Prevention is better than cure

2010-03-12 00:00

SOUTH Africa’s new health minister laughs easily. He exudes warmth, goodwill and enthusiasm. Those who have interacted with him, including many foes of his predecessor the late Dr Manto Tshabalala- Msimang, describe him in glowing terms. “He’s a good guy” (Aids activist). “His heart is in the right place” (state doctor), and “He’s the best thing that has happened to health care in this country” (Democratic Alliance health MEC Theuns Botha).

He bursts out laughing when asked if he ever regretted being handed the job. “I need to be honest with you. For the first time in my life I had to go for a massage because every neck muscle was tense when I first started the job. I had a headache. My shoulders? Phew, I felt myself carrying a really big weight and sometimes I used to wake up at three o’clock and not go back to sleep. It was very heavy, I’m not going to lie,” he grins.

Almost a year into the job, Motsoaledi is slowly trying to heal a broken health system and he has some very clear ideas on what tonic it needs, but he is also someone who listens and has consulted widely and still does.

Many believe that his biggest challenge may not be trying to find the right remedy for the ailing health system, but rather finding the people or capacity to support him in achieving his vision. Under Tshabalala-Msimang and her director general, the national health department hemorrhaged competent staff with only a few now remaining. Motsoaledi is trying to win back the capacity he needs.

How much of an issue is the lack of capacity for him? “Huge. Huge. Make no mistake about it, it is huge. But we are trying our best to bring back some of the people who have left,” he says.

Within a couple of months, Motsoaledi had set up a high-level committee to advise him on the overhaul of South Africa’s health system, or National Health Insurance (NHI) system, as it has been branded by the ANC health committee. The committee has met twice and is working out the finer details, as well as the costing, of such a programme, something cabinet has requested.

Is he in a position to share with South Africans his vision of the much-debated NHI system?

The minister is clear that the Constitution compels him to take action. “It clearly states that health is a right and that the state must do everything in its power to make sure that this right is exercised in terms of access to health. That’s what the NHI is all about. There have been lots of debates because some people are scared of it.”

However, Motsoaledi cautions that the NHI will not be “an event” where South Africans go to sleep one night and wake up the next morning to find an NHI system. He is clear that it will be implemented as part of his wider 10- point plan for health and that the upliftment of the entire health system will go hand-in- hand with the NHI roll-out, which could take many years.

Key to Motsoaledi’s success is the co-operation of the provinces. The mess in the Free State in 2008 and 2009, which saw thousands of people denied antiretrovirals (ARVs) and other life-saving medication when the province ran out of money, exposed the danger of not being able to control the provinces. Most of the provinces are in the red, with overdrafts totalling billions of rands.

In many areas, the national Health Department gives policy direction, but the provinces have the final say over how and where they direct their resources. This has seen South Africa develop some of the best policies in the world, only to reach a dead end at provincial and municipal level. However, when things collapse, the national health minister is held to account.

“We give money for ARVs, if they are not there it is me who is questioned. They say ‘Minister, what has happened?’

“Last week, we had to renegotiate with the company that supplies ARVs to supply a certain province because the company was not being paid. I’m not going to name the province yet. Do you know why that aggrieves me?

“Because in October 2009 I convinced the cabinet and the minister of finance and they understood very well — Minister Pravin Gordhan gave us R900 million. That money was distributed to the provinces. How does it happen that we now have to beg and negotiate with one of the suppliers?

“What happened? Some provinces are in an overdraft so whatever amount you give them goes into the overdraft,” says Motsoaledi.

Motsoaledi is clear that he will be working closely with Gordhan to ring-fence certain budgetary items as “untouchables, non-negotiables”, forcing provinces to invest the money where it is needed.

“The immunisation of children and primary health care is one of them. School health is one of them. The issue of maternal and child health is at the centre of those. Nobody must tell me that these things are not central because these things have far-reaching implications and I can’t just sit here and fold my arms,” says Motsoaledi.

Motsoaledi cautions that he is not at war with the provinces and that he has a good working relationship with the MECs, but also cites the example of another unidentified province that had run out of iron tablets and started prescribing blood transfusions for the patients who were anaemic. Motsoaledi’s eyes flash behind his rimless spectacles: “That’s outrageous and I’ll tell you why. Iron tablets are one of the cheapest pharmaceutical items, but blood is extremely expensive. Not only in monetary terms, it’s a rare commodity.”

Motsoaledi is adamant that South Africa’s current approach, which is geared toward the curative, is unsustainable and unaffordable and that the focus needs to change to prevention, at all levels.

He uses cholera as an example.

“We have a sewerage pipe leaking into a river, but nothing is done. Our system is geared towards waiting for 100 people to get cholera and then you rush there, find them, connect drips and call the WHO. Treasury gives money because it’s an emergency. But it could’ve been prevented with the health-care inspectors stopping it immediately, on the day it happened. All those things must come back into the health-care system.

“We need to close the tap. If you keep on mopping, the mops will be finished and you will get 100 mops and keep on mopping. And in HIV/Aids and other areas we need to close the tap. I’m really begging the country, leaders and everybody — we have got to help each other to close this tap, absolutely.”

Motsoaledi often uses his experiences as a young rural doctor to make sense of current challenges.

“You never allowed anyone to die in your hands. There is one incident I cannot forget. One day I was in theatre alone to do a Caesarean section with no anaethetist. The pregnant woman had just arrived, she had 10 children and she was going to deliver the 11th, and her children had come to see her.

“I saw them when I came to fetch her for theatre. While I was stitching up the mother the sister screamed that the baby was not crying. I rushed in, resuscitated the baby, did the incubation and gave oxygen. When the baby started crying, the colour came back, because they turn blue when they are not able to breathe.

“I rushed back to the mother. The nurse had not been aware that the woman was bleeding. When I returned there was no blood pressure and no pulse. You know, I looked at the door, I thought about the 10 children who I had seen. I felt like bolting, just disappearing into nowhere. It was one of the biggest crises of my life. But I started by putting up a drip because I found that the one that was there was stuck and the sister hadn’t detected it. I started putting up an intravenous line.

“When the monitors started showing a pulse everybody cheered, they clapped hands and she lived, she lived. I can tell you, I was not going to forgive myself if she died.

“Now we want to bring back some of these values. Why should women die under our care? Why should it be normal and acceptable for somebody to die? It shouldn’t, because it was not so then, why should we accept it now?”

“The death of a woman in pregnancy is not an ordinary death, it’s extraordinary. Do you know how many people are going to suffer? Children are left behind, a husband is left. It’s a very big thing, so it was not allowed to happen. But these days it looks like it’s just one of those things and some doctors will tell you: ‘Look, 46% of the women are HIV-positive, what can we do?’ But we know for sure that for the remaining 54% there is a lot we can do.” — Health-e News.

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