Committee Annual Report and Report of HIV/AIDS Task Team: briefing

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Health

23 February 2004
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Meeting report

HEALTH PORTFOLIO COMMITTEE

HEALTH PORTFOLIO COMMITTEE
24 February 2004
COMMITTEE ANNUAL REPORT AND REPORT OF HIV/AIDS TASK TEAM: BRIEFING

Chairperson:
Mr L Ngculu (ANC)

Documents handed out
Operational Plan for Comprehensive HIV and AIDS Care
Progress on Implementation of the Comprehensive HIV and AIDS Plan
Sites identified for initial HIV/AIDS Treatment Implementation (see Appendix)

SUMMARY
The Department Task Team briefed the Committee on the its comprehensive Operational Plan with detailed guidelines for the care, management and treatment of people living with HIV/AIDS. The Department elaborated on the progress of the plan, which it hoped would be rolled out rapidly despite its complexity. The Committee expressed budgetary and regulatory concerns that needed to be addressed if the plan was to be successfully implemented.

MINUTES
The Chairperson stated that this meeting would be the last Committee meeting of this term. Therefore, it was important that they conclude the session with an important discussion. The Minister of Health would be joining the meeting, but he did not know exactly when she would arrive. A party would be organised for the Portfolio Committee. The date was as yet unknown, but the Committee would be kept posted.

Briefing by Department on the HIV/AIDS Operational Plan
Dr K Chetty, Department Acting Director-General, and Dr N Simelela, Department Cluster Manager for HIV/AIDS and TB, explained that this programme was initiated on 8 August 2003, when Cabinet requested the Ministry of Health to "as a matter of urgency, develop a detailed operational plan on an antiretroviral (ARV) treatment programme by the end of September 2003." Extensive work had been undertaken so that the programme could be quickly implemented. Eventually, it became misleading to exclusively describe the programme as an antiretroviral treatment programme because the plan included a comprehensive strategy for HIV/AIDS care, management and treatment. Most importantly, this plan attempted to ensure that uninfected people remained HIV-negative. It was necessary to integrate the plan into other government programmes on social support; reduction of poverty; and job creation. The plan also outlined methods to slow down the progression to AIDS in HIV-positive persons.

Guiding principles of the programme were quality of care; equitable programme implementation; prevention, continuum of care strategies; programme sustainability including combating drug resistance; financing; healthy lifestyle; individual choice of treatment; and treatment safety. The programme moreover aspired to strengthen the national health system and so faced many challenges. For example, services needed to be integrated at the facility level. Possible interaction of traditional and Western medicine needed to be researched. Human resources; training; laboratory services; pharmaceutical services; drug procurement and information systems demanded co-ordination. It would be critical to improve the quality of care in the private sector, along with increasing 'pharmaco-vigilance' in both the public and private sectors. The plan's budget allocations had been detailed on a yearly basis. These figures correlated with the number of ARV users. Details were also provided on who received ARV treatment, and on which regimens.

Progress of the Operational Plan
Dr Chetty explained that a treatment protocol had been completed with specific focus on paediatric regimens; pregnant women; adults; and patients who had HIV/TB co-infections. The team had amended all existing Department guidelines so they were aligned with the comprehensive plan. Chamber manuals had already been amended to add ARVs according to their protocols. The guidelines would be presented to MinMEC on Friday, 27 February 2004. Subsequently, the plan's endorsement would be expeditiously printed. By the second week of March, service points would receive the draft guidelines. This would allow people to begin to familiarise themselves with the guidelines' content.

Dr E Mhlanga, Department Chief Director for Child and Women's Health and Nutrition, reported that the Department had just received an additional Treasury grant of R4 billion. Now additional supplemental meals could be purchased for patients who were suffering from malnutrition. Additionally, these patients would have access to Social Security Grants. The existing tender would continue and a new tender would begin in June 2004. There would be an increase in funding for this.

In the past, the importance of multivitamins had been understated. Although the majority of people had acceptable diets in terms of quantity, their diets were lacking micronutrients. In people with chronic diseases like HIV/AIDS, micronutrient deficiency was common. Therefore, the Department had acquired multivitamins and other nutrients to give to patients, especially those taking ARVs. South Africa did not have good health literacy and this needed to be improved. Currently, health care workers and communities were being trained in this.

Ms C Serenata, Director within the HIV/AIDS Department Cluster, briefed the Committee on the accreditation of service points. In December 2003, the accreditation process had been refined and piloted. This had resulted in the development of a ten-page questionnaire to provide a more thorough method of service point assessment. Locations of service points had already been designated. Copies of service point location lists had been made for the Committee [See Appendix]. Some of the provinces had suggested minor changes to their site locations, but this list was 99% accurate. The Department had started the accreditation process late last January. The final two facilities would be accredited today. From the ten-page questionnaire they had used when visiting the sites, a large amount of information about facilities had been generated. The team hoped to complete a more in-depth analysis of this data. However, this would take some time. In the meantime, the Department had created a summary checklist for service points to use when determining if they met the standards of minimum type criteria. The report on these checklist outcomes would be presented to MinMEC on 27 February, 2004.

From this accreditation process, the Department had learned that the majority of issues were systemic. For example, patient information systems were not electronically linked between facilities, and there were staffing shortages. Site-specific problems could be addressed more quickly, such as the need for additional cabinets to store drugs. The accreditation process had allowed provinces to develop business plans which indicated where funding should be directed. Also, the Department could allocate resources much more efficiently when giving resources directly to facilities. This was superior to giving provinces a lump sum and allowing them to spend this money.

Ms C Gumede, Department Chief Director of Human Resources, indicated that the current status of human resources would be presented at MinMEC. Provinces needed assistance with their own training programmes so the Department would be meeting with Provincial Human Resource Directorates this month. A tender would be awarded at the end of March 2004. The Minister would hold a briefing session on 16 March to explain the plan to all stakeholders and inform them of their roles and responsibilities. Accreditation service providers would be appointed to provide training in the interim. Official training supported by the national tender, would commence in April. Also, CDV points would be strengthened.

Dr Z Zkufa, Department Chief Director for Pharmaceutical Services and Planning, briefed the Committee on drug distribution. The Department would aim to reduce the shrinkage of the drug Africare to below 5%. "Bringing this drug into the public health system is comparable to bringing in gold". Criminals could try to steal drugs from the public sector and distribute them to other markets, such as the local private sector or overseas, where drugs would fetch a higher price. To prevent this, the Department needed to strengthen the entire drug delivery distribution system.

The Department had worked with provinces on drug labelling and drug dispensing. There was a general consensus that ARVs would be handled as Schedule Five medicines that were difficult to access. Trained and dedicated personnel would have to monitor these ARVs. The 'tracker system' was an integral part of drug distribution. It was an electronically-based system that tracked a drug until it reached its final destination. The Department was busy drawing up specifications for this system so that the tender process could begin. Within South Africa, many companies had very interesting systems for drug tracking.

The drug supply management system could not experience 'stock-outs'. Each dispensing facility had to know the minimum and maximum levels of drug stock that it could sustain, and account for every drug it prescribed. Also, dispensing facilities would have to order the drugs from the depots. This meant that depots would need to know when they should order more supplies and when manufacturers could deliver.

The process of obtaining the drugs had to be seen to be fair; objective and robust. Local production had to be promoted. The Department had to bargain with companies to get the lowest drug prices possible. Whoever received the tender to produce the drugs in South Africa, would need to show a medium- to long-term strategy on how the active ingredient could be sourced over time.

Since 13 February, the Department had been advertising in newspapers asking for interest in such activities. A tender had not been awarded yet so this was just the first step of the process. On 5 March, the Department would put out another advertisement requesting people to submit proposals to participate in the drug production. On 9 March, the Department would hold an information session for people who had expressed interest. This session would explain project details and the criteria on which proposals would be assessed. After determining who could best do the job, the Department would request quotations. Then, negotiations with the potential tenders could take place. It would be very prudent to split the tender among different companies. The Competition Commission was advising the Department on issues of fair trade.

Ms C Kotzenberg, Department Chief Director for Non-communicable Diseases (including Chronic Diseases and Disabilities), briefed the Committee on the strengthening of laboratory services. The whole laboratory infrastructure needed improvement, especially testing infrastructure. The volume of liver toxicity tests and blood count tests would be increased. This would not have much of an impact on laboratories because these tests had always existed, although for lesser volumes. Viral Load and CD4 tests were more rare. Fortunately, the process of improving capacity for viral load and CD4 testing in laboratories had just been completed. The tender had been evaluated. They expected test prices to be available in the next week. These test prices would be determined in the same way as drug prices - the volume of tests would influence the cost.

Currently, the Department had identified 18 laboratories that would do CD4 testing. This was about 36% of the proposed laboratory sites. These 18 laboratories had been identified based on their cost-effectiveness. Six laboratory sites had been designated for viral load testing.

A tender had been awarded to upgrade the transportation infrastructure. The Department had identified 1 726 pick-up points where specimens could be transferred to the laboratories. Equipment needed by the laboratories had also been identified. The sites would begin training on the use of the new testing equipment as soon as the equipment was delivered. Not all laboratories were linked to the laboratory information system. Software had been bought and would be installed shortly.

Ms J Collinge, Department Chief Director of Communications, briefed the Committee on the importance of having a strong education and information communication system. It was essential that patients and the general public had access to information about the programme. Information within the health system also needed to be strengthened. Communication needed be established between national government and provinces, health districts and facilities that carried out this programme. The Department had isolated key stakeholders as an important communication mechanism.

Dr L Makubalo, Department Custom Manager for Health Information Epidemiologist and Research, briefed the Committee on the Patient Information System (PIS). This system could lead to a better understanding of patient risks; the sustainability of the programme, and when to change patient drug regimens. From the PIS, they could also learn how many patients were being treated for HIV/AIDS. The Department wanted to improve and upgrade the PIS. Given time limitations, they would settle for an interim PIS that would have a paper-based back-up system. This paper-tracking component would be ready to use immediately. The electronic component had been in the development stage since late last year. They were concurrently developing a more comprehensive PIS, but this would take a long time. Hospitals had different versions of information systems that were not compatible with each other. Provinces were now integrating components of their IT systems to create a comprehensive information system.

On the research programme, the Department was required to apply for transfer payment so that funding could be sent to the Medical Research Council. The MRC would provide significant financial support for the programme. Stakeholders and academic institutions had been integrated into the research programme. Academics sat on Research Advisory Committees to review research proposals and identify research questions.

Discussion
Dr E Jassat (ANC) asked if it was possible to avoid a holistic approach to centre treatment. He desired an approach that would allow specialised personnel to focus on the development of a specific type of treatment. For example, perhaps there could be a centre that focused only on TB or a centre where only HIV patients were treated. Maybe one centre could work exclusively with nutritional supplements.

Dr R Rabinowitz (IFP) understood that these programmes would only be implemented in existing health establishments. Were they just going to find 54 of the best-equipped sites?

Dr Simelela responded that the Department was not attempting to establish ARV speciality centres. They had designed their plan to be integrated into current existing services. This was because of the human resources challenge. If they expanded and created more centres, they might not find personnel. Provinces would decide how to operate their own centres. For instance, a provincial service point might designate a day to focus on HIV/AIDS treatment and another day to focus on hypertension treatment. Provinces were currently reviewing their resources and seeing how they could best implement the HIV/AIDS programme in an integrated matter. An integrated approach was essential because patients often could not manage their own care, especially if they reached the ARV treatment stage. It would be critical that care came from the entire community because once patients were feeling better from the ARVs, they needed support to continue to take their medication. Community, NGO, counsellor and family support had to be strengthened to ensure that patients returned for their treatment.

Provinces needed to select a central hospital rather than a primary health care facility to initiate treatment. The primary health care facility would likely be lacking in skills and laboratory capacity. This was thus a doctor-driven programme where the doctor had a team, a counsellor, and an adherence person to provide patient support. When a patient developed complications, a doctor had to refer up to a tertiary institution. When the patient improved, the doctor should make a referral down the system. The next step could be patient follow-up by a nurse who understood the situation. Finally, the patient would have three months with a doctor so he/she could monitor how the patient's CD4 levels were responding.

One way to encourage general practitioners to seek more training on HIV/AIDS would be to award CPD points. This way, more doctors would be involved in confronting the problem of HIV/AIDS. Doctors needed training on patient follow-up.

Dr Rabinowitz asked if, while they were rolling out this programme, they would wait until all facilities were ready to do the same thing on the same day - or would they would start where there was the best capacity, learn from experiences there, and then expand the programme?

Dr Simelela stated that they were very cogniscent that piloting programmes had created problems. There were provinces that had always had done well because they were the first to take action. There needed to be a concerted effort to bring the weaker provinces 'up to speed'. This was why there was a commitment to provide at least one service point for each health district by the end of the first year. The Department wanted to circumvent a situation where one province had multiple service points, while another province had none. In this situation, people would migrate and keeping track of their status would be difficult. The accreditation process was not exclusionary. The Department would not shut down a centre that did not meet criteria standards. Instead, centres would be evaluated to find what they were lacking. Then the Department would see if the centres had the money to address these shortages. If a centre did not have a laboratory or enough medical personnel, a plan would be established to address those shortages.

Mrs S Baloyi (ANC) asked about funding sustainability. Once the programme was started, its message should be ongoing.

Dr Sinelela replied that the issue of funding sustainability had been discussed at length with Treasury. The latter had made a commitment to provide money if the Department advanced the programme and had the capacity to spend. If the Department demonstrated that they were managing to get patients on treatment, then the Treasury would reimburse money that was overspent. Also, Treasury would consider providing more money as it was needed.

Mrs Baloyi asked what was currently being done to educate communities about treatment.

Dr Simelela explained that education and empowerment of communities was part of the Department's communication strategy. Ms Collinge could provide an update on the communication methods. Television and radio addresses would be aired soon. They had been training Lifeline counsellors, who had provided the Department with critical information on common questions that communities were asking. Every other week, the Department would be able to do a briefing on the progress of this counsellor training.

Mrs Baloyi questioned the effects of dual treatment. How would treatment provided by both traditional and mainstream practitioners be controlled? Would they let the patient be on traditional medicine for about six months, observe the effects, and then start ARVs? Or would the patient take both treatments at once? She was concerned about drug resistance. Since this was a new field, more research needed to be conducted.

Dr Simelela confirmed that the issue of dual treatment was a cause for concern. However, they could not tell patients to abstain from taking traditional medicines. Instead, they ask have patients to indicate if they were taking traditional medicine in medical evaluations. Then, if a patient requested ARVs, a doctor could deny a patient this treatment. They could monitor patients closely, and if they saw something that 'they could not read in the papers', they could, with a patient's consent, request a sample of the traditional herb the patient was using. This might allow them to understand its effects. They had built a research approach into this plan because they needed to learn more about the impact of traditional herbs. At this point, there was not any scientific evidence that proved drug interactions were occurring. However, they would monitor dual use and make it an important part of the research agenda.

Mrs Baloyi asked about the Department's current position on service points. What points had they identified and when would the points be ready for the programme to begin?

Ms Simelela replied that she would make a copy of the sites identified by the provinces. These sites were not in the handout but were in the main plan.

Ms Baloyi wanted the Department to expand on the production of generics in South Africa. Yesterday she had read that Mozambique would start its first manufacturing project. South Africa had a larger population than Mozambique. Why was Mozambique, rather than South Africa, able to accomplish this? This would mean that drugs would have to be imported from Mozambique when South Africa was better equipped for generic production.

Dr Zokufa responded that South Africa had much spare capacity to produce these drugs and there were a couple of companies now positioning themselves to do this. In the chapter on drug procurement, Cabinet had approved this. Medicines had to be purchased at the lowest possible price.

Dr Chetty added that maybe the progress report would address this issue. What had appeared in the operational plan, and what had now been allocated in the Division of Revue Act, represented about one third of their original request. This created an implementation problem. If there was more spending, this would be adjusted for in the Adjustment Budget. They did foresee problems because they did not have this money upfront.

The Chairperson thought that the current allocations were R2.1 billion for HIV/AIDS and ARV treatment and R41 billion for the provincial budgets. These figures were from the budget statement of 18 February 2004. While this problem might not be addressed today, this would be information they needed.

Ms S Kalyan (DA) replied that this was a very good operational plan but she found it fell short on the specifics of implementation. At the end of October 2003, there were 23 500 vacancies in the health sector. The plan did not actually specify how and when these vacancies would be filled.

Dr Simelela replied that the vacancy rates in the provinces were quite high. Currently, many strategies were being enacted to address this. Provinces were reviewing their staff establishments. They were looking into retired workers who could be re-employed and trying to 'repatriate' workers who had migrated. Starting next year, they would introduce community service funding. Some of their strategies were longer-term strategies, but in the meantime, there were a number of things that had been done to address these high vacancy rates.

Ms Kalyan stated that the plan indicated that much strengthening needed to be done. How would this actually happen?

Dr Simelela replied that when they had visited the provinces and evaluated the sites, they had identified gaps in the system. They had reviewed each facility's human resource and laboratory capacity, as well as the physical space to put patients and do consulting. They noted if there was a pharmacy; how close the facility was to the surrounding communities; and if people needed transportation. They learned if the facility made referrals and what the patient information system was like. Where they identified gaps, they made a list of these issues for the province to address. Together, they would develop a strengthening plan with this list in hand. Where there were not enough personnel, they would have to restructure the system. For example, perhaps new community doctors could deal with other illnesses, and more experienced doctors could run the HIV/AIDS programme? So the strengthening was broad - it did not just address how and when the drugs were coming. The strengthening plans would eventually be changed into business plans that the provinces would submit to access Conditional Grants. These site evaluations reflected the problems with the health system as a whole. In general, patients did not receive follow-up treatment. With the HIV/AIDS drug distribution system, they could not afford to be ignorant of where treatment was being accessed. This would be a challenge because of stigma and discrimination. Patients could shop around across the provinces, and they might not be able to be found. So it would be a challenge in terms of follow-up, adherence and resistance monitoring.

Ms Kalyan asserted that two weeks ago, the Minister of Health had said that the Department was in a shambles. That was why she could not roll out the ARV programme. On Page 18 of the Operational Plan, there were some figures on the number of new patients starting ARV treatment: In 2003-4, 53 000 patients had started ARVs. Were these patients already on ARVs or were they going to start ARVs? What was the commencement date?

Dr Simelela stated that the development of this plan had taken a while. When the Department had estimated how much money was needed from Treasury, they had used the percentage of patients known to be in Stages 3 and 4 of the disease. For example, that with a prevalence of 20% HIV infection, 10% of patients were in stages 3 and 4 and so would soon need drugs. Significantly, the plan was endorsed in November, but then there was a break over the December holidays. They did not have as many patients on drugs now because they had started much later than they had anticipated. The numbers that the Committee saw were not the numbers they would achieve by the end of March or even April 2004. They had thought that they would now be much further in strengthening and advancing the plan. If they relooked at their capacity and how many people would be on ARVs by the end of March or April, this would allow the Department to make the appropriate submissions to Treasury.

Dr I Cachalia (ANC) asked more about drug resistance.

The Department team reported that it had been aware of the issue surrounding resistance and the use of Nevirapine. In fact, the results of the well-known report presented at an international forum were the results of research that they had funded. When they had started PMTCT (Prevention of Mother-to-Child Transmission), there were tales of resistance to Nevirapine from Uganda. So parallel to the programme being implemented, they had investigated this by following up groups of women from Chris Hani/Baragwanath and from KZN. However, the media had failed to report was that this resistance was found at 36 weeks. Evidence had been found that these resistant strains actually disappeared with time. So, at one and a half years, a very small percentage of the woman would show resistance to Nevirapine. They had catered to this issue in the plan by saying that they would pay particular attention to women who had been exposed to anybody previously on ARV. Also, patients would be put on a regimen that did not include drugs to which they had been previously exposed. Plan guidelines indicated that the Department would provide ARV triple therapy to women who qualified clinically. Any pregnant woman who came in with a CD4 count of less than 200 would be put on triple therapy. Those women who exhibited symptoms late would get just Nevirapine. Women with CD4 counts above 500 would not be given ARVs if they were not pregnant. This strategy would be followed everywhere in order to avoid confusing health workers and the general public. However, the Department would focus on pregnant women to ensure that practitioners did not recommend drugs that were dangerous for their babies.

Ms Malumise stated that the US Government had donated US$15 billion to fight HIV/AIDS. How much of that money would be for South African use?

Dr Simelela explained that this $15 billion dollars would be distributed among 14 countries and South Africa would receive $70 million. The money would not only fund the government plan but would fund private institutions; NGOs; and any person who submitted a successful proposal. A very small amount of this money would reach the Health Department. The US had defined prevention, treatment, orphans and vulnerable children, and palliative care as the areas they wished to fund. In order to receive some of this money, the Department had begun work with other government departments to meet the proposal deadline of 31 March. The Department would request money to cover some of the gaps that they had found in the programme. They would speak specifically to the Office of Vulnerable Children and to the Office of Palliative Care, both government areas that still needed improvement.

The Department was already in the process of drafting proposals to receive more money from the Global Fund. The money from Round One of allocations had been sent to KZN, Love Life and Soul City. The money from Round Two allocations was expected by the end of February for the TB and HIV International Department. They would receive money for Round Three after the Western Cape produced its set of endorsed verifications. At the end of April, the Department would have the money from Round Four. It was essential that that the public sector co-ordinate all the donations. It was tricky to do this because every fund had its own specific requirements. Also, some of the funds wanted to bring in their own people to help manage the money which created diffuculties.

Dr Cachalia asked about private sector involvement.

Dr Simelela replied that the Department was working on including the private sector. Unfortunately, the environment currently was a bit acrimonious. In the past, they had interacted with the private sector on the Sexually Transmitted Infection (STI) strategy. In some of the provinces, the Department had piloted an approach that would give the private sector drugs. However, there was always the potential for abuse if there was insufficient monitoring. Currently, the Department could not monitor the private sector's use of ARVs and knew they were offering mono-therapy and dual-therapy. The Department hoped that through its continuous interaction with the Health Professions Council, it could align strategies and also speak to medical aid schemes to make ARV a prescribed minimum benefit. These discussions would obviously be informed by prices. They would also have General Practitioners consult in public health facilities. This was the safest way because they would use the same regimens, and drugs would be prescribed by the pharmacy.

Mrs N Gxowa (ANC) wondered if the Department would use Local Government to interact with community workers. Would the Department identify community workers to provide home-based and other types of health care?

Dr Rabinowitz asked about the R2 billion given to the Department - would it go the same way as before? In the last budget, much more money was put into the Provincial Lump Sum. She was sure that this was easier to spend because it was the conditional grants that had trouble getting through the bureaucracy. This was such an important programme. Wasn't it time now for the people doing this hard work, to start lobbying the Minister of Finance and the Minister of Health to use a different method of distributing the funds? She was concerned that they only had one third of the money needed.

Dr Chetty replied that the allocations in the form of conditional grants for the provinces for 2004-5 amounted to R300 million; was R600 million for 2005-6; and was R1 billion for 2006-7. The Department had been allocated R90 million until the end of this financial year on 31 March. That money would be used to fund infrastructure needs and the Patient Information System. For 2004-5, R55 million; R40 million; and R45 million had been allocated to the Department. Dr Simelela had indicated that the budget of the Operational Plan was lower than what they had allocated, so they were having discussions with National Treasury. Treasury had stated that if the Department overspent their funds, this money would be allocated in the Adjustment Budget. They would have preferred to receive the correct amount of money because this would have allowed for better budget planning, assistance, and a guarantee of funds.

Dr Rabinowitz asked about the issue of patents. Had there been a tender put out to the companies who had already produced these drugs? It was dangerous to assume that just because they made generics, their prices would be cheaper. Just before the new regulations were drug priced, the generic companies pushed up their prices. The companies who already made the medicines should thus be also offered the tender. This might form a competitive base to bring down the price of generics.

Malumise (ANC) questioned further about the affordability of drugs.

Dr Zukufa responded that there were three components affecting drug affordability. The first component was the cost and the amount of the drug bought. There had to be a sustainable supply of those volumes at those costs. The negotiating team appointed by the Minister and mandated by this plan, was in the process of engaging potential tenders. If they reached the point where the price needed to be negotiated with four or five companies, they would negotiate the lowest acquisition cost. In order to bargain intelligently, the Department would need to know how much it had cost the company to bring in the active ingredient from source, and manufacturing; distribution; and profit margin costs. When negotiating, the Department would request companies to remove advertising; marketing; and corporate costs. The Department would be buying huge volumes of drugs, so companies did not have to advertise to them. A company would need to demonstrate how they would decrease their annual cost as the Department placed more orders.

The Chair praised the Department's presentation, saying the plan was not too idealistic. It offered a revolutionary change from the HIV strategy plan now in place. Within a year of implementation, there would be one service point in all of the provinces. The Committee needed to deliberate on the actual information, not on perception or suspicion. If they ignored the pressures on the health system, the plan would fall flat.

Dr Rabinowitz added that this had been a very valuable exercise and the Department had an excellent team. She was most worried about drug distribution as they had been hearing for a decade that government hospitals could not control theft. The Department had mentioned electronic monitoring, but thieves could interfere with the system. They should discuss the possibility of having one person or company responsible from the point of production to the point of delivery. This plan needed very careful co-ordination, especially if the Department wanted to delve into areas that without current capacity. Any problems areas could affect resistance and opportunistic infections. She wished the Department luck with their 'fantastic programme'.

Ms Malumise asked about the drug tracking system.

Dr Zkufa replied that drug distribution was more difficult in some areas. The system that carried these drugs was actually more important than the drugs themselves. In the first two years, they might be at the margins of controlling the drug flow. The stock control tracking system had worked well for other companies, such as Kinesis. To an extent, this same system could work well but not in areas with an inadequate electricity supply. If the IT system was not robust enough, then criminal could track drugs. Drug supply management and distribution in the public sector had been problematic for 20 years. Each province was currently trying to deal with drug distribution in its own innovative way. Provinces had yet to come up with a system that adequately distributed drugs from hospitals to clinics. This programme would afford an opportunity to revisit and prioritise the drug distribution system. The implications were huge because if it succeeded, other drug groups would also be safer.

Ms P Tshwete (ANC) asked if each province had its own depot with have enough capacity to distribute drugs.

Dr Zkufa asserted that each province had a depot and the Eastern Cape had two. Each province would buy from the manufacturer, who would deliver the stock to the province's depot. Provincial hospitals would buy from the depots and deliver to the clinics. Unfortunately, this system was not robust. There was a tension between ensuring that ARVs were procured strictly according to the rules, and meeting the expectation that ARVs would be distributed immediately. They had to be fair to all the interested players and allow everyone an equal opportunity to participate in the programme.

The Chairperson asked for further elaboration on under-resourced and disadvantaged facilities.

Dr Simelela responded that the problem of under-resourced facilities had been central to the development of the plan. While there might be enough money, there were sometimes not enough personnel to do the work. Provinces were continuously advertising in the newspapers, but there were insufficient applicants. The Department was talking to subordinates who might supply containers or more vitamins. However, additional supplies demanded an increase in human resources. The private sector had not been utilised adequately - after all, they could get Coca-Cola to the most remote villages. The public needed to be educated on what to expect so that people would not buy stolen medicine and doctors should be confronted if they were not doing the right thing. If the Department empowered people to know their rights, the programme would be more successful.

Mrs Baloyi congratulated the Department on their good plan. Had the Department considered including retired health workers in all categories, including nursing assistants, as they would require less training? Could the Department please ask the provinces to report their number of nursing assistants? She would like to be first on the retiree list to volunteer!

Mrs Baloyi was concerned about the slowness of the bureaucracy. If they had to take this back to the Cabinet, it would take way too long. Treasury should be brought on board. As a Chief Officer, Dr Zkufa needed to discuss the situation with the Minister and the Treasury.

The Chairperson responded that time frames were already in progress. It would be futile to make another presentation. Requests for proposals would have to be made by March. This allowed only 28 days. They were all hoping that the process would be quickly concluded so that they could see the programme's progress. However, there was no way to short-circuit the process, which was elaborate but fair.

Dr Simelela stated that on their visits, they had asked the provinces to think of innovative ways to respond to gaps and conduct outreach. If people could get to a facility, health workers could possibly be brought into the rural areas over weekends to provide care. Sometimes rural communities were so small and separated, the construction of a big hospital or clinic could not be justified.

The Chairperson mentioned that the Minister was often criticised for the importance that she gave to nutrition, but he supported her that best nutrition was essential. Last week, the Task Team had presented on pricing and dispensing of medicine. Today, the Task Team had presented another leg of the entire spectrum of health. He had read in a number of newspapers, magazines, and bulletins, that the Department was slow and hesitant, and that the plan was only an election ploy. However, it was evident that there could be no short-cuts in this process. He thanked the team and the meeting was adjourned.

Appendix

Table 6.3: Sites Identified by Provinces for Initial HIV and AIDS Care and Treatment Implementation and Current Assessment Visit Status

Province: Eastern Cape
District: OR Tambo; Facility: Umtata Hospital Complex; Assessment Conducted: Yes
District Amatole; Facility: Frere/ Makiwane Hospital Complex; Assessment Conducted: Yes
District: PE: Nelson Mandela; Facility: Dora Nginza Hospital Complex; Assessment Conducted: Yes

Province: Free State
District Lejwe Le Putsha; Facility: Bongani (Welkom) Hospital; Assessment Conducted: Yes
District: Thabo Mofutsanyana; Facility; Elizabeth Ross Hospital; Assessment Conducted: Yes
District: Motheo; Facility: National Hospital; Assessment Conducted: Yes

Province: Gauteng
District: Johannesburg Metro; Facility: Johannesburg Hospital; Assessment Conducted: No Facility: Hillbrow CHC; Assessment Conducted: No; Facility: Helen Joseph Hospital; Assessment Conducted: Yes; Facility: Coronation Hospital; Assessment Conducted: Yes; Facility: Discoverer Clinic; Assessment Conducted: Yes; Facility: Chris Hani-Baragwanath Hospital; Assessment Conducted No; Facility: Lillian Ngoyi Clinic; Assessment Conducted: No; Facility: Zola Clinic; Assessment Conducted: No

District: West Rand; Facility: Leratong Hospital; Assessment Conducted; Yes; Facility: Carletonville Hospital; Assessment Conducted: No; Facility: South Clinic; Assessment Conducted: No

District: Ekurhuleni; Facility: Natalspruit Hospital; Assessment Conducted: Yes; Facility: Tembisa Hospital; Assessment Conducted: No; Facility: Daveyton Main Clinic; Assessment Conducted: No

District: Sediobeng; Facility: Sebokeng Hospital; Assessment Conducted: No; Facility: Kopanong Hospital; Assessment Conducted: Yes; Facility: Empilisweni Clinic; Assessment Conducted: No

District: Tshwane/Metsweding; Facility: Pretoria Academic Hospital; Assessment Conducted: No; Facility: Kalafong Hospital; Assessment Conducted: No; Facility: Laudium Clinic; Assessment Conducted: No; Facility: Garankuwa; Assessment Conducted: Yes; Facility: Soshanguve II Clinic; Assessment Conducted; No

Province: KwaZulu-Natal
District: EThekwini (Metro); Facility: King Edward Hospital; Assessment Conducted: Yes; Facility: Prince Mshiyeni Memorial Hospital; Assessment Conducted: No; Facility: Mahatma Ghandi Memorial Hospital; Assessment Conducted: No

District: Ethekwini (Metro); Facility: Addington Hospital; Assessment Conducted: Yes; Facility: RK Khan Hospital; Assessment Conducted: Yes

District: Ugu; Facility: Port Shepstone Hospital: Assessment Conducted: Yes; Facility: Murchison Hospital; Assessment Conducted: Yes; Facility: GJ Crookes Hospital; Assessment Conducted: No

District: Ilembe/King Shaka; Facility: Stanger Hospital; Assessment Conducted: Yes

District: Amajuba; Facility: Madadeni Hospital; Assessment Conducted: Yes; Facility: Newcastle Hospital; Assessment Conducted: Yes

District: Umzinyathi; Facility: Church of Scotland Hospital; Assessment Conducted: Yes

District: Zululand; Facility: Vryheid Hospital; Assessment Conducted: No; Facility: Benedictine Hospital; Assessment Conducted: No; Facility: Nkonjeni Hospital; Assessment Conducted: Yes

District: Umgundundlovu; Facility: Grey's Hospital; Assessment Conducted: Yes; Facility: Edendale Hospital; Assessment Conducted: Yes; Facility: Northdale Hospital; Assessment Conducted: No

District: Uthukela; Facility: Ladysmith Hospital; Assessment Conducted; Yes; Facility: Escourt Hospital; Assessment Conducted: No

District: Uthungulu; Facility: Ngwelezane Hospital; Assessment Conducted: Yes; Facility: Lower Umfolozi/Empangeni Hospital; Assessment Conducted: Yes; Facility: Nkandla Hospital; Assessment Conducted: No

District: Umkhanyakude; Facility: Bethesda Hospital; Assessment Conducted: No; Facility: Mosvold Hospital; Assessment Conducted: Yes; Facility: Manguzi Hospital; Assessment Conducted No; Facility: Mseleni Hospital; Assessment Conducted: Yes

Province: Limpopo
District: Capricorn; Facility: Polokwane/Mankweng Hospital Complex; Assessment Conducted: Yes; Facility: WF Knobel Hospital; Assessment Conducted: Yes; Facility: Lebowakgomo Hospital; Assessment Conducted: No; Facility: Seshego Hospital; Assessment Conducted: No

District: Bohlabela; Facility: Mapulaeng Hospital; Assessment Conducted: Yes; Facility: Tintswalo; Assessmet Conducted: Yes

District: Sekhukhume; Facility: St. Rita's Hospital; Assessment Conducted: Yes; Facility: Hlogo Tlou Hospital; Assessment Conducted: Yes; Facility: Matlake Hospital; Assessment Conducted: Yes; Facility: Mecklenburg Hospital; Assessment Conducted: No

District: Vhembe; Facility: Siloam Hospital; Assessment Conducted: No; Facility: Elim Hospital; Assessment Conducted: Yes; Facility: Messina Hospital; Assessment Conducted: Yes; Facility: Tshilidzini; Assessment Conducted: No

District: Mopani; Facility: Nkhensani Hospital; Assessment Conducted: Yes; Facility: Letaba Hospital; Assessment Conducted: No; Facility: Mapthutha Malaji Hospital; Assessment Conducted: No

District: Waterberg; Facility: Mokopane Hospital; Assessment Conducted: Yes

District: Waterberg; Facility: Warmbaths Hospital; Assessment Conducted: Yes; Facility: George Madebe Hospital; Assessment Conducted: No

Province: Mpumalanga
District: Gert Sibande; Facility: Evander Hospital; Assessment Conducted: Yes; Facility: Bethal Hospital; Assessment Conducted: Yes

District: Ehlanzeni; Facility: Rob Ferreira Hospital; Assessment Conducted: Yes

District: Nkangala; Facility: Philadelphia Hospital; Assessment Conducted: No; Facility: Witbank Hospital; Assessment Conducted; Yes

Province: Northern Cape
District: Frances Baard; Facility: Kimberley Hospital; Assessment Conducted: Yes

District: Siyanda; Facility: Gordonia (Upington) Hospital; Assessment Conducted: Yes

Province: North West

District: Southern; Facility: Klerkdorp/Tshepong Hospital Complex; Assessment Conducted: Yes

District: Central; Facility: Mafikeng/Bophelong Hospital Complex; Assessment Conducted: Yes

District: Bojanala; Facility: Rustenburg Hospital; Assessment Conducted: Yes

District: Bophirima; Faciltiy: Taung Hospital; Assessment Conducted: Yes

Province: Western Cape
District: Metro; Facility: Khayelitsha Clinics x 3; Assessment Conducted: Yes; Facility: Gugulethu Clinic; Assessment Conducted: Yes; Facility: Tygerberg Hospital; Assessment Conducted: No; Facility: Groote Schuur Hospital; Assessment Conducted: No; Facility: Red Cross Memorial Children's Hospital; Assessment Conducted: No; Facility: GF Jooste Hospital; Assessment Conducted: No; Facility: Langa Washington Road Clinic; Assessment Conducted: Yes; Facility: Hout Bay Main Road Clinic; Assessment Conducted: Yes; Facility: Hottentots Holland Hospital; Assessment Conducted: No; Facility: Mitchells Plain CHC; Assessment Conducted: No

District: Garden Route/Klein Karoo; Facility: George Hospital; Assessment Conducted: Yes

District: Boland/Overberg; Facility: Worcestor Hospital; Assessment Conducted: No; Facility: Paarl Hospital; Assessment Conducted: No


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