Health Systems Trust Activities: briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
14 June 2005
HEALTH SYSTEMS TRUST ACTIVITIES: BRIEFING

Chairperson: Ms M Madumise (ANC)

Documents handed out:
Health Systems Trust PowerPoint presentation overview
Health Systems Trust PowerPoint presentation on Research Programme
Health Systems Trust PowerPoint presentation on Initiative for Sub-district Support
Health Systems Trust PowerPoint presentation on key equity issues

SUMMARY
Health Systems Trust (HST) briefed the Committee on its work over the last twelve years, and highlighted challenges and priorities for the future. Their current motto was "Health Systems Supporting Health for All in Southern Africa": They made five presentations on an overview of the organisation and examples of their four main work clusters; Research, Initiative for Sub-District Support, Community Development and Health Link.

The Committee expressed their concern regarding the inequity of health service provision and delivery of anti-retroviral drugs. They also emphasised the need for future inter-departmental co-operation to achieve success with the Community Development Programme. They hoped to work more closely with HST on future projects.

MINUTES

Health Systems Trust briefing
Ms Lilian Dudley (CEO) made an introductory presentation. She explained that HST had expanded significantly since the original formation in 1992; increasing from a small non-governmental organisation (NGO) with four staff to a non-profit organisation (NPO) with a staff of over 70. Priority areas included District Health Systems and Priority Health Problems; such as HIV/AIDS, tuberculosis (TB), Sexually Transmitted Infections (STI), nutrition, maternal child and women’s health, and Support Systems such as Health Information systems, financing and human resources. Key outputs were capacity building and supporting access to information throughout the Health Service, solution finding and supporting implementation of policies. It worked with funding partners, the Department of Health, research and academic institutions, South African and international NGOs plus regional and international agencies. She highlighted the challenge for a small organisation to effect large scale changes in health systems.

Ms Virginia Zweigerthal (Director: Research) briefed the Committee on the HST research programme that focused on organised responses to health and disease. She explained that most research was undertaken by HST’s own researchers. The latter had produced the ‘National Primary Healthcare Facility Survey: 2003’ which monitored the progress in implementation and equity in the provision of the primary healthcare package. Areas of research included Decentralisation, Environmental Health Services and HIV. HIV research focused on mapping the provision, planning and management of HIV/AIDS services at sub-district level and identifying gaps within these services. They had monitored two Prevention of Mother-to-Child Transmission (PMTCT) sites and evaluated the impact of the ‘Good Start Infant Feeding Study’ and assessed Voluntary Counselling and Testing programmes. She concluded that key challenges for the health system included human resources, inefficiencies within the system, lack of drugs and facilities and the need for integrated services. Future priorities included a ‘comprehensive plan’ for the national roll out of ARV and PMTCT treatment, the decentralisation and implementation of the district health service, operational research to strengthen TB services, human resources provision and development and women and child health.

Ms Nomsa Mmope (Associate Director: ISDS) briefed the Committee on the Initiative for Sub-District Support (ISDS). The Initiative aimed to improve the standard of primary healthcare through provision of support to sub-districts. It had achieved improved service delivery through identifying factors affecting healthcare at the local level and addressed challenges with practical solutions. She explained that integrated programmes were required at the national and provincial levels, including a coherent HR strategy and support to care providers. Providers were often flooded with directives from above of which they had only limited understanding. This resulted in a lack of morale.

Ms Nomande Bam (HST Director: Community Development and Fundraising) introduced the Community Development Programme established in 2001, aimed at promoting behavioural change at the grass roots level. She reasoned the State needed to empower communities through integrated nutritional programmes and developing household food security. Trial projects utilised existing community based organisations and provided training to volunteers. HST infrastructure was able to monitor the implementation. She stressed the importance of a multi-sector approach involving the Departments of Health, Social Development and Agriculture and suggested the greatest challenge was the lack of skills within the community and their inability to access information. She highlighted the need for improved infrastructure in rural areas to ensure projects were sustainable and concluded that the resources existed to implement these programmes and that household food security could be a catalyst for economic development and self-sufficiency.

Ms Antoinette Ntuli (HST Director of HealthLink and Chairperson of the Equity Gauge Alliance Co-ordinating Committee) presented the Committee with some key issues on equity in health. The programme examined four areas: the ‘Equity Gauge’ that monitored determinants of health; the ‘Treatment Monitor’ that evaluated research and access to ARVs; the ‘HIV Gauge’ that monitored access to ARVs through strengthening community empowerment; and the ‘Equitable Distribution of Human Resources for health’ that promoted research and policy dialogue within SADC. They had monitored the socio-economic determinants of health and found slow increase in provision since 1996. She provided an example of flush toilets to illustrate the current inequity, with access as low as 16% in some provinces.

The State had shifted its emphasis from being a ‘provider’ of services to an ‘enabler’ of access to services which had resulted in additional costs for those in remote areas. She highlighted the dangers of disparity in services between rural and urban areas such as cholera out breaks and fires resulting from dangerous heat sources. She also discussed the findings of the Treatment Monitor programme, which illustrated inequity in provision and found implementation was most successful where civil society was strong. Concerns relating to the migration of trained medical staff from ‘South to North’ and the detrimental effects of this on the health system at the lowest levels were raised. She called for the State to fulfil its commitment made in the Abuja Declaration that 15% of the national budget would be spent on health and suggested the State needed to protect free primary healthcare and basic public services to provide for the most disadvantaged.

Discussion
Mr I Cachalia (ANC) requested the opinion of HST regarding statistics on the prevalence of HIV/AIDS, how accurate were the figures and what could be done to improve the data?

Ms L Dudley clarified that HST were not involved in the collection of national data but that the annual anti-natal survey provided accurate information on levels of HIV/AIDS prevalence which was corroborated by further independent surveys. She believed that, overall, South Africa had very reliable data.

Mr Cachalia believed that education and prevention was important. Was enough being done in this area?

Ms L Dudley supported the importance of prevention and education initiatives but suggested mass media efforts were not enough. Communities had to be mobilised.

Ms Bam added that despite the amount of information on HIV/AIDS, the message was not filtering through to the communities. There was a need for materials to be published in local languages and for more personal interaction and education to raise community awareness. The advantage of community programmes was that time could be spent explaining the issues and engaging with individuals.

Mr Nijikelana (ANC) raised the importance of an oral medium of information and the need to evaluate the effectiveness of written publications in the English language.

Mr Cachalia noted that despite increased provision of Conditional Grants and hospital revitalisation programmes money was not utilised and often returned in part or in full. Monitoring mechanisms were now in place to report to the Treasury on a monthly basis, but what were the implementation problems?

Ms Dudley expressed awareness of the grants; but HST was not specifically engaged with monitoring.

Ms Mmope highlighted the importance of financial training at management level and the need to plan and monitor service provision.

Ms C Dudley (ACDP) raised concerns following reports from the recent AIDS conference in Durban that South Africa had dropped back from being a world leader in AIDS research to commissioning hardly any at all; what was the actual situation?

Ms L Dudley acknowledged the need for increased research and noted the limited resources currently available.

Ms C Dudley expressed alarm at the reportedly high levels of MTCT (mother-to-child-transmission) following breastfeeding. What methods were available to reduce the number of cases?

Professor D Jackson (University of the Western Cape) explained that research into MTCT at three pilot sites had recently been completed and presented to the Department of Health. The Department had not yet had time to review and comment on all the information. However, evaluation of the sites demonstrated that provision of Nevirapine was very effective in preventing transmission. That the levels were very similar to those at the clinical trails was good news for the programme.

However, infection levels after nine months demonstrated disparity between the sites. It was important to realise that while breastfeeding could expose the child to infection other determinants were also important and the site with the highest level of infection also had the highest rate of infant mortality regardless of HIV status. They found that socio-economic factors had the most important contribution. It was important to discuss the need to address inequality in healthcare systems and socio-economic factors. It had been realised that some programmes in the poorest areas would require additional resources; however they usually received less. PMTCT was working and should continue; however the introduction of duel therapy would address many of the implementation problems encountered so far.

Ms C Dudley queried why mothers continued to breastfeed if they were aware of the risks of infection.

Professor Jackson responded that the greatest risk of transmission emerged out of a mixture of formula feeding and breastfeeding. He explained that mothers were given the information but telling them once was not enough. Mothers needed counselling and support to make and stick to their feeding choice. As such ‘mixed feeding’ was the current norm, the choice of single method resulted in stigma for the mother and health workers needed training to provide the additional support

The Chairperson referred to her own information regarding levels of PTMTC. She queried whether shortages of the drugs were a factor?

Professor D Jackson commended the government’s foresight in retaining the original 18 PTMTC pilot sites for monitoring and research. It was the only research project of its kind in the world. Research into transmission rates pointed to a lack of resources as a factor and this included drug shortages. However, despite disparity between the sites in administrating the drugs to the mothers on time, all sites achieved timely delivery to the babies

Ms C Dudley asked whether there was evidence of a deliberate poaching strategy by the USA of medical staff from the South?

Ms Ntuli referred to the Rockefeller Foundation and the World Health Organisation survey of Human Resource Migration to the North that backed her opinion and to the practices of private recruitment agencies. She directed the Committee to the HST website for further information.

Mr Nijikelana raised his difficulties in accessing the HST Annual Health Survey, commended HST for their progress and asked what the procedures were for requesting their assistance and services. Were there particular criteria for their choice of projects?

Ms Ntuli offered to provide a copy of the most recent Annual Health Survey. The next copy would be available in August 2005. HST had worked with the Portfolio Committee in the past. However, funding was no longer available and the relationship had become more informal, with HST assisting with individual requests where possible.

Ms Mmope added that HST had no specific criteria for choosing projects and sites, but were dependent on funding. Projects were donor driven and therefore usually the poorest provinces, such as KwaZulu-Natal and the Eastern Cape, were chosen by the donors in consultation with the Department.

The Chairperson asked whether the community nutrition projects were available countrywide?

Ms Bam explained that the current projects were established as sites of best practice in selected areas. It was hoped local governments would take over the projects in the longer term. She illustrated one success from the Eastern Cape where the government had come on board and eventually planned to take over 30 clinics. The HST and government were working side-b- side in transferring skills for the long-term.

Mr Nijikelana asked for clarity on HST’s definition of ‘primary healthcare’.

Ms L Dudley suggested that the broadest definition of primary healthcare would be the most appropriate as HST would also look at the underlying determinants of health, not just diseases.

Mr Nijikelana understood the HST position but pressed whether there was evidence of a universal understanding and definition of primary healthcare.

Mr Cachalia noted his personal experience of primary healthcare clinics in Gauteng where he had encountered serious staff shortages and a lack of supplies and facilities. He also raised the neglect of psychiatric medicine and questioned how it could be improved.

Ms L Dudley replied that HST had not undertaken any specific survey on psychiatric health systems, and this illustrated a gap that might be addressed in the future.

Mr Cachalia queried whether HST reported back to the provinces with findings and suggestions on how to address the problems and challenges.

Ms Bam highlighted that HST alone could not address the challenges and stressed the need for inter-sector collaboration. She provided the example that although HST had secured funding for ‘water harvesting’, this was a small-scale initiative and the broader issue of water provision needed addressing at a higher level.

Mr Nijikelana asked whether HST had assessed how community participation had impacted on health care.

Ms Ntuli replied that while there was no specific evidence from South Africa of a direct link between community participation and improvements in healthcare, it was a strong theme in HST projects. HST would be researching ways of increasing participation and would be monitoring this impact.

Mr Nijikelana asked for clarification of the dangers of the State ‘enabling’ policy. Was international trade agreements part of this policy?

Ms Ntuli referred to the ‘Equity Gauge’ as evidence of the effects of ‘enabling policies’. She noted the limited resources available to the State and that were the finds available then the priority would be to provide basic services to the poorest communities free of charge. Contracts with the private sector were currently used to fill the gap in service provision. However, the result was inequitable in that those in the most remote places had to pay more for access to the same services. She also referred to the role of trade agreements in opening up the resources of poor countries to companies from another and noted the danger for health services. She suggested that where profit motives were involved the priority would not be equity.

Mr Nijikelana sought insight into how the Parties to the Abuja Declaration decided on 15% for the level of budgetary spending on healthcare.

Ms Ntuli was not aware of the reasons for the Parties choosing 15% as a target. Even if a high level of spending was provided for the health system, inequity could still occur if the emphasis was on high-level urban tertiary provision instead of rural primary healthcare.

Mr Nijikelana thanked the HST for their presentations and proposed that the Portfolio Committee engage with the issue of the State as a provider / enabler and highlighted the need for lawmakers to be aware of the dangers. He also emphasised the effects of socio-economic factors on health, diseases related to poverty and the importance to recognise the possibility that nutrition could serve as a tool for economic development. The challenge was to ensure the Departments of Agriculture and Health worked together.

The meeting was adjourned.