Tuberculosis: briefing

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19 March 2001
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HEALTH PORTFOLIO COMMITTEE
20 March 2001
SOUTH AFRICAN NATIONAL TUBERCULOSIS ASSOCIATION (SANTA) AND TB ALLIANCE DOTS SUPPORT ASSOCIATION (TADSA): BRIEFING

Chairperson: Dr Nkomo

Documents handed out:
- Speech to Parliament by Dr Ratsela, Chief Executive Officer of South African National Tuberculosis Association (See Appendix 1)
- Observation of the National TB Control Program - an NGO perspective by Mr Ian Mackenzie, Executive Director, TADSA (See Appendix 2)

Additional Documentation:
"Santa head office faces closure", Paul Kirk, Mail and Guardian, March 23 to 29 2001, p 3. (See Appendix 3)

SUMMARY
The South African National Tuberculosis Association (SANTA) cares for TB patients. Dr Ratsela, CEO of Santa, said this country ranks amongst countries with the highest reported cases of TB in the world, with an estimated number of 160 000 new cases of infection every year. South Africa's cure rate is below the 85% required by both the Department of Health and the World Health Organisation (WHO). In its endeavours to combat TB, South Africa has adopted Direct Observation Treatment Strategy (DOTS), a strategy highly recommended by the WHO.

According to Dr Ratsela, CEO of Santa, there is currently a post-Apartheid conflict within Santa itself. The organisation has been reluctant to become more representative of the people of South Africa. This infighting is having a negative impact on the organisation's ability to control TB. Santa is asking government to second a task team to look after its interests in the organisation. Santa's CEO does not think the organisation will survive without intervention from the Department of Health.

The TB Alliance DOTS Support Association (TADSA) is a non-profit TB-HlV Resource organisation, based in the Western Cape, operating in all nine provinces. It is a training agency for the volunteers who work for both Santa and the Health Department. It uses the WHO's DOTS Strategy - Directly Observable Treatment Short Course. With the implementation of the DOT strategy, cure rates are increasing, and the National TB Control Programme is committed to reaching a target of a National 85% Cure Rate. At the same time, it is said that the roll out of the DOTS strategy is slow, inconsistent, and often only on paper and that DOT is misunderstood and often only exists in name. Interruption rates remain high.

See the Appendices for the presentations by both organisations.

The Director of TB Care in the Ministry of Health, Dr Matshi, painted a bleak picture of the state of the disease and Santa's efforts when asked to respond at the end of the meeting.

Discussion
Ms Baloyi (ANC) asked why the Department of Health was not there to make a presentation before the Health Portfolio Committee. She believed the Department would have been able to shed light on some of the issues raised by TADSA and Santa. She went on to say that the Department gave her the impression that DOTS had been a success in communities but this is not what TADSA was saying in its presentation.

The Chairperson replied that the Department will make its presentation at the review meeting with the Ministry of Health. He did point out that the Health Department is represented by its TB Director, Dr R Matshi.

Ms Baloyi asked who decides on the composition of the hospital committees which Santa is intending to set up within six months, and will that time frame be maintained, especially considering the tensions currently within the organisation?

Dr Ratsela said a uniform structure has been developed and will be introduced in hospitals as soon as the review team reports to the Minister.

Ms Baloyi also asked about the relationship between Santa and the Department of Health.

Dr Ratsela replied that his organisation has good relations with all the stakeholders including government but the main problem centres around management in the Board, because this Board itself is divided along racial lines. There is no unified mandate from the Board and this is the root of the problems experienced by Santa.

Ms N B Gxowa (ANC) asked about the composition of Santa management. She also asked about the monitoring of the 7,5% of the budget given to Santa for management. She said it seems as if Mr Ratsela is suggesting government should be responsible for monitoring how the money is spent. She asked why Santa does not monitor its own funds.

Dr Ratsela replied there was no mechanism in place at Santa on how money should be spent. Second, he said there was also no policy on how Santa should be run; in the past, it was run along family lines and by friends, with some members having a vested interest in running the hospitals.

Ms Gxowa said she was glad to hear there are extra beds in Santa because in the past patients used to sleep on the floor.

The Chairperson pointed out that the time period for treating TB had been slashed from 18 months to six. TB patients were discharged earlier than before and this led to many of the beds being redundant.

Ms Gxowa asked TADSA how they identify the people they train.

Mr McKenzie said the National TB Control Program has entered into contracts with local municipalities to identify people in their communities. These people are then trained by TADSA.

Ms M A A Njobe (ANC) said the level of commitment shown by the volunteers who went door to door monitoring patients impressed her. She suggested that Santa intensify its education campaign in the rural areas.

Ms S F Baloyi asked TADSA what is the number of people they have trained since their inception.

Mr Mackenzie said he did not have the figures on him but he would forward a report to Dr Ratsela.

Dr B Mbulawa (ANC) asked who was responsible for the day-to-day management of the hospitals.

Dr Ratsela responded that of the 22 Santa hospitals in the country, fourteen have management committees. Those with management committees make it difficult for the executive to visit them, he said. This situation is made worse by the fact that some of the Board members are on the management committees of some of these hospitals. This leads to a situation where Dr Ratsela, as the CEO, feels he has no authority or influence on the management of these hospitals.

Comments from Ministry of Health Director of TB Care
The Chairperson told the committee that he would give Dr Matshi of the Ministry of Health the opportunity to respond to some of the issues raised in the in the meeting.

Dr Matshi reported that the previous year the Minister of Health had formed a review team to investigate what was happening with the funds allocated to the fight against TB. This came out of a concern that while government was funding Santa to fight TB there was no apparent reduction in the disease. The government was giving Santa R100 million and yet the reported cases of TB were not subsiding; instead, they were increasing.

Dr Matshi said some of the problems with Santa are that their hospitals are situated in remote areas, where relatives of patients are unable to visit their loved ones. The patients would reach these hospitals only to find there were no doctors to treat them. The care offered to patients by health workers in these Santa hospitals was appalling.

The doctor said Dr Ratsela had spoken of empty beds in their hospitals that can be made available to HIV infected patients. However she has a fundamental problem with the idea that HIV-infected patients can be taken into TB hospitals because their immune systems are very weak and therefore susceptible to TB.

Dr Matshi also said Santa's presentation suggests they are still in need of funds, but she asked what are they doing with the current funding they have received. She asked how government could give them more funding if they cannot even account for funds they have already received. Unlike TADSA, which provides figures to the Department of the number of people they have trained, Santa does not disclose the number of people they have cured.

The meeting was adjourned.

APPENDIX 1
SPEECH TO PARLIAMENT BY DR RANTSELA, CHIEF EXECUTIVE OFFICER OF THE SOUTH AFRICAN NATIONAL TUBERCULOSIS ASSOCIATION

I would like to take this opportunity to thank the members of this portfolio for inviting me to give a presentation on the disease TB and the organisation, SANTA.

History of SANTA
Volunteers founded it in 1947 for the purpose of taking care of the TB patients. SANTA then established TB settlement in isolated areas. These settlements were funded through donations. Government followed to fund them when donor fatigue set in. They paid a levy of 7.5% for the running of the head office so that there could be co - ordination of the services.

There was however no monitoring of the activities, and no written contractual relationship. This meant that there was no accountability for the money used.

When the New government came into being, there was an insistence to have proper representation in organisations like ours, the first black Chief Executive Officer was appointed. When this person was appointed there was no sector of SANTA which was transformed.

Chairperson, I want to submit that the problems we have in this organisation centres around the running of the hospitals and their funding People seem to be more concerned about the money in SANTA than TB control, which is the primary role of this organisation.

I have been asked to shed some light on some aspects of TB control in the SANTA. This I propose to do by addressing a topic at a time.

TB statistics
Honourable members the incidence of TB is on a rise in the country and in Africa as a whole, particularly sub-Saharan Africa This incidence is made worse by the co-infection with HIV and AIDS. It is estimated that South Africa has an average of 160 000 new infections every year. The average infection rate is at 350 per 100 000. Our cure rate has not reached the required level as set by the World Health Organisation of more that 85%. South Africa has been identified as one of the countries with high burden of TB in the world. This is exactly the reason why we attended and participated in the summit, which was held last year in Armsterdam. We are therefore the signatories of the celebrated Amsterdam declaration.

The rate of Multi-Drug Resistance TB is about I% for the primary infection. This is still low as compared to other countries like the former Soviet Union.

The relapse rate is about 21 %. As you may know, the high relapse rate like this one will lead to a sharp rise in the MDR -TB infection.
Co - infection is presently at 50%, meaning that half of the patients with TB have HIV and vice versa. This figure is higher in admitted patients. This is unde[standable because these a~e sicker. This clinical state can easily be attributed to HIV status.

Progress with regard to DOTS
This popular method of TB control was introduced in 1997 in South Africa. Since then we have seen a steady increase in its implementation. The progress is however too slow to make any significant impact on the TB treatment. To understand this better let me analyse it according to its basic elements:

Political will
The National TB Control Programme has been set up and the team is trying to get everybody on board including the NGOs, like ours. However education has not reached all the nurses and doctors. As a result some health workers are still using old methods of TB control. The relationship with NGOs is still not satisfactory. At some clinics and provinces, we are seen as interfering in the affairs of running the clinics. Our volunteers are not welcome at some clinics.

Uninterrupted drug supplies.
Some provinces run short of TB drugs like it happened last year in Mpumalanga, when patients stayed months without any treatment. We hope there is no repeat of this.

Sputum smear microscopy
It looks like most provinces have adequate services. The sputum turn around time of average 48 hours seems to be maintained.

Monitoring and recording.
There has been great improvement we are told.

The above reporting is with regard to government services. With regard to SANTA, it is difficult to measure what our actual impact is. There are reasons why our services are still in a confused state.

Let me take members back to the time when I came in SANTA as the Chief Executive Officer. SANTA was run in a very loose manner with no set budgets for the National Office. There was no clinical and managerial support to the hospitals. The only discernible support was in the field of industrial relations. I then started talking to the department of health about two questions:

· As the accounting officer of SANTA I should be able to know what is going on in the hospitals.
· That government should have a formal contractual relationship with SANTA.

I then wrote a letter to the minister to ask her to intervene in the running of SANTA because there was complete turmoil. This was caused by my insistence to be accountable for what is happening in the hospitals. This war is still going on with no end in sight. The minister and the DG appointed a review team to look at SANTA. This team came up with findings, which show the shortcomings that I mentioned earlier.
Therefore we can only have progress on DOTS coverage after the infighting has been aborted.

SANTA provincial services
SANTA has two main wings:
· Hospitals
· Community services

We have 22 hospitals with a total bed capacity of close to 4500. This is about 50% of the total TB beds in the country. For the running of these hospitals the government pays about R100m per annum. 7.5% of this is allocated as management fee to run the national office. As said above there has not been a way of monitoring what we do, and whether the money given to us is used properly. This is one of the reasons, which made me, speak to the department of health. There has been a fight between the hospitals and the national office. Some hospitals insisted that we ask for permission from the board of directors before we could come in. Therefore our visiting of these hospitals has been erratic, because of the problems with the management boards. I shall try to outline these services in the provinces

Eastern Cape
We have eight hospitals in this province. The budget for 2001 - 2002 is about R44m. Most of the hospitals are in a bad state, and desperately need repair. Due to lack of funds we are not able to reach all the areas for the DOTS coverage. Instead we are expecting to retrench people if we do not get enough money
For this sector we need about R1m per annum to pay for the DOTS services. Presently the province is not paying for these services. The national office spends about R900 000.

Kwazulu Natal
SANTA has five hospitals in this province. The budget is about R1,8m. Just like the hospitals in all other provinces the hospitals are in a poor state. The DOTS services are also severely under funded. We estimate the budget for this sector to be about R1 m. Presently the province is only paying about R550 000, with a deficit of about R400 000. There is an MDR - TB hospital that SANTA is running in the province. This hospital is responsible for all the MDR patients in the province.

Gauteng
The three hospitals in this province are quite large. The budget is about R20m per annum. The expenditure in the DOTS services is about R500 000. The province is not paying anything for this service.

Mpumalanga
There are three hospitals in this province. The budget is estimated at about Rl6m. The province is not paying for the DOTS services by SANTA. Our expenditure is about R400 000. We do run an MDR -TB hospital in this province, which takes care of all such patients in the province.

Western Cape
We have two hospitals, and the budget is about R10m per annum. This province is refusing to pay the management fee. About R2m is owed to the National office. The DOTS services are paid for to the tune of R500 000.

Free state
We have only one hospital in this province and the budget is about R6m per annum. The province has committed them to pay R500 000 per annum.

Northern, North West and Northern Cape Provinces
SANTA services are very weak in this province and our involvement is through the National Development Agency who gave us about R1m last year. This year we do not know what to do with these workers. The only province paying some money for the DOTS processes is the Northern Cape. The other two are cross-subsidised by the other provinces.

Our services in the provinces have been severely hampered by the in fighting that is going on in the association, about who owns the hospitals, in particular. There are a total of 200 branches in the provinces doing DOTS. The processes are still moving very slowly. SANTA workers are adding to this community involvement, in the provinces, which government finds it very difficult to do? I would like to believe that given a chance, and with the resolution of the problems in SANTA, this organisation could contribute hugely to the control of TB in the country.

Linkages between SANTA and other NGOs
SANTA has collaboration and linkages with TADSA and TB care in the country. We are working on a strategy to allow TADSA deal with all the training in the TB business.

Internationally SANTA is a member of the largest TB NGO in the world, the International Union against TB and Lung Disease. We have even won the bid to host the 14th conference of the Africa region, of this body next year.

HIV/AIDS and TB
SANTA is experiencing more problems with the increasing HIV. About 60% of our patients in hospitals have HIV. This is causing these patients to be in hospital for a longer period. We are failing to discharge our patients in two months time, because they are too sick. We think that the strategy to combat HIV should include TB because the two conditions are not mutually exclusive. SANTA also has a lot of empty beds that can be used for our patients who are HIV positive and need hospice care. We are busy talking to the provinces to get this going.

Strategic vision of SANTA.
The vision of SANTA is to help in the control of TB in the country, by being a full partner with government and other NGOs. But SANTA is involved in the fight against racism and resistance from the old guard. This is really retarding progress in the TB control. I do hope however that with the new MANCO and the first black chairperson, we shall win.

We can only realise our vision if the following happen:

- SANTA stops having in-fighting, which are having a negative impact on TB control and the envisaged partnership. In this case we believe government can bring sanity to us by seconding a task team to look after the interests of government in SANTA. If this does not happen, do not see us surviving.

- For all those provinces which are not paying for the DOTS processes to do so. This will help us discharge our duties properly with no constraints.

- For us to have accountability, transparency and good governance, we do need a contractual relationship with government.

- SANTA should be given a chance to improve their present performance. The government should set the time period.

In conclusion, I would like once more thank you for inviting us to present to you. We do invite you to visit our hospitals and see for yourselves the state in which they are.

APPENDIX 2
Observations of the National TB Control Program- an NGO Perspective
Ian Mackenzie, Executive Director: TADSA

TB Incidence in South Africa on the rise
South Africa is burdened with one of the highest TB epidemics in the World. The national incidence in 1999 was 419:100 000, which is more than double that in other developing countries and 60 times higher than any rates seen in USA or Europe.

New York declared a State Of Emergency when their TB incidence rate reached 50:100 000 in the 1980s.

TB Incidence is dramatically rising.

Dr Karin Weyer of the TB Research Program- Medical Research council, South Africa would have seen 273 365 new cases of TB in 2000, with 46,7% being HIV+.

TB Rates have doubled in most provinces in the last 5 years and projections done by Dr Weyer show that if the current trend continues, we can expect a five fold increase by 2005 resulting in a case load in excess of 600 000 with more than 400 000 cases being directly attributable to HIV Infection.
(Weyer, 2000, Noxious Synergy TB & HIV in South Africa)

1 % of new cases and 4% of retreatment cases are estimated to have MDR TB.

How is South Africa responding
In 1996 South Africa adopted the World Health Organisation (WHO) guidelines for a National TB Control Program.

This program is based on the WHO DOTS Strategy - Directly Observable Treatment Short Course. This Strategy has 5 elements:

1. Direct Observation of Therapy
2. Identifying infectious patients through microscopy
3. A reliable reporting system
4. Standardized drug combinations
5. Political Commitment
(National TB control Program, 1998)

The success of the response
The South African National TB Control program has a high level of political commitment. The TB Register allows the Program to measure the success of the program against hard data-cure rates are an absolute indicator of whether a program is successful or not.

The 9 TB Managers from each Province meet quarterly, and TB Outcomes are reviewed openly creating a healthy level of competition and incentive for Provinces to proactively tackle under performing districts. These efforts are supported by the NTCP as well as a DFID Management Consultant based in the NTCP, responsible for District Development. The expansion of the DOTS Strategy is measure by the number of Health Districts adopting all 5 elements of the strategy.

In 1997 17 out of 174 districts had adopted the DOTS Strategy with only 3 achieving an 85% cure rate.

By 1999 82 districts had adopted the DOTS Strategy with only 3 achieving an 85% cure rate and by 2000,148 districts had adopted the strategy.

Due to this Cure Rates are increasing, and the NTCP is committed to reaching a target of a National 85% Cure Rate.

In 1997 the National Cure Rate was 57% In 1998 the National Cure Rate was 620/0

Progress is clearly being made, however as a non-profit organisation operating on a national level, TADSA would like to make the following observations.

Challenges to the National TB Control Program
The WHO has stated that there are 16 nations not taking the TB epidemic seriously. 8 of these have enough money to do so, but either failed to do something about it or have left it too late. South Africa is listed as one of these countries.
(Dr Bernard Fourie, 1999, The Burden of TB in South Africa)

The impact of HIV/AIDS is overtaking a methodical TB program.

The roll out of the DOTS strategy is slow, inconsistent, and often only on paper.

DOT is misunderstood and often only exists in name. Interruption rates remain high.

The largest TB NGO in South Africa, SANTA is focussed on Hospital management, has an ill-defined role in community TB programs, relies on volunteer social groups to provide treatment and is presently embroiled in internal disputes.

TADSA
TADSA's core business is to build capacity in Health Districts to provide a comprehensive Community Based TB Care program.

TADSA is a non-profit TB-HlV Resource organisation, based in the Western Cape, operating in all 9 provinces. TADSA does not conduct any training on behalf of the Western Cape TB Control Program, as this is the only province to have set up its own Community DOTS Training organisation at Cape Technicon. (TADSA is however contracted directly by Districts in the Western Cape to conduct training but a gap remains in training outside the Metropole.)
TADSA has 6 full time staff and operates on a budget of just over R 1m per year.
In 2000 and 2001 TADSA has received no funding from the National TB Control Program although all work carried out by TADSA is carried out under the instructions of the National TB Control Program. TADSA has been granted US AID funds for 2001.

In 2000, TADSA's income was divided as follows
38% USA Funders
4% other international grants
8% local corporates
5% IDT
37% HIV/AIDS Directorate
5% Provincial Health Departments
3% Local Health Departments.

APPENDIX 3
"Santa head office faces closure", Paul Kirk, Mail and Guardian, March 23 to 29 2001, p 3.

An audit report has found that the office wastes much-needed money and resources, and has little contact with its own hospitals and clinics

Following a series of exposés by the Mail and Guardian, auditors have recommended that the national office of the South African National Tuberculosis Association (Santa) be closed down.

The audit report, which has not yet been made public, claims that that national office of Santa in Gauteng has little or no communication with the 22 hospitals and clinics run by the association and wastes much-needed money and resources that should be used to combat tuberculosis (TB).

Dr Andrew Ratsela, the CEO of Santa, is paid a salary of R500 000 a year for working two days' each month.

He also had a Santa credit card with a R50 000 a year limit for "incidentals", a petrol card and a top-of-the-line BMW for his use. Previous Santa CEOs had been either unpaid volunteers or were paid a taken allowance.

Following articles in the M&G about Ratsela's package, the national Department of Health ordered an audit of the organisation, which leads the battle against TB in South Africa.

Though the audit has not yet been made public or given to Santa's executive committee, the M&G has been shown parts of the report.

Among its findings are that Ratsela blew R5 000 on alcohol in a week, bought himself thousands of rands worth of clothing and frequently treated his entire family to lavish meals at top hotels and restaurants in Sandton.

Ratsela obtained a duplicate petrol card, which auditors suspect was used by his relatives. This financed thousands of rands worth of petrol. Ratsela denied having two petrol cards when quizzed by members of the organisation.

Santa centres throughout South Africa donate roughly 10% of their income to their national head office. Money collected by Santa centers comes entirely from donations and fund-raising schemes. It is supposed to be used by the national office to fund the administration of the association to help bail out poorer operations in rural areas.

Ratsela, according to the report, used all this income to finance the national office.

This week Ratsela agreed to be interviewed by the M&G, but changed his mind when he was told he would be questioned on the contents of the audit report. When the M&G phoned Santa's national office, an assurance was given that Ratsela wanted to speak in order to "clear his name".

However, when the M&G called back - after the deadline given to Ratsela had passed - we were informed he had left to test-drive a new 4x4.

In South Africa 160 000 new cases of TB are diagnosed every year, said Minister of Health Manto Tshabalala-Msimang at a briefing to announce the global launch of World Tuberculosis Day, which will be marked on Saturday March 24.

Tshabalala-Msimang said a new approach to combatting TB - establishing demonstration centres where volunteers ensured people with TB completed their cours eof medication - had "encouraging results". These centres will be established in every district of South Africa by the end of the year.

South Africa has one of the highest TN infection rates in the world - 492 per 100 000 people.

But some Santa executive members believe the only way to break the back of TB in South Africa is to keep patients in hospital for the full course of their treatment.

Although the Dots (directly observed therapy short course) programme has worked well in nearly every country in the world, from rural Uganda to urban New York City, in parts of South Africa the scheme is failing.

Before the implementation of Dots, Santa kept patients in hospital for six months allowing them to complete their medication under supervision, and to teach them life skills needed to prevent their becoming sick again.

With Dots, patients are kept in hospital for two months, then sent back home. The idea is that they are hospitalised only for the period they are most sick.

"There are problems with sending people home to complete their course of medication. And these problems are worse in the rural areas. If patients have to travel 60km on foot to a clinic to obtain medication, then chances are they simply will not complete the course," says John Budge, executive committee member of Santa.

"The other problem is that the medication to treat TB is quite unpleasant if taken on an empty stomach. A large proportion of the rural poor who suffer from TB are too poor to buy food and too ill to work the soil to produce food. That prevents people completing their course of medication."

Santa staffers estimate that about half of their patients do not complete their course of medication.

"That leads to multiple drug-resistant TB," says Budge. "If patients keep interrupting their treatments they are very likely to find themselves with this. And not only does it usually kill patients, it costs a fortune to try to save them."

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