Health Funding

Full text of the Minister of Health’s Budget Speech

Read the full text of the Minster of Health’€™s budget speech presented to parliament on May 13.

Madame Speaker! Honourable Members!

Over the past year, we have been on a journey of discovery ‘€“ a discovery of our nation’€™s capacity to rise to the many challenges of our times. A discovery, also, of our ability to remain steadfast and advance our cause in the face of obstacles and setbacks.

We have experienced the highs that come with evident success but we have also experienced the lows of occasional failure. Through this, one thing has remained certain. We shall not be deterred, for we know that ‘€“ through our efforts – our health system is today better positioned to respond to the expectations and needs of our people.

As we near the end of the 1st decade of freedom, we know that:

§                 We have built a unified system for health care delivery with institutionalised mechanisms ‘€“ such as MinMec ‘€“ that give concrete expression to our system of co-operative governance.

§                 More South Africans today have access to health care.

§                 We have deracialised our clinics and hospitals, built new facilities and physically rehabilitated many of the existing institutions.

§                 The distribution of medicines has improved and we are on the threshold of significant changes that will see further reductions in the cost of medicines.

§                 The private health care sector remains robust and provides credible choice for those willing and able to pay for their care.

§                 We are expanding partnerships between the public, private and the NGO sector, driven by the imperative to gain optimum benefit from resources and make health care more affordable and accessible.

§                 Our academic and training institutions continue to provide credible platforms for the generation of future leaders in the field of health.

§                 We are increasingly seeing professionals from the ranks of the previously disadvantaged rising to take the helm as Deans of Faculties in the health field.

§                 Our pre-eminent research institution, the Medical Research Council, is today stronger and expanding to respond to a broad spectrum of challenges, adding the public health dimension to a more traditional biomedical approach.

§                 Our National Institute for Communicable Diseases (NICD), backed by increasingly skilled outbreak teams in the provinces, ensures that we are able to respond to any disease outbreak.

§                 We have also consolidated our medical laboratory infrastructure and established the National Health Laboratory Service.

§                 We have better information to monitor fiscal flows and the impact of our policy interventions to ensure the necessary relationship is maintained between policy priorities and resource allocation.

§                 All these are important achievements in a concerted effort to build a secure National Health System that is robust enough to respond to the varied health needs of our nation

Madam Speaker and Honourable Members, in this context, I have the privilege and the responsibility, once again, to stand before this House and propose the adoption of the budget vote for health.

The health allocation amounts to R8,38-billion and forms part of a larger amount of about R40-billion devoted to the public health sector. A significant portion of the budget will be used to consolidate existing programmes. However, I would like to highlight a notable new feature ‘€“ that is, the special allocation to attract and retain the valuable services of skilled health professionals.

Important elements of the budget include substantial increases in the school-based nutrition programme; capital works to revitalise selected hospitals and expansion of programmes to combat HIV, AIDS, TB and STIs. Of course we will not neglect the area of non-communicable diseases.

If we take a few steps back ‘€“ far enough to see broadly and to achieve the perspective of a decade of progress – we can confidently say that South Africa in 2003 is a better place than SA in 1994. The tide has truly turned!

I would like to outline our plans to consolidate on this foundation by highlighting priorities for the coming year.

Firstly, our intentions in terms of securing the foundation of care, is our skilled human resources.

In the health sector quality of service depends critically on the availability of adequate numbers of appropriately skilled professionals.

There has always been a poor distribution of health professionals between the public and private sectors and between the urban and rural areas.

The problems in the public sector have become more acute as we have expanded access to care, particularly to meet the health needs of people living in the least developed parts of our country.

Our well-trained health professionals have also become a sought-after resource in high paying industrialised countries. However, the actual number of health workers leaving the country is less dramatic than media reports suggest. It is the abrupt nature of these departures causes great destabilisation.

In recognition of this critical situation, the Health sector has been allocated R500-million for the first time this year to recruit and retain scarce professional and attract new recruits in rural areas. The Medium Term Budget Framework provides for some expansion ‘€“ to R750-million next year and to R1-billion in 2005/6.

The money will be used to introduce a system of allowances for professionals with scarce skills and professionals serving in rural areas and to change the salary structures of health professionals where the State pays rates significantly lower than the private sector.

We therefore have our sights set on implementing the new allowances from the 1st of July 2003, subject to the collective bargaining process.

In a few days, at the World Health Assembly in Geneva, Health Ministers will be discussing this issue. On May 18, Health Ministers from the Commonwealth will adopt a code for ethical recruitment that will be binding on all Commonwealth Nations.

We have made progress towards the introduction of mid-level workers to assist professional practitioners. Several professional councils have amended scopes of professional practice to accommodate mid-level assistants and created new occupational categories.

In addition to the human resource factor, the state of health facilities and the availability of appropriate equipment are key factors in improving the quality of hospital and clinic services.

Our capital investment in hospital buildings and major equipment under the Hospital Revitalisation Programme will be R717m this year and is due to rise to R911m next year and R1bn the year after.

This substantial increase in the national budget is mirrored by capital spending increases in most provincial budgets.

The Revitalisation Programme is proceeding well, with an additional 18 hospitals now added to the initial nine. A total of 18 out of the 27 projects involve the building of new hospitals, either to replace a dilapidated facility or to create a new service.

You will recall that we embarked some years ago on the construction of three major academic hospitals, in Durban, Pretoria and Umtata. The first of these facilities, Inkosi Albert Luthuli Hospital in Durban, is now open for business. It is a large hospital ‘€“ 840 beds — and has already notched up an award for the private-public partnership that manages its information technology and medical technology.

The Nelson Mandela Complex in Umtata is now almost complete. With 460 beds, it provides Unitra with a top class teaching facility. We expect to see patients in beds before this year is over. Phase two of the new Pretoria Academic Hospital, which will be a 780-bed facility, will be completed in 2004.

We recognise that improved management is a critical factor in achieving better health care. Earlier this year we established the Arthur Letele Institute for Health Care Management. The Institute was named after a medical practitioner and veteran in our struggle for democracy, who embodied the qualities of service and expertise that we aspire to.

In the middle of last year, we launched a consultative process with our medical specialists on the future of tertiary health care services. The goal is to develop a 10-year vision that will involve some reorganisation of services in order to equip them better, ensure their long-term sustainability and generally make them more effective.

Expanding universal access to a clearly defined basket of Primary Health Care Services is a major challenge that we continue to confront.

Over the past nine years more than 701 new clinics have been built and another 249 have been substantially expanded. The singular importance of expanded access to primary care is its impact within a broader programme of poverty eradication.

Therefore, it is particularly disturbing to note that the Intergovernmental Fiscal Review reflects major discrepancies in primary health care allocations among provinces.

In 2002/3, the per capita allocations ranged from R70 to R238, with the national average running at R148. A clear area of focus in the coming years, therefore, must be the tracking of resources allocated to primary care in all districts and municipalities across the country, driven by the imperative to provide adequate funding at this level.

This is critical to ensure that we attain our targets for immunisation; that we can fully implement the Integrated Management of Childhood Illnesses; and that we are able to make the changes recommended by the Committee for Confidential Enquiry into Maternal Deaths.

A strong emphasis on vaccine preventable diseases is one of the most effective and affordable ways of limiting child mortality and illness. In 2002, 72% of children were fully immunised at one year ‘€“ representing a significant increase compared with 63% in 1998 ‘€“ but we have still have a long way to achieve the targeted rate of 90%.

The World Health Organisation has adopted Healthy Environments for Children as its theme for 2003, drawing attention to the fact that environmental factors play a critical role in the deaths of about 5-million children worldwide each year.

In order to recognise the significance of environmental health interventions, the Department last year launched the Alfred Nzo Awards for outstanding work by environmental health officers. It is perhaps not widely known that our first Foreign Affairs Minister of the democratic era was an environmental health officer.

Maternal health services at all levels have been under close scrutiny since we received the latest Report of the Committee for Confidential Enquiry into Maternal Deaths. The report indicated a rise in maternal mortality.

While this was partly attributable to the increased impact of HIV and AIDS, other factors also played a part ‘€“ factors related to the management of the health system, the skill of the individual practitioner and social circumstances of the patient.

Disability is a substantial contributor to poverty and, in recognition of this, President Mbeki announced, in his State of the Nation address, that health care would be made available free of charge for people with disabilities.

I am now in a position to expand on the President’€™s announcement by indicating that this provision will cover outpatient visits to hospitals as well as admissions, including all inpatient care and major assistive devices, such as wheel chairs and hearing aids.

The benefit will include people who have permanent disabilities that result in moderate to severe difficulty in executing normal tasks of living. It will include older persons who are considered to be frail and long-term patients in institutions for mental health care.

However, it will not be available to people who have medical aid cover, who have a temporary disability or who have a chronic illness that does not cause substantial loss of functional ability. The extended health benefit will come into operation on 1 July 2003.

There is presently still a backlog in the supply of wheelchairs and hearing aids. The Department aims to eliminate this backlog by this time next year, expending about R30-million to assist those presently on waiting lists. This means that provinces will be responsible under the free health care policy only for replacement devices and for assisting those newly disabled.

In terms of combating hunger, the Primary School Nutrition Programme has proved its worth in sustained delivery over a period of nine years. Last year Cabinet made a series of recommendations to strengthen this programme. As a result of this, the budget allocation for the Programme has been substantially increased ‘€“ from R592-million to R809-million.

The increased funding offsets the impact of inflation and ensures that all provinces can meet the standard menu requirements and the minimum number of feeding days. There will also be a slight increase in the number of Grade ‘€˜R’€™ children who were included for the first time last year.

Regulations are now in effect for the mandatory fortification of bread and mealie-meal with specific vitamins and minerals.

This Government ‘€“ and indeed this Parliament ‘€“ has adopted the approach of building the nation’€™s health by tackling major health risks.

Our early recognition of tobacco use as a major public health risk that contributes to 4 million deaths a year worldwide ‘€“ enabled South Africa to play a significant role in the successful negotiation of the global Framework Convention on Tobacco Control.

Consensus on the Framework Convention was achieved in March 2003 in Geneva and will be presented to the World Health Assembly later this month for adoption. We do intend to draw on the experience of the past two years to amend the Tobacco Products Control Act again this year.

Government’€™s effective controls on tobacco use inevitably raise questions about our commitment to tackling the abuse of alcohol. Government has little doubt about the dangers of alcohol abuse and its ability to destroy life.

In the Northern Cape, one out of 10 children starting school shows features of Foetal Alcohol Syndrome, caused by the mother’€™s consumption of alcohol during pregnancy.

These children suffer a range of physical and intellectual impairments. The situation is also extremely serious in the Western Cape where one in 20 children is affected.

Indications are that we are dealing with a problem that takes a grip very early in life. Our reference for this is the Youth Risk Behaviour Survey undertaken on our behalf by the Medical Research Council.

Of learners surveyed, 50% had taken alcohol at some stage, and one out of three had consumed it during the last month.

Mortality figures show that 46% of male deaths in the age group 15 to 29 years in the period 1997 to 2001 were due to unnatural causes ‘€“ accidents, suicides and crime, often linked to alcohol use.

Any effective strategy against alcohol misuse must take account of the complex nature of the problem and this requires a wide range of organisations to play an active role. I have been encouraged by the approach of the producers in the preliminary discussions we have held with them.

In contrast to tobacco ‘€“ which is harmful no matter how you use it ‘€“ alcohol can be safely and healthily consumed. This means that our strategies in relation to alcohol will differ in some respects from our approach to tobacco. The Department has researched the effectiveness of warning messages and will soon be in a position to publish regulations under the Foodstuffs Act.

This brings me, Speaker, to the – National Programme on HIV, AIDS, STIs and Tuberculosis.

A total of R664-million is allocated in the national Health Vote for interventions related to HIV, AIDS and TB. This amount is almost equally divided between the national office and provinces.

By far the largest amount allocated for these programmes ‘€“ an amount exceeding R1.1-billion ‘€“ falls outside the ambit of this vote as it is contained within the equitable share to provinces. No matter what route state funding takes, it all goes to reinforcing implementation of the Strategic Plan on HIV and AIDS and TB.

Therefore, whatever the challenges we continue to face, they should not detract from our national effort in confronting the twin epidemics of TB and AIDS. Every passing day confirms the wisdom of a comprehensive approach to this challenge, an approach that is anchored and based on a developmental perspective.

The year ahead will see the continuation of the Government’€™s Khomanani awareness campaigns with their strong prevention and care elements. They also play a vital role in promoting and mobilising care and support. Between September last year and February this year, the Khomanani campaigns reached 21-million radio listeners and 60% of the country’€™s 8,5-million television viewers.

The year ahead will also see strong advocacy initiatives on tuberculosis

The facts are ‘€“ quite simply ‘€“ that: (1) TB is curable even in the face of HIV infection; (2) treatment is free and available at most public clinics; (3) failure to complete the 6-month course of treatment is a major problem that contributes to the spread of drug resistant strains of TB which are extremely hard to cure.

TB ‘€“ no less than HIV and AIDS ‘€“ requires strong social partnerships and we intend to build these in the year ahead.

The fact of the matter is that TB is on the increase and last year alone there were about 200,000 cases countrywide.

The cure rate is well below our intended target of 85%. Only two out of three patients complete their treatment.

Hunger is a factor in the interruption of TB treatment. In our country where vast numbers live below the breadline, nutrition must become essential part of the treatment.

Another major focus this year will be the promotion of counselling and voluntary HIV testing.

There is clear evidence that good nutrition, the use of immune-boosting supplements, including some traditional herbal remedies, constant emotional support and generally healthy lifestyles prolong good health and delay the onset of AIDS.

In the case of traditional medicines ‘€“ that are quite widely used in relation to HIV and AIDS, but poorly understood ‘€“ the Medical Research Council has set up a Unit on Indigenous Knowledge Systems to evaluate the safety and efficacy of these traditional herbal remedies.

The programme to prevent mother-to-child transmission (PMTCT) of HIV infection through the provision of Nevirapine has expanded. There are now more than 650 service points participating in this programme.

A selected cohort of mothers and babies is being studied to establish the impact of the programme in terms of the health status of mothers and babies.

Research into the possibility of sustained drug resistance in the PMTCT programme is also continuing.

The latest HIV prevalence survey ‘€“ the 13th undertaken at our antenatal clinics ‘€“ confirms that the rate of infection has stabilised, but not yet declined overall. However, for the 4th year in a row we are seeing a small drop in the levels of infection among our teenagers.

When it comes to treatment, three absolutely critical factors are good health infrastructure, adequate numbers of knowledgeable health workers and the availability of affordable medicines. This remains true, to varying degrees, whether or not the element of antiretroviral drug therapy becomes part of the treatment programme.

Honourable Members will be aware that Government appointed a Joint Health and Treasury Task Team to undertake a comprehensive projection of the costs of various treatment options, including the use of ARVs.

The report of this team will be presented to Cabinet in the very near future and a decision will be taken on this issue that has come to dominate the public debate on HIV and AIDS.

The budget also provides for increased support to organisations involved in home- and community-based care.

Good progress was made last year to strengthen this form of care ‘€“ through appointing coordinators, standardising training, providing guidelines and distributing care kits. But we would admit that we still have a long way to go in developing care outside of institutions.

In a letter following his recent visit to South Africa Professor Richard Feachem, executive director of the Global Fund, said he had been very impressed by the commitment and the work he had seen in South Africa in both public and civil society sectors. Despite technical requirements that delayed the signing the Global Fund agreements, the Fund’€™s visit was fruitful and he was confident that the agreement will shortly be formalised.

Turning to the legislative programme for this year, I am confident that this session of Parliament will, at last deliver the National Health Bill. The delays in tabling this Bill, since its approval by Cabinet last year, relate to the length of the legislation and some complex constitutional issues.

The Draft Traditional Healers Bill is currently in the public arena for comment. This Bill aims to establish an interim Council for self-regulation for various types of traditional health practitioners. We believe that this legislation holds benefits for practitioners themselves by recognizing their practice and assists in safeguarding the public from dangerous forms of practice.

When we passed the law on termination of pregnancy, our concern was to ensure reasonable access to safe abortion as a life-saving, public health measure.

Certain quality problems seem to arise from an overload on limited numbers of designated facilities. And we are continuing to see some deaths due to septic abortions. For this reason we propose to change the legal requirements that apply to health institutions where terminations may be legally performed. On May 2 the two Medicines Control Amendment Acts and their regulations came into operation, activating mechanisms to increase access to essential medicines. I am confident that date will stand as a milestone in our national project to build a better life for all, and I want to thank all those who contributed to this achievement, including some members of the pharmaceutical industry.

We continue to expand and strengthen the administrative capacity of the Medicines Control Council.

We are reconstituting the Council and we have already called for nominations for the Pricing Committe

On May 2 a provision of the Pharmacy Act also came into effect, opening ownership of pharmacies to non-pharmacists. We are confident this will significantly improve the public’€™s access to safe medicines of good quality.

Certain provisions under the Medical Schemes Act will soon come into effect. These allow medical schemes to designate preferred health service providers ‘€“ in either the public or private sectors ‘€“ which their members will be required to use.

The regulations also prescribe minimum benefits for medical scheme members in the area of chronic illness, which will especially benefit the elderly people.

We are hard at work on the social health insurance component and a firm proposal will be on the table in the latter half of this year.

The regulations on the Mental Health Care Act will be implemented in July.

In April we participated in a major advocacy and social mobilisation initiative, known as Racing against Malaria. This involved convoys of vehicles traversing the length and breadth of Southern Africa, spreading the message of malaria prevention along the route, and converging in Dar es Salaam for a unique joint celebration of Africa Malaria Day.

In September this year, South Africa will host the annual WHO-Afro Regional Conference. It is a privilege to hold this significant meeting in our country and to receive Health Ministers from the entire continent.

We continue to engage in international activities as Africans, guided by the objectives of NEPAD, firmly anchored in the SADC Region.

Throughout 2003 we will put every effort into fulfilling our part of the global programme to eradicate polio. If we fail now to meet the high disease monitoring standards set by the WHO, we will not be able to declare ourselves Polio Free at the end of 2005.

The recent outbreak of Severe Acute Respiratory Syndrome (SARS) has underscored how critical international co-operation is in the containment of emerging and re-emerging diseases. Infectious diseases know no boundaries and it is only through scrupulous surveillance and sharing of information across nations that we can protect our people.

Honourable members, our international activities are driven both by global public health agendas and by wider considerations. Major diseases ‘€“ particularly communicable diseases ‘€“ are increasingly recognised as global strategic issues with the potential to influence and shape geo-political, trade and demographic configurations.

In these opening years of the 21st Century health is emerging as a key factor in stability across the world. Consistent with the general objectives of our foreign policy, we shall do everything possible to contribute to the preservation of peace ‘€“ and the pursuit of development ‘€“ through the instrument of effective global public health initiatives.

The task at hand remains a daunting one. But the prize is big. We need all hands on deck.

We need the private sector and civil society in all its varied formations. We need individuals inspired by the spirit of Letsema to help us build the caring humane society of our dreams.

 Every day we take comfort in the fact that, whatever the occasional failures we experience, history and destiny have afforded us a rare opportunity to be the architects of a better tomorrow.

 I wish to thank members of this Assembly who have guided us towards this vision ‘€“ most notably the Chair and members of the Portfolio Committee.

 I also wish to express appreciation to my Cabinet colleagues ‘€“ especially those in the Social Cluster.

To my provincial counterparts, the MECs for Health, I am indebted to them for their support and camaraderie.

 In President Mbeki we have a leader who neither denies the enormity of poverty ‘€“ nor seems overwhelmed by it.

I am deeply grateful that the challenges of health can be addressed within an increasingly substantial response to poverty and the challenges of development.

Finally, and with heartfelt appreciation I acknowledge the managers and workers of the public health system ‘€“ foremost and most uniquely, the Director-General of Health Dr Ayanda Ntsaluba.

Particular mention should also be made of the support I receive from the Ministerial advisors and the cooperation of the provincial heads of health and representatives of the South African Local Government Association.

Further than that, I wish to extend my thanks to each and every one who has worked with dedication and a spirit of service. We appreciate that your repeated cry has been one for more resources in order to provide the quality of care that our people deserve.

To all health workers ‘€“ the call to battle is simple and clear. Let us endure. Now that the tide has turned, surely we shall prevail.

I Thank You!

About the author