HEALTH-E: Minister, you have been in your job for a couple of weeks. What are your priorities for the next six months?

HOGAN: Six months is a short period of time but I think there are a number of things I think need to be done pretty quickly. Obviously HIV and Aids is a major challenge and we have the South African National Aids Council which is a body representing everybody in South Africa concerned with HIV and Aids. And that body has already been working fairly well, but there are a number of matters which I think will be expedited to make it very efficient. We are looking at the prevention to mother -child transmission program because there are some health districts where the take up is pretty low and we’€™re looking at a campaign around that.   There are administrative issues that we can look into to make it a smoother working body and more effective body because that is really our outreach and our major thrust around HIV and Aids.

That is one issue. The other issue of course is the quality of our health care services. You know I have just been reading reports, been interacting, getting emails, getting everything and all of us know the poor quality both of our referral hospitals, our district and health care levels, our primary health care levels.

There I am going to be looking at various initiatives of people who have already started looking at doing a diagnosis of what is wrong in those systems and for me it is very clear that part of the problem is that our health system is not an integrated health system. We have a national department that sets standards, we have provinces that are supposed to implement, we’€™ve got districts that are’€¦ that do not have control of the resources allocated them by the provinces and it’€™s a very un-integrated system. So I think what we need to be doing is two things. One, we need to be looking at just the system dis-functionalities. We need to prepare for whoever comes in, in the next elections – whether it’€™s myself or anybody else – preparing that ground for those things to be systematically addressed. But I don’€™t think its stops us from already taking on some of the issues that we can already start addressing and I have being consulting with my colleagues and my heads of my departments in the national office and I will be doing it with my colleagues at provincial level as well to start identifying certain things I think we can start doing within those facilities. So it’€™s those two areas I consider to be priorities at this stage.

HEALTH-E: Coupled with the issue around Aids treatment, there’€™s a whole problem around TB. South Africa hasn’€™t had great success in terms of treating tuberculosis. What is your plan around that?

HOGAN:   I do not have a specific plan at this stage but certainly XDR is of major concern and that is linked to an infection rate in hospitals as well and the adherence problems we have.

You also cannot isolate HIV/Aids campaigns, HIV and Aids initiatives from TB – the two are intertwined. So I would imagine that as we accelerate our work through SANAC that will have the same spin off effects for TB. I see it as almost indistinguishable from the HIV and Aids pandemic now.

HEALTH-E: Minister, you have identify some priorities, one of the hurdles that always keeps coming up is Human Resources. We have huge vacancies. The Lancet mentioned 46 000 vacancies for nurses over 9 000 vacancies for doctors. What can we do to remedy that?

HOGAN: Look, firstly I think no one wants to work in an environment that is an unhappy environment. I think its extra-ordinary how people continue to work in hospitals and institutions where there is so much dis-functionality. I think you only keep people in a profession if you support them to perform their duties and responsibilities in a decent way. So I think in a long term and medium term you have to start making the systems work for the people working in those environments.   In a short term I think that there’€™s a number of initiatives. One is engaging with particular unions. I’€™m speaking now of Denosa for instance, the nursing association, I’€™m talking about Nehawu. Some remarkable pioneering work is already been done in Chris Hani Baragwanath Hospital around engaging unions.

You know I come from a trade union background and I believe that workers actually want to work in a well ordered environment where they know what is required of them. So I would want to be engaging with bodies like that to see in what way we can start improving environments within hospitals. But I do believe that if you are able to demonstrate that you are going to have an effect, not just short-term effect but long term effect on the quality of health care services you will keep people there with the hope. We have been able to increase salaries for both nurses and doctors. It’€™s unfortunate that the dispensation hasn’€™t come in as fast as it should have. There has been problems with that dispensation coming in which might mean further problems for people which is unfortunate. But at least we’€™re trying to get those kind of things right. But I believe we’€™ve got to be more much energetic.

You know these are system problems, these are HR issues. These aren’€™t in a standard sense health issues. It’€™s good corporate governance, its accountability, its responsibility. So I would like to identify just a couple of institutions and to start doing pilot work because I’€˜ve got masses of literature on what is wrong and what can be done to set things right. I think we’€™ve got to venture out in that field, take advice from people who have done good turn- arounds in our country and around other institutions and start looking at what we can do on a small scale almost as pilot projects so that you can look bigger and you know in the next five years we can see what have we learned from this. There are also initiatives that have taken place if you look at Ukhahlamba, I have been receiving reports from the province about what they have been doing   and what partnerships they have entered into to try and sort out Ukhahlamba’€™s problems. We need to go back to those and actually see what interventions we use, what worked and what hasn’€™t work to learn so that we can build up a coherent and successful  project. There’€™s money for the revitalization of hospitals, the take up isn’€™t as good as it should be you know. If you read National Treasury statistics it is not as good as it should. Why is that? What are the blockages in the system? To do the most obvious of things, we need to learn from experiences well, what is going wrong and I think we need to pilot some things at this stage and engage with everybody in the field. I think we’€™ve got to be interacting with CEO’€™s of hospitals, District Health Managers, and local and provincial governments to get their view of things because I think you learn much more from the ground than often informed reports.

HEALTH-E: A lot of the people who actually work in hospitals such as doctors, maybe CEO’€™s to some extent would actually love to see a better health care service. In the past we’€™ve seen a culture whereby people who actually report bad conditions in their hospitals face reprisals against them which in turn hampers the delivery of health care services. Are you open to such kind of criticism?

HOGAN: Absolutely!  I mean I have experienced it firsthand – that kind of problem, I won’€™t say the circumstances but I know of a nurse who was a very professional nurse and who was victimized for drawing attention to problems in her particular clinic. And it finally led her to nearly having a nervous breakdown and I really mean we just can’€™t simply have that. We have whistle blower protection but it’€™s not only whistle blower protection it’€™s creating a climate where accountability is important.

Accountability above all else, it’€™s creating that climate where’€¦and this is where I think we at national level we need to take responsibility for setting what the standards of performance have to be so that it’€™s understood what the key performances indicators of a clinic is or a hospital are. What are the outcomes that are expected and if those are not being achieved then there has to be accountability for that. So it’€™s not just dependant on some poor person who has a sense of respect and commitment to the profession to be drawing matters to our attention. Our own systems need to be revealing that to us. I would want to speak further of other initiatives, some people have suggested to me maybe we need an ombuds. I certainly would say that   with all the weaknesses that it does have , having local health committees that are sub-committees of ward committees who monitor what is going on in the health facilities are invaluable as long it doesn’€™t become a power   contestation . As long as all the role players understand that work. But I think civil society engagement, not in a sense of being watch-dogs, but assisting to ensure that there’€™s good health delivery help us enormously and stops people from being victimized within our system itself.

HEALTH-E: Have you been surprised at the state of our health services, did you expect this, are you a bit daunted. Did you really have a sense of what is going on?

HOGAN: Two things. One, I think we are blessed with the most incredible skills and dedication and commitment in terms of the health professionals in our country. We have I think compared’€¦just speaking to the World Health Organization Regional Director, we have astonishing resources in this country and I mean that surprised me even more. I’€™ve always known that we have good quality but if you look at the way that this Viral Haemorrhagic Fever outbreak was dealt with by our professionals. It was completely professionally dealt with. People knew what they were doing, it was a marvelous example of co-operation between the private and the public sector. So I think we do have the basis on which to create a very good health system. Secondly it is very daunting when you look at the quality and the state of our institutions and am not saying all of them are bad you know. Just in working with my advisors we have identified at least 20 health districts that are in a bad way but I mean there are 53 and I think it’€™s not all a bad story and there’€™s some where there’€™s incredibly good service. It varies between provinces, some provinces like Gauteng with the tertiary academic hospitals they have a much better record in what’€™s happening in their provinces. It’€™s variable, but you know I keep on saying to myself’€¦you know I come from a financial background. I was fortunate enough to, in parliament to oversee the transformation of the South African Revenue Services and I remember coming in the first year in parliament and having people coming to tell us that they didn’€™t even have ribbons to print out the tax returns in the Revenue Services. I mean Revenue Services was a joke in those years and if I look at the turn ‘€“around that happened there and certainly we will be taking advice from people who were central to that turn- around and also to people who have been central to turn-arounds elsewhere in the world. We will be taking advice from people who know about institutional reforms, reforms of systems and I think it is doable from that point of view. Health is difficult, it’€™s complex, and it’€™s a whole range of things. It’€™s under enormous stresses from HIV and Aids but we should be able to effect a turn-around within a period of five years. There’€™s nothing in my mind that is as substantial a stumbling block that should not enable us and the goodwill that is there. I mean I have been overwhelmed both internationally and nationally of people saying we will do anything just call on us. We will drop things, we can work weekends, and we can do this. So I think we can build on the impetus and energy that has been unleashed and see what we can do.

HEALTH-E: You seem passionate about the issues of HIV and Aids.. What do you think the gaps are so far in terms of the implementation of the national strategic plan and are there successes wecan we build on?

HOGAN: Well look, I think the greatest success is having 550 000 people on treatment now. That alone, apart from the well being of the people involved. I think that alone help us to take the burden off hospitals and institutions that I think is critical that we accelerate the treatment programs. We have to work with our partners in social development around issues like home-based care as well and also voluntary counseling and testing. You know getting those synergies right and up and running. Also getting people to come out more, to be comfortable with taking the treatment and so the acceleration of that, but also the acceleration of the prevention of mother to child transmission. That should not be as complex as the antiretroviral roll-out because that is a series of incidents. It’€™s not long-term treatment that you are talking about and getting children free of any Aids which will help us so much in the future. Treatment is very important and needs to be expedited but prevention is equally as important. When we’€™re seeing that the incidences are very high in age group between 25 -40, we’€™re talking about our economically active population. There I think our prevention campaigns need more focus, more direction . I understand the difficulties. You just can’€™t give adverts. You can’€™t just sort of say ‘€˜ABC’€™. It’€™s much more complex than that’€¦ You know, some have said that ‘€œthe sociology of HIV and AIDS is probably more difficult than the health issue of HIV and AIDS’€. It’€™s encouraging that we seem to be seeing some kind of levelling off, but prevention is extremely important as well. And we will be focussing on the quality of our prevention programmes, the efficacy of that.

HEALTH-E: Minister, the success of many programmes depends on political will’€¦ do you find that within the Cabinet, among colleagues, the Finance Minister’€¦ people in these positions are supportive of trying to improve our health system or is that something you have to convince them of?

HOGAN: Fortunately for me, I come in post-Polokwane where the Polokwane conference of the ANC, the ruling party, took a decision that education and health must be the two priorities. I’€™m seeing that already ‘€“ that emphasis. Behind the scenes the ANC has been working very hard with a number of very skilled, very experienced people on a programme around HIV/AIDS and health generally, and diagnosing where the problems are. So, I would imagine’€¦ and am very certain that health and education are going to receive the priority that they do require. But it’€™s also going to require co-operation from us. You can’€™t throw money into a leaking ship. You can’€™t throw resources at something that is not working, and so it’€™s going to be a parallel process. Yes, we will need more funding, there’€™s no doubt about that, and we’€™re coming to an economic time of great uncertainty given the events of what’€™s happened even in this last week. So our fiscal space is going to be even more limited, which requires us looking at inefficiencies, looking at mending that leaking ship. I do not anticipate that we will have the kind of resistance that might have occurred in earlier times to the issues of health. I don’€™t find that resistance. I think there’€™s a common recognition in Cabinet that this is something that has to be driven. I mean, that’€™s what I was told by the President and Secretary-General of the ANC. He said: ‘€œYou’€™ve been appointed. We’€™ve got to sort out these issues.’€ So I take it very seriously.

HEALTH-E: You’€™ve taken over at a time when there have been some rumblings around the private health sector and wanting to regulate that. Is that something that’€™s going to be placed on the back-burner for now or is it still a priority?

HOGAN: I want to work at it, but not with undue haste. I’€™ve dealt a lot in the financial sector with matters pertaining to regulation and you’€™ve got to be very careful to get the right regulatory mix. Because you can undermine industries if you get your regulatory mix and regulatory regime too stiff at the same time there has to be some form of regulation. I think the issue of what the relationship with the private and public sector is, is a critical talking point and an important issue. I do not want to rush into any view, pre-determined view on this at this stage. I prefer to engage in a debate. Initially what I am looking at is we need a good relationship between the two sectors. We need some kind of adjustments in both sectors but if we’€™ve got a poor public health sector it does not make sense to undermine the private health sector through bad regulations or bad policy. My emphasis will be on improving the public health sector too.  

HEALTH-E: South Africa has many challenges. One of the challenges we face in the health sector is the issue around child and maternal health. We are one of the countries that are not meeting the Millennium Development Goals on that front and we seemingly are not recognising that as a problem, your thinking around that?

HOGAN: Obviously it’€™s very clear that it is dramatically influenced by the prevalence of HIV and Aids. But it’€™s not only that, you know everyone talks about the health environment. If you look at the Ukhuhlamba phenomenon, a lot of that was due to the poor quality of our water in that area and unless we start addressing the total environment in which health has to operate, we will still have worrying trends. We are also dealing with an HIV and Aids epidemic and it is essential to reducing those mortality rates but it has to go along with creating a better health environment and that means working with colleagues in provincial and local government. To make sure that local municipalities are operating at optimum rates. That we have the kind of skills we need in local government to make sure particularly our water systems, our waste removal systems as we saw in the Free State recently, that they are performing at an optimum. There is recognition in government that those skills need to be recruited with great urgency within local government. But I would agree with you the mortality incidences in both those fields are very worrying and it brings down our predicted age which now says people will die at 52 and it’€™s extremely worrying. Our millennium development goals are going in the reverse direction at this stage. What do we say to that?    

HEALTH-E: Minister, we took the liberty of sending emails to some of our contacts when we heard we had been granted an interview and we asked if they could ask you one question, what would it be… A nun  in Limpopo sent this question. She is looking after orphans and child-headed households. ‘€œHealth Minister how do we keep hope alive in the midst of the HIV pandemic? Can the Health Minister give us a word of encouragement to keep going on in our efforts to care for the sick and dying.’€  

HOGAN: I want to firstly to salute the work that they have done. They are the silent heroes in our country. Ever since my appointment even before, I was coming across so many people who have literally given up their lives, their time, their families to assist people affected and infected with HIV/Aids. I believe in South Africa as we did in the struggle days, that we have a commitment as a nation to get down and do the work, to get down and do the caring. To open up our arms, our homes to people who are in need and we are lucky that we have a hugely developed civil society. I would want to say to those people who are working and experiencing the heart-ache, the trauma and the harshness of living in that kind of environment , that government hears you, government is enormously respectful of what you are doing and grateful for the kind of energy and love which you are giving to the people of South Africa. I would wish more than anything else in our treatment of this pandemic that we are able to reach out to civil society in ways so that we can provide from our side the kind of resources and support that they need. I no longer believe that HIV/Aids must be something that is hidden away it’€™s got to become a major focus in government, everywhere in our public life and in that way I think we can assist them as well. I just want to say to them: Thank you so much and I certainly would like to engage with them.

HEALTH-E: Your predecessors in this position have actually come from a health background and you do not. You’€™re coming from a financial background. In your words what are you bringing to this key position?

HOGAN: You know I think I come with being less obsessed with stats and outcomes. Well outcomes are very important but less obsessed with the nitty-gritty health issues and allowing myself to take a step back and looking at the Institutional framework within which we have to deliver health. I believe that reforming that institutional framework is critical to health care delivery in South Africa. Firstly I think having a mind towards systems, particularly financial systems, HR systems is a great value. It takes you out of the normal discourse of health issues which doctors tend to get waylaid by.  Secondly I also come from a Trade Union and Civil Society background. I’€™ve worked with NGOs, I’€™ve worked in trade unions for a good part of my life. NGO’€™s are innovators, they are the people who are streets ahead of government quite often. They are the people who fill the gaps and I am enormously respectful of the work they do. I would want to garner and harvest the energy and insights that they have because that lies at the heart. We have to mobilise the entire population but I also think exposure in the financial world to people who have to make things work is extremely useful. You know I go back to the SARS example, the South African Revenue Services example. In the financial world if your systems don’€™t work things collapse as we have seen it now, you know, overexposure to certain bad debt. And so that’€™s the part that I enjoy very much is just looking at the regulatory environment and institutional frameworks.   The kind of things that make health work or not,  given the synergies   that need to develop in government. I think that’€™s an advantage.

Certainly it’€™s a disadvantage not being a doctor but it would be a disadvantage if I was in a country that didn’€™t have the high quality and numbers of health care professionals we have. I can call on within my own department, within the countries at large any amount of advice I wish to take. I mean we have the National Health Consultative Forum in the Act, I can set up any number of consultative bodies that I can take advice from. I don’€™t think you need to be a health professional per say. I think you need to be somebody with the eye on the ball on what the problems actually are.

HEALTH-E: There’€™s a sense that instead of one National Health system we have nine disparate health systems all working on their own. Have you got some specific, practical measure you would like to implement to get some of the provinces to speed up their services? We thinking of Mpumalanga, some parts of the Eastern Cape where the stats are showing, the indicators are showing things are horrendous.

HOGAN: Well you see I don’€™t want to say that the Constitution is the problem. I don’€™t want to sound like am not respectful of our Constitution. Health and education interestingly are two of the functions that are critically affected that have not been the great performers since 1994, are interestingly the two functions that are concurrent with both provincial and national. In other words National government has to take responsibility for certain things and provincial government take responsibility for the actual delivery of stuff and that creates enormous problems because I, as a Minister   cannot instruct a MEC in the province to do something. That MEC is responsible for delivery, so you have these dis-junctures in information flows. I wouldn’€™t be advocating changing the constitution or anything like that but I do believe that we need to free up resources in decision making to the appropriate levels. What I have been noticing is that CEO’€™s from hospitals have very little control over their resources even over their budgets. It’€™s all getting determined at provincial level. Now if you have an institution you’€™ve got to have control over your resources. I believe there are a number of misfits in the system that need addressing pretty fast and that’€™s related to the inter-governmental fiscal relation system that we have. It doesn’€™t mean that the Constitution has to be necessary tinkered with but I think we need smarter ways to deal with that lack of an integrated national health system. Very importantly, I believe that the relationship between the National Minister and the MEC’€™s for health is a critical relationship. We have to see ourselves as a team, working together as Team Health, jointly solving problems and learning from each other’€™s experience. Having communication but where we have success and where we have failures   and I would want to build up that kind of team spirit and looking more at relationships between what works between national and provinces, because sometimes I think provinces are better positioned. I also feel that the National Department needs to do some of the stuff which it hasn’€™t done like the regulations arising out of the National Health Act aren’€™t properly promulgated yet. I think you are right, there are all kinds of problems in the way that these different things synchronise, between the districts, provinces and hospitals. There’€™s a whole series of dis-junctures which I would imagine that both myself and Minister Pandor, Naledi Pandor, Minister of Education would willing to be sharing experiences on and reflecting on it and that’€™s certainly what I would like to be doing in the next couple of months and just looking at what we can get cleared in the public health system arising out of those dis-functionalities .

HEALTH-E: I just wanted to pick up on what you said earlier when you said that the ANC after Polokwane took a resolution to have a renewed focus on Health and Education. I would imagine that one of the issues is to make more funding available for the Health and Education portfolio budgets. Can you take us through all the energies that will be put into these particular aspects of portfolios?

HOGAN: Well you know Polokwane is only seven months away so it’€™s difficult to say exactly what kind of energies. I know within the Health sector, the ANC is engaged on …they have been involving a large number of stakeholders – on a pretty extensive diagnosis on whether they see problems in the health sector. I have read some of it and a lot of it make a huge amount of sense in what they are doing. We’€™ve got to do a balance. I would be worried if we go back to re-thinking everything you know. We don’€™t want to go back where we were in 1994. Where we have these huge kinds of blue prints and nothing gets implemented. We are policy-rich and delivery ‘€“poor at this stage. I would prefer for us to be a little bit of both. Drawing on the extensive experience and diagnosis of the problems that we’€™ve got. I would like us to start with some initiatives drawing on the experiences of the people who have done turn-arounds as well, drawing on people in the world who know what is what around health in terms of delivery. I would like to be doing both at the same time doing initial pilot projects, seeing what can be done and learning from those experiences in order to roll-out a broader program. Also identify things like the PMTCT campaign that would be a major campaign which we are hoping to launch in the distant future. So that you raise a profile. Funding, obviously we would want much more funding and a lot of analysis is going into the funding short-falls. But the grim reality is that we going to be facing very difficult times. Internationally credit is even difficult to get hold of never mind anything else and this is going to impact on everybody’€™s budget just besides ourselves. The question is going to be, to what extent health and education get prioritised? Certainly the Treasury has been sympathetic and has given fairly generous grants over the above baseline and we tend…that will come out in time to come but certainly the battle around resources is going to a big battle.