READ: Mkhize’s speech on the National Health Insurance & women

Zweli Mkhize
Health Minister Zweli Mkhize.

Health Minister Zweli Mkhize spoke at an exclusive Bhekisisa event for editors on 6 August about the National Health Insurance and what it means for reproductive justice.


Thank you for the invitation to speak to the media on this important topic: How will the NHI advance our movement towards reproductive justice.

Let me start with what our Constitution enjoins us to achieve and I quote from section 27:

1. Everyone has the right to have access to

a. health care services, including reproductive health care

And Section 12:

2. Everyone has the right to bodily and psychological integrity, which includes the right

a. to make decisions concerning reproduction;

b. to security in and control over their body; and

c. not to be subjected to medical or scientific experiments without their informed consent.

So, in terms of reproductive justice, our Constitution is clear on what rights those who live in South Africa have.

I am informed that the working definition of reproductive justice proposed for discussion in this forum is: “the human right to maintain bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities”. It is clear to me that this definition coheres well with the provisions in our Constitution. The key question is how we achieve this everywhere!

The White Paper characterises the NHI in the following way:

National Health Insurance (NHI) is a health care financing system that is designed to pool funds to actively purchase and provide access to quality, affordable personal healthcare services for all South Africans based on their health needs, irrespective of their socioeconomic status. NHI is intended to move South Africa towards Universal Health Coverage (UHC) by ensuring that the population has access to quality health services and that it does not result in financial hardships for individuals and their families.”

The NHI is therefore designed to fund quality and affordable health services so that everyone who needs access to health care can receive it regardless of their ability to pay for these services.

In addition, the White Paper provides a list of services to be provided under the NHI. It speaks to primary health care as the foundation of the NHI and among the services to be prioritised are:

  • Prevention and Health Promotion, including but not restricted to, providing information education and support for healthy behaviours and primary healthcare outreach and appropriate home care;
  • Maternal, women and child health, including family planning and reproductive health services;

We are currently working on a package of primary health care services that will be provided under the NHI. Our starting point is to ensure that services currently provided in the public sector are included. We are also working with the Council for Medical Schemes to ensure that every medical scheme pays for the same package of primary health care services as that provided by the public sector – this is part of the process to revise the prescribed minimum benefits that the CMS is working on.

We are ready to provide condoms in schools as part of comprehensive sexual education.

Health Minister Zweli Mkhize

Let me now turn to the sexual and reproductive health services that we are currently providing in the public sector. As you may know, we have the integrated school health programme (ISHP). It is called integrated as these services are provided by three departments: health, basic education and social development. As part of the ISHP school health nurses provide age-appropriate sexual and reproductive health services to grade 4 (called know your body) and again to grades 8-10. We acknowledge that there are challenges as we currently do not have sufficient numbers of school health nurses. Under NHI we plan to increase these numbers so that both coverage and quality improve.

I know that there have been several questions about the provision of condoms for example in secondary school – to address the unacceptably high rate of teenage pregnancy. This issue has been addressed by the Minister of Basic Education who has acknowledged that there is a problem. We are ready to provide condoms in schools as part of comprehensive sexual education.

We also acknowledge that young people do not find health facilities friendly – there are reports that when a young person goes to clinics for contraception they are asked to bring their parents! This is unacceptable and we will work with health workers and the organisations that represent them to ensure that young people are not unfairly treated. We have established youth zones in more than 300 clinics so far –  clinics set aside 2-4pm daily during which they prioritise youth health. We are also working with Lovelife to train health workers to be sensitive to the needs of youth.

There have been reports that, contrary to our policy which offers a wide range of contraceptives, health workers promote Depo Provera above all others. This is definitely not the policy of the Department. We offer a wide range of contraceptives including male and female condoms, injectables, oral pills, IUCDs, the sub-dermal implant, terminations and sterilisations.

While it is true that depo is the most widely dispensed contraceptive, we also have high numbers of other contraceptives as follows (2018/19):

METHOD VOLUME
Condoms 726-million male condoms and 17.6-million female condoms
DMPA (depo) 6 206 245
Norethisterone 1 939 006
Oral 4 257 198
IUCDs 51 334
Implants 213 260
Sterilisations 45 372 (females); 1 366 (males)

I also know that there have been views about the relationship between depo and acquisition of HIV. In fact, some suggest the reason for high levels of HIV in southern and eastern Africa is related to high rates of depo use! The recently released Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomised study researched HIV acquisition in women using three different contraceptives:

  • DMPA- intramuscular (DMPA-IM), a three monthly, progestogen-only, reversible injectable contraceptive;
  • Levonorgestrel implant, a progestogen-only implant inserted under the skin in the upper arm that can be used for up to five years;
  • A copper-bearing IUD, a device inserted into the uterus that can be used for up to 10-12 years.

While the study found no statistical difference between these three methods it did find high levels of HIV and STIs which led the researchers to propose the integration of HIV and sexual and reproductive health services. These results have been published in The Lancet.

After 30 years of speculation about whether the three-month shot makes women more likely to contract HIV, we finally have an answer.

Despite these results, I understand that some researchers and activists are already calling for the removal of DMPA from the range of contraceptives provided. The WHO is currently reviewing the results and will provide global guidance on the implications of the research within the next month or two. We will await the guidance from the WHO before we react to these findings.

We are committed to providing termination of pregnancy services in line with the Choice on Termination of Pregnancy Act. We acknowledge that the number of facilities able and willing to provide these services is not optimal – there is significant resistance from some health workers to provide TOPs. We are working with the World Health Organisation as well as the Global Health Strategy (GHS) to strengthen access to sexual and reproductive health services including terminations.

As I am sure you know that we also have a programme on cervical cancer. This includes vaccinating girls aged 9 with the HPV vaccine as well as screening for HPV using liquid-based cytology (LBC). To date, we have vaccinated with two doses more than 1.5 million young girls. In addition, since we moved from PAP smears to LBC we have tested 1 million women since April 2017 for cervical cancer with this technology. We will continue to improve diagnostic and treatment services for women.

You may have seen the 2019 mid-year population estimates from Stats SA on 29 July. I am encouraged that Stats SA reports the infant mortality rate continues to decline and is now 22.1/1000 live births – we are edging towards the SDG 2030 target of 20/1000. Stats SA also reports that life expectancy continues to increase towards the 70 years by 2030 in our NDP. It is now estimated at 61,5 years for males and 67,7 years for females.

Finally, I was also requested to share information on progress on maternal mortality. All the data we have show that we have seen a decrease in maternal mortality over the past 10 years. The Rapid Mortality Surveillance Reports from the Medical Research Council estimates report of January this year suggests that the maternal mortality ratio has declined from 200/100 000 in 2011 to 134 in 2016 (their latest estimates). Preliminary data from the National Committee on Confidential Enquiries into Maternal Mortality (a ministerial committee) suggests that the institutional maternal mortality ratio declined from 154/100 000 in 2013 to 123/100 000 in 2018. However, the major causes of mortality continue to be: HIV; pregnancy-associated hypertension; and obstetric haemorrhage. It is noteworthy that deaths due to HIV and obstetric haemorrhage continue to decline but hypertension has not yet shown a decline. This means working harder to improve the quality of antenatal care.

In conclusion, I think that I touched on the most important issues that we are currently dealing with related to reproductive justice.

I thank you for this opportunity to provide a rather wide ranging overview of services that we provide as well as some of the challenges we are dealing with.

To download a copy of the speech, click here.