Chairperson, fellow Cabinet colleagues, Deputy Minister of Health and other Deputy Ministers, hon members of the House, distinguished guests, ladies and gentlemen, it's a great honour and privilege to present to the House the national Department of Health's policy priorities and budget for the financial year 2011-12 for its consideration.
I am presenting this speech at a time when the health care system is at a crossroads. We may choose the best route, or the worst one ever, which will, of course, make our situation worse than it is now. The choice lies with us as South Africans in general, and as elected leaders in particular.
Last year I signed a performance agreement with the President, what we call a "negotiated service level agreement". According to this agreement the health sector must provide four identifiable and measurable outputs with the ultimate aim of ensuring a healthy life for all South Africans.
Over and above these four identifiable outcomes that we have set ourselves to achieve, we also have a Ten Point Plan, which I presented to this House in 2009. This plan further guides us on how to go about achieving our outcomes.
Extensive studies commissioned by the prestigious British medical journal The Lancet but conducted by our own scientists and researchers in South Africa, have clearly revealed that South Africa is going through four major pandemics. Put differently, the country is faced with a quadruple burden of disease. It is important for members to understand what these four pandemics are in order for them to understand how we arrived at the outcomes agreed upon with the President.
The first, most severe and extensive burden or pandemic is that of HIV/Aids, and the second is TB. The second results in unacceptably high, and I emphasise "unacceptably high", maternal and child mortality rates.
The third is the alarming and ever-increasing incidence of noncommunicable diseases, that is, high blood pressure and other cardiovascular diseases, diabetes mellitus, chronic respiratory disease, various cancers, and mental illness.
The fourth and last is the one that every South African knows about because we worry about it on a daily basis, and that is because the media, both print and electronic, have taken it upon themselves to speak about it on a daily basis. That is the pandemic of violence and injury.
If only all four pandemics could be spoken about together on a daily basis, that would be a very good start for our country. Yes, I do accept that some of the media and members of the public talk a lot about child mortality. They do not do so, however, with an interest in helping our country to achieve solutions to the four pandemics that our country is sadly faced with. They do so as an instrument with which to attack individual public hospitals and individual health workers in the form of witch hunts. Of course, this is not helpful in our daily search for solutions for our country.
Having said so, I must say that these four pandemics are occurring in the face of a reasonable amount of health expenditure as a proportion of the gross domestic product, GDP. Available evidence indicates that we spend 8,7% of the GDP on health, the bulk of which, as is commonly known, is unfairly spent in the private sector.
This expenditure is significantly more than that of any other country on the African continent and in some instances even of countries outside our continent. A serious anomaly here is that our health outcomes are much worse than those of countries spending much less than us.
Evidently there is a very serious underlying problem that needs our attention. The effects of our burden of disease are clearly aggravated by inequitable distribution of human and financial resources between the public and the private sectors, in which resources are seriously skewed in favour of the private sector. The private sector serves only 16% of the population, in contrast to the public sector, which serves a whopping 84% of the population.
I will now go through these pandemics one by one because I want each and every member to understand fully what our country is faced with.
The first pandemic, as I have said, is that of HIV/Aids and TB. If I were to summarise it, I would say that South Africans make up only 0,7% of the world's population, but we are carrying 17% of the HIV/Aids burden of the world. We have the highest TB infection rate per population and our TB and HIV coinfection rate is the highest in the world, at 73%. A total of 35% of child mortalities and 43% of maternal mortalities are attributable to HIV and Aids. One in every three pregnant women presenting at our public antenatal clinics is HIV-positive.
Surely this needs very serious and extraordinary measures. Hence the announcement by the President, on World Aids Day in December 2009, came as a big relief to many people who are given the responsibility of fighting this illness. These measures of starting antiretrovirals, ARVs, when the CD4 count is 350 or less in pregnant women and HIV and TB coinfected people; of starting prevention of mother-to-child transmission, PMTCT, at 14 weeks rather than 28 weeks; and of treating HIV-positive newborns regardless of CD4 count, have gone a long way in reversing the tide of HIV/Aids. We started these measures in April 2010.
We are looking forward to a day, not very far away, when commencing treatment at a CD4 count of 350 will be universal and not only for specific target groups. This is imperative in the light of the newly released research findings that starting ARVs very early has huge benefits for the prevention of HIV infection and for protecting individuals against TB.
Before these new measures were implemented, the scenario as of the end February 2010, which was the end of the last financial year, was as follows: Only 490 health centres were then able to provide ARVs as accredited ARV service points. I am very proud to announce that the figure has grown to 2 205 health care centres providing ARVs. This has increased access to treatment in a manner unimagined just over a year ago. Our target is that all 4 000 health care outlets should be accredited as ARV centres by the end of the year.
Only 250 nurses were certified to provide ARVs by February last year. I am proud to mention that the number has now grown from 250 to 2 000 nurses who are certified and trained, further increasing access. Our target still remains 4 000 nurses to be certified by the end of the year.
Before the HIV counselling and testing campaign, HCT, was launched by the President on 25 April 2010 at Natalspruit Hospital, only 2 million South Africans were being tested annually. I am very happy to mention that since the launch of the campaign only a year ago, 11,9 million South Africans have already been tested and the figure is growing every month.
Many South Africans want to know their status. We will, therefore, take the campaign further. I wish to announce that on 12 June we will, together with the National House of Traditional Leaders and the Congress of Traditional Leaders of South Africa, Contralesa, launch a massive HIV counselling and testing campaign at village level. The launch will be at Mafefe village in Limpopo. Before the campaign, as at the end of February 2010, we had 923 000 people on ARVs and now, due to the campaign and the increase in access made possible by the expansion programme I mentioned earlier, 1,4 million people are on treatment.
We have been able to reduce the prices of ARVs by 53%. The significance of this is that we can now expand coverage of treatment and put more patients on treatment. As we achieve universal coverage at 350, it means that a further reduction process will be necessary.
As part of our programme to expand treatment, and in an effort to reduce the burden of HIV/Aids and TB, we will be providing treatment to inmates in all our Correctional Services institutions, who have been diagnosed and put on HIV/Aids and TB treatment. We will be working with the Department of Correctional Services and have already signed an agreement in this regard.
I have time and again expressed my worry about and regret at the number of newborns who are born HIV-positive. It is a big strain on our emotions and the psyche of the nation, and it causes untold problems in the health care system, as I mentioned earlier.
I am extremely excited to inform you that in the next few days, at the HIV conference in Durban, the Medical Research Council, MRC, researchers will release figures that show that there has been a significant reduction in the transmission of HIV/Aids from mother to child by six weeks post delivery. They reveal that a reduction of 50% transmission has been achieved. Of note is the significant reduction in the province of KwaZulu- Natal because of the very effective PMTCT programme there. This is to be celebrated, because it is a first sign that by 2015 we may be able to eliminate the phenomenon of mother-to-child transmission of HIV.
On 24 March 2011, World TB Day, I announced our three-pronged strategy to deal with TB. Firstly, we have acquired the new GeneXpert technology. This total revolution in the diagnosis of TB is the first breakthrough that has been developed after more than 50 years of relying on microscopy and cultures.
With the GeneXpert technology, diagnosis of TB takes only two hours. It used to take up to a week. Whilst the microscopy method has served us well for the past 50 years, its sensitivity was only 72%, meaning that 28% of people with TB could be misdiagnosed or missed. The sensitivity with GeneXpert is 98%, meaning that we may only miss 2% of the diagnosis. Moreover, it used to take us at least three months to know that a patient had multidrug-resistant TB, MDR-TB. Now we are able to know that within only two hours.
We have distributed 30 of these machines in districts that have high case loads of TB. We will be rolling these out to every district in the next six months and to every facility in the next 18 months.
The second strategy that we have implemented is that of active case-finding for TB. Starting in February this year, we have put together teams of five people each to trace TB contacts, that is, to visit families of patients on our database who are being treated for TB. There are 407 000 such families in South Africa and all of them need to be screened for TB, in the light of our knowledge that every TB patient has the capacity to infect 15 others in his or her lifetime.
I am happy to announce that since we started these household visits in February this year, we have already visited 41 000 families and screened 112 000 people. Our aim is that by World TB Day next year we will have visited at least 200 000 families.
It is important for me to disclose that in the past, before the advent of GeneXpert technology, when tracing TB contacts and screening them using ordinary microscopy, as we have been doing for the past 50 years, we would detect between 2% and 7% of TB in the screened population. Since the introduction of GeneXpert in March this year, we are now detecting 18% of TB cases.
The simple fact here is that we have been underdetecting TB, even when it was there. This means that we are now putting more people on treatment early on and reducing the pool of infective people. This also means that we stand a better chance, more than ever before, to turn the tide of TB.
We know that it will mean more money from the fiscus, as happened with HIV/Aids, and more work for health workers in the initial stages. However, in the long run the amount of money needed and the demands on health workers will be markedly reduced.
This, then, is the miracle brought to us by GeneXpert technology and house visits. May I add that we are the first country in the whole of Africa to have acquired this technology. [Applause]. Yes, you can applaud! It's not illegal! We wish to thank the World Health Organisation, WHO, for making it available to us and the United States Agency for International Development, USAID, for helping us to acquire it.
The third strategy against TB is that we have unveiled nine specially designed MDR-TB hospitals using technology from the Council for Scientific and Industrial Research, CSIR. These hospitals, at least one per province, have been made possible by a generous donation of R100 million from the Global Fund.
The design markedly reduces the chances of health workers, particularly nurses, being infected with MDR-TB by their patients. Unfortunately, patients have to stay in these hospitals for 18 months. Hence, it is imperative that we increase our household visits so that we stop TB from spreading and prevent our people from developing MDR-TB.
A lot has been said about the high maternal and child mortality rates in our country. You will have noted that most of our interventions in HIV and Aids are directed at pregnant women and children. We will work hard to reduce these mortalities in these targeted groups.
Remember that maternal mortality is not just the death of a woman; it is the death of a woman because she dared to fall pregnant! She becomes vulnerable by bringing somebody into this world!
We know that the mortalities brought about by HIV/Aids are disproportionately affecting young women of childbearing age more than men. This can't be right. It leaves the country with lots of orphans. We now have no less than 1,3 million orphans in our country, and most of them are maternal orphans.
This type of situation cannot be allowed to go on. It has other negative societal consequences beyond health care, such as crime, poor educational outcomes, teenage pregnancies and abortions, and the total social disorientation of young husbands. It is a well-known fact that young husbands lose direction in life if they lose their partners early on.
This does not happen to women, of course. Female partners are known to have a stabilising effect on the lives of young people. South Africa is fast losing this social stability due to the high maternal mortality rate which, according to evidence at our disposal, affects young women more than older ones. We will have to run a serious campaign on immunisation.
We also know that breastfeeding is a time-honoured strategy in child survival; medical science has proven that. For this reason, we will call together a big summit on breastfeeding in August this year.
The issue of noncommunicable diseases is very seldom spoken about in our country, and it's our third pandemic. It is also not very clearly understood, even though it preceded HIV and Aids by several decades. This is because HIV and Aids came as such a shock to the whole nation, to the extent that many strong civil society groups were formed.
Last week I tried to bring this issue of noncommunicable diseases to the attention of members of the Portfolio Committee on Health, but unfortunately some people in the media got excited because they thought I was specifically raising the issue of the dietary behaviour of Members of Parliament! [Laughter.] It is, therefore, very important for me to explain this matter clearly in order for Parliament to understand.
Noncommunicable diseases, generally referred to as NCDs, are diseases that are not propagated by germs moving from one person to another. In fact, it is safe to say that the "germ" that propagates NCDs is the human being!
I am saying so because NCDs are not only biomedical; they are largely diseases of lifestyle. These are divided roughly into four categories: high blood pressure and other diseases of the heart and blood vessels; diabetes mellitus and a few other metabolic disorders; chronic respiratory diseases and asthma; and cancers. Let me not forget mental illness. I am adding to these the increasingly high incidence of mental illness.
These diseases are driven by four identifiable risk factors. They are smoking; the harmful use of alcohol; unhealthy eating behaviour, that is, diet; and lack of physical activity. If these four risk factors and related unhealthy behaviours were removed, the world would be a safer place to live in.
The question is: Just how serious is this problem of noncommunicable diseases? Is it global, or is it only in a few countries? Well, the answer is it is a fast growing global phenomenon and becoming more devastating in sub-Saharan Africa because it is adding to the already existing problems of communicable or infectious diseases that have been plaguing Africa for centuries.
So serious is the issue of NCDs that the WHO and the UN called all Ministers of Health to Moscow on 28 to 29 April 2011, for what was called the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control.
The outcome of this conference was a document formally referred to as the Moscow Declaration. I have decided to make copies of this declaration available to members. Even those in the public gallery must get copies of this declaration. It's important for humanity.
In summary, the Moscow Declaration deals with the following issues. It notes that policies that address behavioural, social, economic and environmental factors associated with NCDs should be rapidly and fully implemented. It further emphasises that prevention and control of NCDs require leadership at all levels. It recognises that a paradigm shift is imperative in dealing with NCDs, as NCDs are not only caused by biomedical factors, but also influenced by behaviour.
The Moscow Declaration says that the rationale for action is that, worldwide, NCDs are important causes of premature deaths, striking hard at the most vulnerable and poorest populations. Subsequently they impact on the lives of billions of people and can have a devastating financial impact that impoverishes individuals and their families, especially in low and middle-income countries.
It goes on to state categorically that examples of cost-effective interventions to reduce the risk of NCDs, which are affordable in low- income countries and could prevent millions of premature deaths every year, include measures to control tobacco, reduce salt intake and reduce the harmful use of alcohol.
It says particular attention should be paid to promoting a healthy diet; that means low consumption of saturated fats and transfats, salt and sugar, and high consumption of fruit and vegetables and physical activity in all our daily living.
According to the Moscow Declaration the control and prevention of NCDs needs the whole of government at all levels. Lastly it states that the effective control and prevention of NCDs needs the active and informed participation of leadership, individuals, families and communities, civil society, the private sector and, where appropriate, employers, health care providers and the international community.
It is with this as background that I mentioned this issue to Members of Parliament last week. Unfortunately they said I was mentioning it because there's some gravy train activity going on in Parliament. I want to state that this is a very serious matter, and it can't be turned into a circus.
Just to demonstrate what I'm talking about, let me give you a few figures. In South Africa, for instance, out of 100 percentage points, the following points have been allocated by the MRC as risk factors in diseases. It says that as a risk factor unsafe sex is allocated 31,5 points; interpersonal violence, 8,4 points; alcohol harm, 7 points; tobacco smoking, 4 points; excess body weight, 2,9 points; childhood and maternal underweight, 2,7 points; unsafe water and sanitation, 2,6 points; high blood pressure, 2,4 points; diabetes, 1,26 points; high cholesterol, 1,4 points; low food and vegetable intake, 1,1 points; low physical activity, 1,1 points; etc.
Sometime in 2009 members of this Parliament questioned me about renal dialysis for people with kidney failure. A wrong debate about why government does not increase the number of dialysis machines in public hospitals ensued. This is the wrong debate. It is no different from asking why government is not increasing the number of mortuaries in our country because they are in demand. The intelligent question we should be asking is why so many people need dialysis.
In Gauteng alone the total number of patients on chronic dialysis is 561, with 238 on the waiting list. This is in a province that is regarded as being well-resourced. What happens in the other provinces? A single patient on dialysis will cost R150 000 per annum in the public sector and about R300 000 in the private sector. Moreover, these patients have to be in hospital three times a week for a minimum of four hours a day, whether they are employed or not.
What causes this? We know that in 40% to 60% of people with end-stage renal failure, it's due to high blood pressure at an average age of 39 years. What are the main risk factors for high blood pressure? They are smoking, lack of exercise and a high salt intake. So, instead of demanding more dialysis machines and subsequently demanding new kidneys, to the extent that the rich are trying to concoct schemes to steal kidneys from the poor - as happened recently in our country - we must reduce the prevalence of hypertension by eliminating the risk factors.
The need for targeting tobacco and alcohol has already been outlined. No matter how much noise financially powerful people and institutions make about it, I can stake my life on the fact that we are going to fight with our bare knuckles to achieve this, particularly with a ban on the advertising of tobacco and alcohol. This is the point of no return, and the sooner the tobacco and alcohol industries understand this, the better. There's no way of pulling back. [Applause.]
In South Africa the average consumption of salt is 9,8g per day, when physiologically you need only 4g to 6g. So, we are consuming more than twice the required amount. In Britain they have taken the lead; since 2006 they have reduced the salt content in foodstuffs by 40%.
In South Africa scientists have demonstrated that if we reduce salt in just one food commodity, eg bread, we will save 6 500 lives per annum. In Britain, in just the second year of a reduction of salt intake by 10%, they saved 6 000 lives and saved ?1,5 billion sterling.
Another issue which is extremely important and ranks at No 5 on the MRC list - after unsafe sex, injuries and violence, alcohol and tobacco - is high body mass index or excess body weight. This, coupled with a lack of exercise, which is ranked as risk no 12, is very important.
It is an international problem, so it is not only in South Africa. It is a fast-growing phenomenon. In South Africa, it is increasing amongst school- going children. In 2002 only 17,2% of schoolchildren were regarded as overweight, but now it is 19,7%. This means that those who moved from being overweight to being obese were 4% in 2002, and they are now 5,3%.
What this means is that at present 23% of schoolchildren can be classified as either obese or overweight. This is fast approaching a quarter of the school-going population! Consequently there will be a devastating impact on the population.
In the general population the National Income Dynamic Study shows that 60% of women and 35% of men are either obese or overweight. If you consider women over 37 years, the figure rises to 70% of women who are classified as either overweight or obese. This is why the Moscow Declaration is so important.
Let me give just one example from Australia. They have agreed to ban advertising of foodstuffs on free-to-air TV from 18:00 to 09:00, and 16:00 to 09:00 on weekdays. On weekend mornings, when children tend to watch more TV, they have banned it from 06:00 to 12:00. On children's programmes, like cartoon networks, they've banned advertising of foodstuffs altogether. Eighty-six per cent of Australians agree with this. [Applause.]
On the issue of injury and violence, Unisa, together with the MRC, has proved that when we talk about Arrive Alive, we talk only about those who have died. They have also proved that for every person who dies of their injuries, 30 more are hospitalised and 3 more are treated for less serious injuries and discharged. They further state that, depending on the cause, severity and circumstances of the injuries, many of these result in varying degrees of physical, psychological, educational, social and economic disadvantages.
I know that many people believe that my speech will not be complete until I have spoken about the National Health Insurance, NHI. There are two groups of people in this case. There are those who are very concerned, and legitimately so. There are also those who are driven by a greed that would shame even the devil, and who believe that they can do anything in their power to stop the NHI. I just want to mention that we haven't stopped; we are very busy with it.
The present health care system, whether public or private, can be identified by four very clearly identifiable negatives. Firstly, it is extremely unsustainable; secondly, it is very destructive; thirdly, it is extremely costly; fourthly and lastly, it is hospicentric or curative.
We are going to make sure that we re-engineer the health system so that its is in three basic streams - at the district level, in the community and at school level. I will give you the details later.