Address by the Deputy Minister of Health, Dr Molefi Sefularo, to the Medical Students' Conference at the University of the Witwatersrand (WITS), Johannesburg
25 Sep 2009
Dr B Goqwana, MP and Chair of the Health Portfolio Committee
Professor Y Veriava, University of the Witwatersrand (WITS) School of Clinical Medicine
President, Deputy President and members of the Students Medical Council
Medical Students from WITS, University of Cape Town (UCT) and University of KwaZulu-Natal (UKZN)
Ladies and gentlemen
It is indeed an honour to address you at this important conference of the medical students. The conference comes at an opportune time, five months into our fourth democratic period of governance, an era in which we have renewed our emphasis on improving the national health system and service delivery by government. The urgency of our tasks requires of us to use innovative approaches to improve outcomes and the performance of our national health system.
As medical students and/or junior doctors, you each have a moral obligation and professional responsibility to understand the system in which you are going to practice. You have to appreciate that our profession is noble. You have to grasp every opportunity to internalise our obligation to strengthen, protect and defend the medical profession. We have to work together to make members of the medical profession and our communities to appreciate that ours is a vocation, a calling and a profession that is anchored on discipline, high values expressed in the Hippocratic Oath and self sacrifice.
Our discussions during this conference should, over and above, provide you with greater insight into how things work in real life and in practice in the private and public health sector. These discussions should make us aware of the joys and satisfaction, frustrations and inefficiencies in the health system. They must also assist us to define our roles and propose concrete ways in which all of us, and you in particular, should contribute positively to improve the health system to the benefit of patients and staff alike.
Many students who came before you, especially those who were in medical schools before the dawn of democracy, grappled with most of these questions within the context of apartheid and injustice in conditions devoid of democracy. Most of these students divided their time between their studies and their deep involvement in the struggle for the total liberation of the country. They valued their studies, whilst balancing their struggle to improve their conditions on campus with their focus on their struggle against apartheid.
Many students suffered and were victimised. They became casualties as they either could not finish their studies or died in the course of their fight for freedom. Their sacrifices made it possible for you to have a better life here on campus and in a democratic South Africa post 1994.
When these students qualified and worked in the private and public health sector, they continued with their toils and struggles against apartheid health. They joined many of the organisations of the people, which included the National Medical and Dental Association (NAMDA), the Health Workers’ Association (HWA) and the National Progressive Primary Health Care Network (NPPHCN), to continue with their noble efforts to change the health system towards a democratic order. Our current policies and practices take root from the work done during those difficult days.
In 1994, at the dawn of democracy, we inherited a health system which was highly fragmented. The system was based on tribal, racial and class divisions. It was biased towards privileged groups and communities. Poor and rural communities had little or no access to services. The system focused mainly on curative care. It was characterised by inefficiencies and inequities. Corruption and nepotism were rampant, but were accepted as a norm.
The system before 1994 did not emphasise team work. The doctor played a dominant role within the hierarchy. Great emphasis was on medical care. Little emphasis was put on good health, its achievement and maintenance.
The challenge then was to put in place a democratic, unitary and integrated national health system within the framework of the new democratic order.
We had to design a comprehensive programme to redress social and economic injustices, and promote greater control by communities and individuals over all aspects of their lives. In health this involved the complete transformation of the national health care delivery system. All legislation, organisations and institutions related to health had to be reviewed.
The guiding principle was that every person has the right to achieve optimal health, and also that it is the responsibility of the state to provide conditions to achieve this ideal. Focus was on health and health care. Special emphasis was placed on women and children, to prevent their suffering as a result of the disparities and inequities in the system. Promotion of good health as well as increasing access to health care services were at the centre of the envisioned single comprehensive, equitable and integrated system. All these were translated into a concrete plan, the 1994 African National Congress (ANC) national health plan, which is the foundation of the policies and programs of the post-1994 democratic government and South Africa of today.
Progress that we have made in transforming the health sector in the fifteen years of democracy is encouraging. However, we can and we could have done more. The health sector, private and public, is facing serious challenges. Access to services has been greatly improved. Our greatest challenge is to improve the quality of health services. The problem of inequities in health remains acute. The country, especially the public health sector, has a serious shortage of all categories of health workers.
Our health system faces considerable challenges in relation to health care financing and expenditure. There are large disparities in the allocation of health care resources between and within provinces, and between the private and public sector, resulting in our inability to deal with our burden of diseases, ill-health and premature death from potentially preventable diseases. This inequitable resource allocation compromises the health of the nation. It is unsustainable.
Our country is also facing large scale and complex health conditions. Scientists have described the burden of diseases in South Africa. The most important, at this point, are Tuberculosis (TB), HIV and AIDS, other poverty related diseases, chronic diseases of lifestyle and high rates of injury.
The general health outcomes in South Africa are poor. This means that the results or outcomes of our work and treatments are not satisfactory. Our results are dismal when compared with those of our counterparts in other countries. These outcomes are not commensurate with the level of health expenditure in the country. Our doctors and other health workers, and the entire South African health system, perform badly when compared to Mozambique and Zimbabwe. These countries have less money and other resources available for their health systems. Our people continue to die in large numbers and unnecessarily from TB, a disease that is curable. Our children die young and maternal mortality continues to worsen, mainly because of HIV infection. South Africans die young as compared to many other countries with similar or worse expertise and resources.
Government has identified health as a top priority. It has adopted the 2009 Health Program of Action (POA) based on the health ten point plans for 2009 2014. The Ministry of Health and the national Department of Health drive the implementation of this POA. The national Department of Health supports and guides provinces and health districts in the implementation of this POA.
Our strategic plan for 2009/10 to 2010/11 provides a vehicle for the implementation of the following priorities derived from our POA:
* Provision of strategic leadership and creation of social compact for better health outcomes
* Implementation of National Health Insurance (NHI)
* Improving the quality of health services
* Overhauling the health care system and improve its management
* Improved human resources planning, development and management
* Revitalisation of health infrastructure
* Accelerated implementation of the HIV and AIDS strategic plan and the increased focus on TB and other communicable diseases
* Mass mobilisation for the better health for the population
* Review of drug policy
* Strengthening research and development.
These are the priorities that the public should hold the health ministry and department accountable for in the coming five years. This government regards the private sector as an important role player in the delivery of health care. The private sector and all stakeholders, including academics, researchers, civil society and the labour movement, have been invited to become active participants in the implementation of these priorities.
All these parties have been requested to familiarise themselves with the ten point plan and the 2009 health sector program of action, and to identify areas in which they will make meaningful contributions to the improvement of health care in South Africa. You are also invited to join in! At this stage, let me address some of your concerns, guided by a list of questions which was forwarded to me as part of my brief:
* Issues of the curricula and ongoing curricular renewal, i.e. the five year programme and six-programme?
* What to expect in the public health sector?
* Shortage of health professionals?
* Production of doctors?
* Community service for doctors?
* The need for more doctors in rural areas?
* Strikes by doctors, was it right or wrong?
There are currently three universities following a five year curriculum (Free State, KwaZulu-Natal and Walter Sisulu) while the other five follow a six year curriculum. The five medical schools who still offer a six year curriculum did not want to convert to the five year curriculum when it was introduced. Those who are in favour of the five year curriculum, state that it differs from the six year curriculum in that it is integrated, student centred, and problem based. They also state that it focuses on self directed learning and community based outcomes. Training of medical students should be at least five years. However, currently universities have the liberty to decide on either the five year or six year program.
A study has been commissioned by the Medical and Dental Board of the Health Professions Council of South Africa to look into the following:
* To identify the difference between the five year and six year curriculum
* To analyse the difference between one year and two year internship.
You requested that we clarify you on what to expect in the public health sector. We expect excellence from you and the entire public health sector. Programs and plans that have been put in place and work that is being done by the ministry and department aim at the continuous improvement of health services and health outcomes. It will also result in the improvement of conditions of work of all those who work in the health sector.
The POA alluded to the above as the framework that guides our work. It starts with our resolve to provide strategic leadership, the implementation of the NHI, the improvement of our health services and ends with our commitment to strengthening research and development.
The conclusion of the agreement on the Occupational Specific Dispensation (OSD) and the speedy, correct and successful implementation of the said agreement will assist in stabilising conditions of health professionals in the public health sector. Improved salaries should bring long lasting labour peace and stability. Better salaries should also translate into better productivity and motivation. Health professionals should be at work on time, working and remain at work for prescribed time schedules. Improved salaries of nurses, doctors and other health professionals makes it unnecessary for health workers to do Remunerative Work Outside of the Public Service (RWOPS), locums and moonlighting.
Concrete steps are being taken to improve the production, recruitment and retention of health professionals. The OSD is one of those steps. We are in the process of refining the human resource plan for health. We have directed officials in the department to prepare for the reopening nursing schools and colleges. We must produce more enrolled nurses and enrolled nursing assistants to reverse the artificial shortage of nurses that we currently experience. We cannot as Minister Motsoaledi often says continue to fight with an army of generals, in the form of professional nurses, without riflemen and foot soldiers!
We are working on integrating all categories of community health workers. We are working on concrete steps to implement task shifting in our facilities. We have indicated our concerns about policies that continue to compromise our ability to improve the state of human resources for health. We will change the laws and policies that are a hindrance to us meeting our objectives. We are continuing with international recruitment of health professionals through existing government to government agreements in line with our existing policy.
The Minister of Health, Dr Motsoaledi, has already met with the Deans of Medical Schools, where it was agreed that that the current status quo must change. We have agreed with the Deans that we have to find ways to increase the number of doctors that qualify per annum and improve the quality of graduates from medical schools. This matter will be pursued further with all relevant stakeholders.
Medical students, who qualified after five or six years, must do a two-year internship as stipulated by the Health Professions Council of South Africa (HPCSA), followed by one year of community service. Community service was introduced to improve the professionalism of young graduates. It started with medical practitioners and was planned to be extended to all categories of health workers, with the ultimate aim of this practice being adopted by all graduates of all professions. Community service was also introduced to ensure that doctors who opt for independent practice would do so with requisite skills and pose no danger to the general public.
Community service is an opportunity for young professionals to develop skills, acquire knowledge and internalise correct values and culture that make medicine the noble profession that it is. Other benefits of community service are the provision of health services and equitable distribution of human resources, particularly in the rural and underserved area of our country.
The unwillingness of many professionals to work in rural areas is a challenge in many countries. It is not an exception that is specific for South Africa or for the medical fraternity. We have to find ways of ensuring adequate staffing of our rural facilities. That is a challenge we have to face and win. You asked for clarity on whether it is right or wrong for doctors to strike. This is a question that I would pose to you.
It is wrong for doctors and other health workers to strike. It is law in this country that those workers who are classified as essential staff cannot withdraw their labour. Remember that as doctors we have the power and privilege that no other profession possesses. We are entrusted with the responsibility of saving and protecting lives. We also have a responsibility to decide on which life to save, for example the decision to save the mother instead of the child in certain obstetrics situations.
Our view that it is wrong for doctors to strike must be understood well. It contains within it our sympathetic view of the plight of doctors and other health workers. However, it is based on the fact that death cannot be postponed. Patients lives cannot be put at stake because of any reason, because once a life is gone, it cannot be brought back. Our conscience and the Hippocratic Oath requires of us to regard life as sacrosanct. Our actions as doctors cannot be the cause of death of patients. That includes strikes.
The last strike by doctors was mainly a result of the unjustified delays and failure by the Department of Health to conclude agreements on the Occupational Specific Dispensation (OSD). We have apologised for these failures. However, we could not and cannot agree that it was correct for doctors to have abandoned their patients as a result of this problem.
The current debates and struggles by the health sector were focused narrowly on salaries and conditions of work. What is lacking, and the point that should have been focused on by health workers and medical students, is the link between these challenges and broader health and social issues. The students of yesteryear accorded us the wisdom that struggles for the improvement of working conditions should always be linked to the fight for the improvement of social conditions.
Medical students and all health professionals should understand that the quest for improved salaries should be linked to the need to improve service delivery in poorly performing health districts. As we demand improved working conditions we should also be advocates of good nutrition, adequate supplies of clean water, and the provision of efficient and appropriate sanitation. This approach, which is different from that which only seeks to affirm workers without seeing them as part of the community, is the cornerstone of Primary Health Care.
In conclusion, I am convinced that we are all committed to a better health for all. We have a duty, as members of the medical profession, to respect, defend and promote our profession. We must join hands and build partnerships to ensure that through our professions we contribute positively to the improvement of the quality of health and the strengthening of the national health system. We must be champions of progressive approach to health care delivery.
We have put in place a solid foundation for an integrated national health system. We are strengthening the system. We do not tolerate corruption and inefficiencies. We aim to improve funding and financing through the NHI. We are working hard to integrate the private and public sectors into one efficient entity. We also aim to implement our POA through partnerships and active participation of all stakeholders.
The medical profession must regain and maintain its rightful place in the struggle for better health. We must be second to none in our defence of our profession and the right of our patients. Health is our life. We must continue to promote the best of values that characterise our profession. And this noble work by medical students and doctors has to be pursued with our full acknowledgement that our communities remain central to our lives. Let us work together to make our 2009 program of action a success, as together we can do more!
I wish you great success in your studies.
Issued by: Department of Health
25 September 2009
Source: Department of Health (http://www.doh.gov.za)
Issued by: Department of Health
25 Sep 2009
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