Wednesday, 6 March 2002
Introduction and background
Before commenting on the interim report of the Health Systems Trust, I would like to take a minute to explain how this report of the HST came about.
Towards the end of 2000, when I and my colleagues in the provinces decided to establish the operational research sites on preventing mother-to-child transmission of HIV, we also decided to commission an independent organisation to record and analyse progress at these sites.
Hence the Health Systems Trust was asked to undertake this task.
Even though the provincial and national departments of health would be collecting information from the sites and would be evaluating progress, we felt that we needed to have a more objective appraisal of the programme.
The interim report of the HST on MTCT, therefore, comes as no surprise, as it poses the operational questions that we all agreed were important and seeks to provide some answers on the basis of the first six months of experience at the sites.
I am pleased that we have this report to assist us in future decisions and policy formulation on this programme.
Scope of an interim report
But I think I should highlight -- as the HST itself does -- what this interim report does and what it cannot do.
The presence of the word "interim" in the title of the report is a clue to its limitations and it also indicates that there will be further reports at a later stage.
The report does not deal with the impact of the use of Nevirapine in reducing HIV rates among the babies born at the research sites. This is because the programme is simply too new to yield this information.
Every baby given Nevirapine will be tested at one year to determine his or her HIV-status and, because the first sites only began in May, we will only begin to see the outcome in terms of HIV-prevention in the second half of 2002. Hence it is only then that the issues of universal access will be considered.
The report does, however, examine the operation of the existing sites in some detail.
And, in the light of what is actually happening at the research sites, it discusses and makes recommendations
Let me highlight some of the findings of the report
Coverage
Within the 18 national research sites, the MTCT programme is being provided in over 200 health facilities. This is equivalent to approximately 6,090 antenatal bookings per month.
This means that we are already covering between 10 to 15 percent of all antenatal bookings in the country in less than one year. This translates to approximately 3,133 pregnant women per month that we are reaching through this programme.
This is the largest MTCT programme in Sub-Saharan Africa.
It is a fact that in the whole world, there is not a single country which provides universal access to MTCT.
All countries are doing research of one kind or another. Health Systems and Infrastructure
The report comments on 4 main issues, namely staffing, management infrastructure, physical infrastructure and service integration.
Staffing
The reports says: "Human resources are the bed-rock of a well-functioning health system and PMTCT programme".
Their recommendations are:
Management Infrastructure
The report says: "A functional health system with effective sub-district health management teams capable of integrating community-based, clinic-based and hospital-based services is critical".
This means that an MTCT programme cannot be implemented as a vertical programme. It must be integrated with all levels of care, through the District Health System.
We are working hard with the Department of Provincial and Local Government Affairs on the implementation of the District Health System to ensure that all our health services reach everyone in every district council, local municipality, municipal ward and village.
Physical Infrastructure
The report says: "inadequate physical space and privacy has hampered the ability to provide adequate counselling and HIV testing services, as well as intra-partum (childbirth) care in many facilities".
It says that this is a major barrier to coverage.
Therefore, we need to expedite the upgrading of the physical infrastructure of the primary health care facilities and district hospitals across the country.
Service Integration
The report says: "Counselling has been too strongly associated with consent for an HIV test and it needs to be incorporated in a broader set of activities that include empowering women with knowledge and information about their childbirth, HIV, MTCT and infant feeding'.
It says we must consider couple HIV testing and counselling.
It says we must explore the use of rapid saliva HIV testing as an alternative to rapid blood testing. Of course we will explore these proposals but we will not compromise the standards and quality of HIV diagnostic testing.
The report says we must address the lack of clarity about clinical and obstetric management of HIV positive women in labour.
It also encourages the use of patient held records instead of keeping patient files in health facilities. This, it argues, should be done to protect patient confidentiality.
As you can see, Honourable Members, some of these recommendations need serious planning and cannot be done overnight.
The researchers say that: "Plans for expansion must therefore address the systemic and infrastructural constraints in order to avoid a multiplication of poor and/or non-sustained service delivery, as well as to reduce health care inequity".
And that's exactly what we are striving for, to improve our health care delivery system and to ensure that every citizen has equitable access to quality health care.
The HST report cautions that: "The impression created that implementing the PMTCT programme is as easy as dispensing aspirin, fails to convey the many genuine complexities that are outlined in this report".
It argues that we should use the lessons learnt in implementing an MTCT programme as an engine and a catalyst for the improvement of the health care system and primary health care services in general".
The HST specialises in public health and is not qualified to do clinical research.
The investigation of questions relating to resistance to Nevirapine within the PMTCT programme is being carried out as a separate research programme with the National Institute for Communicable Diseases providing the necessary expertise.
(The National Institute for Communicable Diseases - NICD is the new name for the National Institute for Virology).
As the HST report points out, research in other countries establishes that resistance does occur and that maybe the levels are higher than initially thought to be.
We hope to provide more conclusive answers by taking a relatively large experimental sample of 300 women.
This research is being co-funded by Boehringer-Ingelheim, which manufactures Nevirapine and which is required by the Medicines Control Council to supply information on resistance as a condition of registration of the drug for PMTCT.
This clinical research is being done amongst 300 women at a cost of approximately R4m in order to monitor closely issues of resistance and adverse drug reactions due to Nevirapine.
This research has not been done before.
I must remember this House that there is still no cure for AIDS, and in the absence of a cure, our focus remains on prevention strategies, health promotion and education, the vigorous treatment of opportunistic infections, and the care and support of those who are infected and affected by HIV and AIDS.
We must not forget that the drug Nevirapine is not a cure for AIDS and it should also not be used as a contraceptive. Our responsibility is to encourage every South African to take appropriate actions to prevent the transmission of HIV.
We continue to remind each and every South African to Abstain from sex, and for young people to delay their sexual debut for as long as possible. Everyone must be faithful to one partner. And those who cannot do any of the above, to use a condom.
Quality of the report
If I could, I would make the HST report compulsory reading for every Member of this House.
This is largely because the document recognises the complexity of the programme and examines this in a helpful way.
When the health authorities argue that the PMTCT programme is much more than providing women with a pill and babies with a few drops of Nevirapine, they are, in the current unfortunate environment, seen as making excuses to delay the expansion of the programme.
When the HST makes a similar assertion, and substantiates it by describing the issues involved, we hope it facilitates fruitful discussion, which focuses on solutions.
The HST report also reflects on some of the scientific questions in a manner that makes these understandable even to those of us who are not conversant with this field of work.
This in turn helps us all to engage in the related policy debates.
Of particular interest is the HST's assertion that the key policy issue that confronts government is not the provision of anti-retrovirals, but the question of infant feeding.
It points out that mixed breast- and formula-feeding by HIV-positive mothers will result in some babies being infected after birth, even if they receive Nevirapine at birth.
But the HST points out that interfering with established infant feeding practices, and particularly introducing breast milk substitutes, may pose a more deadly risk to many infants.
These children may be prone to malnutrition and some may die from diarrhoeal diseases.
The issues of affordability and the cost implications of rolling out formula feeding throughout the whole country also need prompt consideration.
And it broadens the debate from an HIV issue to a general public health issue. The challenge is not only to reduce HIV rates among the babies, but ultimately to reduce the overall infant mortality and morbidity rates.
We must find ways to avoid substituting one set of health risks - diarrhoeal diseases, malnutrition and infections -- for the another, namely HIV/AIDS
As the HST points out, there is no simple formula for this - but close monitoring of the situation through our sites will at least provide reliable information on which we can work.
Response to recommendations
The HST makes a whole series of recommendations for consideration by provincial and national government.
It is regrettable -- but perhaps understandable in the current context -- that only two have been highlighted: That is the recommendations on:
I know that some members of this House are looking for a simple "yes or no" answer from me. And they will, for the present, be disappointed.
I have tried at all times to indicate that decisions on the mother-to-child transmission programme are coordinated through MINMEC, and that holds true for government's response to the HST recommendations that touch on fundamental policy direction.
We will continue to present progress reports on our 5 Year Strategic Plan on HIV/AIDS and STDs, including the progress we are making on the National MTCT Research Sites.
What I can say, is that I feel assured that we are making good progress, and we have a very solid piece of research in front of us.
Its recommendations are well-rooted both in the reality that the researchers have witnessed at the South African sites and informed by international experience.
I can assure you that aspects of the report that relate to policy development will be considered with the seriousness they demand.
There are many recommendations, however, that relate to implementation rather than top-level decision-taking.
I know that, even as the public debates continue, various provinces have been acting on these findings and striving to strengthen the PMTCT programme in places where it is not meeting targets in terms of the quality of care, based on national norms and standards.
Particular attention is being given to management and co-ordination issues.
But above all, we must provide avenues for the women themselves to speak up on how they perceive the progress we are making in the implementation of this MTCT programme and tell us how it should be shaped to adequately meet their needs.
Conclusion
In conclusion, I would appeal to Members of this House and the public at large to read the full HST report and not to rely on journalist's reports that lift out only the newsworthy elements.
One of the unfortunate aspects of the debate on mother-to-child transmission of HIV has been a tendency to depict research as a stumbling block or an enemy of extended access to care.
The HST report shows just how systematic information gathering can become the key to an effective programme.
We do not want a PMTCT programme that does not deliver the goods - we want one that works.
And different strands of research - each with different time-scales - will continue to underpin our work enable us to review our policy from time to time.
Finally, Madame Speaker, let me remind some of the members of this House that I am indeed trained as a medical doctor and as an obstetrician gynaecologist. I have also specialized in public health.
As such, I do not take these issues of public health policy lightly. I have to think about them carefully in order to advise my colleagues in Cabinet, including the President.
Therefore, Madame Speaker, we will examine this report carefully and take whatever steps are appropriate to increase the coverage of HIV positive women giving birth to health and HIV positive children.
We will develop national norms and standards to ensure that wherever this programme is provided, there is adequate health infrastructure, the service is staffed adequately, and that there are sufficient and sustainable resources.
We are also committed to see to it that for the women of this country, pregnancy and childbirth are not seen as an illness but are part of their normal lives, and for those women who are HIV positive, the ANC-led government will see to it that they have an opportunity to lead productive and loving lives in the company of their children, partners and families.