The Minister of Health, Dr Aaron Motsoaledi, briefed the Committee on the public sector strike, the child mortality rates, with specific reference to three hospitals, and medical male circumcision. He said that the public sector strike was unfortunate, but all health centres were kept open, with assistance from the South African Police Services and the South African Military Health Services. He praised the support from many volunteers, as well as the extra work and effort by many nurses and medical staff, and noted that he and professional staff from the Department of Health had also assisted at hospitals. This strike confirmed that it was critical to move away from an expensive curative health service where tertiary and secondary centres were the entry points, and to undertake major reforms in primary health care at community level.
The Minister noted that the child mortality statistics painted a grim picture and suggested that
The Minister noted that Medical Male Circumcision was one of the strategies for HIV prevention, having been shown to reduce woman-to-male transmission by between 50% and 60%. King Zwelithini in Kwa Zulu Natal spearheaded a campaign for circumcision, which had been highly successful, with medical practitioners assisting amakhosi and elders. A target was set for 2.5 million circumcisions by 2015, using a variety of centres, and social skills camps were set up.
Members were concerned about the effect the strike had on the death rate in the country. They also wondered how the government aimed to avert future similar strikes, questioning, in particular, why the question of what constituted essential services remained unresolved, and asking for details of doctors’ salaries, whether service level agreements had been finalised, and whether the Occupation Specific Dispensation was put into effect. They questioned why the strike showed less effect in certain provinces, and raised problems in
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
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
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
This process had already started with a three day conference in
Before speaking about the specific neonatal deaths, the Minister said it was necessary to provide some background.
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
The Head of the Medical Research Council (MRC) had said that most women in
Out of 22 countries that carried 80% of the global TB cases,
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,
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
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.
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
Ms D Rantho (ANC,
Ms B Mncube (ANC,
Ms M Moshodi (ANC,
Mr M De Villiers (DA,
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
Ms M Makgate (ANC,
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
Mr W Farber (DA,
Mr T Mashamaite (ANC,
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
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
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
Minister Motsoaledi confirmed that the findings on the deaths at
The Minister then said that, in relation to the link between mortality and antiretroviral treatment, the history of
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
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
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
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.
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