An interview with Minister of Health, Aaron Motsoaledi
When the idea of a National Development Plan was first mooted, Health Minister Aaron Motsoaledi was one of those who opposed it. He thought that a group of non-health professionals would not be able to come up with a plan for health – but he was pleasantly surprised.
Interviewed at his office in Cape Town, Motsoaledi said the good thing about the NDP is that at least departments are no longer operating on a hit-and-miss basis:
“You work towards a particular direction because you’ve got things to achieve. You have a framework of a plan and I must say, we as the Department of Health, are extremely lucky.
“When the National Planning Commission was set up, I was one of the Ministers who argued very strongly that we had to appear in front of that committee to defend our departments or to help design a plan for our departments. That was forbidden. They said that the NPC had to find its way without influence from particular ministers that had no turf to defend. It was a plan for the country not for one ministry.
“I was disappointed because I was under the impression that what I thought should happen in health might not be included. This was not because the planners and commissioners are not clever, but because I am in health and therefore know first-hand what is missing. I was pleasantly surprised and quite excited when the Plan came out. It was exactly what we were envisaging for health.
Motsoaledi said it is ‘extremely important’ for the NDP to succeed. “The NDP mentions seven different things for health. In the paragraph where it summarises the issues of health, it says that by 2030 life expectancy must be 79 years. If life expectancy is only 70 years today, then we need to work out what needs to be done to improve this. What is the cause of such a low life expectancy? How can this be reversed?
“The NPD goes on to say the generation of under-20s must be HIV/Aids free – that’s another huge programme, even on its own. How do you make those born today free of HIV/Aids by the time they are 20? They should not be like the present generation. What do you put in place to make sure that such a thing happens?
“Thirdly, it says the infant mortality rate must be less than 20 per 1 000 live births and the child mortality rate must be less than 30 per 1 000 live births. Infant mortality refers to children who die before their first birthday and child mortality means dying before their fifth birthday. What are the causes? What can be done to reverse this? What are the commonalities that cause children’s deaths before they reach their first birthday or their fifth birthday and what can be done to change that?
“The NDP then goes on to say the burden of disease must be markedly reduced. In other words, it augments the findings of
The Lancet, a famous British medical journal, one of the top four in the world.
The Lancet commissioned researchers in South Africa to do a study in 2009 about the burden of disease; there are four highways through which South Africans are marching to their deaths: the first is HIV/Aids and TB; the second is maternal and child mortality; the third is non-communicable diseases – diseases of lifestyle which we share with the whole world – and the fourth is injury, trauma and violence.
“They are not saying we must put up mechanisms to cure those diseases. They say we must identify the cause of the burden of disease. How do you do this? What preventative measures do you put in place?
“This touches a nerve with me because I’ve been arguing that the South African healthcare system is too curative. We need a preventative healthcare system, the heartbeat of which is primary healthcare – the prevention of diseases and the promotion of health. Additionally, we need a healthcare system that’s at the bottom and refers upwards. This is not happening now. The NDP is saying that we must promote health and prevent diseases. To do this we have to put in place a couple of measures.
“The NDP also talks about efficiency, effectiveness and equity. Quality and equity of the healthcare system must be guaranteed and universal health coverage must be available. Universal health coverage is the NHI (National Health Insurance) which is a flagship programme of the Department.
“Additionally, the NDP outlines that by 2030 we must have dealt with the ecological factors that cause disease. In layman’s terms, they talk about the social determinants of health. These include clean running water, housing, education and a clean and safe environment,” says Motsoaledi.
Motsoaledi says the NHI, which is his department’s flagship programme, will not be realised overnight. “If you look at the NDP – that central part which highlights efficiency, effectiveness, quality and equity – it talks about the NHI. It is generally believed that for the NHI to be achieved in South Africa, two great changes need to happen.
The public service must dramatically change in as far as the quality of healthcare is concerned. And the exorbitant prices of private healthcare must be dealt with. These are the two crucial changes required in order for implementation to occur.
“How do we improve the quality of healthcare in the public service? We’ve already identified the areas and believe in an ideal clinic. What should a clinic look like in South Africa for people to appreciate its quality, efficiency and effectiveness? We’ve tried it in ten clinics around the country. A clinic which every person of any socio-economic group can enter and be satisfied with the service received is the ideal clinic.
“We have subjected the pilot programmes to the President’s Operation Phakisa. Eight streams were identified that would bring quality into any clinic. You can also apply that to a hospital. They include human resources, infrastructure and equipment, procurement or supply chain management and financial management, as well as waiting times.
Motsoaledi said that the World Health Organisation has identified certain building blocks for a good healthcare system and these align with the eight streams his department has identified. “If you go on to the website of the World Health Organisation, it outlines that a health system has got six building blocks.
When you look at these building blocks, you will realise that they are more or less the same as what we’ve identified. The first building block is leadership and governance. Second is pharmaceuticals and other commodities which can’t be obtained if there isn’t a good enough procurement and supply chain management system. Third, a health workforce or human resources. Fourth, a healthcare financing system or financial management. Fifth is a health information system and last is a healthcare delivery system.
Motsoaledi said his department has ‘serious NDP deliverables’, but unfortunately people sometimes do not see it.
“The problem in South Africa is that we don’t think about healthcare as keeping people healthy and encouraging an enjoyment in health. Instead, there is the perception that healthcare is disease care and there is a focus on what happens inside the hospital, rather than outside.
“In 2009 we introduced the newest vaccines in the country, the Pneumococcal and Rotavirus vaccines. Children who are vaccinated are thus prevented from being sick. However, this is not seen as an advance in this coutry. Rather, medical gains are acknowledged only when a sickness is cured in a hospital. We want to shift the focus to preventative measures.
“A study done by the NICH (National Institute of Community Health) has shown that preventative action reduced the incidence of pneumonia by 70%. These children would potentially suffer from pneumonia, go to hospital, get put on drips and injected with antibiotics. Seventy percent of that was averted. It also showed that 66% of admissions due to diarrhoea were averted because of the Rotavirus vaccine. This is a huge gain.
“Another achievement is the prevention of mother to child transmission of HIV. Just 14 years ago, in 2004, 70 000 children in South Africa were born HIV positive. Through prevention of mother to child transmission we’ve reduced that to 6 800. That’s a big gain, but because it doesn’t happen actively inside a hospital, people don’t see it. Children who are born HIV positive are 1 500 times more likely to die in their first six months. You can calculate how many children’s lives were saved.
“TB is still a significant problem. The Statistician General calls it the biggest killer in the country. In 2009 we had 70 000 people die of TB. In 2015, we’ve reduced that figure to 40 000. That’s about a 43% drop in deaths, all because of our programmes.
“Maternal deaths and deaths under 5 years of age from 2009 have dropped. We’ve decreased the number of women who die during pregnancy and childbirth and the number of children who die before their first birthday.
Motsoaledi said the biggest obstacle in implementing the NDP is human resources.
“Rather than just focusing on the number of doctors or nurses, I am talking about the whole spectrum – from top leadership governance, productivity, efficiency to placing the right people in the appropriate jobs. We need well-trained people who know exactly what to do.”
Motsoaledi said that the most visible part of his work, in terms of the NDP, would be the NHI. “People are asking me why we don’t tell the public about NHI. I’ve done the first round and discovered that, at the moment, it’s still very abstract and usually people like to see something concrete.
“When they see good infrastructure in the clinics with a generator that does not get affected by load-shedding, a water supply system that is not affected by what is happening in the municipality, where they don’t have to wait for long and where there are friendly nurses, the plan is easier to understand.
One of the reasons why the queues are so long is because in 2004 there were 400 000 patients on ARVs; in 2009 that figure grew to 923 000 and today it’s over three million. The clinics and the staff are not growing – the number of patients are. I visited the clinics to see just how slow the process is.
I discovered that a person can wait for up to five hours in the queue for a file, before being seen by a doctor. To alleviate this problem we have distributed 3 000 computers to 700 clinics where paperless technology can be applied. Instead of a person waiting five hours for a file, it takes only 45 seconds.
“It is this tangible difference that people want to see and it links to the NDP’s plan for efficiency and effectiveness,” says Motsoaledi.
“Unfortunately, I’m starting to develop this doubt. I’m not usually a pessimistic person but I doubt whether we really are serious about the NDP. I look at the type of appointments that are being made in provinces. The NDP made it very clear that if we really want South Africa to be successful, we need to have a competent public service. At the moment nobody can convince me that we are moving towards having a competent public service.
“I am of course open to being wrong. However I haven’t seen any move or plan to move in that direction. That is the part that concerns me the most about the NDP or even the NHI. For the NHI to function, it needs a higher level of healthcare than what we currently have. There is an annual forum on health issues where they usually ask one question: If there’s one huge impactful action you can take to improve healthcare around the world, what is it?
“In South Africa’s situation if you were to ask me what one impactful thing would help to realise the NDP, I would say human resources – quality, not really quantity. Are the right people in the right positions? If we can solve that I can assure you half of the work of NDP is done. My biggest problem is not the direction in which we are heading. It is whether we will be able to get there.”
An interview with Minister of Health, Aaron Motsoaledi