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SPEAKING NOTES FOR THE MINISTER: MEDIA

ROUNDTABLE WITH EDITORS ON REPRODUCTIVE JUS-

TICE AND NHI

Thank you for the invitation to speak to the media on this im-

portant 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.

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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 com-

munities”. 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

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has access to quality health services and that it does not

result in financial hardships for individuals and their fami-

lies.”

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 re-

stricted to, providing information education and support

for healthy behaviours and PHC outreach and appropri-

ate home care;

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• 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.

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.

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As part of the ISHP school health nurses provide age appropri-

ate 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 in-

crease these numbers so that both coverage and quality im-

prove.

I know that there have been several questions about the provi-

sion 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 fa-

cilities friendly – there are reports that when a young person

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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 of-

fers 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 in-

cluding male and female condoms, injectables, oral pills, IU-

CDs, the sub-dermal implant, terminations and sterilisations.

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While it is true that depo is the most widely dispensed contra-

ceptive, we also have high numbers of other contraceptives as

follows (2018/19):

METHOD VOLUME

Condoms 726m male condoms and 17.6m female condoms


DMPA (depo) 6 206 245
Norethisterone 1 939 006
Oral 4 257 198
IUCDs 51 334
Implants 213 260
Sterilisations 45372 (females); 1366 (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 Evi-

dence 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, pro-

gestogen-only, reversible injectable contraceptive;

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• Levonorgestrel implant, a progestogen-only implant in-

serted 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.

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 cur-

rently reviewing the results and will provide global guidance

on the implications of the research within the next month or

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two. We will await the guidance from the WHO before we re-

act to these findings.

We are committed to providing termination of pregnancy ser-

vices 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 sig-

nificant resistance from some health workers to provide

TOPs. We are working with the World Health Organisation

as well as the Global Health Strategy (GHS) with funding

from the Susan Thompson Buffet Foundation 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

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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 technol-

ogy. We will continue to improve diagnostic and treatment

services for women.

You may have seen the 2019 mid-year population estimates

from STATSSA on 29 July. I am encouraged that STATSSA

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. STATSSA also reports that life ex-

pectancy 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 pro-

gress on maternal mortality. All the data we have show that

we have seen a decrease in maternal mortality over the past

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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 esti-

mates). 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 is-

sues that we are currently dealing with related to reproduc-

tive justice.

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I thank you for this opportunity to provide a rather wide rang-

ing overview of services that we provide as well as some of

the challenges we are dealing with.

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