Minister of Health's briefing: Public Sector Strike, Child Mortality, Medical Male Circumcision

Meeting report

Presentation by the Honourable Minister of Health
Dr Aaron Motsoaledi, Minister of Health, noted the Committee’s concern that the presentation had not been received in advance and apologised, saying this would not happen again. The Minister said that he wished to address three issues: namely, the public sector strike, child mortality in three hospitals and medical male circumcision.

The Public Sector Strike: An Overview
The Minister said that the public sector strike by health officials was very unfortunate and that it displayed a lack of concern for patients. The main intention of government during the strike was to keep all health facilities open and functional. This was largely made possible by generous help from the South African Police Services (SAPS) and the South African Military Health Services (SAMHS).

The Minister clarified that, contrary to popular belief, no doctors had gone on strike anywhere in the country. In fact, many doctors acted as nurses in instances where there were no nurses available. It must also be stressed that the largest nurses union, DENOSA, did not call a strike. Many nurses reported that they were only out on strike due to intimidation, and indeed some cases of physical injury and damage to property were reported.
 
One positive aspect of the strike was the fantastic support offered by volunteers from all over the community. The Western Cape was the least affected region, with only 1% staff out on strike. The worst hit region was in KwaZulu Natal (KZN) where more than 300 patients from eThekweni had to be referred to private hospitals, since 46 000 staff members were on strike. However, there were heartwarming accounts of nurses who went the extra mile to assist their patients. These stories could not be reported during the strike, for obvious reasons.
During the strike the Minister, accompanied by doctors, nurses and pharmacists who were employed at the National Department of Health, went to help out at Chris Hani and George Mukhari Hospitals, and many patients were escorted to Chris Hani with military support.  

Provinces chose to manage the crisis in different ways. Gauteng, for instance, used colour codes to designate the impact level of the strike, with red denoting facilities with drastically reduced services and green indicating little if any disruptions.  

The Minister said that some important lessons had to be learnt from the strike. He referred to the shifting psyche of communities. Unlike in the past, health facilities and health workers were no longer protected by members of the public. He urged community leaders to mobilise communities to return to their stance where they had protected health workers and facilities in order to provide uninterrupted services to the communities. The strike had confirmed that South Africa was running a highly destructive, unsustainable, expensive, curative health service, with patients using secondary and tertiary hospitals as their point of entry. This pointed to the need to reconstruct the primary health care movement, with community involvement, to ensure the strengthening of professional culture and ethics of health care workers.

This process had already started with a three day conference in Durban, attended by professionals from all over the world. The conference established that in most communities there was a variety of primary health care workers and agencies, to the extent that communities were confused. It was decided to integrate all these services, where a central coordinated programme was in place. KwaZulu Natal had already started coordinating primary health care services, and that was the path the country needed to follow.

Child Mortality
Before speaking about the specific neonatal deaths, the Minister said it was necessary to provide some background. South Africa was only one of 12 countries in the world that failed to bring down child mortality in the previous ten years. In South Africa, infant mortality had started to rise disproportionately since the early 1990s, when the HIV epidemic became statistically relevant. Annually 70 000 children were born HIV positive (HIV+) in South Africa, compared to 400 000 on the entire African continent. France had four HIV+ babies born in the previous year.

Maternal mortality had also been on the rise during this corresponding period. Infant survival and maternal mortality were closely linked. In 1990, only 0.7% of pregnant women who visited clinics were HIV+. By 2008, this had worsened to one in three women. The worst hit areas were KZN, followed by Mpumalanga and the Free State. The Actuarial Society of SA estimated life expectancy in South Africa to be 13 years below what it would be without HIV.

The Head of the Medical Research Council (MRC) had said that most women in South Africa were dying at child bearing age, which was abnormal from a biological point of view. The Lancet, a prestigious British medical journal, reported on a study by South African professionals that South Africa had four serious pandemics. These were, firstly, HIV and tuberculosis (TB), where South Africa, which had a mere 0.7% of world population, nonetheless had 17% sufferers from these conditions. The second pandemic was maternal, infant and child mortality. The third was in non-communicable diseases, such as high-blood pressure, diabetes and cancer, which were also linked to HIV and tuberculosis, whilst the last pandemic was injury caused by violence.

Out of 22 countries that carried 80% of the global TB cases, South Africa ranked first in terms of population units. Stillbirths were at 20 000 annually whilst mortality of infants (those under one year old) was at 22 000 annually. Mortality of children (those under five years old) was at 75 000 annually. Unless South Africa could effectively combat the scourge of HIV it would not meet the Millennium Development Goals set for 2015.  During 2007, 57% of child mortality was due to HIV. Babies who were HIV positive were 15 times more likely to die within the first six months than uninfected babies. According to Statistics South Africa (Stats SA), deaths had doubled in nine years, being 306 000 in 1997 and deaths and 612 000 in 2006.

The Minister then focused on the child deaths in Charlotte Maxeke Hospital (CMH), Natalspruit Hospital (NH) and at Nelson Mandela Academic Hospital (NMAH) in Mthatha. . In May 2010, six babies at CMH died due to an outbreak of gastroenteritis that affected babies in the neonatal unit. At NH, 11 babies died (as opposed to the 10 reported by the media), also during May. A committee consisting of specialists in the area of neonatology and infection control, Profs Velapi, Wittenberg and Duse, was established to investigate the possible cause of these deaths and was also tasked to make recommendations. The cause of death of the babies at CMH was identified as Norovirus, a gastrointestinal virus that was spread by contamination from hands, food or materials. The Klebsiella virus was isolated, but did not contribute to deaths. In the case of NH, four of the reported deaths were macerated still births, where the foetus died before mothers were admitted to hospital, and five babies were HIV+. The committee also found overcrowding, a high nurse to patient ratio, and lack of adherence to infection and prevention control. At both these hospitals, steps were taken to improve conditions. Extra facilities capacity was provided and additional staff were appointed and steps were put in place to improve infection and prevention controls. Regular morbidity and mortality review meetings were held and closer working relationships were established with communities and feeder institutions.

In May 2010, there were reports of 179 babies having died at Nelson Mandela Academic Hospital (NMAH) between January and April 2010. The Eastern Cape Department of Health was appointed to investigate and report back to the province, led by Professor Moodley, and three visits were made to Mthatha to investigate, make recommendations and support their implementation, resulting in several improvements.

Medical Male Circumcision (MMC)
Dr Motsoaledi noted that the prevention of HIV needed a multi-pronged strategy, of which medical male circumcision (MMC) was an important element. Research had shown that MMC proved to be between 50% and 60% effective in reducing woman-to-male transmission of HIV. During a South African National Aids Council (SANAC) plenary session, in July 2009, a decision was reached to roll out MMC. The King in KZN had decided to re-introduce male circumcision, breaking the 200-year tradition of non-circumcision. All chiefs had called camps, but had ensured that doctors were in attendance, together with amakhosi, elders and HIV experts. A target of 2.5 million circumcisions had been set for 2015. The Minister himself had promised to perform 1 000, of which he had completed three. These camps were in essence a social school where youngsters were tested, educated and circumcised.

The Minister noted that the Committee had wanted detailed information on how the circumcisions were performed. Although the World Health Organisation (WHO) did not approve any devices, it did advise using the appropriate caution in any procedure, and had advised South Africa to do research on what was most effective, given the high prevalence of HIV. South African specialists and urologists had done scientific testing of different devices, but there were arguments as to the respective merits and even about tender specifications, which would regrettably delay the process of combating HIV. KZN had decided to test various methods, and was monitoring any adverse effects. The campaign had been launched officially in April 2010, by the King, at KwaNongoma, and 555 males were circumcised over that weekend. He wished to express thanks to His Majesty King Zwelethini for his efforts in leading the fight against HIV. The MEC for Health was given a mandate to carry the process forward. Males between the ages of 15 to 49 years old were targeted, although younger or older males were not excluded. The most commonly used method was the conventional Forceps Guided method, and the use of the device called the Tara Klamp.

In order to reach the target of 2.5 million circumcisions, a variety of centres would be used, including academic hospitals, regional hospitals, district hospitals, Community Health Care centres, Primary Health Care clinics, camps at Further Education and Training (FET) colleges, schools, universities and community halls, correctional service centres and private sector institutions. A variety of human resources would be used including surgical specialists, general practitioners, professional nurses, enrolled nurses and counselors. Critical to the entire process would be the social partners like the amakhosi, socio-cultural experts, parents and guardians, government departments, peer groups and NGOs.

Since the KZN launch in April 2010, over 18 000 presented themselves for the procedure, of whom 17 690 were circumcised. Approximately 99.5% tested negative for HIV, whilst approximately 0.5% were not circumcised because they presented without parental consent, had penile deformities or were HIV positive. The HIV positive were counseled, and referred for further management. Further details on the camps were set out in the presentation.

The KZN achievements were significant in that 5 000 males were circumcised by the Tara Klamp method without adverse events. No one had died or been mutilated, and none required corrective surgery. There was even some suggestion that in the future all male children should be circumcised, as was done in certain religions.

The Minister was at pains to emphasise that the Department of Health was following scientific studies and that negative media publicity was merely retarding the process. Other tender or procurement problems, and even stories about political interference, with the Tara Klamp should be addressed through the right channels. He urged leaders to consider the health of the nation.

Discussion
The Chairperson thanked the Minister for his very elaborative and interesting presentation, which would enable Members to educate communities about the circumcisions. She asked if the Minister could recommend a venue to which people from some areas could be referred, noting a high incidence of deaths and mutilations in this area. She supported the proposed study into child circumcision.

The Minister said that the Ministry urged leaders from the Eastern Cape to keep up their traditions, but to involve medical professionals in circumcisions. The Ministry was not asking communities to abandon their traditions, but merely to apply more scientific methods, particularly where the traditions were resulting in unnecessary deaths. The study had not looked at child circumcision, but was focused on the best possible devices, and he was aware that in some parts of Eastern Cape the Tara Klamp was available for use.

Ms D Rantho (ANC, Eastern Cape) asked if the strike had any impact on the death statistics. She asked if there was any chance that the volunteers used during the strike could be used on an ongoing basis. She urged that training should be focused on the hospitals where child mortality was worst. She needed more information about the plan to centralise and integrate the primary health care services within communities. She asked whether the statistics included any foreigners, and how they were treated when statistics were taken. She enquired whether it was possible to use the Klamp in traditional venues, noting that some young men believed that having a circumcision done in a hospital meant that they were less manly.

Ms B Mncube (ANC, Gauteng) also asked whether deaths had actually increased during the strike. She was concerned that the service level agreements with medical staff were not finalised and that the strike could rear its head again in the next cycle of wage negotiations. Clarity was needed as to which members of the medical profession could or could not go on strike. In respect of the infant deaths, she noted that the findings did not quite correspond with the allegations made at the time, and wondered if the findings should not be published more widely. Ms Mncube also asked if access to proper medication affected the HIV mortality rate. She asked what lessons South Africa could learn from the low child mortality rate in France. She also asked if the Minister knew of any other interventions besides the one spearheaded by the King in KZN.

Ms M Moshodi (ANC, Free State) referred to slide 8 and asked what action had been taken against the culprits who set a car alight and assaulted a nurse. She enquired whether all the staff who assisted the Minister at Chris Hani and George Mukhari Hospitals were registered professionals. She noted that in the area of Edenvale, Free State, there was no doctor, and a shortage of nurses, and most people (who were poor and unemployed) would have to travel 47 kilometres to consult with a doctor, or wait for up to three hours for an ambulance. She wondered if the Minister could assist.

Mr M De Villiers (DA, Western Cape) thanked the National Department of Health (NDOH) and the South African National Defence Force for the manner in which they had assisted the hospitals during the strike. He asked if there was anything the government could have done to avoid the strike. He mentioned that the Departments of Education had complained of inaccurate information on numbers of strikers being reported by the schools, and wondered if the NDOH had similar problems. He wondered if any lessons were learned from the low number of strikers in the Western Cape, and wondered if there was also information from hospitals other than those in Gauteng on their functionality.

Mr De Villiers asked for further details about the proposed reconstruction of the primary health care movement, including the status of the plans and who was involved. In respect of child mortality, he asked how many of the 70 000 HIV births resulted in death. He asked if the Minister could explain the leveling off of the graph between 2005 and 2008 on Slide 20. He also asked if the Minister could shed more light on the success rate in the Western Cape, and whether the decision to provide antiretroviral (ARV) medication to pregnant women had any impact. He also enquired if it was possible to intervene if the weight of the unborn child was deemed to be far below par.

Ms M Makgate (ANC, North West) found it strange that no mention was made of the strike trends in the bigger areas of the North West province, and asked if there was a reason for that omission. She would like to know more about the workshop on circumcision held recently with doctors from Israel. She felt that too much of the education on circumcision was focused on rural areas, whilst townships seemed to be neglected. She expressed great concern that most of the people dying in townships still seemed to be young.

Mr S Plaatjie (COPE, North West) felt that there were still widespread misunderstandings of the meaning of the  concept ‘essential services’, because in many quarters, including the unions, there was uncertainty about who could strike and when certain workers could strike. He was concerned that South Africa counted amongst the twelve countries with the highest child mortality rate and asked what could be done to normalise the situation. He shared the Minister’s passion for primary health care and asked the Minister to consider a strong advocacy campaign to popularise that thinking. He asked if there was any chance that some interventions could be introduced to deal with some of the attitudinal problems that existed at some health care centres.

Mr W Farber (DA, Northern Cape) objected to certain remarks by the Minister about the DA, and said that the Chairperson should have protected him, since he was representing his province, just as the Minister should be representing the government and not taking a political party stance. He expressed deep concern for the rising number of HIV deaths, and found King Zwelithini’s direction to be very positive and helpful.

Mr T Mashamaite (ANC, Limpopo) asked what steps would be taken against those strikers who invaded the hospitals during the strike. In his opinion the strikes dented the image of government. He asked if any concrete plans were in place to avoid a repeat of such strikes in the future.

The Chairperson concurred with Mr Mashamaite on the negative impact of the strike and asked if the Minister could shed more light on possible mitigatory steps to avoid negative impact on health care workers and patients in the future. She enquired whether the review of doctors’ salaries had been completed so as to avoid a repeat of the doctors’ strike in the previous year. The Chairperson sought confirmation of exactly how the NDOH planned to integrate all the different community health care workers. She thanked the Minister for the invitation to the National Health Forum and encouraged the Minister’s office to invite the Committee Members to more of such forums in the future.

Minister Motsoaledi replied in general on the points raised. He firstly said that it was not easy to answer questions about the impact of the strike on the death rate, because it was difficult even for doctors to pinpoint the precise cause of death, so it was not possible to establish direct links between the strikes and deaths. He pointed out that at Chris Hani the mortality rate actually dropped during the strike. However, this did not necessarily mean that the strike had no effect on the mortality rate, because it could simply have meant that more people died at home. There were, however, one or two cases where there was some certainty that the strike was responsible for a death.

In regard to the volunteers, the Minister said that it would not be easy to involve volunteers on an ongoing basis because of the notion in South Africa that volunteers should eventually receive a salary. They could also not simply be drafted into the service without meeting some basic criteria.

Minister Motsoaledi agreed that the child mortality rate was of concern, and could be reduced drastically, but a host of interventions had to be in place. Many issues were involved in child mortality. These included considerations around the quality of the water, breastfeeding versus bottle feeding, quality of primary health care in communities, and immunisation of mothers and babies. The enormous role of breast feeding could not be underestimated. The strategy known as “GOBIFFF” – involving growth monitoring, oral rehydration, breast feeding, immunisation, female education, family planning and food supplementation – could, if followed, increase the infant’s chances of survival, but this could not work if primary health care was not available at community level. It was too late to try to apply GOBIFFF at hospitals, and it must be applied in communities.
There was widespread belief, even among educated communities, that due to the HIV threat, breastfeeding should be avoided. In fact the contrary was true. Human beings suffered more diseases than animals, because all animals were breastfed. The importance of breast milk was highlighted in Brazil, where breast milk banks were established. The Department was planning a campaign about the importance of breastfeeding. In addition, massive immunisation programmes were planned for the next year. Large scale female education would be done, especially around breastfeeding.

The Minister explained that Brazil managed to reduce its infant mortality rate drastically, because it had set up centralised community health care services, using community health care agents trained and employed by the State, who assumed responsibility for a number of households, and therefore was well versed in that family’s health hazards. In South Africa, certain parts of this plan were being practiced, but this was done on too haphazard a basis, and stronger coordination and integration were needed to gain sufficient impact.

Minister Motsoaledi confirmed that the findings on the deaths at Charlotte Maxeke Hospital were indeed published. The MEC had called a press conference and announced the findings.

The Minister then said that, in relation to the link between mortality and antiretroviral treatment, the history of South Africa must be borne in mind, since it had been embroiled in many arguments about the drugs, even ending up in court actions, while people were dying. He urged all to avoid stirring up new debates about such matters and to help steer the country out of the pandemic.

The Minister acknowledged the importance of finalising the service level agreements of health sector workers, particularly as this related to the notion of essential services. He said it was not the Minister’s responsibility alone to determine that service level agreement. Many sectors of society, from the unions to the press, had different expectations of what constituted the service levels, but no-one was prepared to sit around the table to decide, once and for all, a reasonable interpretation of who should be included under essential services.

Minister Motsoaledi pointed out that there were other focused interventions, including the large-scale roll out of AVR distribution to all of the 4 000 centres across the country, as opposed to only 490 being included up to February of 2010. He cited the successes of the Right to Care Organisation as an example of what was possible in health care.

Minister Motsoaledi noted the concerns in different provinces, but said that when making comparisons, the socio-economic indicators must be considered. The Western Cape, for instance, never had a single Bantustan area, whereas the provinces of Limpopo, Eastern Cape and KZN still suffered from the effect of these declared areas.  

In regard to primary health, he noted that the NDOH had started workshopping the integration of primary health care services.

The Minister then explained the flattening of the statistics and the graph, by referring to the difference between incidence and prevalence of HIV. He said that “prevalence” referred to where the diseases existed, whereas “incidence” referred to new discoveries of infected persons. Because of all the efforts and improved awareness, the level of incidents did flatten over a period. He said it was difficult to state how many of the 70 000 HIV babies died from HIV-related causes, because doctors entered other diseases on the death certificates, with the result that although HIV was the underlying cause, the direct cause of death might be recorded as TB or pneumonia. Following this trend, Statistics SA ranked HIV as the ninth most frequent cause of death. Until HIV become a notifiable disease in terms of legislation, it would not be possible to pinpoint exactly how many people died from HIV. Doctors were thus reluctant to enter HIV as the cause of death, and some families specifically requested that this not be recorded, for insurance reasons, so Stats SA was therefore not capturing the true picture of what was the prime killer.

Minister Motsoaledi reported that the North West was not heavily affected by the strike, and therefore not much was reported from there. The relative calm in the Western Cape could perhaps be ascribed to a less militant trade union movement or less anger amongst the workers. He indicated that when the Office for Standards Compliance was established, with its own ombudsman, there would be no place where individuals who were guilty of inappropriate attitudes or actions could hide. There would be no more chance to blame government for every failure in the health care sector.  The Minister also said that the complaint of a shortage of staff at health care centres was not true, because South Africa had the best staff to patient ratios on the Continent. He noted that the poor conditions in Edenvale resulted from poor management, but his office would try to assist.

Minister Motsoaledi conceded that there was migration of doctors, but said that most countries suffered from this problem, which was linked to the wealth of a nation. Many doctors migrated to South Africa, as it was the richest country on the Continent, just as doctors migrated from Canada to the United States of America. The Ministers of Health in the Southern African Development Community (SADC) had signed an agreement that no country in Southern Africa would recruit each other’s doctors. On the other hand, the International Labour Organisation (ILO) would defend the right of doctors to work where they wished. There had to be a balance between what the ILO stood for and the stance of the WHO that no developed nation should recruit doctors from a developing nation. South Africa and England had agreed that no nurses would be recruited from South Africa any longer, resulting in a decrease of nurses leaving, from 1 700 to only about 70. There was also an issue around why some doctors had to wait lengthy periods before they were registered to work in South Africa, owing to the different standards between countries. He noted that whilst doctors in South Africa had to study for twelve years before achieving specialist status, other countries might require only six years of study. Some doctors also came from countries where they had been forbidden to study or treat the female body, so their knowledge was limited to male anatomy only. Some foreign doctors failed the Health Professionals Council examination, and he noted that they could not be allowed to start working on South African citizens, as it was vital that the quality of the profession was upheld. Some doctors who arrived in South Africa illegally, expecting to be allowed to work. This meant it was easier all round for South Africa to hire doctors from countries with similar systems and standards of training.

Minister Motsoaledi confirmed that the Occupation Specific Dispensation (OSD) for the salaries of doctors had now been completed, and a doctor entering the profession now started with a salary equal to that of a Deputy Director.

The meeting was adjourned.