Issued by Department of Health
15 August 2002
Introduction
Because of constraints on time during media briefings, we run the risk of giving you a progress report that creates a sense of activity - but leaves you a bit confused about the direction in which we are headed.
So I'd like to preface this briefing with some points about the strategic direction of the Department of Health.
1. We view public health programmes and public sector health services very much as an instrument of poverty alleviation.
*We put particular effort into fighting the diseases that are a manifestation of poverty. *We adopt interventions to arrest some of the most destructive effects of poverty. *And we aim to develop enough decent public hospitals and clinics for the poorest to have access to treatment of good quality.
It is always a challenge to keep this pact with the poor on course - to adopt policies that really advance equity; to create quality service in adverse circumstances; to divert funds for preventive efforts when the curative services don't get enough. We are notching up some victories, but we recognize that it will be a long haul.
2. Important though poverty alleviation is, it is not the sole concern of the Health Ministry and Department. We need to respond to the entire range of disease burden and to ensure that we facilitate access to good quality health care across society. We recognize that ill health, exclusion from services and poor care take many forms and can occur in all social and economic groups. We see our role, therefore, as developing a national health system able to cater in different ways for variety of needs.
The notions of poverty alleviation and developing a national health system are really central to my presentation today.
Poverty alleviation
Health and Rural Development The Government's Integrated Sustainable Rural Development Strategy asserts the position that people living in the country's poorest areas require the concentrated attention of all government service departments to rise above deprivation.
The Health Department has focused development aid for primary health care development in these development nodes and has engaged universities and non-governmental organisations to assist in strengthening primary care there.
Dedicated health coordinators have been employed for each district. They will focus on achieving functional integration between primary health care services provided by provincial and local government within the same geographic areas and strengthening the ability of personnel at clinic level to run programmes to tackle the diseases of poverty -- such as, tuberculosis, the diarrhoeal and infectious diseases of childhood, HIV and AIDS.
Health and nutrition Departments involved in the Social Cluster have resolved to merge their efforts in the area of food security and nutrition. The Department of Health would make two major contributions:
The first is a stronger primary school feeding scheme - with standardized menus, norms for the number of days on which learners receive food and better targeting to reach those most in need. The programme is already reasonably successful. It reaches 4,7-million children at 15 000 schools - and has sustained this level of delivery for more than eight years. It is estimated to reach 87% of targeted children and has achieved clear results in terms of improved school attendance and attentiveness of learners.
The second is fortification of basic foodstuffs such as mealie meal, bread and wheat flour with micronutrients, including iron and vitamin A. The groundwork has really been done - including surveys on the response of consumers in rural communities. Before the year is over, regulations will be published for comment. Food fortification is one of those areas where there are vested interests and divided opinions. But we have looked closely at the international experience, we have adapted the approach for local conditions - and we know, from the Food Consumption Survey done four years ago that we are addressing serious nutritional deficiencies that we are not likely to combat through other means. The Survey, which we have referred to previously, showed high levels of micronutrient deficiency and low levels of energy intake among our children.
In addition to these programmes - and particularly in support of positive living among TB patients and people with HIV - we have initiated community-based programmes to promote the cultivation of food gardens.
Communicable diseases
The 2001 survey among pregnant women attending public sector antenatal clinics released earlier this year, indicated encouraging results in both HIV and syphilis prevalence. The levels of HIV continue to level off, whilst syphilis prevalence is at its lowest level since 1990. Trends of HIV infection among our youth have dropped over the past three years.
To build on these gains:
We are implementing six campaigns aimed at mass mobilisation around HIV and AIDS. They include youth prevention, support for vulnerable children, health worker excellence and tackling TB and STIs.
We have revised our strategy and increased our target for Voluntary Counselling and Testing (VCT) coverage from 12,5% to 20% of the population aged between 17-49. This arises from a public-private partnership with the private sector covering 7,5% of the target population. We have almost doubled allocation for this programme from R26 million in 2001 to R56 million this year.
By the end of May, 101 200 women had visited antenatal clinics at PMTCT research sites. 62 percent of them opted for an HIV test and 27% of the group tested positive. About 7 300 babies born to HIV positive mothers had received nevirapine. There were variable levels of uptake in different provinces and variable infant feeding preferences.
Nevirapine continues to be provided in facilities outside of this research programme in compliance with the Constitutional Court order
We successfully hosted the 14th Conference of the International Union Against TB and Lung Diseases in Durban in June this year.
Experts from the Stop TB Partnership reviewed our TB control programme in June. They noted significant progress, such as: *The launch of our Medium-Term Development Plan that outlines plans and targets until 2005. *The expansion of Directly Observed Treatment Strategy also known as DOTS to cover 150 of the 174 sub-districts. *The review of laboratory services. *The new information system implemented in five provinces (Gauteng, KZN, Mpumalanga, North West and Western Cape).
The problem of Multi-drug resistant TB is being addressed and there are some effective private-public partnerships for TB in control, for instance between the mining industry and Free State province.
We recently concluded a national survey on multi-drug resistant TB. Although the analysis is not yet complete, we are encouraged by the evidence that the problem of MDR has not grown worse. This points to some success in our case management. We will make the full results of the survey available before the end of the year.
Following the forensic audit of SANTA, which uncovered irregularities in that organisation's national office, we are working towards conducting forensic audits in all provinces where Santa hospitals are utilised.
While there has been substantial decline in cholera cases, we will continue with cholera control programmes until we get rid of the isolated cases that continue to be reported in KZN and Eastern Cape. Central to this intervention is acceleration of the Government programme to provide safe water and sanitation. As the Social Cluster, we have previously reported on a significant increase in the budget of Department of Water Affairs and Forestry for this purpose, commencing in 2002/3.
We continue to make successes in rolling back malaria through the Lubombo Spatial Development Initiative. Following the first round of spraying in southern Mozambique, the parasite infection rate in children between 2-15 years old was reduced by approximately 40% from an average pre-spraying infection rate of approximately 68%. After the second year of spraying (June 2002) the reduction was approximately 70% of the baseline.
In comparison to the peak epidemic year of 1999/2000, Swaziland showed an approximately 80% reduction in malaria incidence in 2001/2002 and KZN approximately 90% reduction in malaria incidence.
Hospital revitalization The Hospital Revitalisation Programme - where we seek simultaneously to improve physical infrastructure, facility management and quality of care - has only just begun at nine pilot sites. The number of hospitals in the programme will increase to 36 a year from now.
Sites are selected largely on the basis of achieving maximum impact. We have included some remote and resource-poor hospitals in our test batch. I have no doubt that building a new hospital in Colesburg or upgrading that in Lebowakgomo is more critical than intervening in the cities where the basics of decent care already exist. However, even within Gauteng the choice of Mamelodi as the first provincial site represents the targeting of an underserved population within the urban context.
Equity and grant allocation
The new basis for allocating conditional grants that I spoke of in my budget speech has begun to take effect. This change applies to the grants for Tertiary Services and for Health Professional Training and Development. In the past, the bulk of national grants for tertiary care went to 10 central academic hospitals in only four provinces. From this year, we are spreading the grants across tertiary service units wherever they are situated, within and outside central hospitals. This means that the Western Cape and Gauteng get a fraction less than they would have got - but provinces that used to receive very small amounts get up to double last year's funding.
The Eastern Cape is the biggest beneficiary - but serious questions arose as to its ability to manage this additional funding productively. Significant under spending last year came close to causing a cut in the Eastern Cape Treasury's allocation for health.
At the end of June we held a special Health Minmec in the Eastern Cape to see how the national Department and other provinces could support the Eastern Cape in developing its health system. At the end of the visit, firm targets were set for filling a large number of vacant posts, strengthening facility management and improving transport and emergency services. External expertise has been "loaned" to the province to help meet these targets. The critical success factor is often the transfer of appropriate skills.
Minmec plans to visit other provinces, with Mpumalanga scheduled for next week.
Resource mobilisation and funding
One of the major successes we have made as a country is to mobilise extra support from bilateral and multi-lateral partners to strengthen our health system and ability to bring about better health for all.
We are currently in discussion with the European Union about a 50 million Euros grant (about R500 million) that they have made available over the next six years for strengthening the delivery of primary health care in partnership with NGO's and CBOs.
South Africa is amongst ten developing countries in Africa and the Caribbean that can benefit from a sum of US$500 million (about R5 billion) by the US Administration to fight HIV and AIDS, particularly by prevention of mother-to-child-transmission. We intend to participate in this initiative.
The allocation of about R1, 63 billion from the Global Fund to Fight AIDS, Tuberculosis and Malaria is now well known to all of you. Approximately R930 million has been allocated for strengthening national capacity for treatment, care and support related to TB HIV and AIDS, as well as building on successful behaviour change. Another amount of more than R700 million has been allocated to the KwaZulu-Natal proposal for enhancing care for those infected and affected by HIV and AIDS in resource-constrained settings.
Like 30 other countries whose proposals were approved by the Board of the Global Fund in April, we are in the process of working out the details for receiving and allocating resources and indicators for monitoring programme implementation.
What is important now is to focus our energies on how these resources should be utilized in a way that will render maximum benefits, strengthen our capacity and contribute to our campaign to reduce the burden of disease in our country.
Building a national health system
Last week Cabinet approved two Bills for tabling in Parliament. Each contributes to the building of a national health system.
National Health Bill
I have Gazetted a notice of my intention to deal with the National Health Bill during this Parliamentary session - and every effort will be made to meet this target. However, the Bill has yet to be certified by the State Law Advisor and I am aware that our timetable is an ambitious one.
Some sections of the National Health Bill have been substantially redrafted in response to submissions received from a wide range of organisations during the three-month period for public comment.
At heart, the National Health Bill is a measure taken in terms of the Constitution to assist us to achieve our obligation to ensure progressive access to health care services.
Besides replacing the old and outdated Health Act of 1977, its most significant aspect is the fact that it defines the national health system, describing the functions of various elements in the system - from the national level down to facility level -- and indicating how they relate to each other.
The Bill also deals quite extensively with patients' rights - including emergency care, the right to patient information, confidentiality and privacy. It sets out the responsibilities of public health bodies and of health care institutions; and provides mechanisms for ensuring that norms and standards are maintained.
The Bill contains a section on the fairly complex area of health districts. You are probably aware that health districts have operated without any statutory foundation for several years, based on the willingness of municipalities and provinces to build co-operation.
It has been a challenge to find a mechanism that allows for increased local control of primary health care services within the framework of existing laws on local government and the constitutional obligations of municipalities. We think we have found a solution - and we expect more input on this matter during the Parliamentary process.
The provisions of the Bill extend across the entire health system, including the private and non-governmental sectors. Sections dealing with research, human resources, the minimum requirements to be met by health facilities and the regulation of health technology - to name just a few -certainly touch the entire health system.
There has been some speculation about the impact of the Bill on human stem cell research and related practices. So perhaps I should indicate that we have followed the dominant international thinking on these matters and the Bill only contemplates human stem cell research for therapeutic (and not reproductive) purposes -- and then only in particular circumstances, with Ministerial permission.
Medicine and Related Substances Amendment Bill 2002
We will be presenting to parliament a Bill to amend the Medicines and Related Substances Control Act (No. 101 of 1965) and repeal the South African Medicines and Medical Devices Regulatory Authority Act of 1998.
Act 90 of 1997 - the Act that caused such uproar in the pharmaceutical industry, amended the Act that we are currently seeking to amend for the reasons I going to indicate to you now.
Since 1997, there have been new developments that have necessitated this additional Amendment Act. The changes we are introducing do not represent a shift in medicines policy but take account of the new constitutional order and create a better "fit" between the principal Act, the first Amendment Act and regulations that will be published soon after the amendment.
*The search and seizure powers of the inspectorate of the Medicines Control Council are defined in a way that is consistent with the Bill of Rights.
*There is provision for appointment of a Deputy Registrar or Deputy Registrars for the MCC to assist the Registrar as the workload increases.
*Various provisions that apply to pharmacists are extended to cover other health practitioners who are licensed to dispense and compound medicines. These include professional fees and the obligation to inform the clients about generic drug options.
The Amendment Act also deals with appeal procedures with regard to decisions of the Director-General of Health and the MCC. These provisions have provoked some alarmist reporting in the media about the powers conferred on the Minister.
The formulation in the latest version of the Bill is that any party appealing against a decision made by the Director-General on the granting of dispensing licences must approach the Minister directly.
Any party appealing against a decision of the MCC on medicines registration will have recourse to an appeal committee established by the Minister.
I would like to remind the media that the committee would be bound by the same standards as the MCC itself and would consist of individuals with the expertise to apply these standards. In addition to that, the Administrative Justice Act introduces a general climate of transparency and ensures rational decision-making in a way that simply did not apply in the past. There is no intention to tamper with the autonomy of the medicines regulatory process and scientific evidence will continue to be the sole basis on which medicines are registered in this country.
Medical Schemes Act amendment We previously reported on consultations I was having with the Minister of Finance on points of intersection in regulatory oversight maintained by the Financial Services Board and the Council for Medical Schemes. These were successfully concluded and will result in a minor amendment to the Medical Schemes Act later this year, to complement the FAIS Bill of Treasury. The essence is to retain the regulatory oversight of the Council for Medical Schemes over brokers acting within the jurisdiction of the Medical Schemes Act whilst recognizing some overarching and common code of conduct applicable to all brokers for which the FAIS Bill will be the instrument of oversight.
Retention of human resources On Tuesday, during a meeting with the MECs for Health as well as at a joint Minmec with Treasury, we particularly pondered how to develop a programme to attract and retain health workers in the rural areas. This is a huge and vexing problem. The only certainty is that its solution is critical to the sustainability of the health care system at the periphery.
I have also instructed the Director-General to work with the private sector, nursing organizations, trade unions and other relevant bodies to conclude a clear framework for attracting and retaining nurses. My intention is to present and debate this framework in the Health Minmec within the next two months. If there is major - and insidious - threat to our overall health effort, it is the continued outward migration of key health professionals, particularly nurses, with a consequent de-skilling of the professional base.
In conclusion, I should point out that we shall be tabling our Annual Report for 2001/2 in Parliament in the next three weeks as required by law. It will include substantial detail on some of the areas I have touched on as well as several others.
I thank you and would like to avail myself and the Director-General to take questions and issues that you may like to raise.