The minister of health reveals how for the first time in the country´s history the healthcare sector is following a clear roadmap with the National Development Plan, a vision for where the country should be in 2030, how the National Health Initiative will mean a total reconstruction of the healthcare environment and why the best solutions to TB, HIV and AIDS must come from within South Africa.

In 2014 you returned for a second term as health minister. What was your reaction when President Jacob Zuma announced you would be filling this position again?

I was ready, I had a mandate to fulfil. When I was first appointed health minister in 2009 it was my first direct involvement in health. I had been in government at a provincial level since Mandela was first elected president, and had worked on education, transport and agriculture, but never on health. With my re-appointment I knew what to expect. For the first time in the history of South Africa, pre and post-apartheid, the country has a clear roadmap under the National Development Plan (NDP), and it has been accepted by all political parties.

The NDP is a vision for where the country should be in 2030; a framework for growing the economy while tackling unemployment, poverty and inequality. With regards to health, it sets a number of key priorities. It says that by 2030 life expectancy should be 70, and that we must produce a generation of under 20s who are HIV-free. It goes on to say that the quadruple burden of disease must be markedly reduced. Six years ago the British medical journal, The Lancet, commissioned a study on the burden of disease in South Africa. This was at the height of the argument concerning HIV/AIDS, when South Africa was being attacked by many for having the wrong approach. This study demonstrated beyond doubt that the country was going through a quadruple burden of disease: the HIV/AIDS epidemic alongside a high burden of TB; high maternal and child mortality; high levels of violence and injuries; and a growing burden of noncommunicable diseases. Concerning HIV, it stated that we constitute just 0.1 percent of the world’s population and yet have 17 percent of all HIV related deaths.  The NDP states that the healthcare system must be efficient, effective, of good quality and equitable. It says that universal health coverage must be available, and this is where our National Health Insurance (NHI) scheme comes in.

The NHI is one of your flagship policies. To judge by what we have heard from people on the ground it is taking a long time to implement. Do you agree?

When the NHI was announced in 2011, we said it would take 14 years to implement. Those who are criticising the time it is taking to roll-out the NHI believe that the system will provide medical aid for the entire population; but this is a misunderstanding. 20 years ago, before Nelson Mandela became our president, we had healthcare systems based on your racial group. In 1996 the constitution abolished this set-up, replacing it with one healthcare system for all. Unfortunately we ended up with two separate healthcare systems, something not written into the constitution, not planned for, but which just occurred. Today we have a very strong, well-equipped private healthcare system catering for just 16 percent of the population; and an under-resourced public healthcare system looking after 84 percent of the population, who are mostly poor, unemployed and lacking in education. You can enter the private healthcare system if your credit card is big enough, or if your pockets are deep enough, or if you belong to a company which provides you with a medical aid card. Those who criticize the implementation of the NHI believe the entire population will be provided with a medical aid card; but the NHI, in the manner in which we are planning it, will mean a total reconstruction of the healthcare environment.

What are the key steps required to ensure that the NHI delivers on its promise of improving the healthcare on offer to the majority of South Africans, while remaining affordable?

For South Africans to have universal health coverage, two issues need to be confronted: first, we need to raise the quality of care on offer in the public sector; and second we need to address the cost of private healthcare, which is becoming unaffordable to ever more people. Private healthcare in South Africa is following the American model and not the European one. The American system is known to be the most advanced in the world, but it is also the most expensive. Within the BRICS, Brazil spends 9 percent of its GDP on health, equivalent to the European average; then comes South Africa with 8.5 percent; following us comes Russia spending 5.4 percent; and finally China at 4.6 percent and India at 4.2 percent. Yet when we look at the health outcomes, those four countries are all far ahead of South Africa. This is because we are adopting the American model, something not appropriate for a developing country. South Africa’s private healthcare is as good as what you will find in the developed world, and people believe that at the stroke of a pen you can simply move the remaining 84 percent to this system. This is simply unaffordable.

The heartbeat of South Africa´s healthcare system has to be primary healthcare, essential if we are to tackle the quadruple burden of disease. The government has launched the Ideal Clinic initiative: a concept that involves overhauling the primary healthcare system and introducing changes that will improve the quality of services on offer. Ten elements are at the core of this concept, including how the administration of the clinic should function; what policies, protocol and clinical guidelines should be followed by staff; what service a clinic should offer, as well as infrastructure requirements. Waiting times are a considerable problem in South Africa. The reason waiting times are becoming a real issue is because back in 2004 we had 400 thousand people on antiretrovirals, today we treat over 3.1 million. You cannot increase the number of doctors and nurses at such a rate. What is increasing is the number of patients.

Nkaki Matlala, Vice-Chairman of the Public Health Enhancement Fund (PHEF), was telling us how in 2012 the health ministry and the private health sector signed a ground-breaking initiative, partnering together to tackle some of the country´s healthcare challenges. How excited are you by this initiative?

The PHEF has been one of our best initiatives. It brought together a collection of private companies to help improve the country´s human resources while also working together to tackle the scourge of HIV, AIDS and TB. We agreed to work together to improve the skillset of the country: increasing the number of medical students, training the CEOs of public hospitals and setting the ambition to produce one thousand PhDs within the next ten years. I am very excited to see the results of this initiative. I have long argued that the best solutions to TB, HIV and AIDS must come from South Africa.

Can South Africa become a regional hub of expertise in healthcare?

I believe that we already act as a regional African hub. The National Institute for Communicable Diseases (NICD) is a continental giant. It has the only biosafety Level 4 laboratory, a laboratory that can deal with the worst pathologies in the word. Throughout the entire Ebola crisis the 15 Southern African Development Community (SADC) countries all looked to South Africa. Within the SADC, every single Ebola suspect had their blood tested at the NICD in South Africa. This is just one example of the role we play as a regional hub of expertise.

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