The Minister of Health set out the priorities for the health sector for the next five years and looked briefly at impending legislation . The Minister covered, amongst other things, the plans to improve primary health care, the challenges facing the hospital sector, the need to improve the quality of care, transformation of health care training institutions and the war against HIV/AIDS.

Two Departmental officials, namely Dr Pretorius Deputy Director-General and Mr Mabope, Chief Director: National Health Systems accompanied the Minister. The Minister spoke to her briefing [please refer to the document " Briefing of the Portfolio Committee of the National Assembly by The Minister of Health – Dr Manto Tshabalala-Msimang" ]

Mr Ellis (DP) welcomed the Minister’s constructive engagement and stated that the Democratic Party was genuinely committed to improving health in the country. He inquired as to whether the Minister had chosen her advisors yet.

The Minister replied that she had retained Dr Ian Roberts until the end of December. She mentioned that although she will in time come to choose certain advisors, it is ultimately up to the Department of Public Works to ratify her choice. Dr Tshabalala-Msimang did say that she might require an advisor on labour issues.

Dr Gous (NNP) inquired about revenue retention and whether the revenue generated by private paying patients in public hospitals would be retained by the hospitals. The Minister answered in the affirmative.

Dr Gouws inquired further as to whether the Minister was contemplating the implementation of a quota system for selection into tertiary training institutions for the health sector.

The Minister felt strongly that it is important to train South Africans in health care especially at the Post –Graduate level. She maintained that currently most black post-graduate students at these training facilities are not South Africans and that a quota system was certainly an option if the situation was not otherwise rectified.

Dr Gouws also asked whether those health workers doing community service may be utilised in the greater Southern African region as part of the SADC health initiative.

The Minister said that Swaziland was responsible for human resource development in SADC was and therefore it was not within her power to say. At present community service will be carried out within South Africa. However, Tshabalala-Msimang said that in time South Africa may open up its borders to health workers from SADC.

Ms Southgate (ACDP) asked about what progress has been made in terms of making AIDS a notifiable disease.

The Minister responded that a document has already been submitted for public comment and that the AIDS unit is currently reviewing the comments. Mr Pretorius, of the Department, added that the comments were very diverse ranging from those strongly supporting the proposals to those strongly against. Of great importance is the need to put in place a system to prevent the transmission of AIDS to health care workers attending to infected patients.

A committee member inquired as to whether the case of foreign qualified doctors was to be revisited.

Mr Pretorius responded that the new Health Professionals Council was currently dealing with the issue. Central to the issue was the proposal that foreign doctors sign contracts. As there was some resistance to this, the negotiations would continue.

Ms Njobe (ANC) asked whether the patient’s charter was to be drawn up at a national or district level .

The Minister responded that this was to be done at a national level and that much work had already been done on the charter.

Ms Njobe also inquired as to whether there had been an official evaluation done of completed community service .

The Minister responded that this had not been done officially, but that it appeared that those doing community service had provided an invaluable service to those communities. It was also her feeling that although there had been some initial opposition to community service, that this was no longer the case. The Minister said that she aims to meet with some of the doctors later this year. She added that the pharmacists were very keen to begin community service as soon as possible.

Ms Njobe queried whether the demarcation of districts had been completed yet.

Mr Maboba said that it had been completed on a national level but not at the local level. As the demarcation of districts fell under local government jurisdiction, the national demarcation preferences would give way to local preference.

Mr Maphalala (ANC) was concerned about overcrowding in the hospitals. He felt this was due to the inadequate quality of care given at the primary level, which then deterred people from going to the clinics. This resulted in overloading the hospitals.

The Minister alluded to a referral system to deal with this problem of patients going to the hospitals when they can be dealt with at the primary level. She also said that training of staff had been taking place but perhaps needed to be accelerated. She said that the promotion of an ethos of caring would be an important part of this training.

Issues around HIV/AIDS were profiled during the meeting. It was suggested that HIV should be notifiable and not only AIDS.

The Minister responded by saying that public awareness plays a large role in the control of the spread of HIV/AIDS. Although up to 90% of South Africans are aware of the disease and how it is spread, this has not lead to an alteration in their lifestyles. The Minister felt that focussing on notification alone was not sufficient and that community openness and the de-stigmatisation of the disease were imperative. She called for a multi-sectoral partnership to halt the spread of AIDS . She also called for a multi-pronged approach in teaching of abstinence, faithfulness to a single partner and then the use of condoms. The Minister said that the World Bank was assisting the Department in putting together an AIDS package.

As regards the transmission of AIDS from mother to child, the Minister highlighted some of the difficulties in administering drugs. She alluded to the price of the drug itself, the cost of counselling and testing as well as difficulties with deciding the stage at which the drug should be administered. She acknowledged that the price of Niverapine is significantly cheaper than AZT, but that the side affects are as yet unknown. She said that research into this would continue.

First I wish to thank those colleagues still present in this committee for the period we spent together when I chaired this Portfolio Committee. I will always treasure your assistance. I also will always value that opportunity as it is proving to be of great benefit to me during this, my new responsibility. I hope those who are joining the Portfolio Committee for the first time this year will enjoy working with us.

Naturally my thanks also go to the President for providing me the opportunity to serve my country at the ministerial level and to the African National Congress and all South Africans for their contribution to my own personal development.

I have always looked forward to today because I have always wished that our first meeting indeed signal the beginning of a true partnership between myself and my department and you -the elected representatives of the South African people.

Let me therefore at the outset, categorically and unambiguously commit myself to a constructive partnership with all of you across the political divide. I wish to assure you that my door will be open. I have no doubt that working together particularly with Dr Nkomo, your Chairperson, we shall be able to handle even those difficult areas where we may disagree.

To give true meaning to this, I wish to suggest that we hold a national consultation to include myself, the MEC's, senior officials and the members of the National and Provincial Committees and the Select Committee of the NCOP. Such a meeting would provide us an opportunity to share in greater detail the strategic direction of our country for the next 5 years so that we could have a context to our ongoing work.

Should this proposal be acceptable to you, as I think it should, and I invite you to accept the proposal, the Director-General would set in motion the arrangements for such a consultation certainly before the end of November 1999. We could then collectively on the basis of such an experience decide on the nature and regularity of subsequent consultations.

Over the past 2 months, I have held numerous meetings with stakeholders in the health sector. I also have had extensive briefings by the different Units in the Department. That has given me insight into the enormous effort that has been put by my predecessor and the lot of ground that has been covered.

It has also highlighted some of the many critical challenges that confront us if we are to be true to our constitutional obligations. Central amongst these are the need for the restoration of a caring ethos amongst our health workers and the inculcation of a culture of efficiency and quality.

On the 22nd of July 1999, we also held our first MINMEC where I conferred with my colleagues, the Provincial MECs. I wish to convey to you our expressed commitment to work together. In that meeting we took particularly 5 important decisions.

1. To agree on a common strategy framework for the next 5 years. This is partly what we would wish to share with you, should we agree on the consultation I suggested.

2. To accelerate the programme of decentralisation of Management Autonomy in the hospital sector. We committed ourselves to a tight time frame currently being further fleshed out by the Director-General and the Provincial Heads of Health Departments.

3. To provide more visible political leadership and support to the health workers.

4. To introduce a Patient's Charter as a specific ingredient of the Batho Pele initiative.

5. To bring an end to Limited Private Practice.

I shall return to some of the important areas we are looking at later including the challenge posed by the scourge of HIV/AIDS.

Last year, Parliament enacted two vitally important pieces of Legislation, the Medical Schemes Amendment Act and Tobacco Control Act.

The Department has now received comments following publication for comment of the necessary regulations for the Medical Schemes Act. In due course I shall publish the final regulations.

As regards the Tobacco Amendment Act, the necessary regulations are at the final stages of preparation. Once completed we shall publish them as expected for public comment.

Two and possibly three pieces of legislation will be dealt with during this parliamentary sitting.

This will be a short Amendment whose aim is to provide for the introduction of Community Service for Pharmacists. The draft bill has been already published for comment in the government Gazette. (Copies of the Gazette are available).

This Bill provides for the establishment of a single parastatal to provide laboratory services for the public health sector primarily. It will be formed from the existing SAIMR (South African Institute for Medical Research) and the provincial laboratory services. I suggest that a more detailed briefing on this Bill be given to the Committee in due course.

The draft Bill has now been sent for Cabinet consideration in advance of a wider distribution for public comment. Key stakeholders have already been consulted including all the Medical Schools and those involved in Pathology laboratory services and their views are incorporated in the Bill which is to be distributed for general comment.

We hoped to effect some amendments to SAMMDRA during this parliamentary sitting. However, the nature of the latest court ruling has given us reason to want to defer this Bill till early next year. I am still consulting on this matter.

It is common knowledge that there was a review of the medicines regulatory process in South Africa conducted in 1998. It is also common knowledge that the review made certain recommendations some of which were accepted by my predecessor. The recommendations of that review as well as the need to streamline the medicines regulatory process remain as valid now as they were then.

It is also common knowledge that an error was committed by the Department in recommending the promulgation of the whole of SAMMDRA for commencement on April 30th. This was conveyed in our joint application with the PMA to the Supreme Court. Following the appeal by the PMA, it is also common knowledge that the courts ruled that we revert to the pre-April 30th legal situation, i.e. use of Act 101 of 1965 as amended as the legal framework for the regulatory process.

We shall in due course finalise our approach on SAMMDRA, which approach will include dealing with certain weaknesses the Department would wish to rectify in the construction of SAMMDRA.

We shall inform you once we have made any decision on the matter.

1. To consolidate the achievements of the previous 5 years especially as regards improving access to PHC (Primary Health Care) services for all citizens of our Country. In this regard there will be specific focus on the following activities.

a. Eradicate Polio, sustain gains made in reducing the burden due to Measles - Aim for elimination of Measles by 2002 largely by increasing routine coverage to 90% (from current 82%) and carrying out targeted Measles campaigns. Countrywide to achieve 90% full immunisation at first birthday with at least 80% attained in each Province.

b. Ensure 100% availability of drugs in the EDL for PHC in all facilities. To achieve this, we need to both popularise and train health workers on the EDL, improve stock management and ensure reliability of pharmaceutical distribution to all our facilities. We will deal decisively with the theft of drugs.

For example we have agreed with the pharmaceutical industry on the exclusive labelling of drugs for the public sector in order to trace these drugs easily when they are stolen. We are also cooperating with the SAPS in this regard.

c. Ensure appropriately trained personnel are available in all our PHC facilities.

d. Reduce Maternal Mortality and improve reproductive choice.

e. Provision of assistive devices for those with disabilities.

f. Unfold a Telemedicine network to support our Primary Care System. Currently there are 28 sites which commenced in July as a pilot phase. Building on these, we need to build a comprehensive network over the next 5 years. This initiative will also link some of our institutions with counterparts in the SADC Region and could contribute significantly to the vision of the African Renaissance.

2. A key challenge for us is to improve the functioning of our hospital sector.

a. We need to make our hospitals operate more efficiently; be more responsive to the users; provide a conducive work environment for staff; see the right patients at the right level of care through introduction of a referral system.

b. Central to the success of all these initiatives is the introduction of a System of Decentralised Management in all our hospitals. This would enable managers to manage more effectively and have the necessary agility to respond rapidly to changing situations.

c. We are commencing this financial year with decentralising management to 15 hospitals countrywide including the 10 biggest hospitals in the country.

d. A critical element for this decentralisation is to ensure that our Management Teams are equipped with the necessary competencies to carry out this task. A companion component of improving, overall, our hospitals is to speed up implementation of the hospital rehabilitation programme.

e. We all need to implement appropriate incentive schemes to support the management reforms. One such scheme being worked out together with provincial treasuries is Revenue Retention.

f. We are encouraged by recent agreements between the Health Departments and Treasuries in Gauteng and Western Cape on revenue retention. In essence the treasuries have accepted that a portion of the revenue generated in health facilities be kept within the sector. Combined with our management reforms, this offers a challenge for innovation by our hospital managers. Those who make their facilities more attractive will have the ability to generate more income over and above budgeted amounts to further effect improvements in the work environment.

3. Improve the Quality of Care throughout the health system. This perhaps is the Achilles heal of our health system. Currently the Department is working with other stakeholders on such initiatives as:

a. The Patient's Charter

b. Peer review Systems

c. Continuing Health Personnel Education

d. Appropriate and effective Complaints Systems.

We intend entrenching some of the key principles of these initiatives in the national Health Bill to be tabled next year (2000).

We need to make the point also that to sustain this initiative and entrench a culture of quality - our training institutions need to review selection criteria; the content of curricular as well as confronting the difficult challenge of ensuring that our educators themselves are appropriate role models for the younger generation. In particular we need to promote a caring ethos in our health workers; create conducive work environments; empower communities to interact constructively with our institutions to ensure their needs are met; empower individual users to claim their right to dignity.

4. Speeding up transformation of training institutions.

a. In particular ensure greater accommodation of those from historically disadvantaged backgrounds especially women and the rural. It is unacceptable that 5 years after our democratic victory we continue to detect hesitation from our institutions of higher learning. I am aware that the previous Portfolio Committee was seized with this issue. We need to work together to accelerate the pace of change.

b. We should also decisively tackle the hypocrisy of those who attempt to colour particularly their postgraduate contingent with a new found cynical concern for those who originate from North of us.

c. Let me be clear, South Africa commits itself to being an active player in the development of our appropriate human resource pool in particular for SADC. But equally we recognise our priority duty to enhance the opportunities of South Africans historically disadvantaged. On this there can be no compromise.

5. Escalate the War Against HIV/AIDS and TB. In particular:

a. To ensure a truly multi sectoral response building on the Partnership Against Aids launched by the former Deputy President, on October 1998. In this regard a meeting of the different sectors was held on the 6th July 1999. This was a successful meeting. A group led by the Director of the HIV/AIDS Programme has been put together to formulate a National 5 year strategic plan. We hope that this will provide a basis for a true partnership in this struggle.

b. Recently as you know, we went to Uganda. I was moved by what they have achieved. Central amongst their reasons for success has been the approach of Social mobilisation. This war can only be won once all communities take an active part. Top down approaches with not work. A second key lesson from Uganda is decisive political leadership. The Inter Ministerial Committee on AIDS under the leadership of the presidency is therefore a very appropriate intervention. We need now to ensure greater and effective participation of all the layers of our political leadership. I appeal to you to take this challenge. My Department will be available to assist where necessary.

c. Provide care and support for the growing number infected or affected. It is reality now that our health services are beginning to feel the impact of this epidemic. Our medical wards in particular reflect this impact. We all learnt recently that in King Edward VIII in Durban, around 50% of patients in medical wards have illness to which a positive HIV status is the main contributor. We need to ensure greater involvement of the Religious community in this battle. In fact were it not for this meeting, I was scheduled to have a consultation with representatives of this important community in Pretoria today.

d. Establish a particularly robust programme for the Youth as the most vulnerable group. In this regard, work with the Department of Education to ensure an effective Life Skills Programme in all schools. A major consultation on the Youth Programme was held on 28-30 July 1999. This consultation has led to the constitution of a group led by the youth to formulate strategies to escalate youth involvement in effective programmes. A key decision we need to take in this regard is the specific targeting of the age group 12-15 years. This is critical. We should all preach this message. It is the only way we can begin to tackle the high incidence amongst teenagers.

e. As a specific health sector intervention, to ensure effective syndromic treatment of Sexually Transmitted Diseases and other opportunistic infections.

f. Participate in international efforts in search of an HIV/AIDS Vaccine. The work done in South Africa coordinated by the MRC is in this regard very important. I appeal particularly to the Private Sector to take an active part and support this initiative.

g. We are following closely the current interest on NIVERAPINE as an intervention in Mother to Child transmission. We welcome the possible availability of a more affordable intervention and are particularly excited by the involvement of South African scientists in trials on this drug.

h. Speed up implementation of the DOTS strategy to reduce direct burden of TB as well as its contribution as the Aids defining illness in our environment. By March 2000 we aim to have rolled out the implementation of DOTS to 114 districts in the country (2/3 of districts). We are also happy to have been host to 2 major workshops on TB over the past few days.

(i) Stop TB initiative from 19th - 21 August; and now

(ii) The Southern African TB Control Initiative (SATCI ) from 23-25th August. These consultations are helping us better understand and review our programme for effective implementation.

6. Expand partnerships between the Public and Private Sectors to maximise benefits for our country. Some key initiatives in this regard include:

a. Continuing to expand contracting out of non clinical services where appropriate.

b. Enter into lease agreements for hospital equipment.

c. Explore the value of Private Finance Initiatives in the provision particularly of physical infrastructure in the health sector.

d. Use private sector resources subject to mutually agreed conditions to the benefit of those dependant on the public sector.

e. Increase the number of Private "fee paying" patients seen and admitted in our hospitals. The aim should be to use revenue generated to improve the overall quality for the entire public hospital sector to the benefit of those dependant on this sector.

f. Also build strong partnerships with other State Departments to improve functioning of government. We need to plan in a much more integrated manner and stop working in Silos.

g. NGOs and CBOs play an important role that complements the efforts of government. We shall seek to strengthen ties with them with a view to continuously identifying areas for collaborative action.

7. Speed up development of District Health System with particular focus on ensuring service integration and effective multi sectoral interventions at this level. This process will be given momentum by the work of the demarcation board. We need to speedily establish intersectoral districts so as to give effect to the imperative of integrated planning.

We are working closely with other sectors, especially Welfare, Labour and Finance towards the establishment of a social health Insurance as part of a comprehensive social security system. This would enable those in employment to make a contribution to the cost of their care and enable us to provide better health care for all South Africans. An interdepartmental team has started working on this area. A draft proposal will be available for wider debate by March 2000.

We will concentrate on the following areas of work:

a. Strengthening of the Gender Focal Point in the Department;

b. Develop a gender policy for the Department;

c. Greater responsiveness of health workers to victims of sexual abuse and domestic violence;

d. Improvement of skills of health workers for forensic examinations;

e. Working in the area of including the implementation of the Domestic Violence Act;

f. Criminalisation of the intentional spread of HIV.

The SADC Summit in 1997 decided on the establishment of a SADC health sector following a recommendation of the SADC Health Ministers. South Africa is Chairing the Sector. The Sector Coordinating Unit (Director: Dr Thuthula Balfour) is located within the Department. There is an agreed upon policy framework. On the basis of the framework - A protocol has been prepared. This Protocol was signed during the SADC Heads of State Summit held in Maputo last week by heads of State. It now needs to go through the national ratification processes. In our case parliament (Portfolio Committee) will play a critical role to finalise ratification process. The regional protocol will only have legal force once two thirds of the member states have ratified it. However, the Health Sector Ministers felt, correctly so, in one of their meetings in 1998, that there was a need to identify some areas to immediately work on together during the biennium 1999 & 2000. That work is ongoing.

The 5 priority areas identified in this Protocol are:-

· HIV/AIDS & STDs

· Reproductive Health

· Standardisation of Health Information and Surveillance systems

· Communicable Disease Control and Prevention

· Resource Mobilisation : Finances and human Resources

I shall meet my colleagues from SADC during the WHO Afro Regional meeting in Windhoek between 30 August - 3 September 1999. South Africa attaches great importance on the need for regional collaboration. We see the SADC health Sector as providing us a solid platform from which to launch the African Renaissance. We are finalising the Malaria Protocol to be signed by the Ministers of Health of Mozambique, Swaziland and myself. This is to give added effect to the Lubombo Spatial Development Protocol which was signed by the Heads of State at the World Economic Summit in Durban late last month. We are confident that this Protocol on the eradication of Malaria will improve the investment climate and quality of life for people in the Lubombo Region.

Ladies and Gentlemen, in these few words, I have tried to give you a flavour of the priorities of the Ministry of Health for the next five years, and I sincerely hope that you will support this programme of action. I thank you.