Department Budget Analysis

Meeting report

HEALTH PORTFOLIO COMMITTEE
25 April 2002
DEPARTMENT BUDGET ANALYSIS

Chairperson: Mr James Ngculu (ANC)

Documents handed out:
Presentation by Health Systems Trust (see Appendix 1) and Spreadsheet with diagrams/graphs used by HST
Information document on pertinent health issues and challenges (see Appendix 2)

SUMMARY
The Committee was briefed by Health Systems Trust on the comparative changes to the Health budget from the previous financial year. The purpose of the briefing was to empower committee members with the necessary budget analytical tools before their meeting with the Health Department to discuss the Health budget. The briefing focussed on the national budget allocation for Health, contrasting this year's allocation with that of last year.

MINUTES
Mr Solani Khosa briefed the committee on where the increases in the budget allocation went.

A committee memberThe on the increase in allocation for administration. He also touched on the many international meetings that the Health Department hosted last year and wanted to know if they were budgetically allocated for from the start.

Mr Khosa's reply was the increase was only 6%. He said the money was not budgeted for. He said the Treasury released extra funds to cater for that from the money reserves meant for these extraordinary expenses.

There was no time for discussion as the presenter had to catch an early plane flight.

The chairperson adjourned the meeting.

Appendix
Document distributed by Mr Khosa:
REPORT FOR FOREIGN AFFAIRS 5 APRIL 2002

The following document provides some details of pertinent health issues and challenges that should be brought to the attention of South African government representatives abroad.

This document is by no means a comprehensive overview of the health sector, but rather focuses on only those that are considered vital. These are:

1. Primary Health Care Expansion
2. Access to Drugs
3. Maternal and Child Health
4. Hospital Management
5. Tuberculosis
6. HIV/AIDS

This document is longer than originally requested, but is provided for the sake of ensuring a more detailed background knowledge of health issues.

EXPANSION OF PRIMARY HEALTH CARE SERVICES

Creating the District Health System
The Department adopted the District Health System (DHS) as the most suitable vehicle to render primary health care in ways that would assist in eliminating many of the problems inherited from the pre-1994 government. Chief amongst which were: fragmentation; duplication; top.down management; lack of responsiveness to the needs of local communities; inefficiency; and inequity (especially between race groups and those living in rural versus those living in urban areas).

Between 1995 and 1999 the country was divided into 174 health districts, and district health management teams were appointed in more than half of the provinces. It could be argued that in the provinces where municipalities were small, underdeveloped and lacked resources, the provinces were able to create functional health districts. However, the policy intention was always to link health districts to municipalities.

By December 2000 new boundaries were created for municipalities and with the election of local government councillors on 5 December 2000 new municipalities were created. This meant that the district health boundaries had to change to be coterminous with those, of the 6 metros and the 47 district municipalities in terms of a decision taken by the Health MINMEC in February 2001. In theory there are therefore 53 health districts nationally but in practice these are in the process of being established in terms of national and provincial decentralisation strategies that are currently being worked out.

Since 1999 a national DHS competition (more recently called as assessment) is carried out annually using a nationally agreed upon set of indicators. The rationale for this competition/assessment is threefold:

(a) To assist in institutionalising the use of indicators to monitor progress;
(b) To find and share good practices and districts in need of further support; and
(c) To reward health workers and communities who are doing good work often under difficult circumstances.

A number of categories in which districts may compete have been established and districts competed against each other first at provincial level and then at national level. The categories are:

- Urban with and without support (some districts are supported by NGOs to improve systems and service delivery);
- Rural with and without support;
- Metros;
- District with best health information system;
- District with best HIV/AIDS programme;
- District with best quality of care programme.

Increasing access to Primary Health Care
In 1994 then President Mandela announced, as part of the Presidential Lead Projects, that health care will be available free at the point of delivery to children under six and pregnant and lactating women seeking care in the public health sector. This was done in an attempt to reduce ability to pay as a barrier to access to care. This programme was extended to all those seeking primary health care at public health facilities in 1996.

In addition to the above measure, government also undertook a major national clinic building and upgrading (CBUF) project in 1995 in an attempt to improve access to those reliant on the public health sector especially in disadvantaged areas. Under the CBUP 594 clinics and community health centres have been built. Also 215 mobile clinics were purchased, major upgrading done in 249 clinics and community health centres and minor upgrades done to a further 2298 clinics. In addition, municipalities have built a number of primary health care facilities using their own resources to improve access to care.

Government has acknowledged that a strong primary health care system depended on having hospitals to which patients in need for care at other levels could be referred. It therefore undertook the first ever audit of the physical condition of hospitals in 1996 (which found that about one third of all hospitals by value needed to be rebuilt and a further third needed major refurbishment - both of which would cost an estimated R10 billion). Government has embarked on a major hospital revitalisation programme to improve hospital facilities and services. Since December 1998 an amount of R605.3 million has been spent on 492 completed projects in 141 hospitals, and a further R486.3 million is to be spent on 474 projects in 210 hospitals. Provinces have built 14 new hospitals in addition to the three almost XXXXXXX

a) Notification of and confidential enquiry into maternal deaths were instituted in 1997. The Minister of Health established the National Committee for the Confidential Enquiry into Maternal Deaths (NCCEMD), made up of experts in obstetrics and maternity care. The committee produced a report "Saving Mothers", which had recommendations for improved care of women. The processes of notification and enquiry are helpful in identifying preventable causes of maternal deaths, and thus not only quantify the deaths, but also act as learning tools for improved health care. The report is produced every 3 years, and will help guide the Mini sty and Department of Health in identifying factors that must be attended to.
b) Teams of experts from the Colleges of Medicine of South Africa produced protocols and guidelines for the management of the commoner causes of maternal deaths.
c) The Department of Health produced maternity case records and guidelines for the antenatal care of women.
d) The Department of Health also is training advanced midwives in order to enable midwives to care for high-risk pregnant women. These midwives manage these women through to term. These midwives are also responsible for co-ordinating meetings to look at the adverse outcomes of pregnancy and labour. There are centralised and decentralised programmes for training in advanced midwifery and neonatal nursing science, The aim is to have an advanced midwife available at any time a woman is delivering, as this is the time that is most risky in the absence of skilled and competent birth attendant. It is also the aim to have a skilled birth attendant at every delivery'. Training is also open to nurses from neighbouring countries
e) Choice on Termination of Pregnancy Act, 1996 (Act No.92 of 1996) was passed, and enacted in 1997, in order to reduce the number of deaths from unhealthy termination of pregnancy (often by untrained persons under unhygienic conditions). Although the Abortion and Sterilisation Act, 1975 (Act No.2 of 1975) allowed pregnancy termination, the requirements made this inaccessible to poor and rural based people. The new Act is aimed a reducing maternal deaths from unsafe abortions. The act allows nurses and doctors who have undergone specific training to provide termination of pregnancy services. The Act also allows women to make the decision for pregnancy termination without the prerequisite of parental or spousal consent. Implementation of the Act has seen an increase in the number of women accessing this service. Implementation has resulted in more women accessing termination of pregnancy services and fewer deaths from illegal unsafe abortion ("Saving Mothers" report).
f) Contraceptive policy guidelines were launched in 2002. In these guidelines, emphasis is laid on informed choice on contraceptives. The guidelines also include innovative practices such as the Natural Family Planning, community based distribution of contraceptives and reducing the medical barriers to contraceptives. Emphasis is also placed on dual protection against unwanted pregnancy and HIV infection.

Integrated Management of Childhood Illness (IMCI) Strategy
In 1998 the South African Demographic Survey (DHS) indicated that SA has an infant mortality (IMR) and under five mortality (U5MR) of 45 and 59 per 1 000 live births respectively. The main causes of morbidity and mortality are acute respiratory infections, diarrhoeal diseases and malnutrition. HIV/AIDS now contributes significantly to the burden of disease amongst children under five. On the other hand measles, a killer of thousands of children in the past, is now rare. Immunisation is part of the IMCI strategy.

To address the high childhood morbidity and mortality (attributed to these largely preventable illnesses), in 1996 South Africa adopted the Integrated Management of Childhood Illness (IMCI) Strategy developed by WHO and UNICEF.

Status of IMCI in South Africa

- By July 1998, the first Case Management Course was conducted in Mpumalanga Province. Full political and administrative support from the highest levels of government was given for continued implementation.
- By January 2001, all nine provinces were self sufficient with respect to personnel training.
- Four provinces, namely KwaZulu.Natal, Northern Cape, Limpopo and Mpumalanga, are already in their third year of implementation. A health facility survey was carried out in these 4 provinces in May 2001. The objectives of the survey were to obtain quantitative information on the quality of MCI implementation, and to train consultants in Health Facility Survey techniques.
- The MEC for Health in Mpumalanga launched the Health Facility Survey Report on behalf of the National Minister at Health in November 2001.

Community Component

A Household and Community Component working group has since developed the following documents:

· IMCI Household and Community Component: A guide for local level implementers
· IMCI Household and Community Component Developing a communication strategy
· Performing a participatory situational assessment
· Training modules for community workers
· IMCl flyer

Other groups that exist include:
- Adaptation group, which adapts training materials to suit South Africa. These materials include HIV/AIDS. Guidelines, which are in line with the PMTCT protocols, have been developed to enable health workers to identify and manage children with suspected HIV infection. (NB: IMCI is an essential component of the primary health care package)

- Research group, which encourages and monitors research projects, and develops monitoring criteria.
- Pre-service group, which is responsible for pre-service training of nurses and medical students,

Some of the constraints/challenges in the implementation of the IMCI Strategy include:

· Sustained management support of IMCl implementation
· Frequent rotation of health workers immediately after training
· Supervision and follow-up of trained health workers often superseded by other priorities
· Transportation and supplies (medications) shortage is frequent
· Mobilization for the implementation of the Household and Community component

Expanded Programme on Immunisation (EPI)
The ER is implemented to help prevent vaccine-preventable diseases, especially among children. South Africa has implemented the expanded programme which covers 8 conditions. In 1995 hepatitis was added, and in 1999 haemophilus influenza type b was implemented. South Africa has also introduced the intraderrnal BCG.

Coverage

According to the Demographic and Health Survey (1998), the Coverage under 1 year of age was 63%. South Africa had relied on campaigns and regular immunisations. However, more targeted monitoring and surveillance has helped raise Coverage. EP] reviews are also conducted in each province to identify gaps in the system. There is active surveillance for acute flaccid paralysis and measles (laboratory and case based) and neonatal tetanus.

Impact of The EPI

No polio case has been seen since 1986, and South Africa is in line to be certified polio-free. Measles has become rare, almost to the point of elimination. Hib vaccination (introduced in 1999) has reduced the incidence of fatal diseases among the under-1 year olds.

Introduction of vitamin A supplementation will also be pegged onto the ER initiative.

Some of the challenges in the ER programme include:

- The cold chain maintenance, regular supply of vaccines, and district and sub-district surveillance
- Follow-up of Adverse Effects Following Immunisations
- High motivation in the face of low case loads and case fatalities
- Countdown to a polio-tree certification
- uninterrupted vaccine supply

Youth and Adolescent Health

Adolescent and youth health has always been a priority of the government. The priority areas are development and implementation of the Youth and Adolescent Health policy guidelines, development of appropriate lEC materials for the prevention of teenage pregnancy and sexually transmitted infections, particularly HIV. Health workers also need to be trained to provide youth and adolescent friendly health services. There is collaboration with the various organisations in raising awareness about reproductive and developmental responsibilities. Programmes such as loveLife, UNFPA and UNICEF provide support to the government programmes.

Some of the major achievements in this programme include:
· The Policy Guidelines on Youth and Adolescent Health were launched on the 26^th March 2002. The youth centres established by loveLife are useful as resource and recreational centres, especially in under-resourced areas. Participation by celebrities helps encourage adults to discuss matters with the younger generation- A popular version of the Youth and Adolescent policy guidelines is being finalised, so that it will be a resource for parents, teachers and young people themselves. A flyer has also been developed for young people and was disseminated during the launch. Two young people were contracted to develop IEC material on prevention ci teenage pregnancy, STIs & HIV/AIDS.

· A National Adolescent Friendly Clinic Initiative (NAFCI) has been established in South Africa. Clinics and hospitals are being accredited based on their responsiveness to the needs of young people. This is done in collaboration with the Reproductive Health Research Unit. Training of master trainers in providing youth friendly services will commence shortly (April 2002).

Prevention of teenage pregnancy and HIV/AIDS
This was addressed through provincial workshops and campaigns for the prevention of teenage pregnancy and HIV/AIDS. There is also collaboration with various government departments, primary, secondary and tertiary institutions, NGOs and the private sector in promoting the health of young people. In addition a consultant assisted the unit over three months in developing a national strategy on prevention of teenage pregnancy.

One of the major challenges is the lack of enough people with skills in youth and adolescent health. This translates into poor implementation at provinctial level There are also not enough advocates for youth and adolescent health.

DECENTRALISATION OF HOSPITAL MANAGEMENT
In 1994, when the new government came to power it was apparent that the overwhelming need was to improve the accessibility of primary healthcare services to the people of South Africa. A great deal of work was subsequently done to build and refurnish clinics. This has increased access to basic health care for all people.

In 1995 attention began to focus on hospitals. Extensive recommendations were made on how hospitals should be managed, including that appropriately qualified management teams should be in place with the necessary delegations of power for the local (hospital) managers to be effective.

The Department of Health has ten critical priorities for 2000/04, one of which is the Revitalization of Hospital Services. The main elements of this programme include the development of a policy direction to decentralize hospital management to operational level so as to ensure increased and improved responsiveness of hospitals to the needs for efficiency and effectiveness in service delivery.

This will further improve:
- Capacity for the management of resources, especially financial, through implementation of Cost Centre Accounting in public hospitals.
- Capacity of health professionals through training and development, to enable staff to deal with the dynamics of health care delivery including clinical management.

The critical objective for this policy direction is to ensure increased/improved responsiveness of hospitals to the needs of the population served by hospitals throughout the public sector.

This programme has been piloted in 15 hospitals as phase 1. Good progress has been made on the project, as depicted below.

Delegation of powers
Provinces are now delegating certain powers of authority and responsibilities to hospitals. These are driven by the Hospital Superintendent/Chief Executive Officer (CEO). At this level, each CEO or Superintendent authorises the appropriate delegations to each level of management, internally through job descriptions and key results areas or key performance areas.

One of the important elements of this programme is that CEOs do not necessarily need to have a medical background. Chief Executive Officers may be chosen from individuals who possess management skills in a hospital environment or management skills in general.

Prerequisites for decentralised hospital management
In order to ensure that the hospital is fully prepared to assume the "decentralised status", the following internal infrastructure must be in place in a hospital:

a) The existence of a strategic plan and the capacity to implement the strategic plan;
b) The capacity or track record of the hospital management to monitor and evaluate the implementation of the business plan, through quarterly provincial monitoring mechanisms;
c) The existence of referral protocols;
d) The capacity of the management to comply with the legislative framework for human resources, financial management and procurement delegations.
e) The existence of written, communicated and updated policies and procedures.
f) The existence of standards for budget and expenditure control mechanisms;
g) The existence and utilisation of information collection systems;
h) The existence of a competent Tender committee with appropriate delegation levels of approval;
i) The existence of a formal link with active trade unions and/or any workplace forums;
j) The existence of a functioning Hospital Board,
k) The existence of clinical governance in:

· Quality issues;
· Clinical Audits; and
· Patients' charter.

The National policy is being finalised, but Provinces are now cascading the lessons further to other hospitals. There is also further funding from National Treasury to assist with systems development and implementation.

TUBERCULOSIS
The case finding rates for South Africa (2000 data) are:

· 150 696 Tuberculosis cases were reported - 82.7% reporting rate
· The incidence rate of all TB cases - 346/100 000 population
· 119638 Pulmonary TB cases were reported
· 75 652 of these were New Smear Positive cases

In terms of treatment outcomes, the data is currently only available for 1999

· New Smear Positive cases registered - 61 564 = 79.6% reporting rate
· Successful Treatment Completion rate - 72.3%
- Cured: 60.3%
- Completed:12.1%
· Treatment Failure rate: 1.7%
· Treatment Interruption rate: 17.2%

DOTS Expansion
The current status of the DOTS expansion is:
· 4 Provinces with 100% coverage (Free State; Gauteng; North West; Western Cape)
· 3 Provinces with >= 80% coverage (Eastern Cape; Limpopo and Mpumalanga)
· 1 Province with 60% coverage (Northern Cape)
· 1 province with 24% coverage (KwaZulu Natal)

In November 2000, the Director of the National TB Control Programme (NTCP), together with programme managers of the other 21 high burden countries, agreed to develop a Global DOTS Expansion Plan. This plan has two pillars:

· Development of a National Medium Term Development Plan (MTDP), and
· The building of partnerships

The Minister of Health launched the National MTDP for South Africa in January 2002. The National MDTP contains a plan for 2002-2005 of the NTCP of South Africa. It provides a template for mobilisation of human and financial resources needed to expand tuberculosis control as part of the national health system in order to achieve the targets the country committed itself to towards its own community and to the international community.

During February and March 2002, a team from the National Office and a representative from the KNCV (the Royal Dutch TB Association) visited the provinces in support to develop Provincial MDTPs.

Multi- Drug Resistant Tuberculosis (MD P T8)
Recent studies by the National Tuberculosis Research Programme of the MRC in three provinces indicate a rate of approximately 1% MDR in new tuberculosis cases and 4% in previously treated cases. This translates into about 2 000 new cases of MDR tuberculosis in South Africa each year.

MDR tuberculosis is difficult and expensive to treat, with current cure rates range from 30.50%. Two year case fatality rates are around 30% to 50%, and higher in HIV positive patients. The cost of treating a case of MDR tuberculosis in South Africa is 10 to 20 times the cost of treating an uncomplicated drug susceptible case, but is probably much higher when factoring in the cost of prolonged hospitalisation cultures and drug susceptibility testing. To better understand the magnitude of drug resistance in South Africa, a nation-wide surveillance project is underway and will be completed in 2002

In 2000, the NTCP and MRC published Guidelines for the Management of MDR TB in South Africa.
The management of MDR-TB patients in South Africa is the responsibility of the NTCP. Drug resistant tuberculosis especially multi-drug resistant tuberculosis (MDR-TB), forms a serious threat because MDR-TB is not only extremely expensive but also very difficult to treat. Recalling that MDR-TB is the result of inappropriate prescription of drugs failing drug management (bad quality of drugs, interruption of stock), or inappropriate taking of drugs (Jack of DOT), the first priority of any programme is to identify the causal factors for the emergence of drug resistance in that setting and to prevent further development of drug resistance.

The use of second-line drugs must be strictly supervised during both intensive and continuation phase of treatment. A rational stepwise approach to control of MDR-TB includes surveillance of drug resistance, prevention of the development and spread of drug resistant tuberculosis, assessment and strengthening of the quality of (MDR-TB)-treatment in South Africa and systematic implementation of infection control measures in MDR-TB-treatment centres.

To assure the proper management of MDR-TB in South Africa, each province has established an MDR-TB Referral Centre to ensure high quality, evidence-based management of MDR-TB.

TB/HIV Training sites
S TB/HIV training districts have been established in all provinces with the exception of the Western Cape. The training districts provide all the services rendered by the pilot sites except TB preventive Therapy. The target will be to achieve at least 50% coverage by 2005.

HIV/AIDS
The issues of HIV/AIDS in South Africa are very extensive, but only some of the selected issues are highlighted in this document.

Strategic Focus of Government
The following points summarise the strategic focus of Government in the response to HIV/AIDS.

1. Our response is anchored on the orthodox model of the cau5al relationship between HIV and AIDS.
2. The scourge we are dealing with affects all sectors of our society even though it is most vicious and hits with greater ferocity in contexts of poverty and underdevelopment. Thus, a multisectoral comprehensive response based on a developmental approach is critical. The fight against poverty and underdevelopment is a key and essential component of our response.
3. We understand human knowledge to be relative. At any given time we have to work on the basis of the best available information and evidence, knowing fully well that what constitutes truth today may well be shown with the passage of time to have been incomplete truth at best but may even prove to have been wrong at worst. It is important therefore that as we act today vie open our minds to new and emerging knowledge.
4. Given the importance a successful outcome in the fight against this pandemic has to the process of successfully reconstructing our country, it is important that we base our actions on as complete a picture of the nature of the challenge as is possible
5. Notwithstanding (1) above, a platform for scientists to engage has been established - the Presidential Advisory Panel on AIDS - to deliberate on some of the key concerns around aspects of this orthodox model.
6. We need to understand the impact of HIV/AIDS on every sector of our national life.
7. The key challenge is both to prevent the destruction of the immune system as well as intervene to reconstitute it when destruction has commenced. It is in this context that good nutrition; prevention and treatment of opportunistic infections and the promising work on immune stimulants occupy an important position.
8. As regards our health sector response, it is important that we invest systematically in the total strengthening of our national health system-so as to enable it to prevent illness, treat and rehabilitate all those afflicted by illness including those associated with AIDS. In this regard it is important to record that it is mainly the existing, commonly occurring diseases that occasion death due to AIDS. For example, all indications point to TB being the disease most associated with death from AIDS in our context. Necessarily, an effective response against TB that would reduce our overall TB load and new infections from TB will of necessity reduce deaths from AIDS associated TB. Furthermore, adequate treatment of sexually transmitted infections (STIs) is associated with reduced HIV transmission. Also extensive condom use, in addition to reducing HIV transmission, also reduces STIs and also reduces unplanned pregnancies, especially teenage pregnancies - again very important interventions. We argue therefore that only a well functioning efficient and well managed health system will effectively respond to the challenges posed by HIV and AIDS.
9. Government policy is not predicated on a knee-jerk aversion to the use at ARVs. Rather it is based on an approach that calls for caution when it comes to the call for wide scale use of ARVs for long term treatment in the public sector. Antiretrovirals, whilst having a place in carefully targeted and planned interventions, require some basic prerequisites before they provide any benefits. Notwithstanding costs, the simple truth is that the public health system as it exists cannot support such a programme. In addition, the compliance levels necessary for success pose a challenge particularly in situations of socio-economic deprivation. However it is erroneous to project such an approach as equal to NO treatment for AIDS. The public health system provides on a non-discriminatory basis the full package of care for the treatment of opportunistic infections that are associated with AIDS. Where deficiencies may exist, they do not reflect lack of policy directives but rather relate to operational and implementation challenges.

Presidential AIDS Review Panel
Early in 2000, the President established a panel compromised at scientists from across the orthodox and dissident divide. The terms of reference of the Panel where built around answering the following questions.

[Please note the last few pages of this document were not included. Attempts are being made to obtain them]