Dr Aaron Motsoaledi rubbed his forehead and repositioned himself in his chair, leaning forward as if to make sure his point came across clearly: "I will say it upfront. There is no way National Health Insurance (NHI) will function anywhere if the public health system is not functioning well."
Motsoaledi has been on a long-overdue mission to transform South Africa's health system since he took office more than three years ago.
Motsoaledi said he has two pre-conditions for the NHI on which he will not compromise: overhauling the quality of care in the public health system and reining in and regulating the pricing of healthcare in the private sector.
The minister said he has identified five areas that are already being worked on in the public sector.
The first is infrastructure and there are a number of projects in the pipeline, including the revitalisation of nursing schools, more mother- and-child health facilities and the incorporation of breast-milk banks and kangaroo-care rooms in maternity facilities.
The next focus area is human resources. "There are people who wrongly believe we can do NHI without addressing our human resources challenges. Nowhere in the world, not in the United Kingdom or Norway, did countries introduce NHI when everything was hunky dory. They introduced it when they were not well off. It was a political decision," he said.
Motsoaledi revealed that, for the first time ever, the department has a human development strategy. It includes, among other things, plans to increase the number of doctors trained, to build a ninth medical school in Limpopo, to rebuild other medical training facilities and increase the number of South African doctors trained in Cuba.
The minister aims to increase the number of doctors trained in South Africa from 1 200 to 3 600. Medical schools are already raising their intake by 160 this year, made possible by a R48-million grant from the health department.
Going for what he called a "big bang" approach, Motsoaledi has also sent 1 000 matriculants to Cuba, where they will be trained as doctors.
Cuba, which has a population of 11-million and excellent health outcomes, has 27 medical schools. Doctors are trained to deal specifically with issues at primary healthcare level, an approach that suits Motsoaledi's focus on primary healthcare or preventative medicine as part of the NHI roll-out.
His third focus is the quality of healthcare in the public sector and legislation to enable this is at an advanced stage.
The Office of Health Standards Compliance will oversee the establishment of units of inspectors to scrutinise all healthcare facilities, a health ombudsman will handle complaints and specially trained facility improvement teams will be appointed to address and solve problems in hospitals and clinics.
Motsoaledi's fourth emphasis is on what he called "the heartbeat of NHI" – the re-engineering of the primary healthcare system.
"Our healthcare system must be based on the prevention of disease and the promotion of health," he said.
The first phase, which launches this month, involves the deployment of retired nurses to schools in the 10 NHI pilot districts.
The second phase will include ward-based primary healthcare teams led by professional nurses.
Children will have their eyes and ears tested and their teeth checked and corrective measures will be taken where needed. Their immunisation schedules will be checked and corrected if not up to date.
Programmes focusing on drug and alcohol abuse will also be rolled out.
Acknowledging that it is a sensitive area, Motsoaledi said he is determined to address the booming incidence of teenage pregnancy, coupled with the spike in both illegal and legal termination of pregnancies.
HIV counselling and testing programmes will also form part of the schools intervention and condoms will be made available.
Already, there are 30 custom-made trucks ready to roll out to schools and the number will increase to 90 in the near future. Each vehicle is equipped with what the minister described as "world-class" equipment to examine pupil's eyes, ears and teeth and take corrective measures on the spot, whether it be dispensing spectacles or filling cavities. Male circumcision services will also be available.
Motsoaledi was at pains to point out that these services will not interfere with the children's school time and will move to outlying communities and farms while the children are writing exams or tests.
Motsoaledi's "last dream" and fifth focus involves the deployment of teams of specialists, including gynaecologists, paediatricians, family physicians, anaesthetists, midwives, paediatric nurses and primary healthcare nurses to the health districts.
"I want to start in April and I want it to be a permanent feature," he said.
He revealed that Cuba had offered to send specialists, but said he first wanted to exhaust all local avenues, including requesting universities to send specialists on a rotational basis.
Quizzed on the massive challenges in Gauteng, a visibly angry Motsoaledi repeated his assertion that healthcare had become "tendercare" in the beleaguered province.
"Go and check the books. These problems started six years ago when they started buying very expensive commodities that had nothing to do with basic healthcare. They spent their money buying unnecessary things and we want the Special Investigating Unit to find those who are guilty of fraud and arrest them," Motsoaledi said.
He used the example of Chris Hani Baragwanath Hospital, where ultraviolet lights – which have shown some success in tuberculosis infection control – had been purchased for a staggering R72-million.
Refusing to help
"Who bought them? What was the motivation for buying these things that did not change the healthcare system for the better?" Motsoaledi said.
These types of purchases have led to the province having no money for healthcare basics, he said.
"They stopped paying suppliers and continued to do so for three years while these suppliers suffered silently. I begged some of them personally to supply the services and they told me that they were not refusing to help, but were being liquidated because they had not been paid.
"We are working around the clock to resolve this issue, which has reached the point where services are collapsing," he said.
Motsoaledi confirmed that similar patterns have been playing out in Limpopo and the Eastern Cape, but said the problems were exposed much sooner in Gauteng because of the size of central hospitals and other stakeholders.
Motsoaledi's focus is not only on his own backyard, however. The minister is determined to address the pricing of healthcare in the private sector.
"There is broad acceptance that there is something wrong there. Recently, a listener told me on a radio show that every time I speak about healthcare I attack the private sector. I am not attacking private healthcare, but I am worried about the cost. Anyone who feels they are being attacked is being unfair," said Motsoaledi, slowly shaking his head.
"No health minister wants unaffordable healthcare. Once healthcare becomes unaffordable, people die, and for that reason I cannot keep quiet."
Motsoaledi said that it does not make sense to regulate only certain areas in the healthcare sector.
"We regulate medical schemes, but there is not a single body regulating those who provide healthcare."
The minister said some mistakenly blamed the medical aids, but they are collapsing under the strain of trying to pay for services.
"In 2001 we had 180 medical schemes; we are now left with 95. They are simply collapsing under the weight of what is being charged. This proves that it is the law of the jungle and only the fittest will survive," Motsoaledi said.
He often uses personal examples to illustrate inconsistencies. This time, it was a friend in Gauteng who wanted to send his child for a "procedure".
"The doctor wanted R21 000 and basically told him to take it or leave it. He tried elsewhere and was quoted R5 000 for the same procedure. How do you reason that?" he said, throwing his hands in the air.
"It seems to me there is a serious imbalance if we regulate only one side. And one has to ask if they are hiding something if they insist on fighting any investigation," said Motsoaledi. "Health is not just any commodity."
The minister is already looking at how to involve the private sector, more specifically general practitioners, in the NHI.
He and his director general, Precious Matsoso, have outlined plans to contract these doctors to deliver services in areas where clinics are far away.
However, Motsoaledi insisted that these doctors will be paid from the national budget because he does not want a scenario in which service providers are not paid.
"I don't want to hear that something did not happen or went wrong because people were not paid."
Motsoaledi is a man on a mission to ensure that the ability of patients to get access to good healthcare and be treated does not depend on their ability to pay for it.
He needs to succeed.
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