Budget Hearings: Department of Health

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Health

28 April 2002
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Meeting report

HEALTH PORTFOLIO COMMITTEE

HEALTH PORTFOLIO COMMITTEE
29 April 2002
BUDGET HEARINGS: DEPARTMENT OF HEALTH

Chairperson
: Mr L Ngculu (ANC)

Documents handed out:
Achievements and Budget Priorities 2002/3
Expenditure per Sub-programme 2001/2
HIV/AIDS Conditional Grants 2001/2

SUMMARY
The presentation by the Department of Health focused largely on decreasing morbidity and mortality in terms of maternal, child and women's health issues, but also highlighted plans to improve the quality of care, speeding up delivery of primary health care, revitalisation of hospital services, improving resource mobilisation and management, improving human resource development an management, reorganisation of certain support services, legislative reform, improving communication within the health system and the community and strengthening co-operation with international partners.

The following matters arose from the discussion on the presentation:
- the presentation does not mention implementation of strategies and plans;
- future provision of Diflucan by the Department;
- role of the Traditional Leaders HIV/AIDS Forum;
- the number of VCT sites, its staffing and budget;
- pricing of pharmaceutical drugs;
- plans by the Department to take over control of SANTA;
- measures to combat the health care practitioners "brain drain";
- proper training to administer Anti-retrovirals;
- the high costs of laboratory tests; and
- the importance of NGO's and possible areas for support.

MINUTES
The Chair commenced proceedings by welcoming all present, and requested Members to observe a moment's silence for the passing of Minister Tshwete.

Dr Ayanda Ntsaluba, Director General (DG) from the Department of Health (the Department), introduced the delegation to the committee: Dr Kami Chetty, Deputy Director General, Dr Nono Simelela, Chief Director: HIV/AIDS, Professor Melvin Freeman, Directorate on Mental Health and Substance Abuse
, Dr E Mhlanga, Dr Thabo M. Sibeko, Chief Director: Hospital Services, Mr Bennet Asia, Acting Chief Director: District Health System, Mr Gerrit Muller, Chief Financial Officer, Ms D.L. Pearmain, Senior Manager: Legal Services, and Dr H Zokufa.

Briefing
Dr Ntsaluba explained that the presentation follows the Ten Point Plan for 1999-2004 as provided in the presentation, and stated that his briefing would be in the form of a general overview of the Achievement and Budget Priorities for 2002/3. The rest of the delegation would deal in greater detail with the different portions of the presentation.
The DG discussed the following issues:
- the vision and mission of the Department;
- decreasing morbidity and mortality in terms of maternal, child and women's health issues, nutrition, HIV/AIDS and STI's successes and challenges in the improved treatment of TB, cholera and malaria, chronic diseases and the impact of the Mental Health Care Bill.
- improving quality of care regarding the policy framework and challenges, completion of the primary health care (PHC) package and awards for good performance.
- speeding up delivery of PHC;
- revitalisation of Hospital Services, especially in terms of improving education and rehabilitation programmes;
- improving resource mobilisation and the management of resources regarding the study on the impact of HIV/AIDS on the public health sector and the use of technology in the sector;
- reorganisation of certain support services, such as the Medical Control Council and National Health Laboratory Service;
- legislative reform;
- improving communication; and
- strengthening co-operation with international partners.

With respect to decreasing morbidity and mortality through strategic interventions, Dr Sibeko discussed the proposed methods to improve the effectiveness of Emergency Medical Services, especially the finalisation of pre- and in-hospital regulations.

An official from the Department
dealt with Non-Personal Health Services and Health Promotion via the implementation of policies and guidelines.

Dr Chetty discussed Chronic Disease and Disability and the distribution of material on such issues, as well as the five year plan to address Communicable Disease Control.

Dr Simelela dealt with policies, guidelines and programmes in the Chief Directorate on HIV/AIDS and TB. These include the Pregnant Mother to Child Treatment (PMTCT) programme, sustaining Diflucan initiatives, improving STI treatment in the private sector, youth programme campaigns, the importance of inter-sectoral collaboration and training health care workers in an integrated TB/HIV approach.

Dr Zokufa
discussed legislation relating to Pharmaceutical Services, including food fortification and nutritional supplements regulations.

Dr Mhlanga
dealt with Maternal, Child and Women's Health and Nutrition, and discussed Vitamin A supplementation programmes and nutrition campaigns, food fortification programmes, the development of a training package for health care workers, the progress made with the 1998 Saving Mothers Report, Contraceptive Service Delivery Guidelines and Youth and Adolescent policy guidelines.

Professor Freeman
dealt with Mental Health and Substance Abuse, especially policies on alcohol/counter advertising, development of psycho-social rehabilitation and substance abuse prevention and treatment policies and the training of practitioners in the Mental Health Care Act.

Discussion
Dr E Jassat (ANC) inquired whether the portions of the presentation dealing with food fortification relate to milk as well.

Dr Mhlangu replied that this would be looked into.

Secondly, has the Department considered introducing free testing for prostate cancer, so that men above the age of 50 may be encouraged to go for such testing?

Dr Chetty replied that guidelines on this matter are presently being discussed and formulated.

Ms S Mnumzana (ANC) inquired whether a time frame for the fixing of the definition of the term "municipalities" has been set.

Mr Asia
replied that this term is defined in the National Health Bill. Indeed, in a meeting held on Friday 26 April 2002 the Director General called for all such unresolved matters to be resolved within one month. At the moment a narrow definition of this term is preferred, with the provincial structures being responsible for the Primary Health Care Package (PHCP).

Dr Ntsaluba added that the practical problem experienced here is that, while some provinces were ready, others ran into major fiscal complexities. The Department is engaged in discussions with the Departments of Provincial and Local Government and Finance in this regard, but it has to be conceded that this process is moving "slower than expected".

Ms S Baloyi (ANC) expressed her concern at the fact that the presentation focussed exclusively on guidelines and development, whereas implementation was not mentioned at all. A time frame for such implementation is thus required.

The DG responded that the obstacle here is that the Department cannot get around the reality of the Constitutional structure, and if no progress can be made then the Department has no choice but to report the position to the Minister of Health. The Department cannot make any progress if the provinces themselves do not either welcome or initiate assistance or support from the Department. It cannot simply bypass them in addressing the problem that has arisen. The Limpopo Province has, however, set the standard for the rest as it actively informs the Department when it is in need of assistance and is prepared to work with the Department in this regard.

The presentation does mention that the Department plans to complete such implementation by the end of this year. The reality of the matter is that there are certain guidelines and protocols that have to be complied with in the implementation process, as these ensure that quality health care is delivered.

Secondly, clarity is requested on why Diflucan is not available at all the sites, and whether the Department will top up provisions should the supply run short.

Dr Simelela replied that it was not the Department's intention to make Diflucan available at all these sites. The training activities have to be completed first, especially the establishment of a referral system. The model adopted by the KwaZulu-Natal province employs a cascading system of training, and this model has exhibited the best results to date.

It is expected that the Department, via an agreement with the Pfizer pharmaceutical corporation, would be able to provide the necessary funds for this treatment as the Diflucan patent expires at the end of 2002, which means that the costs involved in supplying it would drop significantly.

Dr Ntsaluba added that the generic version of Diflucan will be available at the end of 2002 even if Pfizer
does not continue its Diflucan programme, because of the expiration of the patent.

Thirdly, it was mentioned during the presentation that the current cure rate for TB stands at 85%, but clarity is requested on the accuracy on this figure in view of the increase in HIV/AIDS and the connection between the two.

Dr Simelela replied that 85% is merely the target cure rate, as the current cure rate stands at 60,5%.

Dr Ntsaluba added that there are certain demarcation and training districts that have achieved these cure rates, but the national average is less than 85%. The current treatment interruption rate stands at 17%, but the target figure here is below 10%.

Ms S Kalyan (DP) required clarity on the Traditional Leaders HIV/AIDS Forum, such as when it was established, who exactly its members are and its mandate.

Dr Simelela replied that that forum itself devised its own mandate, and its members initially regarded the forum as a platform to canvass and resolve political issues. Provincial representatives have since become Members of the forum, and these have defined their own mandate, as well as means to increase awareness and education regarding HIV/AIDS issues. The forum has initiated and hosted its own provincial workshops on HIV/AIDS because it sees itself as a critical role-player, as does the Department. The Department only builds capacity and provides the forum with training and information.

Secondly, clarity is also requested on the 359 VCT sites mentioned in the presentation, such as the total number within the Republic, its budget, the current number of HIV/AIDS counselors and the projected counselor to patient ratio.

Dr Simelela replied that it was decided in a 2001 Minmec meeting that the target would be set at reaching 12,5% of the population within three years, and the goal was set at 500 sites. These were identified by province, and 359 sites are currently operational, as stated in the presentation. The problem here is that this system is flawed in principle because it requires health care workers themselves to provide this service, but it has recently been established that this is not the answer and lay workers should instead by employed. This in turn causes an additional problem because lay workers are not properly equipped to administer all the tests, and thus only provide HIV/AIDS status counseling. An extension of the existing boundaries is thus required so that different health care workers may provide their services.

It is difficult to fix the precise ratio of counselors to patients because there are different types of counselors and counseling being provided, and there is an increasing need to invest in lay counselors. Training also has to be provided for such counselors.

Ms Kalyan reiterated her previous question on VCT's, and requested clarity on the budget amount for the 2002/3 financial year regarding both infected and affected groups, as well as the target of 500 sites and the number of counselors expected to be trained.

Dr Simelela replied that the budget has been projected at R22m, and would be rolled out by the end of this financial year.

Dr I Cachalia (ANC) expressed his uncertainty at the fact that the notification of the AIDS status of partners was mentioned during the presentation, as he was under the impression that HIV/AIDS is not a notifiable disease. How then does the Department plan to handle this issue?

The DG replied that the former Minister of Health published the regulations on notification just before the 1999 Elections. The dominant view that arose from the public hearings held by this Committee was founded in a human rights approach which caused the Department to adopt a cautious approach to this issue. The matter is once again under discussion, and it has to be agreed that some sort of notification system is needed. Cabinet has decided, based on a report compiled by Statistics South Africa on current mortality trends within the Republic with respect to HIV/AIDS especially, that the present uncertainty regarding the impact of HIV/AIDS has to be clarified. This Committee should consider rounding up the public's view on this.

Secondly, clarity is requested on the institutionalisation of patient development structures and support services outside health care institutions.

Professor Freeman
replied that the aim here is to empower local support service providers with better training, so that patients may then be handed over to them. This exercise is done at low cost. The problem arises when the Department wants to transfer portions of its budget to these service providers, as Department officials are reluctant because they are not absolutely certain that they would use the funds properly. It has however been shown that the incidences of relapse by these service providers are very low. They also have to be trained in managing and using funds, as well as in accounting principles, as part of the general training process.

Thirdly, the current state of the pricing of pharmaceutical drugs is out of control. It is believed that policies are being devised to establish a pricing committee. Clarity is requested on this.

Dr Ntsaluba responded to Dr Cachalia's question by saying that this is an important concern, but informed Members that good initiatives are being taken by medical schemes
in particular, which have implemented a plan to ensure greater promotion of generics. This initiative, amongst others, decreases the prices of pharmaceutical drugs. The Pricing Committee does not set prices as this is done by the pharmaceutical industry itself, and no single clear fee is established. The Pricing Committee can consider international pricing trends, and if it decides that a particular price is unreasonable high, it can employ other incentives to correct this, such as parallel importation. Yet these measures may only be taken if the price set by the industry is unreasonable.

Mr M Ellis (DP) referred to a statement during the presentation that the Department would be assuming responsibility of South African National Tuberculosis Association (SANTA) hospitals because of the trouble they are currently experiencing. Clarity is requested on the reason for this decision.

Dr Ntsaluba replied that one of the primary reasons here is the misalignment of SANTA's TB policies with those of the Department, as the former focuses on in-patient care and does not follow up on Direct Observation Treatment Strategy (DOTS) care. This impairs the quality of care provided to patients, and this problem, it was alleged then gave rise to strife within SANTA, as Mr Ellis mentioned, with regard to the difficulty being experienced with its CEO. The Department has conducted a study that has illustrated that it has to take active steps to address this issue, so that increased synergy between the provinces and SANTA may be ensured and maintained.

The Department also considered whether it alone should provide the services offered by SANTA, as SANTA does not operate within the North West Province, and that province is
doing great by integrating TB into the general community package of care. It was thus decided at a Minmec meeting that the Department should move to take over control of SANTA over a three year period, as a forensic audit was completed on SANTA which illustrated irregularities within its structures. The Department thus recognises and is addressing a series of problems with SANTA, but remains mindful of its good elements which have to be included in the new structure.

Secondly, the presentation also refers to addressing the issue of the ownership of pharmacies, but as far back as 1997 this Committee passed Act 88 of 1997
that was aimed at addressing this very issue. It thus seems that five years down the track the Department now wants to amend this piece of legislation, clearly indicating that the issue has still not been resolved. Clarity is thus requested on the reason for not yet effecting these changes.

Dr Ntsaluba responded that the need for these amendments arose after the resolution of the court case in April 2001. The Department is also looking at amending Act 101 of 1965
.

Thirdly, it was mentioned during the presentation that the Department would explore and develop a model for local manufacture, and clarity is requested on which local companies would be involved here, whether any progress has yet been made and how the incentives plan would operate.

Dr Ntsaluba said that the Department is engaging with the Departments of Labour and Trade and Industry in this regard, and the first local pharmaceutical companies to be considered are those with a strong generic base. This does not mean, however, that the smaller or up-and-coming manufacturers would be excluded. The Department has examined the models in place in countries such as India, Egypt and Iran where the private sector manufactures the drugs in terms of a series of partnerships with the State, who in turn provides incentives for such manufacture.

A Member (ANC) asked whether the Department has devised a strategy to combat the current "brain drain" problem, because the Government spends significant funds in training health care workers who are then just grabbed by other countries. This is done at great cost to the government, and is disturbing.

Dr Chetty explained that the Department is currently developing a comprehensive strategy on the migration of health care personnel both internationally and internally, from rural to urban areas and from the public to the private sector. This document contains an extensive of review of international developments in this regard. One strategy that has been identified is an International Code of Practice, which has been developed by the Task Team that is presently evaluating what can and cannot be done in this strategy. In this regard the models of the Commonwealth countries are being considered.

It is interesting to note that these countries recruit health care practitioners from each other, with the United Kingdom recruiting South Africans, and the United States doing the same to British health care workers. It would be more feasible if an exchange programme with these countries could be devised, allowing South African health care practitioners to practice in these countries for a limited period, but ensuring their timeous return. Furthermore, post-contractual binding could also be employed to retain their services within the Republic. The World Health Organisation (WHO) has conducted a study on such migration patters, and has also offered reasons for these.

Dr A Luthuli (ANC) said it has been reported that some private health care workers are administering anti-retrovirals (ARV) despite the fact that they are unclear on how to manage their patients. The Department is requested to explain any guidelines it has planned to assist in this matter.

Dr Ntsaluba replied that this is an important issue, and the Member is correct in her statement that ARV's are being administered without a proper understanding of the consequences, which in turn creates a bigger problem as all sorts of combinations of these ARV's are being prescribed. The Department has prepared guidelines for use primarily in the public sector, and it is expected that this would instill a correct approach to the use of ARV's. This issue is made even more important by the fact that insurance is now being provided for persons undergoing ARV treatment, and this figure currently stands at approximately 1 million to 1,2 million people. There is therefore a need to monitor the use of the ARV. The Department has to ensure that these insurance schemes adhere to the proper protocol, as done by MedScheme in its "Aid for AIDS" scheme which requires those health care practitioners that administer ARV to be properly accredited.

Secondly, the Department is requested to explain whether it has devised any plans to address the problem with the high costs of the laboratory tests.

Dr Simelela responded that a South African scientist has recently developed a fairly inexpensive model for such tests, and the Department is currently discussing the matter with him. The Department is also looking at international trends to identify more cost effective methods.

Dr Ntsaluba added that 45-50% of the costs of care provided are covered by pharmaceutical drugs, with the remainder used for laboratory tests. The fact that the new laboratory test mentioned above has been found essentially cuts these costs by two-thirds. This is a significant reduction and one that has attracted much international attention.

Ms S Rajbally (MF) stated that the support services provided by the NGO's are important as they are rooted in the grassroots, and they believe they have much to offer but the problem is that they do not possess sufficient resources. They should be subsidised so that they can better utilised to serve the community.

Dr Simelela replied that the Department has worked closely with the NGO's, but there are certain critical things with regard to funding that have to be addressed. The national budget allocated for their funding has increased, but the Department cannot call for more NGO's but should rather look to improve their current operation standards. In this regard they have to be informed of standard practices regarding the maintenance of records and reports on their expenditure. Furthermore, several NGO's assured the Department that they are capable and authorised to handle HIV/AIDS treatment, but it was later discovered that they had provided fraudulent certificates on such competence. A large amount of these had been received regarding HIV/AIDS treatment as it is the new disease on the scene.

A national mentorship programme has also been established in which funding to the larger Community Based Organisations (CBO's) is increased so that they may take two smaller organisations under their wing and develop them over one or two years. National funding for this project currently stands at R40m.

Dr Ntsaluba added that it cannot be denied that NGO's do contribute significantly, as a starting point, especially the good work being done in the HIV/AIDS and TB areas.

The meeting was adjourned. The Committee did not reconvene after lunch.

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