National Health Laboratory Services & Medical Research Council: Strategic Plans & Budgets 2009/10

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Health

23 June 2009
Chairperson: Dr B Goqwana (ANC)
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Meeting Summary

The National Health Laboratory Services (NHLS) noted that in its first years it had needed significant interventions to resolve problems with financial stability, and the current focus would be on the human resources and customer relations aspects. Its mission was to provide quality, affordable and sustainable health laboratory and related public health services; to train for health science education, and to promote and undertake health research in support of health care providers in their delivery of health care to the nation.
There were huge challenges around the affordability of NHLS services to the public health sector, notwithstanding that it was significantly cheaper than private laboratory services, and this created complaints and a number of outstanding debts from the provinces. Another challenge was the need to improve turnaround times and NHLS had now invested in IT support to have results available on the internet, and remote control technology, including using a remote control aircraft where individuals could collect the specimens and, using GPS technology, could launch the aircraft. NHLS was affiliated with nine Medical Universities and eleven Universities of Technology. It had in the previous financial year spent R178 million in the training of lab assistants, medical technicians, medical scientists, medical technologists and registrars. It needed to have a twenty year plan to look at infrastructure and staffing, as the strides in technology meant that more work could be done by less staff and in smaller buildings.

Members asked for clarification on the statistics relating to KwaZulu Natal, governance issues, specifically the reduction of Exco from eleven to eight people in March 2009, and the impact upon existing staff of the probably downsizing in years to come. They asked if the private sector was paying for services used, and questioned what could and was being done about the failure of the provincial departments to pay on time, including the Committee taking this up through the appropriate channels. Members also asked what was being done to try to reduce costs, whether there were security risks in the use of internet, the types of complaints received, the need to further improvement turnaround times, particularly at remote clinics, and whether there was cooperation with the Department of Science and Technology.
 
The South African Medical Research Council (MRC) noted that its objects were, by using research, development and technology transfer, to promote the improvement of the health and quality of life of South Africans, and to abide by Ministerial instructions to undertake certain research. It set the perameters of its research from the Statistics SA classification of the main causes of death in South Africa, but also used data from the Department of Home Affairs and Actuarial Society. One anomaly was that HIV / AIDS was still 22nd on the list of causes, whilst the top three were Tuberculosis, influenza and pneumonia, and “unknown causes”. However, HIV and AIDS might still be an underlying cause in those categories. HIV and AIDS were research priorities, along with tuberculosis, and chronic diseases, hypertensive diseases and cancer were other focus areas. Violence and injury also caused many deaths. The MRC described how its budget was derived and spent, noting that the majority was funded from non-government sources, although it would like to see this alter. 62 PhD students had been graduated from the 40 research units, and there were 206 more PhD students, or whom 42 black African students were directly funded by MRC. One of the major breakthroughs in the last year had been publication of research on the new TMC207, developed in a public/private partnership, and which, when added to other second line TB drugs, had made significant breakthroughs in speedier treatment.

Members asked whether the priorities were up to date, given the reliance on 2000 and 2004 listings. Several were concerned about the use of Department of Home Affairs statistics, asked questions about the employees, who were not part of a union, and the professional staff associations, questioned the per capita spending and accuracy of the data, and asked why HIV /AIDS was listed 22nd on the causes of death, given other information that would put it higher. Members felt that other areas needing more research included misuse of alcohol and its attendant problems, circumcision and HIV / AIDS, and obesity and cancer. They questioned whether anything was being done, in public/private collaborations, to ensure that the large companies did not benefit at the expense of the country and the poor. Members also wanted to hear whether the PhD students were contributing now to future developments, whether there was an employment equity plan, how it would communicate its research, whether there was alignment with government activities, and oversight over how the budget was rolled out.

Meeting report

National Health Laboratory Services (NHLS)
Mr Sagie Pillay, Chief Executive Officer, National Health Laboratory Services, noted that he had assumed his current post in December 2008, having previously been CEO of an academic hospital. He noted that the
NHLS was one of the success stories for the public health system, and had now repositioned itself to support the rest of the public health system. He said that when NHLS had, during the first five years of its existence, had some major challenges around financial stability, and the interventions put in place at this time had meant less focus on the individuals in the organisation. Since it depended on a variety of health professionals, scientists, and technologists, that area needed more attention. There also needed to be more focus on the customer needs.

The purpose and mandate of NHLS was to provide quality, cost effective and sustainable health laboratory services and related public health services, to provide training for health science education; and to promote and undertake health research in support of health care providers. It had a Board, who appointed the CEO and Senior Executives. Each of the four regions was set up with one or more academic institutions. In 2005 it had had 3 880 employees, which had risen by March 2009 to 6 458. It still needed more staff. He highlighted the movement of executive management and its race and gender profile.

The first objective to provide health laboratory services extended to all public sector healthcare providers, both in and outside South Africa, and any private health care provider that requested such services. It supported primary health care clinics, district, regional and tertiary hospitals, the National Institute for Communicable Diseases and the National Institute for Occupational Health. There were 268 laboratories across nine provinces. KwaZulu Natal had been included only 2 years ago but already showed increased demand for services. It covered 4 036 primary health care clinics with a daily coverage of 2 904. Daily coverage varied over the provinces between 72% and 95%; but the aim was for 100%.

NHLS focused on providing information to provincial coordinators, on tuberculosis (TB), cervical cancer screening, CD4 counts and HIV/PCR 8. There were fifteen TB culture laboratories around the country;63 laboratories dealing with CD4, 18 dealing with viral loads and eight for HIV/PCR. 

Mr Pillay said there were huge challenges around the affordability of NHLS services to the public health sector. NHLS was significantly cheaper than the private sector, and it also contributed to teaching, training and research. The approved tariff for last year was 2.2% but it averaged 2%. In the current economic environment, where it had to respond to salary increases and the weakening of the Rand (this was important because most of the equipment was imported), this was a very low overall price increase. However, even at these low price levels, the public health system was not able to respond to the demands of patients or their ability to pay its bills.

Service delivery issues were important and were tested in relation to customer satisfaction, measured through customer surveys, comparisons with worldwide technical quality, benchmarking against international standards and internal mechanisms and functional audits to measure excellence. One its major challenges remained the turnaround time. It had developed an IT system to have results available online to those provinces who had access to the internet. However, in rural areas there had been remote control technology installed to print results via SMS from laboratory to clinic. Hard copies would be used as backup. It was possible to have laboratories at central points, which could then do cost effective and fast testing at that site when specimens were delivered there.

He noted that in the rural towns in the Eastern Cape, and the villages in Limpopo and Northwest, NHLS was at a very advanced stage of developing remote control technology, around TB in particular. NHLS was in the final stages of piloting a remote control aircraft, which would use GPS technology to launch the aircraft for collecting specimens. It was training schoolchildren in this technology, and how to manage and maintain the aircraft, helping them not only to earn something but also to develop their interest in maths and science. All this would help significantly in turnaround time responses.

Mr Pillay noted that public health services included the National Institute for Occupational Health (NIOH) and the National Institute for Communicable Disease (NIC). NICD undertook training, the surveillance and monitoring of communicable diseases, outbreak response and management. It had a very high international profile; good communication and consultation; and its research was widely applied and was operational. One of its significant successes was the South African Field Epidemiology and Laboratory Training Programme (SAFELTP). Because NICD was a centrally based organisation, the training of epidemiologists would allow these scientists to work in the provinces, where they would be closer to major disease outbreaks.

NIOH had recently appointed a new Head who was keen and committed to improving occupational health in South Africa. It responded to the needs of 11.5 million work health-related issues; supported the development of occupational health services in South Africa and also in the Southern African Development Community (SADC) countries, and there was currently a multidisciplinary team of 100 staff, consisting of scientists, technical and support personnel.
 
Mr Pillay said that NHLS had huge challenges in attracting and retaining pathologists, technologists and other health professionals in its team. Ongoing and increased training was key, but a major difficulty was that NHLS did not have a ten-year plan around the needs for health professionals. NHLS was affiliated with nine medical universities, had an affiliation with eleven Universities of Technology, had signed umbrella agreements with all of them and was at the point of developing bilateral agreements in negotiation, so that they could jointly facilitate the increase in the numbers being trained. In 2008/09 NHLS spent R178 million in the training of laboratory assistants, medical technicians, medical scientists, medical technologists and registrars. Education and training would close the gap between what the NHLS currently had and what it would in future need. It also must find ways to bring down the costs of providing laboratory services. There was a need to look at better and cheaper ways of doing things, to consider how, in a scarce resource environment with scarce expertise, technology and other elements could be used to achieve the goals. 

Mr Pillay noted that while NHLS was awaiting the strategic plan of the Department of Health (DOH) it had drawn up a focus plan for one year. NHLS was conscious of the deteriorating global economic environment, which meant less money for health care than there should be. Other challenges were the changing demography and burden of disease, high healthcare inflation, some policy developments, skills shortages, attaining the technological advancement that would enable it to pass quickly through various stages of development, and problems around debtors.

Mr Pillay said that work still needed to be done on customer perceptions, the challenges around training and development, improving employee satisfaction and morale, changing the culture of the organisation, improving its communication, media and marketing, service and technical quality and its financial stability and costing modes. There was also work to be done around infrastructure. Given the rapid changes in technology, NHLS did not have a sense of how it should look in twenty years. Laboratories would be getting smaller, not larger, and would require less, not more, staff. Technology could reduce both the number of sites and staff. Having larger buildings was not the answer. For this reason, long term planning was needed for the next twenty years to investigate the optimal human resources, infrastructure and technology.

Mr Pillay then outlined the strategic objectives for 2009/10 as including improving accessibility to services and on-time delivery. It would assist and support government in national priority programmes, disease surveillance and outbreak response. It would prioritise academic relationships, but also foster good stakeholder relationships and undertake, promote and support research. Accurate and accessible information would be provided to stakeholders on time. It would have to manage and mitigate risk, improve its processes through technological advancement and provide access to laboratories for the whole country. There was a need to improve the work environment. More women were choosing technology sciences as a career and therefore the workplace would have to be restructured to enable them to continue in their chosen professions whilst also attending to their family responsibilities. Skills would be enhanced and more attention would be given to retention of staff. There might be a need to recruit internationally to close some gaps. Transformation and the current gender imbalances would be addressed. Marketing, branding and communication would improve, and attention would be given constantly to financial sustainability in services, research and health science education. In this regard, he noted that the NHLS was owed about R1 billion by the provinces, which was seriously undermining IT and technology and research objectives. It was now charging interest on unpaid bills. Discussions had been held and were proving useful.

Mr Pillay said that operational efficiency issues remained a challenge. The public health system was the largest consumer of waste management. It put out a tender but could not find providers, and was currently looking at strategic partnerships with the private sector. Accreditation by the South African Bureau of Standards (SABS) was sometimes not fast enough and some health care issues should be prioritised. 

Discussion
Ms T Kenye (ANC) asked for clarification as to why the statistics on personnel excluded KwaZulu Natal.

Mr Sagie Pillay responded that when NHLS was initially created KwaZulu Natal was not included, although it had been included as from 2006.

Ms Kenye asked about governance issues, specifically the reduction of Exco from eleven to eight people in March 2009, especially given the huge amount of work to be done. She also asked whether there were mechanisms to revive the neglected structures if necessary.

Mr Pillay responded that although the numbers of Exco members had been reduced, there were individuals still dealing with the roles. It was a conscious decision not to fill those positions until the strategic decisions had been taken for a new organisational structure. In fact it was felt that this particular level perhaps did not require strengthening, but that this should rather happen at the regional level.

Ms Kenye noted that the provinces were often failing to pay for NHLS services, and asked if the private sector was paying for services used.

Mr Pillay noted that NHLS was a self-funding organisation and had to generate sufficient revenue to cover operational costs, including staff, to cover the costs of training and research and to have a small surplus. The bulk of that revenue came from the public health system. A small percentage of private sector services would be called for. Most of the public hospitals had only 2% to 3% of their patients on health insurance. The systems needed to be realigned to be able to pick up which patients were on medical aid.

Mr Waters said that he was concerned about the outstanding debts owed to NHLS, and asked what the reasons were why the provinces were not paying on time. He also asked that any provinces not paying be referred to the Committee, which could take this up through the relevant structures.

Ms M Segale-Diswai (ANC) said, in relation to the debts, that laboratory services should be paid through conditional grants. There was often a mix-up in the forms used, so that some specimens that were supposed to be paid through conditional grants were not submitted on the correct forms, which meant that the service provider had to pay from the equitable share, which was never enough. This was one reason why there would be under spending on the conditional grant at the end of the financial year, but the equitable share would be completely exhausted. She suggested that there was a need for better training of health professionals, to ensure that they worked as a team, if the failure to fill in correct forms impacted on payment.

Mr Pillay said that NHLS recognised that sending letters and strong emails to individuals did not work, so NHLS would now insist upon more face to face meetings with the individual institutions, and, if this still did not elicit the payment, then with the respective provinces.

Mr Pillay said that if the NHLS was able to see to the proper setting up of mechanisms on the hospital side, then a lot of that money could easily be paid through the conditional grants. NHLS was working with the provinces and had already flagged that as an issue. Pathology payments needed to go directly to NHLS as opposed to going to the provinces.

Ms E More (DA) said that in most tertiary hospitals laboratory services were the biggest cost drivers. She asked if there was any strategy or plan in place to reduce that cost, working together with the Department of Health.

Mr Pillay said that while NHLS was cost effective, it was not necessarily yet still affordable, and the cost centre management system would deal with the questions posed.

Ms More said that Mr Pillay had spoken of internet being used for improvement on turnaround times and asked whether confidentiality might not be compromised through hackers.

Mr Pillay responded that NHLS was very conscious of threats to the important IT technology. He noted that there were protection measures in place before anyone could access results; such as conditions and passwords and this was constantly monitored by the IT division.

Ms More asked what types of complaints were received from the unsatisfied customers

Mr Pillay said that he had only been in the institution for a short time, and so his answer would relate to what he had gathered from his visits to provinces and institutions and his meetings with individual physicians. NHLS would put in the tools to measure what exactly the concerns were, but he had gathered that complaints ranged from people feeling they were over-charged, or over-serviced, or that the NHLS had been attending to inappropriate matters. Some were valid, and  NHLS needed to sit down with the provinces and understand what the circumstances were in which the concerns were raised. NHLS wanted to focus on providing service that was appropriate, setting up mechanisms that the provinces and NHLS could monitor, and there was already significant progress.

Ms More noted that advances in technology meant that less human staff were needed. She asked what would happen in terms of retrenchment.

Ms A Luthuli (ANC) said that one of the human resources development challenges was named as inadequate budget. Although a reduction might be achieved by having less staff, she was concerned that this would lead to unemployment, and questioned what the unions would say to this.

Mr Pillay said that this was not a threat in the short term. Most of the skills were found in five or six urban areas, and some of these staff could be transferred to support provinces that were hopelessly understaffed. People were also leaving the system, so in the short to medium term there was no suggestion of retrenchments.

Ms Segale-Diswai noted that management of TB, particularly sputum turnaround, was still a problem. A patient might arrive at a clinic after the courier had called, so the patient had to come back on another day, which he might not be able to afford. She asked what the NHLS would do to ensure that it did not inconvenience poor people.

Ms A Luthuli (ANC) noted that she had worked in hospitals and in private practice, and remained convinced that medical bills and the cost of laboratory investigation were too high, and asked what was being done. She too stressed that quality health must be delivered to all South Africans, including the very poor.
 
Mr Pillay reiterated that in fact NHLS was a very cost effective service, being 50-60% cheaper than the private sector, although he recognised that one of the challenges was that even this was not affordable to many. One of the challenges for NHLS was its lack of a costing system to give a sense of what investigations actually cost. This was flagged as an important issue in the strategic plan.

In terms of the service, Mr Pillay said that there were no major problems with Gauteng and the Western Cape, but most of the other provinces continued to be a challenge. Resources available to treat outpatients were nowhere near adequate to provide the kind of services NHLS wished to provide. Problems were wide-ranging across institutions and regions. NHLS was trying to quantify where the issues were. It would help if the Committee could bring pressure to bear on the provinces, so that there was better cash flow. 

Dr S Pillay (ANC) noted that at NHLS was conceived from the forward thinking of the new Government. Laboratory services was a scarce skill, which was why the cost of it was so high in the private sector. NHLS was formed to try to provide affordable services for the approximately 85% of the population not on medical aid. The intention was that when the NHI scheme became operational, NHLS would become an asset of government delivery systems. He questioned how NHLS was moving to that vision. He wondered how it would become more cost effective,  and how bring about cost savings to the Department.

Mr Pillay responded that NHLS should become a provider of choice in South Africa for any institution, public or private, and had the potential to become the benchmark for the new NHI.
The issues around loss of results and duplication were real issues in NHLS, which was already engaging with institutions and provinces. The NHLS needed to be better aligned with the provincial systems. Improved efficiency was needed on the service delivery side. He suggested that investment must really be made in electronic patient health records because that was the platform to solve a lot of those problems.

Ms Tshwete asked what was the role of science and technology in addressing some of the challenges.
 
Mr Pillay said that NHLS had not been as active as it should in communication and marketing, but there was some interaction with the Department of Science and Technology (DST), which was undertaking a review of the NHLS and looking to its future technology needs as well as the raising of the profile.

He noted that the current plan was a three year plan consistent with the medium term expenditure framework (MTEF), which would end in this financial year. Everything done in terms of the sixteen priority areas identified was properly aligned with the Department’s plan. NHLS would again align with the Department once the DoH had finalised its ten-point plan.

Mr Sipho Mahlati, Regional Executive Manager, NHLS, said that although he was intending to add some detail to the responses by Mr Pillay, he would not do so now in view of the time constraints.

Medical Research Council briefing
Professor Anthony Mbewu, President, Medical Research Council, noted that the MRC was a statutory council to conduct research, development and technology transfer in order to improve the health and qualify of life of the population of South Africa. Health was, by virtue of the Constitution, a human right and a public good. Although South Africa was classed as an upper middle-income country, there remained huge divisions between rich and poor and these were reflected in the disease burdens that varied according to socio economic status. 23% of South Africans lived on less than R8 per day. There was a high rate of unemployment and many required social grants. Infant mortality was high and 12% of the population was living with HIV/AIDS.

MRC placed its research agenda in the context of government’s plans for health system reform in South Africa. South Africa’s health policy was a national function and healthcare delivery was a provincial function, so many of its interactions were with the National Department of Health, but its activities in research and development also engaged the provincial departments of health. MRC was aware of government’s plans for National Health Insurance to try to ensure that the disparity in the quality of care received by patients in the private sector compared with those in the public sector be removed.

The research strategy and business plan formed 60% of MRC’s core business. The financial model was aimed at giving professional support fro research, but also covered opportunity and risk management, capacity development, and transformation and development through improved health care policy, improved heath care practice and improved health care products (drugs, vaccines, traditional medicines or medical devices), as well as health promotion. It held values around communication, accountability, respect, excellence and innovation and development.

In terms of its governance, Prof Mbewu noted that MRC was a statutory council reporting to the Portfolio Committee on Health through the Minister of Health. Its research was led by Dr Ali Dhansay. MRC had forty research units, of which twenty-five were within the universities and medical schools of South Africa.

The research agenda was informed by the health problems that South Africans faced. One of the principle ways that MRC evaluated its health priorities was through the National Department of Health’s congress that looked at issues of mortality and mobility, and arrived at a ranking of the health priorities of South Africa. The last ranking had been done in 2006 and the research portfolio was aligned to these priorities. Statistics South Africa (StatsSA), when listing the principle causes of deaths in South Africa in 2004, had noted HIV in 22nd position, with the top three positions occupied by tuberculosis, influenza and pneumonia, and ill-defined “unknown causes”. However, since more than half of those deaths involved people living with HIV/AIDS, it could be said that in fact HIV/AIDS was the leading factor leading up to the death from those other diseases. HIV/AIDS was thus the research priority of MRC, receiving almost half of its research expenditure. The second most important research priority was TB. South Africa was also burdened with chronic diseases -  heart disease, events of undetermined intent, stroke, and hypertensive diseases. This was a growing problem in South Africa and as the socio economic status of many of the people improved, so would the prevalence of chronic diseases increase. The third major cause of death in South Africa was violence and injury, and much research was devoted to try to find ways of preventing homicides, sexual violence, road traffic deaths and similar situations. He noted that R15.7 million was spent on HIV/AIDS and R7.6 million on TB research, with R4.9 million spent on cardiovascular disease, which was a growing problem. R5.9 million  was spent on cancer research in collaboration with NHLS.

Prof Mbewu noted that 42% of the MRC income was from Government, and 58% from external sources; of the latter around 82% came from international investment, mostly around HIV/AIDS. The total budget of MRC was R536 million. Half of the research component of that was devoted to HIV/AIDS. MRC produced 550 journal publications every year, as well as chapters in books, technical reports and policy briefs informing the NDH and stakeholders about the research and its relevance to policy or health care practice.

He described the major breakthrough involving the Centre for Stellarmolecular Laboratory Research Unit at Stellenbosch, and the Clinical and Biomedical Research Unit in Durban, who had published the results of a clinical trial from the TB Alliance (a public/private partnership with Johnson and Johnson) with the new agent TMC207. This agent, when added to five second-line drugs used to treat Multi Drug Resistant (MDR) TB, was able to achieve sputum conversion in patients three times as quickly as the previous five-drug regime. This was the first new TB drug in thirty years and would address the major TB problems in South Africa.

Prof Mbewu said that MRC had received an unqualified report. MRC spent 60% of its expenditure on research. 62 PhDs, being 10% of the total science and technology graduates in South Africa, had, during the last financial year, graduated from the 40  research units. 5% pf its budget went to human resources – internships, bursaries, PhDs. There were 206 PhD students in the forty research units. The MRC directly funded 42 black African PhD students, one of the key targets being to increase the number of black South Africans undertaking PhD studies in health research. Transformation in the MRC was progressing but needed to be accelerated. 82% of the 820 employees were black, of which 49% were black African and 68% were women. He tabled and described the increase in the government grants, external income from contracts, grants and services. However, he said that he did not consider that it was advisable to have 58% of budget derived from external income was healthy. MRC would prefer to receive more money from government, to ensure it could address the health research issues that the Department of Health, the Department of Water Affairs, the Department of Transport and the South African Police Service (SAPS) had.

Discussion
Ms F Bikani (ANC) felt the document needed to be updated, especially relating to the budget and health priorities.

Ms P Tshwete (ANC) thanked Prof Mbewu for his presentation, but felt that Prof Mbewu had not addressed the gap that he indicated he would speak to. She said that this large gap was shown by comparing the Burden of Disease Study of 2000, setting out priorities, and the budget of 2009. She noted that more staff associations would be formed, beginning with the Young Scientists Forum, to improve communication, and in this regard the document had not said what had been achieved. 

Prof Mbewu responded that the MRC Board approved the budget in February 2009, to operate for the financial year April 2009 to March 2010. The numbers in the business plan document were funds allocated for those particular priorities during the last financial year. The expenditure, baseline and total budget figures were accurate and up to date.

Prof Mbewu agreed that the national Burden of Disease Study 2000 needed to be updated. However, after that study was done, MRC continued to monitor trends in terms of death and disease in South Africa using mortality data from the Department of Home Affairs on an annual basis. The cause of death list was updated every four to five years; the latest dated from 2004. The research agenda of the MRC was, in 2009, still informed by the cause of death data of 2004, but it was further informed by the annual figures. It was not relying on the data from 2000. 

Prof Mbewu noted that MRC did not have a union for its 820 employees because the employees chose not to unionise. It was difficult to hear the voice of employees in the absence of a body to articulate their concerns, therefore it encouraged the formation of professional staff associations.

The Chairperson said the Committee would have to engage with MRC again, as outdated data could be a problem. However, the focus of today’s discussions should be on budgets.

Dr S Pillay (ANC) raised concerns that the MRC was the authoritative body of South Africa for medical research. He questioned some of the figures in the document relating to the per capita spending, noting that if the budget was about R67 million and the population around 48 million people, of whom 12% suffered with HIV/AIDS, then the figures did not seem to tally.

Dr Pillay noted the comment that in 2004 HIV was named as 22nd on the list of causes of death. He drew on his experiences in practice filling out forms that requested the primary and secondary causes of death, or underlying reasons for death and said that these should perhaps be properly interrogated to ensure that the statistics were accurate. He questioned whether the Department of Home Affairs, not being a medical institution but a population registry, was the appropriate place to obtain these statistics. He feared that reliance on their figures might create a denialist attitude.

The Chairperson noted that MRC had only used the data from Home Affairs as a guide to where it should concentrate research.

Mr M Waters (DA) was concerned that MRC used causes of death to determine health priorities. He noted the comments on the data sources, but expressed concern whether the data by the Department of Home Affairs, which had in the past suffered considerable corruption, was verified against any other data.

The Chairperson said there were two kinds of rural areas – the distant villages and those on the farms. Both NHLS and MRC wished to better the lives of South Africans, but it seemed that some of the people in the far rural areas were not benefiting. They often did not have ID documents, and therefore their deaths would not feature on the national system, so he too questioned the statistics.

Prof Mbewu responded that the death data in 2004 was generated by Statistics South Africa. Primarily, medical doctors would certify deaths and he agreed that there was a section requiring the primary cause of death, the underlying cause, and also a confidential part where the doctor could put that HIV/AIDS was the underlying cause. Despite that, there was still reluctance to name HIV/AIDS as an underlying cause of death on the certificate. The MRC received raw death data generated by Department of Home Affairs around numbers of deaths, which enabled the research unit to show that between 1998 and 2006 deaths among young women aged fifteen to thirty were trebling, whilst deaths for men in the same age groups had increased two and a half times. More recent work had shown that those death rates seemed to be declining, and it was suggested that this might be the result of the comprehensive plan putting 780 000 people in the public sector on anti retro viral therapy. The data was up to date and the latest cause-of-death data had not changed much since 2004.

Prof Mbewu stressed that MRC worked with DHA and StatsSA and also received data from the Actuarial Society of South Africa, because future projections were often needed around the likely numbers of deaths from a particular cause. The Actuarial Society’s data was updated every year. Various government-funded agencies working with the MRC had the task of trying to keep track of the various epidemics in South Africa.

Dr Pillay agreed that TMC207 was a breakthrough for TB. Although the drug was produced in South Africa, the results were published in New England and he questioned why the results had not been published in South Africa first.

Dr Pillay added that misuse of alcohol was a major contributory factor to trauma and violence and that should also be highlighted. He suggested the need for better legislation and banning of alcohol and tobacco advertising.

Mr M Hoosen (ID) asked for clarification on ‘contracts, grants and services rendered’ under MRC Income. He understood that some organisations made an investment to MRC in terms of research, in return for some sort of patent.

Mr Hoosen said, in relation to TMC207 and Johnson & Johnson’s involvement, that there was always a debate about big international companies funding research, since they would obtain patent rights and huge income from the medicines. TB was mostly a disease affecting the poor. He asked if there was a policy in place to ensure that MRC did not assist companies eventually to gain huge profits at the expense of the poor.

Mr Hoosen was excited to hear that MRC funded a number of PhD students. He asked whether they were offering return benefits to the Department, the State or the people of the country.

Ms M Segale-Diswai (ANC) asked whether the MRC had an employment equity plan, as she noted only one female black director, and the delegation before the Committee was male-dominated.

Prof Mbewu said that figures on employment equity could be provided; 82% of MRC was black and 68% was female. Of the intra mural directors, 65% were female and 70% black. Clearly, therefore, there was transformation in MRC, but more needed to be done to ensure that black people and women in South Africa had access to research and science.

Ms Segale-Diswai asked how MRC would ensure that an ordinary nurse at a rural clinic knew the importance of research and how it informed her professional role.

Ms Luthuli noted that obesity had become a huge problem in the country. There was mention in the presentation of nutrition, and she thought that this was an area requiring serious work, to come up with the answers and causes of obesity, which would be contributing to other diseases, particularly chronic illnesses.

The Chairperson was concerned about discussing poverty and obesity. He noted that if more funding was available, there would be more reports.

Prof Mbewu said that the obesity epidemic in South Africa was also tracked. The Youth Risk Behaviour Survey, which was conducted in nine provinces on ten thousand school learners by the Health Promotion Development Unit, identified that in South Africa children who were stunted and malnourished were in the same classes as children who were obese. Interactions with the then-Minister of Health around the growing problem of childhood over-weight and obesity was influential in forming the various strategies of the Department of Health around child and adult obesity, over-nutrition and under-nutrition.

Ms Luthuli noted the comment that MRC would like to receive more from government and asked if the funding from overseas investors came with conditions attached.

Ms Tshwete noted that the South African government had almost met the target of spending nearly R1,2 billion per annum on health research, but she asked where the bulk of this spending was going if so little was directed to the MRC.

Ms Bikani asked how both the MRC and NHLS were aligned or attached to government activities in terms of their health priorities, because that did not seem to feature much in their ten point health plan. 

Ms Bikani asked if there were any oversight or accountability strategies in place on the part of the Department of Health, over how the budget was rolled out.

Ms Bikani asked how the forums still to be set up would assist the greater community. She commented that the lack of unions seemed to be excluding the staff from what was happening in South Africa.

Dr Itumeleng Funani, Biobehavioural Clinical Manager, MRC, addressed the issue of unions and associations, saying that this was an internal matter. Previous attempts to unionise MRC had not been successful. MRC realised it was important to talk to employees, especially the interest groups, so it was decided to try to set up the forums so the scientists could articulate their science ambitions directly, rather than relying on third parties.

Ms Kenye referred to the slide on death statistics. She noted that she, being a nurse who knew of the obligation to preserve life and the ethical codes of sanctity and quality of life, was concerned about HIV/AIDS. She asked if the first three mentioned causes of death, being TB, pneumonia, influenza and unknown complications, as well as deaths from diarrhoea and immunity problems had also included HIV/AIDS complications.

The Chairperson indicated that this had been explained during the presentation.

Ms Luthuli asked the MRC whether any research had been done with regard to links between circumcision and HIV.

The Chairperson said he believed that had something to do with cleanliness.

Ms Tshwete asked, looking at the cause of death in 1994, where cancer was listed; perhaps it was now higher on the list. how far were we now in terms of cancer because lately cancer was one of the killer diseases in South Africa, maybe cancer should be higher the list.

Dr Funani said that MRC was working with the Eastern Cape House of Traditional Leaders and a Memorandum of Agreement (MOU) had been signed. Research was ongoing, lodges were visited and information would be coming to inform government policy. Another MOU was signed last year with the National House of Traditional Leaders to conduct a similar national study to that in the Eastern Cape because there was a concern that HIV could be reduced by medical circumcisions, but that had not addressed traditional circumcision. Further research was also being done into behavioural issues after initiation.

The Chairperson believed those people who were circumcised had less chance of contracting HIV, but it all depended on who performed the operation and where it was done.

Ms Bikani asked for a date sooner than September when the Committee and institutions could have more engagement.

The Chairperson said that there was unfortunately no time to answer the outstanding questions.

The meeting was adjourned.

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