many challenges.
As the hon James said, we are facing challenges which are
often times at the provincial level - so let me turn to
Gauteng, where my constituency is.
In the 2012-13 financial year the Auditor-General found that
the provincial department of health had wasteful expenditure
of R408 million. In the fourth quarterly report presented in
Gauteng just last week it was shown that the same department,
according to the 2013-14 budget, had an underspend of over
EPF 23 JULY 2014
PAGE: 75 of 95
R1,35 billion. This erratic spending, failure to invest in
vital services and squandering of precious public resources is
anything but sustainable.
We therefore call upon the hon Minister to fast-track the
capacitation of health care managers, who are entrusted with
many of these resources. Points have been made on this matter
this morning, but I would really like just to concretise this.
While we acknowledge the recently established Academy for
Leadership and Management in Health Care and the efforts being
made to train hospital chief executive officers, what we
urgently need is a rapid professionalisation of health
management, including formal registration and an adapted
Public Service code for all health care managers. This will
help to ensure that sufficiently skilled, politically
independent and publically accountable health care managers
can be entrusted with resources – with severe consequences for
mismanagement and zero tolerance for corruption.
The above notwithstanding, we still have many dedicated health
care managers. But they are often frustrated by the fact that
the infrastructure is not sustainable. My hon colleague, the
hon Mosala, made this point very audibly a bit earlier on. So,
let me continue with the point of infrastructure.
EPF 23 JULY 2014
PAGE: 76 of 95
While R16,3 billion has been earmarked for the Health Facility
Revitalisation Grant in the Medium-Term Expenditure Framework
period, infrastructure around health facilities also needs to
be maintained. Roads to and from hospitals that carry critical
supplies have to be prioritised, and we simply cannot have an
interruption of water and electricity supply to these
facilities.
We therefore call upon the hon Minister to develop a coordinated infrastructure strategy within the Interministerial
Service Delivery Task Team to drive joined-up governance and
planning in this area. When health systems fail, all of us not just in one province but all of us - are under threat and
they fail when health systems are not sustainable.
As a sobering example of this, the 2013 Global Tuberculosis
Report highlighted the danger of multidrug-resistant and
extensively drug-resistant tuberculosis in our country. Now
the department has, commendably, begun to implement a policy
on the management of drug-resistant tuberculosis, and the
Minister did describe this. However, even with this in place,
if the health system building blocks are not there, there will
be holes in our safety net and a drug-resistant TB epidemic,
simmering just beneath the surface could burst through,
putting us all under threat.
EPF 23 JULY 2014
PAGE: 77 of 95
It is also true that when health systems fail, those who are
at the margins, whose voices are not often heard, are most
under threat. We are reminded of the tragic case in 2011
where, in the North West province, the four starving children
of Kedibone Mmupele, aged nine, seven, six and two, died
trying to find their mother, who herself was desperately
trying to find food for them, just 18 km away.
Now it can be asked, what does this terrible tragedy have to
do with health systems? The answer is simple: A health system
that is unresponsive to the relevant social conditions, called
the social determinants of health, is one that is frankly
unsustainable. While the National Development Plan emphasises
these determinants, they are only briefly discussed in the
annual performance plan, with no clear commitment of resources
in the budget.
Furthermore, while there is a proposed National Health
Commission, that body will focus on noncommunicable diseases.
I therefore ask the hon Minister to establish, as a separate
body, a South African commission on social determinants of
health. In addition to the World Health Organisation
commission, we have a precedent for this in Brazil, where a
National Commission on Social Determinants of Health was
established - to significant effect. A similar commission
EPF 23 JULY 2014
PAGE: 78 of 95
could help to transform the landscape of our country’s health
system. That would be a true revolution.
In conclusion, the DA offers South Africa a compelling health
policy aimed at affordable, accessible, high quality health
for all.
But what is our collective understanding of health? Here we
can find guidance from the Alma-Ata Declaration which
describes health as, and I quote, “a state of complete
physical, mental and social well-being and not merely the
absence of disease ...”
Surely, whatever our political differences are, we can all
strive towards that goal, but we can only reach it if we have
a health system that is dependable, equitable and ultimately
sustainable. Thank you. [Applause.]
The TEMPORARY CHAIRPERSON (Ms T C Memela): Hon Tshishonga, I
would like to bring to your attention the fact that when your
turn came, you were not in the House. You are therefore losing
your chance to speak. There was no excuse. I am looking you
right in the eye.
Mr M M TSHISHONGA: Chairperson, I accept the ruling. I was
booked twice. I was in the Rural Development and Land Reform
EPF 23 JULY 2014
PAGE: 79 of 95
debate and immediately after I finished I rushed here, but I
accept your ruling.
The TEMPORARY CHAIRPERSON (Ms T C Memela): Okay, you may
continue. However, make sure that you do not repeat it because
you actually did the same thing yesterday while I was
chairing.
Mr M M TSHISHONGA: Hon Chair, my apologies to the august House
and the Chair. As I have indicated. I was booked twice. I was
in the debate on the Rural Development and Land Reform Budget
Vote.
The TEMPORARY CHAIRPERSON (Ms T C Memela): Hon Tshishonga, you
are wasting time.
Mr M M TSHISHONGA: Firstly, let me say that we are all
concerned about health, but our take on health as Agang SA is
that health matters must be viewed holistically.
This means that the mental state of the people must be
considered. The physical aspect and the spiritual aspect must
also be considered. It is my take that whatever is reflected
in physical aspects comes from the mind. If our minds are well
treated, then we will have fewer diseases which manifest
themselves in our bodies.
EPF 23 JULY 2014
PAGE: 80 of 95
Without wasting time, let me say that I think the emphasis is
on the holistic approach to health. Let me not go further than
that: I think the Minister will take care of the rest. Thank
you.
Mr A F MAHLALELA: Hon Chairperson, hon Minister, hon
Deputy Minister, hon members and distinguished guests,
let me begin by relating what the Statistics SA report of 2011
stated. It found that 7,6% of the public health sector users
were dissatisfied with the health care services they received,
while 85% were satisfied. Therefore, this means that, despite
the challenges, users of the public health system are
generally satisfied with the service they receive.
Let me come to the issues that were raised by some members.
First, let me deal with the issue that the hon James raised unfortunately the hon James was not part of our committee
discussions. Some of the issues that he raised were
extensively discussed at the committee level and we reached
consensus on how those things should be managed going forward.
The issue of the budget for primary health care was thoroughly
explained at the committee level. The approach is that service
delivery in primary health care is at the district level, and
therefore most of the budget for primary health care is
located at the district level. You can go and check all of
EPF 23 JULY 2014
PAGE: 81 of 95
your provincial budgets; the bulk of the budget in provinces
is located in the district health programme. That is where
primary health care service is being delivered.
Then, you take your annual performance plan - I am not sure if
you have gone through the APP - it has a detailed consolidated
budget for all the programmes, including primary health care.
So, I don’t know why you are now asking the department to give
you the same information that you have at your disposal.
[Interjections.]
The TEMPORARY CHAIRPERSON (Ms T C Memela): Order, members!
Order!
Mr A F MAHLALELA: We agreed that the issue of financial
management remains a challenge, but when we discussed these
matters at the committee level, the department described the
intervention, and the steps that had been taken, to deal with
the challenges of financial management in provinces. They
deployed postgraduate teams in all the provinces to be in a
position to address these challenges.
There has been huge movement from where we were years back to
where we are now. There are still some challenges in provinces
where, for example in Limpopo, there have been disclaimers,
but there has been substantial improvement in other provinces
EPF 23 JULY 2014
PAGE: 82 of 95
where they have moved from disclaimers to qualifications and
some from qualifications to unqualified reports. Therefore, it
is not that nothing is being done about it. Work is going on
and we are making sure that improvement is taking place.
Hon Matiase, I am so disappointed by how you approached this
debate. I thought you were one of the sober fighters in this
Parliament, but you disappointed me severely today, because,
firstly, I am not sure of what you were saying in this debate.
Secondly, when we dealt with the budget in the committee, you
never raised any fundamental opposition to the budget. You
agreed to everything. But now I am not sure whether your boss
told you not support anything that the ANC government
presents. [Interjections.] It is very unfortunate that you
approached the debate in the manner that you did. I hope that
at committee level we will engage with you further.
We strongly affirm the Alma- Ata Declaration, which states
that:
... health, which is a state of complete physical, mental
and social wellbeing, and not merely the absence of disease
or infirmity, is a fundamental human right and that the
attainment of the highest possible level of health is a
most important world-wide social goal whose realisation
requires the action of many other social and economic
EPF 23 JULY 2014
PAGE: 83 of 95
sectors in addition to the health sector.
The Alma- Ata Declaration further states that:
The existing gross inequality in the health status of
the people particularly between developed and
developing countries as well as within countries is
politically, socially and economically unacceptable and
is, therefore, of common concern to all countries.
In order to address the issues raised in that declaration, we
introduced and passed the National Health Act, Act 61 of 2003,
which gives effect to the right of everyone to have access to
health care services as guaranteed by section 27 of the
Constitution of South Africa, 1996. The Constitution places
express obligations on the state to progressively realise
socioeconomic rights, including access to health care, and
this access is for everyone, regardless of their status, which
means no individuals should be unfairly excluded from the
provision of health care services.
In introducing National Health Insurance the ANC-led
government – a caring government - will fulfil its objectives,
which are: to eliminate the current tiered health system; to
improve access to quality health care services and provide
financial risk protection; and to provide a mechanism for
EPF 23 JULY 2014
PAGE: 84 of 95
improving cross-subsidisation in the overall health care
system so that we can do away with inequality in relation to
access to quality health care in order to enable the poor to
also receive a better standard of care.
This view on the link between illness and inequality is
further supported by the World Health Organisation Commission
on Social Determinants of Health. It indicates that the
interconnectedness between the environment, poverty and
inequality is both profound and complex. Environmental issues
represent major risk factors in the global burden of disease,
while poverty and deprivation are major determinants of poor
health. Likewise, inequalities contribute to ill health which,
in turn, exacerbates poverty and deprivation in a never-ending
cyclic pattern.
What this commission arrived at was that health and illness,
according to them, thus follow a social gradient - the lower
the socioeconomic position, the worse the health of the
individual. This was echoed by the late former President
Nelson Mandela when he said, and I quote: “If you are poor you
are not likely to live long.” This is the situation in South
Africa, which characterises how our people are exposed to
these challenges.
EPF 23 JULY 2014
PAGE: 85 of 95
We are raising this to illustrate the challenges of the
quadruple burden of disease, which include diseases;
conditions related to poverty, inequality and
underdevelopment; chronic diseases, injuries and violence,
which the Deputy Minister spoke about; and the issue of
HIV/Aids and TB, which the Minister dealt with extensively.
The WHO Commission on Social Determinants of Health argues
that these are enough evidence for government to take action
according to three principles. These are: improving the daily
living conditions of the people; reducing health inequality,
to which the NHI is the solution; and having the ability to
monitor population health. This is in line with the strategic
thrust of government, which was properly reflected in the
strategic plan of 2014-19 of the department, which states
that:
South Africa is at the brink of effecting significant and
much needed changes to its health system financing
mechanism.
These changes are based on the principles of ensuring the
right to health for all; entrenching equity; social
solidarity; and efficiency and effectiveness in the health
system in order to realise universal health coverage. The
National Development Plan states that:
EPF 23 JULY 2014
PAGE: 86 of 95
... a well-functioning and effective health system is an
important bedrock for the attainment of the health outcomes
...
In order to realise the long-term health goals for South
Africa, as well as the priorities as set out in the NDP, the
department has outlined eight strategic goals in each fiveyear strategic plan. These strategic goals are critical in the
manner in which health care services will be provided in the
coming five years and which will go a long way in addressing
the factors that breed mistrust in the system.
There is a hospital in Mpumalanga - hon Minister, I am sure
you know about it - which is nicknamed “emva kwakho”. When you
do a close analysis of the reasons for this “emva kwakho”
syndrome, you discover that there are other factors beyond the
challenges of the health care services. One of the key
challenges is that our people present themselves to health
facilities very late, when they are already bedridden. The
culture of our people of trying other means first and using
health care facilities as a last resort is what resulted in
the concept, “emva kwakho”.
In this regard, we want to welcome the department’s approach
of establishing the ward-based outreach teams. This will go a
EPF 23 JULY 2014
PAGE: 87 of 95
long way in encouraging our people to present themselves at
our health facilities very early.
We further welcome the step taken by the department to
establish and strengthen health committees in each clinic and
community health centre. This is a correct step because these
formal structures will encourage community participation and
should be used to mobilise our people to become active
participants in issues affecting their health.
We wish, therefore, to call upon our people to take these
opportunities and use them in the context of improving the
health care delivery system, with a special focus on access,
efficiency, quality and sustainability. I am raising this
because it is a vital part of community involvement in health,
as they will act as a bridge between the community and health
facilities. This will enable our community to engage
government and participate in making sure that they monitor
the extent to which the department is succeeding in achieving
universal health care coverage in order to improve health
outcomes, particularly in focusing on the poor, vulnerable and
disadvantaged groups.
There is a challenge in regard to the provision of health care
to people living on farms and in deep rural areas. It is a
matter that we need to look into carefully, and come up with
EPF 23 JULY 2014
PAGE: 88 of 95
the best solutions to how we can ensure that the people living
in farming communities in deep rural areas have equal access
to health facilities, because in most instances services are
not being provided in the same manner.
Let me conclude by quoting one of the former ANC Presidents,
Chief Albert Luthuli, who once said:
We must, in our lifetime, be able to change our Freedom
Charter to say: ...
All are enjoying equal rights!
There are houses!
There is security!
There is comfort for all!
There is peace and friendship!
And, we must be able to say: Afrika isibuyile!
I thank you. [Applause.] [Interjections.]
The TEMPORARY CHAIRPERSON (Ms T C Memela): Hon members, order!
The MINISTER OF HEALTH: Chairperson, I would like to thank hon
members for their inputs in support of this Vote. I am
EPF 23 JULY 2014
PAGE: 89 of 95
standing here to commend the House and express my appreciation
to those who supported this Vote of R33 955 475 000.
Allow me to deal with a few issues that were mentioned.
We agree with the hon chairperson of the portfolio committee
regarding his concern about human resources. In fact, the
World Health Organisation has named human resources as one of
the six building blocks or pillars of the health care system.
We agree with you that there have been several problems in
human resource allocation because, in quite a number of cases,
it was done on a hit-and-miss basis. For the first time in the
history of South Africa we now have a human resource
development policy. This was launched officially in 2011. We
are following it.
Secondly, the WHO has also recognised the anomaly of health
workers around the world generally being allocated in terms of
populations. For example, various documents for example, state
that one doctor is needed for 10 000 people, or maybe one
nurse is needed for whatever number of people. But we have
realised that that formula does not help the world at all.
So the WHO has come up with a new formula called Worklead
Indicators of Staffing Need, WISN. It is a clear, applicable
EPF 23 JULY 2014
PAGE: 90 of 95
mathematical formula and we have been working with it for the
past 18 months.
I am happy to announce that we have completed all primary
health care facilities in this regard. Our having used this
formula means we are now in a position to tell every primary
health care facility how many nurses, clerks or pharmacists
they need, and at what level they are needed. We now have the
information on every type of health worker that is needed to
run a primary health care facility.
We are currently doing the same with tertiary institutions. It
is going to take us some time, as tertiary institutions are
very complex workplaces because of the myriad health workers
needed there.
We have already spoken to the Minister of Finance and, once we
have completed this process, we will present it to Treasury.
At that time we will be in a position to show what the health
care human resources needs for the country are.
Every province must vote for them. We are painfully aware, for
instance, that there are provinces that just ignored or
neglected the hiring of nurses. With WISN it will no longer be
possible to do so, because the human resource requirement will
EPF 23 JULY 2014
PAGE: 91 of 95
be put on the table and will show how many nurses are employed
and how many are needed.
I am sure you are aware that the Department of Education is
better off because they are far in advance. I was an MEC for
Education for many years, so I know. When I was in education
we compiled a database over a long period of time – for over
20 years. That allowed us to know each and every school – its
size, the number of learners enrolled, the number of teachers
it needed, whether it should have a deputy principal, how many
deputy principals, etc.
In Health, we never had that. Now for the first time WISN is
going to give us that opportunity. So I want to assure you
that, in terms of this formula, we will be able to tell any
hospital in any province whether or not it has enough health
workers, and whether it has to budget to fill those posts. We
are looking forward to the day on which WISN will be
implemented.
The second issue I want to deal with is the issue of cancer.
We do have the National Cancer Registry in South Africa. It is
relatively new. The registry captures the epidemiology of the
disease. There are a number of clinical research studies under
way. These might not be widely known. The SA Medical Research
Council is also funding a number of clinical research studies
EPF 23 JULY 2014
PAGE: 92 of 95
on cancer because we want scientifically proven methods. That
is what we are looking for. But we must also realise that
research has to be spread equitably among the diseases known
as the quadruple burden of disease.
Hon James, we do agree with your observation and the research
you mentioned on primary health care. I want to assure the
House that the country cannot run away from this issue. The
issue of the transformation of primary health care is our
historic mission. It is going to happen in two ways. Firstly,
primary health care provision will be re-engineered as
municipal ward-based primary health care teams. We already
have 1 100 teams. We are now busy training 557 teams. Each
team consists of six community health care workers led by a
nurse. We are going to cover every municipal ward in the
country in this way.
The second way in which it is going to happen is on the issue
... [Interjections.] Yes, I was just checking the time because
we have a bell in the NA that guides us. We are at a
disadvantage here because we are not really guided, so we keep
on looking for guidance!
I just want to brief the House on the second way in which this
transformation is going to happen. During the state of the
nation address the President mentioned something called Big
EPF 23 JULY 2014
PAGE: 93 of 95
Fast Results. Big Fast Results is going to be implemented in
the Health environment as we are sufficiently advanced to do
so. Maybe people might not have understood what that meant.
What does it mean? Big Fast Results is a Malaysian system that
argues that every policy in government, anywhere in the world,
no matter how good it is, usually exists at 30 000 feet above
the people. If it is not brought down from there it will never
be implemented. So this system brings initiatives down to the
3 foot level. The mindset is, pull it down from there and put
it here.
We have agreed that we are going to implement this policy in
South Africa. We will start this year on what is called an
ideal clinic. What you do is you create what is called a
laboratory. Then you put a certain number of people in the
laboratory for eight weeks. They never get out of that
laboratory during that time. They must work on that system.
Now, for Health we are going to get about 80 people to sit in
that laboratory for eight weeks. They come from Health, Public
Works, Finance, from every department that is needed to deal
with the work, and even the private sector. They are going to
be put in there. We are going to give them one job, which is
to work on the model of an ideal clinic. They must determine
what a clinic should look like in South Africa in regard to
its administration, treatments, resources, equipment, etc.
EPF 23 JULY 2014
PAGE: 94 of 95
What should it look like? They must work on it from a budget
perspective, through the human capital needs, right up to the
end and say what the ideal clinic would look like.
We have already defined it. The ideal clinic consists of 10
components and 184 elements that are needed in them. These
elements range from the provision of human resources,
electricity, water, sanitation and security, to
pharmaceuticals, waste management and everything else.
So, when these people get out of the laboratory – and it is
going to happen this year – they will hand over a plan with a
budget detailing everything. Until they come up with that
plan, they will not get out of the laboratory. And then we
start implementing.
This must be made public. South Africans must know what a
clinic should look like. The plan must even include the
direction boards to the clinic, as well as the board at the
gate. In the rural villages where I come from, you won’t see a
sign pointing to the clinic. Villagers will direct you via a
bottle store or a lounge in one corner of the ... [Laughter.]
Yes, it’s the one that defines where the clinic is! Under the
ideal clinic method, even the board by the road which points
to the clinic is specified, and when you arrive at the clinic
you will know that it is the clinic because you will have been
EPF 23 JULY 2014
PAGE: 95 of 95
given a copy of the model of what an ideal clinic must look
like. In that way primary health care will start flourishing
in our country. Thank you.
Debate concluded.
The Committee rose at 12:33.