The following speech was delivered in Parliament today by the DA’s Shadow Minister of Health, Dr Wilmot James MP, during the Budget Vote on Health.
South Africa lives with the world’s highest epidemic of HIV/AIDS, a preventable disease that brought widespread death, extraordinary misery and great hardship to the people. Close to half of the 3.7 million orphaned South African children lost their parents to HIV/AIDS.
The reason for this calamity is the failure of political and moral leadership to promote responsible safe-sex practices under circumstances where a vaccine was, still is and likely will be unavailable for a while.
It did not have to be like this.
F.W. de Klerk’s last apartheid government did not know what they were dealing with. A University of Cape Town group led by Mamphela Ramphele went to see Nelson Mandela in 1999 to persuade him to declare a national emergency. He urged health Minister Nkosazana Dlamini-Zuma to declare a health emergency, but she failed to do so.
It was Barbara Hogan and the Honourable Aaron Motsoaledi who led South Africa out of what some have described it as quiet genocide – for which no one has been held accountable.
Dlamini-Zuma has a lot of explaining to do. On her watch, in an act of nepotism, a R14 million contract was awarded to Mbongeni Ngema – a ‘good friend’ he was called – to produce a sequel to the musical Sarafina.
Dlamini-Zuma was also criticised for supporting Virodene, a ‘quack’ remedy for HIV/AIDS, which was, in fact, a toxic industrial solvent rejected by the health science community as ineffective. I was personally present at the meeting with Nelson Mandela when he said that he will call on Dlamini-Zuma to declare HIV/AIDS an emergency and he, as we well know, always kept his word, but she did nothing.
May her soul rest in peace, Manto Tshabalala-Msimang is no longer with us and we will not speak ill of the dead. Thabo Mbeki on the other hand, whose stubborn anti-science denialism, following on Dlamini-Zuma, is the reason why Minister Motsoaledi inherited a budget organised around the health implications of the HIV/AIDS crisis and that stands in the way of implementing a much needed plan for health systems strengthening.
I recall this history because it is important that Honourable Members understand that a health budget should not be designed simply for a crisis. It should be designed to constantly address multiple disease and illness risks. The World Health Organisation (WHO) identified the six building blocks of a health system as follows:
- Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those that need them;
- A well-performing workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible;
- A well-functioning health information system is one that ensures the use of reliable and timely information on health determinants, health system performance and health status;
- A well-functioning health system ensures equitable access to essential medical products, vaccines and technology of assured quality;
- A good health financing system raises adequate funds for health, in ways that ensure that people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them;
- Leadership and governance involve ensuring strategic policy frameworks exist and are combined with effective oversight, regulation and accountability.
There are no objective measures against which we can rate our standing against these goals because our Office of Health Standards Compliance and other research agencies are not geared to collect data on this scale.
Indeed, as we pointed out in Our Health Plan, there is no system in place to assess the performance of the public or private health sectors which means that policy-makers and the Honourable Motsoaledi are flying blind.
What we do know is that for the money we put in, the health outcomes are deeply disappointing. We do not spend small change. The consolidated expenditure for health at all levels of government was R168,4 billion (the second largest after education’s R297,5 billion) or 11,5 percent of our R1,46 trillion national expenditure in the 2016/17 financial year. This is impressive by any standard.
But, our health outcomes, though improving, are dreadful. Experts usually use the maternal mortality rate as a proxy indicator for the quality of a health system measured by its outcomes and ours is embarrassing for a country at our stage of development.
According to the 2014 Department of Health’s Saving Mothers annual report and detailed analysis of maternal deaths due to non-pregnancy related infections, our institutional maternal mortality rate is declining but still excessively high at 141 deaths per 100,000 live births.
The Free State does the worst at 203 deaths and the Western Cape the best at 66 deaths, but even this is simply not good enough. It should be under 50 per 100,000 live births, a millennium development goal we set for ourselves but missed by far.
The consequence of these trends is that the budget before Parliament is not designed to strengthen our health system but to deal with our HIV/AIDS crisis. It is quite simply, reactive.
Of the R42,63 billion set aside for the national ministry, R15,75 billion is for HIV and AIDS, R27,5 million for TB and R18,39 million for maternal and child health or 37 percent of what the Honourable Minister has to spend. There is no measure of the real cost to provinces of treating HIV/AIDS patients in all their clinical settings, but it must be considerable.
Saving lives is, of course, a moral obligation, and we will, therefore, spend, as we must, a monumental amount of money on HIV/AIDS until the epidemic burns itself out. The Honourable Minister has distinguished himself in delivering on this moral obligation, something one cannot say for most of the rest of the ANC Cabinet and certainly not for President Zuma who is everything but moral.
But HIV/AIDS will not burn out unless we stop the new infections, especially among young women. I do not believe that we are aggressive enough with our efforts and I challenge the Honourable Minister to tell us what he plans in this respect.
To deal with the ongoing HIV/AIDS/TB crisis and strengthen our health system will require both more money and better management.
The Honourable Minister is focused on the money. He wants to compel those on medical aid or health insurance to pay their monthly subscriptions to his National Health Insurance in return for services over which they have no control. He would like to have access to the medical aid reserves that run into billions, eliminate the medical aid tax credits and block the universal subsidy to middle to high-income earners.
But the Honourable Minister is not focused on management. He is running out of doctors and nurses. The average quality of hospitals is shocking. We have enough clinics in our country but can only staff half of them properly.
Bad governance and mismanagement is why the Esidimeni tragedy happened.
In any health system worthy of the name, an unusual pattern of deaths would be evident immediately and provoke an immediate response. The Gauteng Province may be the principal frontline offender but the ANC governance failures run wider and deeper, which is why the DA still believes that it is of the greatest importance for Presidential Zuma to appoint a judicial enquiry into the saga.
In South Africa, private and public health systems exist in parallel. The public system serves the vast majority of the population but is chronically mismanaged and understaffed. The better off 20 percent of the population use the private system and are better served.
When in national government, the DA will introduce strategic reforms to extend the coverage provided by medical aid and health insurance to serve 65 percent of the population, which will take off the pressure from and create the opportunity to upgrade the public health sector to meet WHO standards of care for those without jobs in a mixed health economy.
As an example of the DA’s commitment to improving healthcare, where we govern at Metro level in the City of Johannesburg for instance, we have ensured that 6 clinics are now open in the evenings, until 10 pm, and on the weekends to allow more people to access health care. In the new budget, the DA have proposed that millions be allocated to ensure that all other clinics in the City are also able to extend their hours.
The DA believes that every part of our health system should be modernised but priority must be given to building a highly effective primary health care system that responds to the needs of all those vulnerable to illness and disease.