Issued by the the Department of Health, Gauteng Provincial Government
11 March 2008, Birchwood Conference Centre
Programme Director, distinguished guests
Across the world, on a global scale, the health sector and the medical professions are today confronted by a series of unprecedented challenges.
Every day we are faced with the growing burden of disease, more and more patients, placing increasing pressures and strains on already overstretched facilities. Diseases caused by unhealthy lifestyles, severely aggravated by poverty, underdevelopment, pollution and environmental degradation now consume the largest portions of health budgets across the globe.
This is aggravated by a skewed - almost obscene - determination of priorities and allocation of resources. Budgets for research in developed countries are consumed by slimming tablets and miracle cures for obesity while TB, malaria and HIV and Aids kill over 5 million people a year and affect the lives of a further 250 million sufferers.
No less an expert than Dr Pascal Mocumbi, the former Prime Minister of Mozambique, and current advisor to the World Health Organisation, recently wrote that despite the great progress in medical science and the major scientific breakthroughs of the past 50 years the state of global health is still characterised "by the growing gap between the haves and the have-nots - between developed and developing countries."
We are also keenly aware of the fact that worldwide the cost of healthcare is escalating at a rapid pace. This factor is of significant concern for all of us at this indaba - for the public sector as well as the private health care industry, for organised labour and for patients - the consumers of health care who can simply not afford to access the best available treatment for their specific conditions.
But, we also know that more money spent on healthcare does not necessarily result in better outcomes. The question is not how much money do you have to spend? The issue is how do you spend the money? How do you allocate your limited resources? How do you monitor the outcomes? How do you ensure that you receive a positive return on every Rand that you have invested into healthcare?
Ladies and gentlemen,
It is an open secret that public health in Gauteng is seriously under funded. We all know that the demands on our facilities and our services are growing by the hour because not only residents of Gauteng, but also from our neighbouring provinces and from across our national borders into Africa, converge on our facilities to seek treatment and care.
The number of people visiting our primary healthcare facilities has risen from a mere one million in 1994 to the current figure of 12 million. Last year we introduced a provincial health budget of more than R12, 5 billion - a 15 percent increase over the previous year's figures.
In an ideal world, this is clearly not enough. But we are not living in an ideal world. We are living in the real world where there are competing demands - often with equal merit - on limited resources. Obviously, health needs more money, but so does the education of our children, so does crime prevention and law enforcement, so does the repair of our roads and infrastructure, so does the provision of water, power and sanitation, so does the huge backlog in housing. Let me assure you that we are in there fighting for more money for health care, negotiating better salaries and improved working conditions for our staff, pushing for more and better equipped facilities. But, in the final analysis the answer lies in stronger financial discipline, improved controls and a greater sense of innovation in the utilisation of our limited resources.
Programme director,
I have touched briefly on a number of challenges that we in Gauteng share with the rest of the world. However, I believe there is a broad consensus, among most health care experts in the world that the single biggest challenge facing our sector in the coming years is that of limited human resources.
Two years ago the World Health Organisation conducted a survey which indicated that there is an estimated world-wide shortage of 4,3 million doctors, nurses, midwives and other health support workers. Over two million of these workers are needed in 57 developing countries - mostly in Africa and Asia.
In his reaction to the report the former Director General of the WHO, Dr Lee Jong-wook noted that "people are a vital ingredient in the strengthening of health systems. But it takes a considerable investment of time and money to train health workers. Countries need their skilled workforce to stay so that their professional expertise can benefit the population. When health workers leave to work elsewhere, there is a loss of hope and a loss of years of investment."
We in South Africa, we in Gauteng and we sitting in this room today know exactly what Dr Lee was talking about when he referred to "a loss of hope and a loss of years of investment."
But, before I continue to talk about our local situation let me just remind you that this is not only a local phenomenon. The doctors of Uganda don't stay in Uganda; the trained physicians of India and Pakistan relocate to London, the intelligentsia of Kenya move to the United States.
In New Zealand there is a raging debate in the media because the country spends thousands of local dollars to train doctors and specialists and nurses - only for them to be poached by Australia and Canada. Visit Canadian websites and you will find massive efforts to recruit foreign doctors and nurses to practice in the sparsely populated northern territories. And we all know which country is their primary recruiting area.
In the most recent edition of the highly respected medical journal, The Lancet, there is thought-provoking report from a group of researchers, led by Dr Edward Mills of the Centre for HIV and Aids in Vancouver, Canada.
The report claims that more than 13,000 doctors trained in sub-Saharan Africa are now practicing in Britain, the United States, Canada and Australia -- leaving behind colleagues struggling to cope with impossible caseloads.
Moreover, African nurses and pharmacists also are targeted by clinics, hospitals and drug store chains offering better pay, legal assistance with immigration and moving expenses.
It provides details of how much money is being spent on the training of medical professionals in Africa - but also the vast amounts that are being saved by developed countries when they poach professionals that they do not have to train themselves.
The report acknowledges the fact that many professionals leave their countries out of their own free will to pursue better opportunities - but it also hits out at the active recruiting of medical staff from developing countries.
The study reaches the following, damning conclusion: "Rich countries are poaching so many African health workers that this practice should be viewed as a crime."
Ladies and gentlemen, let me tell you that from my perspective, I agree with the broad findings of the report. The drain on our scarce skills and human resources in health care simply has to stop. The negative trend has to be reversed.
Programme director,
I have attempted to sketch a broad background to our meeting at this indaba. This is a profoundly important event for us because we have brought together the best and most productive minds in Gauteng - and, indeed, in our country - to deliberate on a human resource action plan for health care in our province.
We thank you, in advance for your presence and your constructive participation. We want to welcome and acknowledge representatives from the private sector and the private health care and wellness industries, our esteemed academics from universities and training institutions, professional bodies, our valued partners from organised labour and employer organisations and our senior staff in the Gauteng Department of Health who have been wrestling with the vexed issues of human resources for a number of years.
Let me state at the outset what this Indaba is NOT about:
Ladies and gentlemen,
Out of this gathering we want action plans and implementation. We want to see workable solutions attached to deadlines and deliverables. Your function is to tell me where this province should be in six months time, or in 12 months time with regards to human resources. But you also have to tell me how, in practical and realistic terms I have to get there. And you have to commit your resources, your knowledge and your expertise to help us achieve this.
By all means, let us think broadly and outside the confines of conventional thinking. Who knows that wayward thought or outrageous proposal you make might just spark off other new thought processes and innovative solutions to vexed problems.
My function today, is to get the ball rolling. Later on you will listen to the experts and the analysts who will provide you with the facts, the figures and the statistics that will form the backdrop to the rest our deliberations.
The Afrikaans language has got a great expression namely to "gooi 'n klip in die bos." It is similar to the English idiom "to set a cat among the pigeons." Literally it means that when you go hunting, the prey you are pursuing may find a hiding place in a bush. The practice is then to throw stones into the bush, forcing your prey to move into open field.
I want to spend the remainder of my time throwing a few stones into the bush, hoping to elicit some responses from participants over the next few days.
The first, I have already referred to namely the loss of professional skills -- educated and trained in South Africa at taxpayer's expense, at government institutions - to developed countries in the north.
The cost to train a medical student ranges from R280 000 to R350 000 increasing by five to six percent inflation. Training commences in the 2nd year based on good results, calculated on inflation costs at R55 000rands per annum for five years through the education department, medical training is subsidized. A fully trained medical practitioner is thus a walking, talking, breathing investment of the South African taxpayer through the state. Surely we have a right to expect a return on this investment. Surely we have right - nay, an obligation - to direct this investment in the most productive way that we see fit.
The State is "the goose that lays the golden eggs" as far as paying for the training and tuition of medical students. And I think we have a right to have a greater say over what become of these eggs once they are hatched.
We are not saying that doctors should remain in lifelong bondage to the state or the country. But, what we are saying is that we can truly expect of them to make a contribution to South African society that is commensurate to the money, the time and the effort that we invested in them.
I am seriously concerned about the attitude of young medical students who simply cannot wait to finish their studies so that they can leave to "make money" in the UK or Canada. Community service and internships are often regarded as a source of irritation or a "necessary evil" that are "forced upon them" rather than as an opportunity to give something back into the community.
Ladies and gentlemen,
Aligned to this topic is the urgent need for government and the medical academic community as well as the professional organisations to take a fresh, unbiased look at the content of our curriculums and to determine whether we are indeed producing the type of medical professionals that serve the needs of South Africa and its people.
I want to state clearly that our universities and medical schools have done a lot of groundwork on this already and we want to acknowledge the significant transformation that has already taken place in the tertiary sector.
But with developments in the medical field moving at such a rapid pace there is a need for continuous reassessment to ensure that our training institutions do not become islands of isolation in an ocean of desperate needs.
Do we spend enough time and effort on preventative medicine rather than the curative aspects? Are the products of our training equipped to function in a society where the major health issues are those of chronic diseases, TB, HIV and Aids and diseases associated with poverty and underdevelopment? Are we producing the right mix between family practitioners and specialists? Are we doing enough relevant research that can be applicable to local circumstances?
There is an old saying that a fool can ask more questions in an hour than a wise man can answer in a lifetime. But I am putting these questions on the agenda in a very constructive spirit in the hope that you, the wise men and women in the audience, can help us find productive answers.
Allow me to quote from a recent article by the American health care economist, Dr Maggie Mahar, which illustrates the fact that this is part of a much wider debate.
Writing about the situation in America she writes that the share of medical students pursuing careers in primary care has plummeted from 49 percent in 1997 to 37 percent in 2003. Over the same span, the number gravitating toward careers in radiology, orthopedics, ophthalmology, and dermatology has sky-rocketed.
"Yet we don't need more dermatologists, "writes Mahar. "But we do need more primary care physicians. Decades of research done at Dartmouth University show that when Americans visit their family doctors rather than the specialists the health outcomes are better, in large part because patients receive more preventive care and ongoing management of chronic diseases from their family practitioners before they become serious."
I think this observation, programme director, also supports the emphasis we in Gauteng Health are placing on healthy lifestyles and preventative measures to ensure a healthy and productive population. Our estimates are that more than 70 percent of patients who arrive at our facilities are suffering from conditions that could have been prevented by following a healthy lifestyle - smoking, obesity, lack of exercise, alcohol and substance abuse, dangerous sexual practices.
It is such an obvious message that we must continue to spread - let us promote healthy living. Let us provide people with opportunities to improve the quality of life within their own communities. Let us reach people before they are compelled to reach our hospitals.
A similar constructive debate, programme director should be conducted with regards to our relationship with the private health care industry. Simply put - how do we get to a working relationship where medical practitioners working in the public sector are not simply whisked away to move to private hospitals and practices? For example, the state trains all the nurses in South Africa - we employ less than half of them.
Please, don't misunderstand me - I am not suggesting a Stalinist approach where the state decides where every doctor and every nurse should work, how much they should earn and what their conditions of service must be. We are, saying, however, that the state, by virtue of the significant investments it is making in the training of medical professionals, is a key participant in this debate and that we have legitimate expectations in this regard.
And those of us who are honest and knowledgeable will know that this is not an issue that is peculiar to South Africa. In some of the most advanced capitalist societies in the world such as the United Kingdom, Canada, Germany and Australia there are equally heated debates about the relationship between the public and the private health care sectors.
Let us thus, continue this debate here without putting labels on our fellow participants or questioning their bona fides.
To stimulate the debate further I want to admit as a given that the state is not doing enough to retain medical professionals in the public sector or to attract the quality people we need to our service. Obviously, salaries, immediately comes to mind - and clearly this is an issue that must be addressed at national and provincial levels of government as a matter of urgency. If need be we have to rearrange our priorities to ensure that our top level human resources receive the compensation they deserve.
But if you speak to medical professionals in government service you will soon learn that the monthly paycheck is not the only issue. We have to look at a broader menu of working conditions - the hours they work, the quality of the equipment at their disposal, the safety of staff - as was so vividly demonstrated by the recent unfortunate incident at Bara - up to basic facilities and amenities in the rest rooms… hot water in the showers, soap in the dispensers, coffee in the coffee machines.
And, let me state publicly from this platform that I am going to hold the administrators at hospitals, clinics and other medical facilities in Gauteng personally responsible for ensuring that these basic needs are being met within their respective institutions.
It thus stand to reason that we in the Department must get our own house in order to ensure that we not only retain existing medical professionals - doctors, specialists, academics, researchers, nurses, allied health workers, emergency staff - but also create a working environment that will enable us to attract people to our service.
We have to work with our partners in organised labour and the unions to look at training programmes and skills development. We have to ensure that each and every employee in the Gauteng Department of Health have a clearly mapped out career path and that we provide them with opportunities to reach the maximum of their individual potential.
But we also need to take a broader perspective and be prepared to cast our net wider. A major issue of concern is the quality of education in mathematics and sciences in our school system. These subjects are often prerequisites for entry into any tertiary education in the medical field.
In this regard we will engage with both the national and provincial departments of education but I also think there are opportunities for the private sector, foreign donors or international foundations to become involved in raising the quality for maths and science education in the country.
We simply have to create a bigger pool of talent from which to draw prospective candidates for training in the medical sciences.
We are also aware of the fact that there are many South Africans currently employed in foreign countries that might want to come back and continue their careers here. We intend to work with organisations such as the International Marketing Council of South Africa and the Homecoming Revolution to engage these South Africans and facilitate their return.
Similarly, there is a need for a constructive debate about recruitment of medical professionals from other countries where there might be a surplus of supply in specific skills. In this regard we will value the contribution of participants in this indaba who might have knowledge about countries and markets that are compatible to ours.
Programme director,
I trust that I have thrown enough stones into the bush to stimulate a number of healthy and constructive debates. As I have said earlier - we have enough strategies and theories to keep us occupied for a long time. This event must provide us with practical plans and deadlines.
I want to thank all the participants in this Indaba for their presence, for their contributions here - but most of all for their continuous engagement with the department as we implement the decisions taken here.
I thank you.