Medical Research Council & National Health Laboratory Service: Budget & Strategic Plan 2007/08

HEALTH PORTFOLIO COMMITTEE
15 May 2007
MEDICAL RESEARCH COUNCIL & NATIONAL HEALTH LABORATORY SERVICE: ANNUAL REPORT AND STRATEGIC PLAN BRIEFING

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
MRC Submission
MRC Strategic Plan 2005-2010
NHLS Submission

Audio Recording of the Meeting Part1 & Part2

SUMMARY
The Medical Research Council of South Africa  tabled its budget and its strategic plan for 2007/08. It covered fourteen areas ranging from the mandate, strategic objectives, and corporate governance, to issues of transformation. The research priorities were highlighted, and there was an emphasis on productivity and service delivery. The budget highlighted an imbalance between donor funding and government grants. Productivity was measured in peer review publications which totalled 664 in 2007 with a steady increase from previous years. The employment statistics were tabled. Clarity was given on the controversy around microbicide clinical reserach and the termination of trials that were alleged to have been unethical, and the Council stated that an inspectorate had found the project to have been conducted favourably. Questions were asked by Members on on the handling of Extremely Drug Resistant (XDR) TB, collaboration with other African countries, and extensive discussion took place on the discrepancy in funding and whether this caused tension. Further questions addressed the AIDS vaccines, malaria and controlled spraying of DDT, diabetes, and interventions into breast and cervical cancer, and the Council's activities on traditional medicines.

The National Health Laboratory Service tabled an analysis of their budget where a surplus was generated due to the fee-for-service mechanism. The Service's strategic plan looked at the purpose, the lab sites, its corporate structure, the services offered, facilities, human resources, training, and research. The strategic plan also highlighted the CD4 testing, lab expansion programmes, decreasing diagnosis times, and the challenges facing the laboratories. Questions were asked on rapid response and cures for XDR TB, the reasons why the budgets had not included figures for Kwazulu Natal, the situation with the Rustenburg laboratories, the drugs being used to treat TB, the ration between laboratories and districts, the source of revenue for the Service,  response rates for testing, the cost of testing, and issues of confidentiality.

MINUTES
Medical Research Council of South Africa (MRC) Briefing
Prof Anthony MBewu, President, MRC, covered fourteen areas ranging from the MRC mandate, strategic objectives, and corporate governance, to issues of transformation. The presentation highlighted nine strategic objectives (see documents) under the categories of promoting and conducting research, professional support for research, and transition in research. The presentation also emphasised the priority of research development and technology transfer through national collaborative research programmes. Strategic research and key strategic initiatives were also highlighted, and the implementation of shared values was emphasised. The MRC budget component reflected favourable progress and research productivity. The main research priorities lay in areas of HIV and AIDS, TB, heart and stroke and diabetes, violence and injury, brain and behaviour, pneumonia and other infections, cancer, public health research, women’s nutrition and maternal health care, the environment and health, health promotion, malaria, traditional medicines, and finally genomics and proteomics. The former were said to be most salient in South Africa and hence became the MRC’s top priority. The strategic health research priorities included capacity development, refurbishment, and capital expenditure. Here the presentation included a projection of possible outcomes in the MRC if their baseline government funding were o be tincreased. This highlighted the fact that government needed to match contract grant contributions from external funds. An important issue raised by the budget submission was the contract grant contribution of R236 million, that exceeded the baseline government contribution of 180 million. Productivity was measured in peer review publications which totalled 664 in 2007 with a steady increase from previous years. Research translation was also emphasised by the presentation through the programme of Getting Research Results Into: Policy, Practice, Promotion and Products (GRIPPPP). Figures were tabled indicating that of the 838 personal employed by the MRC 49% were black, 18% coloured, 18% white, and 14% indian.

Prof Mapule Ramashala, Chairperson of the MRC board, reminded Prof MBewu to address the controversy around Microbicide clinical research and the termination of trials which the media alleged entailed gross ethical and protocol violations.

Prof MBewu said that the controversy was unfounded, and that an independent inspectorate had been sent to investigate these charges by the media. He said that while investigations had not completed so as to finalise the formal report that would be presented to the Minister, the informal report to the MRC indicated that there were no such violations, but rather the inspectorate had found the project to be conducted in a favourable manner.

Discussion
Mr G Morgan (DA) asked if there was any collaboration with other African countries, especially the SADC region and if funding also come from such collaboration. He also asked if opportunities were being granted to researchers from these African countries to work within South Africa and the MRC, and whether similar opportunities applied for South African researchers in other African countries.

Prof MBewu said that the MRC had extensive and growing collaborations with other African countries, particularly in the area of malaria, both in terms of control personnel and malaria research. He said that health systems collaboration was also taking place with Zambia and Malawi. Prof MBewu said that international funds were also leveraged for these programmes to develop new TB, HIV, and malaria drugs. MRC was also part of the global TB alliance in testing new treatment regiments for TB, to shorten treatment from six months to two or three months. He said that there were other African researchers working within MRC, but MRC was careful not to perpetuate a brain drain in either direction and thus South African researchers were preferred.

Ms N Mathibela (ANC) asked if there was any tension between external competency grants and the baseline funding provided by government to the MRC.

Prof MBewu replied that the MRC did not regret external donor support as it reflected favourably on the standard of the MRC research. However, he argued that it would be useful to gain more funds from government as the MRC was not donor driven. Often the ways in which research projects would be conducted dould be influenced by what the donor wanted as the specific focus area,  and it would be better to have more government funds to enable greater autonomy in research.

Ms M Malumise (ANC) asked if the Italian vaccine programme on HIV had any links or collaboration with the South African Aids Vaccine Initiative (SAAVI).

Prof MBewu said that there was collaboration in testing on the phase 2-B trial of the Italian vaccine, using SAAVI facilities and trial sites.

Ms M Manana (ANC) and the Chairperson said that there was a need to address the reliance on donor funding.

Prof MBewu said that the external funding was useful to establish research networks and for competency analysis, but that greater government funding would be welcomed.

A member asked if the MRC could expand on the Extremely Drug Resistant (XDR) TB testing which the presentation had failed to isolate as a separate issue.

The Chairperson agreed that the presentation had not addressed the XDR TB problem and asked for progress on the treatment of it.

Prof MBewu admitted that this was not specifically included in the presentation. He said MRC was active in terms of identifying outbreaks and developing diagnostics interventions, such as in collaboration with FIND diagnostics, to rapidly reduce the time taken for a diagnosis of XDR or Multi Drug Resistant (MDR) TB, and that work was also being done with the National Health Laboratory Service (NHLS). He said the MRC had also worked with other SADC countries and the World Health, Organisation (WHO) for diagnosis and prevention of cross infection of the strain within wards using UV light for example. The expansion of clinical trial sites in South Africa was needed to expand TB drug development, which he argued might be key to destroying the microbacterium before it developed significant drug resistance.

A member asked for an update from the MRC in regard to instances of malaria and controlled spraying of DDT. Finally he asked to what extent diabetes was a problem in South Africa.

Prof MBewu said that the MRC was at the forefront of developing DDT spraying to prevent malaria. Such spraying was initially thought to be dangerous by the WHO but had now been endorsed. Diabetes and Type-2 diabetes had become more prevalent in South Africa due to the increase in the obesity rate of South Africans. He said steps must be taken to address this

Ms Mathibela asked if the ageing research equipment and the loss of researchers might be due to challenges in the 2007 budget.

Prof MBewu said that the MRC would welcome an increase in baseline grants from government as it would enable them to develop their capacity further and focus the MRC on greater strategic research initiatives.

Ms Madumise asked what was being done to address the presence of breast and cervical cancer in South African women.

Prof MBewu acknowledged that there was a need to spend much more money on such issues in South Africa especially as the occurrence rates of differing forms of cancer were pervasive in different geographical locations. Research was taking place regarding cervical and breast cancer which was among the highest in South Africa. 

The Chairperson asked if the MRC had experienced any problems regarding fraud. He again emphasised the redress of the baseline budget.

Prof MBewu said that the MRC's Chief Financial Officers led the area of risk management, but whistle blowing wasmanaged independently Two cases had been reported but after investigation were found to be groundless. He added that the MRC was trying to build further on the culture of research integrity even though South African medical research integrity was already high.

The Chairperson asked why SAAVI was said to be ‘apparently’ progressing well.

Prof MBewu said that this wording was used as there had been contentions around whether SAAVI should be moved into the Department of Science and Technology, and thus information on SAAVI progress had not been manifestly divulged.

The Chairperson asked for clarity on the MRC’s activities on traditional medicines.

Prof MBewu said much progress was made in plant chemistry that had taken traditional knowledge into account. He said that this research took into account both extractionary means and application of plants in the traditional way. He also pointed out that the MRC has been involved in providing poverty alleviation strategies such as harvesting of medicinal plants for export.

Prof Ramashala emphasised the importance of capacity building and pointed out that there had been a reduction in senior researchers as a result of the retirement of old white professorso that it was important to rebuild research capacity and training. She said additional baseline funds would be useful in this regard.

Mr Muller said that he was glad to see that government's initial R190 million investment could attract an additional R244 million from outside sources, but acknowledged the need to redress the imbalances.

National Health Laboratory Service (NHLS) presentation
Mr John Robertson, CEO, NHLS, presented an in depth analysis of the NHLS budget and emphasised the surplus accumulated from revenue generation via the fee for service approach. The budget also looked at tariff development and its expenditure per province (see documents). The strategic plan briefing covered the purpose of the NHLS, the NHLS laboratory sites, its corporate structure, the services offered, facilities, human resources, training, and research (see documents). The strategic plan also highlighted the CD4, PCR and Viral load lab expansion programme for 2007/08 in the provinces. It further elaborated on laboratory capacity and the NHLS’s approach to MDR and XDR TB. In regard to XDR TB, Mr Robertson confirmed the MRC’s analysis on decreasing diagnosis times via new diagnostic technologies such as the Fast Plaque Response initiative with FIND diagnostics. Finally the presentation looked at some of the challenges facing the NHLS such as human resources and logistics.

Discussion
Dr R Rabinowitz(IFP) asked why there was no rapid response for XDR TB. She asked if any patients with XDR had been cured and what treatment they were getting.

Mr Robertson said that the difficulty faced by the NHLS was the lack of longitudinal studies and unique identifiers to track the progress of individual patients. He said that initiatives had been taken by the NHLS to ensure that every patient that had a test done would be entered in the NHLS database and once the longitudinal study was conducted the effectiveness of the treatment could be established. In regard to rapid diagnosis he said that the initiatives with FIND had been put in place, and that traditionally cultures had been used.

Mr Sipho Mahlati, Executive Regional Manager, NHLS, said that it must be understood that the XDR strain was very recent and thus finding out whether the treatment was effective might be a problem at this stage. He drew a parallel example of the 24-month treatment of MDR TB. He said that the fact that the strain was so recent had also impacted on the speed of diagnosis and research on treatment and drug approval.

Ms Mathibela noted that in many slides on the budget the information for Kwazulu Natal (KZN) had not been  included. She asked if this did not create a problem for the overall budget and the Committee's qualified report construction.

Mr Robertson said the issue around the KZN budget was the lack of information consolidation in KZN, but NHLS was working on rolling out information systems there by the end of next year. He assured the Committee that KZN was on top of the XDR TB strain problem and that the problem did not lie in lack of capacity to do the work, but in the lack of information reporting.

Ms Mathibela asked, in regard to the laboratories, if Rustenburg was new or old.

Mr Robertson said that the Rustenburg laboratory was a large laboratory whose capacity, if it exceeded 65%, would be developed further. 

Ms Madumise asked what drugs were being used to treat XDR TB.

Mr Robertson said that the decision on which drugs were appropriate depended on the provinces looking at the resistance and sensitivity reports by the NHLS, and then choosing from them. He said that there were treatments for XDR-TB but they were toxic, so the treatment programme might not be effective. Mr Roberson pointed out that the strategic plan set out to built a TB reference laboratory to address drug resistance, proficiency testing, internal quality assessment, and training and safety, which hopefully would be completed by the end of 2008.

The Chairperson asked what collaboration had been taking place with the districts as the presentation claimed that one laboratory existed for each district.

Mr Robertson said that the ratio between laboratories and districts was four labs for every district but only one lab concerned with CD4 testing was available to each district. He said if the programme continued to grow there might be two CD4 labs per district.

The Chairperson asked where the healthy revenue by the NHLS was generated from.

Mr Robertson said that a fee for service mechanism was used. He said that other than R55 million in grants the balance was gained from this fee for service mechanism.

The Chairperson asked what the response rate was for the test being taken by the NHLS.

Mr Robertson said that the NHLS had two priority programmes - the Comprehensive AIDS Care, Management and Treatment (CCMT) programmes and the TB programme. CCMT turnaround times would typically be five days, while across the country these times were being exceeded. With the TB programme he admitted that pockets were not reaching the standards for TB, which was 48hours. NHLS was trying to ensure that time within the lab would not exceed 24 hours. He said that though there was a SMS mechanism in place to send results to clinics, this messaging mechanism did not have a central destination that it could be collected from. He said that in working closer with the provinces, turnaround time on the return leg might be improved. In regard to incoming specimens he said that measures were also being considered to improve the incoming times.

Dr Rabinowitz asked what the cost was of the testing for patients.

Mr Robertson said that the province paid the cost of the testing which was around R60 for the CD4 with a national reference price of R147, and R300 for the viral load, with a national reference price of over R640. Regarding the costs to provinces he said that some had had problems with payment while others had no problems, but that every effort was being made to bring payments in within 60 days. He said that there had been an increase in medical patients, and these were more expensive than surgical patients.

The Chairperson, referring to the presentation on the CD4 and viral load tests, asked if the positive effect was a result of the current programmes’ interventions on HIV and AIDS.

Mr Robertson said that if a unique identifier was provided for each patient the results would be more dramatic.

The Chairperson asked if the issue of confidentiality was the main impediment.

Mr Robertson agreed that it was and said the NHLS would be able to assist by taking longitudinal studies using demographics at hand. He said that confidentiality was already lost as the specimens for analysis did contain the name of the patient and only if the information was put in external databases could it be a problem. He said for internal findings it could be important for research integrity.

The Chairperson said that the matter should be addressed more thoroughly at a later date.

The meeting was adjourned.