Social Sector Cluster media briefing on health by Minister of Health, Aaron Motsoaledi

Journalist:  Could you tell us what happened to the plans to replace the Medical Control Council (MCC) with the South African Health Products Regulatory Agency (SAHPRA), why the Bill that would put this into effect was taking so long and how the MCC would manage the new workload that was imposed by the Complementary Medicine Regulations.

Minister: The MCC could not cope with the present regulatory need in the country.  Apart from the expansion on treatment, complementary medicines had to be regulated.  The country was not regulating devices and it was a serious weak point.  The MCC would have to expand regulation on ordinary drugs and include regulations on complementary medicines.  It had to start regulating devices, especially to address the need in HIV/AIDS diagnosis.  Realising that the MCC would not cope, SAHPRA would be established with the capacity to address all these issues.  SAHPRA would not only be a conversion from MCC by parliamentary law, but the capacity of SAHPRA should be the most important aspect.  None of the universities were training students in regulatory medicine and people with master’s degrees in science would be enrolled to study regulatory medicine.  A drug that was already registered through the United States Food and Drug Administration (FDA) would have the process repeated when that drug came to South Africa. The FDA had more capacity but because of present regulations, that capacity could not be interchangeably utilised by South Africa.

Director-General: The Department had been working with the World Health Organisation (WHO), the Bill and Melinda Gates Foundation and the European Union (EU) to establish the Institute for Regulatory Science with a task team that consisted of various experts from different universities to assist.  The same institution would also train individuals who would be called ‘regulatory pharmacists’ in the industry and would serve as a hub for training. In preparation for this a team had travelled to Swissmedic, a counterpart regulatory agency in Switzerland.  Swissmedic adopted a model that took into account decisions made by well-established regulatory agencies and those evaluations did not have to be repeated.  This shortened the medicines approval process and for South Africa to do the same, mutual recognition agreements needed to entered into. The team visited the European Medicines Agency (EMEA), the Medicines and Healthcare Products Regulatory Agency (MHRA) in the United Kingdom (UK) and the pre-qualification of the WHO.  The methods and the approaches that were used there would be the basis on which we would develop internal processes.  There were 35 people ready for training and the training was supposed to start in April.  It was a joint programme with the University of North West and students were recruited from the University of Pretoria, Rhodes University and North West University, as well as unemployed graduates with master’s degrees.  The Bill that would put SAHPRA in effect had been submitted in Parliament and the public hearings were the next step.  The ideal was to produce 1 000 PHDs in ten years and to have 600 competent regulators that would not only serve South Africa, but also the envisioned African Regulatory Authority.

Journalist: What was the progress on the National Health Institute (NHI) pilots, especially in the OR Tambo district in the Eastern Cape (EC) and when should the full roll-out of NHI be expected?

Journalist: How soon would the NHI pilots progress to other regions and would the refurbishment of the clinics be put on hold until the NHI pilots had been dealt with.  What exactly would the team that went to Swissmedic look at and what would be done to reduce the time frames?

Director-General: The team already went to Swissmedic in September 2013. The FDA had about 10 000 full time scientists that did regulatory approval for products used in the States.  South Africa should have a critical mass of regulatory scientists in the country, because if the FDA approved a product, the process of approving the same product did not need to be repeated in South Africa.  We could rely on their decision, but internal processes needed to be established, because the risk benefit of a product needed to be established in the approval processes.  Swissmedic had already established such processes and although Switzerland was well resourced, they still considered the decisions of the FDA and the EMEA.  The team looked at the procedures of how Swissmedic determined the risk benefit profiles and it would be the basis for the training of the 35 individuals.

Minister: Last week I spent 3 days in the OR Thambo district and met with a broad range of stakeholders in preparation of the NHI pilots.  A lot had been said on the poor and deteriorating quality of healthcare facilities, especially in districts like OR Tambo.  If NHI was to survive, the improvement of quality of care in the public sector and the relative reduction of the cost of private healthcare needed to happen simultaneously.  There was no point to start with the right of access to health care if the resources like infrastructure was not dealt with first.  Most hospitals in Africa lacked in areas such as proper buildings, medical waste, technology and sanitation and over the last 18 to 24 months the Department had been going over these facilities in detail and quantified the lacking areas in the OR Tambo and Tshwane districts.  In the OR Tambo district three hospitals and eight clinics were totally debilitated and rebuilding would start in August.  There were 40 clinics lacking space and was currently being refurbished through an innovative method of steel frame reinforcement and would be finalised in the next six months.  The rest of the 134 clinics would be refurbished through the NHI prototype of the ideal clinic which focussed on 11 areas that included necessities such as generators and reserve water tanks.  Health was a concurrent function and the proposed work in the pilot districts did not mean the work in the provinces would be stand still.  The maintenance plan based on the pilots needed to continue in the provinces.

Journalist: Mental illness still remained side lined as a secondary health condition and what sort of achievements had been made in that regard.  In the State of the Nation Address (SONA), significant time was spent on health issues, primarily HIV/AIDS and what else could be focussed on.

Journalist: What was the budget to do all the building and refurbishment?

Journalist: Can you elaborate on staffing as being one of the pillars of the health system.

Minister: It was true that the President outlined the successes of the Department of Health, but it did not mean there were no challenges that still needed to be addressed.  I am not sure why South Africans feel aggrieved by the focus on HIV/AIDS, because this disease changed life as South Africans knew it.  Mortality had doubled since 2006/7 because of HIV/AIDS from 300 000 to 612 000 and experts said only war could double a death rate within nine years.  In many villages new graveyards needed to be opened, hospices opened all over the country and 49% of all maternal deaths were attributable to HIV/AIDS.  The prevalence of cancers like Kaposi’s sarcoma, tuberculosis (TB) infections and babies born with HIV/AIDS exponentially increased due to HIV/AIDS.  Many of those hospices and mortuary businesses closed now, because nine years were spent on trying to reverse the rate of HIV infection. Lancet, a prestigious medical journal said if South Africa wanted to deal with their quadruple burden of diseases, HIV/AIDS and TB needed to be addressed.  In 2009 the decision was made to focus on HIV/AIDS and the strides made were highlighted, but there were still a lot of work to be done in that area.

Director-General: In terms of mental health, a strategy had just been approved that integrated mental health care into primary health care that moved away from institutionalisation. 

Minister: There was a summit in 2011 that dealt with mental health and the strategy was devised from this summit.  It should be known that 43% of people diagnosed with HIV/AIDS developed mental health problems.  Once the burden of HIV/AIDS had been dealt with, it also significantly addressed issues such as depression and anxiety.  From whatever direction, the strategy to focus on HIV/AIDS in South Africa had paid off.

Director-General: The total health estate was R350 billion and a significant portion should be invested in maintaining existing infrastructure.  The NHI pilot budget for the first year was initially R800 million, but had since been adjusted and the overall budget was approximately R9 billion. The planning model was informed by the needs of the people that needed services.

The Minister: The community service model was introduced in 1998 to make sure that health professionals went to rural areas that were previously neglected.  Since that model 44 000 health professionals went to these areas.  Of all the HIV/AIDS infected people infected globally, 17% was South Africans.  In 2009 only 250 nurses were trained in Nurse Initiated Management of Antiretroviral Therapy (NIMART) and currently 23 000 nurses underwent NIMART training.  This number would have to be increased if the number of people on antiretroviral therapy (ART) increased to the envisioned 4.6 million.  The WHO calculated the shortage of health professionals according to the population, but in the poorer countries it did not work.  The WHO then came up with the Workload Indicators of Staffing Needs (WISN) which was a clear formula that took into consideration the pattern of disease.  The last report indicated that all clinics in the country had been visited to assess what the staffing needs were.

Director-General: WISN would be implemented incrementally and the doctor-nurse ratio would be implemented at district level and would be extended regionally, tertiary, as well as to central hospitals.

Minister: the only province that could not be scientifically understood was the Western Cape, which had the highest incidence of TB, but the lowest HIV infection rate.  We wanted to adopt the same strategy that HIV/AIDS was addressed in the fight against TB.  There were three main areas that were vulnerable to TB infections.  There were 150 000 inmates in 243 correctional service facilities and each and every one would be screened using Gene Xpert technology, upon entry and maybe twice a year.  The families of inmates needed to be visited to screen for TB, because in 2011, 3 000 family members of inmates tested positive for TB and was put on treatment. Since discovery of GeneXpert, 4.2 million tests had been done globally, with 2.1 million done in South Africa.  TB in mine workers were seven times more prevalent than in the normal population.  These 500 000 miners would be screened, as well as their families. Communities around the mines constituted about 600 000 people that were the third most vulnerable group to TB infection.  Many miners come from Lesotho and Mozambique and a conclusion was made that unless there was cooperation from the South African Development Community (SADC), TB would not be defeated.  On World TB Day (25 March) in partnership with The Global Fund, World Bank, the International Office on Migration, the WHO and the Stop TB Partnership, South Africa  would gather SADC Ministers of Labour, Mining and Finance for a summit on TB. The outcomes of the summit would have common treatment protocols, a common database, common referral patterns and common cross-border clinics.  The same vigour that was used to fight HIV/AIDS should be used to fight TB.

Journalist: In a briefing to the Health Committee, the Minister made reference to an interesting programme to be launched in schools and what was the status on that programme.  There was a lot of focus on more doctors to be trained, but how would the health leadership gaps, i.e. the people that managed hospitals be filled.

Journalist: was the colour coding done for all districts done in the NHI pilot and how many hospitals were in the red that needed total rebuild?  The NHI grants to the districts have been reported in Parliament to be used for other functions in some districts and was there confirmation that the pilot had been put on hold in the Tshwane district because of money.

Journalist: There had been resistance from the Western Cape to the NHI pilot but was there cooperation now?

Minister: The resistance from the Western Cape was unfortunate, but not unexpected.  I did not know of any country where there was not initial resistance to NHI.  They believed NHI was ANC “madness” because the ANC initiated it.  This phenomena was global, because it was decided upon in the Post 2015 World Agenda and supported by Brasil, Russia, India, China, South Africa (BRICS), the African region WHO, the World Bank.  Child mortality, maternal mortality, HIV/AIDS, non-communicable diseases (NCDs) and NHI or Universal Health Coverage would be a world agenda passed by the United Nations (UN).  It was a waste of time for any province to resist NHI and was irreversible as far as I was concerned.  NHI in the States was what was called Obamacare and was also resisted initially by the opposition.

The colour coding was done for all 11 pilot districts for every single hospital and clinic and for every aspect of that hospital or clinic.  Off my head, there were three hospitals in the red in the OR Tambo district, one hospital in Vhembe district and in Tshwane none was red, but George Mukhari hospital would be relieved by the building of a new hospital to service the Soshanguve and Mabopane areas.

The NHI grants were conditional grants and the issue was the concurrent functions at national level.  If the province misused the funds, the Department was held responsible.  It was a heavy responsibility without responsibility and I wanted the responsibility with the authority to act. 

We worked together with the private sector to establish the Public Health Enhancement Fund.  Part of this fund would be used to produce 1 000 PHDs over ten years and since 2012, 39 PHD students were introduced.  The second part of the programme used money from this fund to train Chief Executive Officers and it was taking longer than expected because I encouraged in-hospital training..  Cancer of the cervix was caused by the Human Papilloma Virus (HPV) and the WHO proposed that not yet sexually active girls should be vaccinated.  Grade four girls from all public schools had been selected and from 2014 onwards would be going through a vaccination process.  The National Development Plan (NDP) stated that the burden of disease should be removed.  Every year there would be 3 500 deaths due to cervical cancer and these vaccinations aimed to reduce that statistic.  The vaccinations would start in March and would be annually administered to every young girl to move through grade four.

Journalist: Are you going to move on making contraception available in school?

Minister: On 27 March 2014 the biggest contraception programme would be launched in clinics, not in schools.  It was up to the population to decide whether they would make use of the services or not.  A new contraceptive method, the transdermal implant, would be introduced.  The transdermal implant was a small gadget which was implanted just below the skin of the arm for at least three years.  It could be easily removed and was very expensive in the private sector (R1700), but would be made available for free to all women in South Africa.  It was easily removed, and a woman could get pregnant within weeks of having the implant removed. 

The briefing was adjourned.